Practical Applications in Supervision - camft

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PRACTICAL APPLICATIONS IN SUPERVISION

INTRODUCTION Practical Applications in Supervision has been revised and reprinted from the version first published in 1990. Section I was revised in 1993, 1998, 2010 and again in 2013. Section I contains an overview of the law and regulations relating to the supervision of marriage and family therapist interns and trainees, and associate clinical social workers. This Section also contains articles that pertain to supervision of marriage and family therapist interns and trainees written by CAMFT’s Executive Director, past and current Staff Attorneys, and CAMFT’s Of Counsel. Section II contains a variety of useful articles selected to assist therapists who provide supervision. These articles were reviewed in 2010 and some information, such as the laws and regulations cited have been revised in 2010. These articles address a breadth of supervision topics. This array of articles is by no means an exclusive compilation, but they do address topics of importance for those who are already supervisors or aspiring to become supervisors. This revised Manual is designed to help you:      

Recognize the legal requirements to be a supervisor for MFT interns and trainees; Describe the Board of Behavioral Sciences’ requirements for obtaining hours of experience for MFT applicants; Discuss the laws and ethical standards pertinent to supervisors and supervisees; Determine the appropriate legal and ethical issues surrounding employment of interns and trainees; Analyze the structure of supervision, including but not limited to, the supervisory relationship, and the role of the supervisor; Assess the different models of training and supervision and theoretical approaches to supervision.

We trust that this Manual will become a valuable and useful resource to those who supervise MFT interns and trainees, and associate clinical social workers, and to others interested in learning more about supervision.

PRACTICAL APPLICATIONS IN SUPERVISION

SECTION I

PRACTICAL APPLICATIONS IN SUPERVISION

TABLE OF CONTENTS

SECTION I LAW AND REGULATIONS

I-6

CAMFT CODE OF ETHICS

I-20

EXPERIENCE GUIDELINES

I-23

FORMS SAMPLE LETTER OF AGREEMENT FOR OFFSITE SUPERVISION

I-26

LINKS TO BBS FORMS

I-28

MFT INTERN/TRAINEE SUPERVISOR RESPONSIBILITY STATEMENT ASW SUPERVISOR RESPONSIBILITY STATEMENT MFT INTERN/TRAINEE WEEKLY SUMMARY OF HOURS OF EXPERIENCE FORM ASW WEEKLY TRACKING LOG FORM MFT INTERN/TRAINEE EXPERIENCE VERIFICATION FORM ASW EXPERIENCE VERIFICATION FORM ASW SUPERVISORY PLAN FORM

ARTICLES

CRITICAL REMINDERS FOR INTERNS AND TRAINEES AND SUPERVISORS TOO

I-29

CRITICAL REMINDERS CHART

I-41

SUPERVISORS TWENTY-FIVE MOST OFTEN ASKED QUESTIONS

I-42

TIPS ON SUPERVISION: SUPERVISOR RECORD- KEEPING

I-49

SUGGESTIONS FOR DEVELOPING A WORTHWHILE SUPERVISORY RELATIONSHIP

I-51

A TALE OF TWO SUPERVISEES

I-55

PRACTICAL APPLICATIONS IN SUPERVISION

DEALING WITH UNQUALIFIED INCOMPETENT OR DISHONEST INTERNS

I-62

THE DOS AND DON’TS OF INTERVIEWING INTERNS AND TRAINEES

I-68

INTERNS/TRAINEES – EMPLOYEES NOT INDEPENDENT CONTRACTORS

I-72

TERMINATION OF EMPLOYMENT “WHO OWNS THE PATIENT?”

I-76

TRAINEE HOURS MAY BE IN JEOPARDY

I-81

RETHINKING PRIVATE PRACTICE INTERNSHIPS

I-83

MYTHS AND REALITIES OF SUPERVISION

I-92

TEN ADVERTISING MISTAKES MADE BY THERAPISTS

I-100

ON ETHICS: AVOIDING PROBLEMS WITH FEES, PAYMENT AGREEMENTS AND HEALTH INSURANCE

I-106

PRACTICAL APPLICATIONS IN SUPERVISION

SUPERVISION - LAW AND REGULATIONS

Following are requirements for supervising the experience of MFT interns and trainees in the State of California. These requirements are excerpted from the licensing law and regulations governing the practice of marriage and family therapy. WHAT IS THE DEFINITION OF “SUPERVISION?” Supervision includes “ensuring that the extent, kind, and quality of counseling performed is consistent with the education, training, and experience of the person being supervised; reviewing client/patient records, monitoring and evaluating assessment, diagnosis, and treatment decisions of the intern or trainee; monitoring and evaluating the ability of the intern or trainee to provide services at the site(s) where he or she will be practicing and to the particular clientele being served; and ensuring compliance with laws and regulations governing the practice of marriage and family therapy. Supervision shall include that amount of direct observation, or review of audio or video tapes of therapy, as deemed appropriate by the supervisor.” [Section 1833 of Division 18, Title 16, of the California Code of Regulations.] WHO CAN BE A SUPERVISOR FOR MFT INTERNS AND TRAINEES? An individual who: 1. Has been licensed by a state regulatory agency for at least two years as a marriage and family therapist, licensed clinical social worker, licensed professional clinical counselor, licensed psychologist, or licensed physician certified in psychiatry by the American Board of Psychiatry and Neurology. If a licensed professional clinical counselor, the individual shall meet the additional training and education requirements specified in paragraph (3) of subdivision (a) of Section 4999.20; 2. Has not provided therapeutic services to the trainee or intern; 3. Has a current and valid license that is not under suspension or probation; and 4. Complies with supervision requirements established by this chapter and by board regulations. [Cal. Bus. & Prof. Code Section 4980.03.] WHAT ARE THE REQUIREMENTS FOR A SUPERVISOR FOR MFT INTERNS AND TRAINEES? A supervisor for MFT Interns or Trainees in California shall comply with the following requirements: • “Prior to the commencement of any counseling or supervision, the supervisor shall sign under penalty of perjury the ‘Responsibility Statement for Supervisors of a Marriage and Family Therapist Trainee or Intern’ requiring that: o (1) The supervisor possesses and maintains a current valid California license as either a marriage and family therapist, licensed clinical social worker, licensed professional clinical counselor, licensed psychologist, or physician who is PRACTICAL APPLICATIONS IN SUPERVISION

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certified in psychiatry as specified in Section 4980.03 (g) of the Code and has been so licensed in California for at least two years prior to commencing any supervision; or (A) Provides supervision only to trainees at an academic institution that offers a qualifying degree program as specified in Section 4980.40 (a) of the Code; and (B) Has been licensed in California as specified in Section 4980.03 (g) of the Code, and in any other state, for a total of at least two years prior to commencing any supervision. o (2) A supervisor who is not licensed as a marriage and family therapist, shall have sufficient experience, training, and education in marriage and family therapy to competently practice marriage and family therapy in California. o (3) The supervisor keeps himself or herself informed of developments in marriage and family therapy and in California law governing the practice of marriage and family therapy. o (4) The supervisor has and maintains a current license in good standing and will immediately notify the trainee or intern of any disciplinary action, including revocation or suspension, even if stayed, probation terms, inactive license status, or any lapse in licensure that affects the supervisor's ability or right to supervise. o (5) The supervisor has practiced psychotherapy or provided direct supervision of trainees, interns, or associate clinical social workers who perform psychotherapy for at least two (2) years within the five (5) year period immediately preceding any supervision. o (6) The supervisor has had sufficient experience, training, and education in the area of clinical supervision to competently supervise trainees or interns. (A) Persons licensed by the board who provide supervision shall complete a minimum of six (6) hours of supervision training or coursework in each renewal period while providing supervision. This training or coursework may apply towards the continuing education requirements set forth in Sections 4980.54 and 4996.22 of the Code. (B) Persons licensed by the board who provide supervision and who have not met requirements of subsection (A), shall complete a minimum of six (6) hours of supervision training or coursework within sixty (60) days of commencement of supervision. o (7) The supervisor knows and understands the laws and regulations pertaining to both the supervision of trainees and interns and the experience required for licensure as a marriage and family therapist. o (8) The supervisor shall ensure that the extent, kind, and quality of counseling performed is consistent with the education, training, and experience of the trainee or intern. o (9) The supervisor shall monitor and evaluate the extent, kind, and quality of counseling performed by the trainee or intern by direct observation, review of audio or video tapes of therapy, review of progress and process notes and other treatment records, or by any other means deemed appropriate by the supervisor. o (10) The supervisor shall address with the trainee or intern the manner in which emergencies will be handled. (b) Each supervisor shall provide the trainee or intern with the original signed ‘Responsibility Statement for Supervisors of a Marriage and Family Therapist Intern or

PRACTICAL APPLICATIONS IN SUPERVISION

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• •

• •

Trainee’ prior to the commencement of any counseling or supervision. Trainees and interns shall provide the board with the signed ‘Responsibility Statement for Supervisors of a Marriage and Family Therapist Intern or Trainee’ from each supervisor upon application for licensure. (c) A supervisor shall give at least one (1) week's prior written notice to a trainee or intern of the supervisor's intent not to sign for any further hours of experience for such person. A supervisor who has not provided such notice shall sign for hours of experience obtained in good faith where such supervisor actually provided the required supervision. (d) The supervisor shall obtain from each trainee or intern for whom supervision will be provided, the name, address, and telephone number of the trainee’s or intern’s most recent supervisor and employer. (e) In any setting that is not a private practice, a supervisor shall evaluate the site(s) where a trainee or intern will be gaining hours of experience toward licensure and shall determine that: (1) the site(s) provides experience which is within the scope of practice of a marriage and family therapist; and (2) the experience is in compliance with the requirements set forth in section 1833 and section 4980.43 of the Code. (f) Upon written request of the board, the supervisor shall provide to the board any documentation which verifies the supervisor's compliance with the requirements set forth in this section. (g) The board shall not deny hours of experience gained towards licensure by any supervisee due to failure of his or her supervisor to complete the training or coursework requirements in subsection (a) (6) (A).” [Section 1833.1 of Division 18, Title 16, of the California Code of Regulations.]

WHERE CAN TRAINEES WORK? “All experience gained by a trainee shall be monitored by the supervisor as specified by regulation. A trainee may be credited with supervised experience completed in any setting that meets all of the following: • Lawfully and regularly provides mental health counseling or psychotherapy. • Provides oversight to ensure that the trainee’s work at the setting meets the experience and supervision requirements set forth in this chapter and is within the scope of practice for the profession as defined in Section 4980.02. • Is not a private practice owned by a licensed marriage and family therapist, a licensed psychologist, a licensed clinical social worker, a licensed professional clinical counselor, a licensed physician and surgeon, or a professional corporation of any of those licensed professions. Experience may be gained by the trainee solely as part of the position for which the trainee volunteers or is employed.” [Cal. Bus. & Prof. Code 4880.43.] “Trainees performing services in any work setting specified in subdivision (d) of Section 4980.43 may perform those activities and services as a trainee, provided that the activities and services constitute part of the trainee's supervised course of study and that the person is designated by the title trainee.” PRACTICAL APPLICATIONS IN SUPERVISION

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“Trainees subject to Section 4980.37 may gain hours of experience and counsel clients outside of the required practicum. “Trainees who are subject to Section 4980.36 may gain hours of experience outside the required practicum but must be enrolled in a practicum course to counsel clients. These trainees may counsel clients while not enrolled in a practicum course if the period of lapsed enrollment is less than 90 calendar days, and if that period is immediately preceded and immediately followed by enrollment in a practicum course or completion of the degree program.” [Cal. Bus. & Prof. Code Section 4980.42.] “No hours of experience may be gained prior to completing either 12 semester units or 18 quarter units of graduate instruction and becoming a trainee except for personal psychotherapy.” [Cal. Bus. & Prof. Code Section 4980.43.] “All hours of experience gained as a trainee shall be coordinated between the school and the site where the hours are being accrued. The school shall approve each site and shall have a written agreement with each site that details each party's responsibilities, including the methods by which supervision shall be provided. The agreement shall provide for regular progress reports and evaluations of the student's performance at the site. If an applicant has gained hours of experience while enrolled in an institution other than the one that confers the qualifying degree, it shall be the applicant's responsibility to provide to the board satisfactory evidence that those hours of trainee experience were gained in compliance with this section.” [Cal. Bus. & Prof. Code Section 4980.42.] “A trainee shall, prior to performing any professional services, inform each client or patient that he or she is an unlicensed marriage and family therapist trainee, provide the name of his or her employer, and indicate whether he or she is under the supervision of a licensed marriage and family therapist, a licensed clinical social worker, a licensed psychologist, or a licensed physician certified in psychiatry by the American Board of Psychiatry and Neurology.” [Cal. Bus. & Prof. Code Section 4980.48.] WHEN CAN A POSTGRADUATE APPLICANT GAIN HOURS OF EXPERIENCE? “Except as provided in subdivision (g), all persons shall register with the board as an intern in order to be credited for postdegree hours of supervised experience gained toward licensure. Except when employed in a private practice setting, all postdegree hours of experience shall be credited toward licensure so long as the applicant applies for the intern registration within 90 days of the granting of the qualifying master’s or doctor’s degree and is thereafter granted the intern registration by the board.” [Cal. Bus. & Prof. Code Section 4980.43.] “An unlicensed marriage and family therapist intern employed under this chapter shall comply with the following requirements: • Possess, at a minimum, a master’s degree as specified in Section 4980.36 or 4980.37, as PRACTICAL APPLICATIONS IN SUPERVISION

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• •

applicable. Register with the board prior to performing any duties, except as otherwise provided in subdivision (e) of Section 4980.43. Inform each client or patient prior to performing any professional services that he or she is unlicensed and under the supervision of a licensed marriage and family therapist, licensed clinical social worker, licensed psychologist, or a licensed physician and surgeon certified in psychiatry by the American Board of Psychiatry and Neurology.” [Cal. Bus. & Prof. Code Section 4980.44.]

WHERE CAN INTERNS WORK? “An intern may be credited with supervised experience completed in any setting that meets both of the following: • Lawfully and regularly provides mental health counseling or psychotherapy. • Provides oversight to ensure that the intern’s work at the setting meets the experience and supervision requirements set forth in this chapter and is within the scope of practice for the profession as defined in Section 4980.02.” An applicant shall not be employed or volunteer in a private practice, as defined in subparagraph (C) of paragraph (1) of subdivision (d), until registered as an intern. While an intern may be either a paid employee or a volunteer, employers are encouraged to provide fair remuneration to interns. Except for periods of time during a supervisor’s vacation or sick leave, an intern who is employed or volunteering in private practice shall be under the direct supervision of a licensee that has satisfied the requirements of subdivision (g) of Section 4980.03. The supervising licensee shall either be employed by and practice at the same site as the intern’s employer, or shall be an owner or shareholder of the private practice. Alternative supervision may be arranged during a supervisor’s vacation or sick leave if the supervision meets the requirements of this section. Experience may be gained by the intern solely as part of the position for which the intern volunteers or is employed.” [Cal. Bus. & Prof. Code Section 4980.43.] “Prior to performing any professional services, the intern must inform each client or patient that he or she is an unlicensed marriage and family therapist registered intern, provide his or her registration number and the name of his or her employer, and indicate whether he or she is under the supervision of a licensed marriage and family therapist, licensed clinical social worker, licensed psychologist, or a licensed physician and surgeon certified in psychiatry by the American Board of Psychiatry and Neurology.” [Cal. Bus. & Prof. Code Section 4980.44(c).] DOES THE INTERN REGISTRATION EXPIRE? PRACTICAL APPLICATIONS IN SUPERVISION

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Yes. “The marriage and family therapist intern registration shall expire one year from the last day of the month in which it was issued. To renew the registration, the registrant shall, on or before the expiration date of the registration, complete all of the following actions: (1) Apply for renewal on a form prescribed by the board. (2) Pay a renewal fee prescribed by the board. (3) Notify the board whether he or she has been convicted, as defined in Section 490, of a misdemeanor or felony, and whether any disciplinary action has been taken against him or her by a regulatory or licensing board in this or any other state subsequent to the last renewal of the registration.” [Cal. Bus. & Prof. Code Section 4984.01.] HOW MANY TIMES CAN AN INTERN REGISTRATION BE RENEWED? “The registration may be renewed a maximum of five times. No registration shall be renewed or reinstated beyond six years from the last day of the month during which it was issued, regardless of whether it has been revoked. When no further renewals are possible, an applicant may apply for and obtain a new intern registration if the applicant meets the educational requirements for registration in effect at the time of the application for a new intern registration. An applicant who is issued a subsequent intern registration pursuant to this subdivision may be employed or volunteer in any allowable work setting except private practice.” [Cal. Bus. & Prof. Code Section 4984.01.] The registration of each intern shall expire at midnight one year from the last day of the month in which the registration was issued. [Section 1846 of Division 18, Title 16, of the California Code of Regulations.] CAN THE BOARD DENY AN APPLICATION FOR REGISTRATION OR LICENSURE DUE TO MENTAL ILLNESS OR CHEMICAL DEPENDENCY? Yes. “The board may refuse to issue any registration or license whenever it appears that an applicant may be unable to practice his or her profession safely due to mental illness or chemical dependency. The procedures set forth in Article 12.5 (commencing with Section 820) of Chapter 1 shall apply to any denial of a license or registration pursuant to this section.” [Cal. Bus. & Prof. Code Section 4982.1.] CAN INTERNS AND TRAINEES WORK AND GAIN SUPERVISED EXPERIENCE AS INDEPENDENT CONTRACTORS? No. “Supervised experience shall be gained by interns and trainees either as an employee or as a volunteer. The requirements of this chapter regarding gaining hours of experience and supervision are applicable equally to employees and volunteers. Experience shall not be gained by interns or trainees as an independent contractor. If employed, an intern shall provide the board with copies of the corresponding W-2 tax forms PRACTICAL APPLICATIONS IN SUPERVISION

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for each year of experience claimed upon application for licensure. If volunteering, an intern shall provide the board with a letter from his or her employer verifying the intern’s employment as a volunteer upon application for licensure.” [Cal. Bus. & Prof. Code Section 4980.43.] “Trainees, interns, and applicants shall not receive any remuneration from patients or clients, and shall only be paid by their employers. Trainees, interns, and applicants shall only perform services at the place where their employers regularly conduct business, which may include performing services at other locations, so long as the services are performed under the direction and control of their employer and supervisor, and in compliance with the laws and regulations pertaining to supervision.” [Cal. Bus. & Prof. Code Section 4980.43.] CAN TRAINEES AND INTERNS PAY FOR OVERHEAD EXPENSES, SUCH AS RENT OR SUPPLIES? No. “Trainees and interns shall have no proprietary interest in their employers’ businesses and shall not lease or rent space, pay for furnishings, equipment or supplies, or in any other way pay for the obligations of their employers.” [Cal. Bus. & Prof. Code Section 4980.43.] CAN TRAINEES AND INTERN VOLUNTEERS GET REIMBURSED FOR EXPENSES ACTUALLY INCURRED? Yes. “Trainees, interns, or applicants who provide volunteered services or other services, and who receive no more than a total, from all work settings, of five hundred dollars ($500) per month as reimbursement for expenses actually incurred by those trainees, interns, or applicants for services rendered in any lawful work setting other than a private practice shall be considered an employee and not an independent contractor. The board may audit applicants who receive reimbursement for expenses, and the applicants shall have the burden of demonstrating that the payments received were for reimbursement of expenses actually incurred.” [Cal. Bus. & Prof. Code Section 4980.43.] HOW MANY HOURS OF SUPERVISION DOES THE TRAINEE OR INTERN NEED? Supervision shall include at least one hour of direct supervisor contact in each week for which experience is credited in each work setting, as specified: • A trainee shall receive an average of at least one hour of direct supervisor contact for every five hours of client contact in each setting. • An individual supervised after being granted a qualifying degree shall receive at least one additional hour of direct supervisor contact for every week in which more than 10 hours of client contact is gained in each setting. For purposes of this section, “one hour of direct supervisor contact” means one hour per week of face-to-face contact on an individual basis or two hours per week of face-to-face contact in a group. Direct supervisor contact shall occur within the same week as the hours claimed. Direct supervisor contact provided in a group shall be provided in a group of not more than eight supervisees and in segments lasting no less than one continuous hour. [Cal. Bus. & Prof. Code Section 4980.43.] PRACTICAL APPLICATIONS IN SUPERVISION

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CAN SUPERVISION BE OBTAINED VIA TELECONFERENCING? An intern working in a governmental entity, a school, a college, or a university, or an institution that is both nonprofit and charitable may obtain the required weekly direct supervisor contact via two-way, real-time videoconferencing. The supervisor shall be responsible for ensuring that client confidentiality is upheld. [Cal. Bus. & Prof. Code Section 4980.43.] HOW MANY TRAINEES/INTERNS MAY A LICENSED PROFESSIONAL SUPERVISE OR EMPLOY? “A licensed professional in private practice who has satisfied the requirements of subdivision (g) of Section 4980.03 may supervise or employ, at any one time, no more than a total of three individuals registered as a marriage and family therapist intern, clinical counselor intern, or associate clinical social worker in that private practice. A marriage and family therapy corporation may employ, at any one time, no more than a total of three individuals registered as a marriage and family therapist intern, clinical counselor intern, or associate clinical social worker for each employee or shareholder who has satisfied the requirements of subdivision (g) of Section 4980.03. In no event shall any marriage and family therapy corporation employ, at any one time, more than a total of 15 individuals registered as a marriage and family therapist intern, clinical counselor intern, or associate clinical social worker. In no event shall any supervisor supervise, at any one time, more than a total of three individuals registered as either a marriage and family therapist intern, clinical counselor intern, or associate clinical social worker. Persons who supervise individuals registered as either a marriage and family therapist intern, clinical counselor intern, or associate clinical social worker shall be employed full time by the marriage and family therapy corporation and shall be actively engaged in performing professional services at and for the marriage and family therapy corporation. Employment and supervision within a marriage and family therapy corporation shall be subject to all laws and regulations governing experience and supervision gained in a private practice setting.” [Cal. Bus. & Prof. Code Section 4980.45.] WHAT ARE THE REQUIREMENTS FOR SUPERVISION GAINED OUTSIDE OF CALIFORNIA? “Experience gained outside of California on or after January 1, 1991 must have been supervised in accordance with the following criteria: • At the time of supervision, the supervisor was licensed or certified by the state in which the supervision occurred and possessed a current license which was not under suspension or probation. • The supervisor was licensed or certified by that state, for at least two (2) years prior to acting as supervisor, as either a psychologist, clinical social worker, physician certified in psychiatry as specified in Section 4980.40(f) of the code, or a marriage and family therapist or similarly titled marriage and family practitioner. • In a state which does not license or certify marriage and family therapists or similarly titled marriage and family practitioners, experience may be obtained under the supervision of a person who at the time of supervision held a clinical membership in the PRACTICAL APPLICATIONS IN SUPERVISION

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American Association of Marriage and Family Therapists for at least two years and who maintained such membership throughout the period of supervision.” [Section 1833.2 of Division 18, Title 16, of the California Code of Regulations.]

Following are requirements for supervising the experience of ASWs in the State of California. These requirements are excerpted from the licensing law and regulations governing the practice of clinical social work. These requirements include changes effective January 1, 2010. WHAT IS THE DEFINITION OF “SUPERVISION?” • •

“Supervision means responsibility for and control of the quality of clinical social work services being provided.” ”Consultation or peer discussion shall not be considered to be supervision.” [See Cal. Bus. & Prof. Code Sections 4996.21, 4996.23.]

WHO CAN BE A SUPERVISOR FOR ASWS? The supervisor possesses and will maintain a current valid California license as a licensed clinical social worker or a licensed mental health professional acceptable to the Board as specified in Section 1874. [Section 1870 of Division 18, Title 16, of the California Code of Regulations.] BESIDES LCSWS, WHO ARE CONSIDERED ACCEPTABLE MENTAL HEALTH PROFESSIONALS TO SUPERVISE ASWS? “For purposes of Sections 4996.20(b) and 4996.21(a), a licensed mental health professional acceptable to the board is one who, at the time of supervision, has possessed for at least two years a valid license as a psychologist, marriage and family therapist or physician certified in psychiatry by the American Board of Psychiatry and Neurology.” [Section 1874 of Division 18, Title 16, of the California Code of Regulations.] HOW MANY HOURS CAN BE GAINED UNDER SUPERVISION OF AN ACCEPTABLE MENTAL HEALTH PROFESSIONAL? An associate shall have at least 3,200 hours of post-master's degree experience in providing clinical social work services as permitted by Section 4996.9. At least 1,700 of these hours shall be gained under the supervision of a licensed clinical social worker. The remaining hours of the required experience may be gained under the supervision of a licensed mental health professional acceptable to the board as defined in a regulation adopted by the board. [See Cal. Bus. & Prof. Code Sections 4996.21, 4996.23.] WHAT ARE THE REQUIREMENTS FOR SUPERVISORS FOR ASWS? PRACTICAL APPLICATIONS IN SUPERVISION

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Any person supervising an associate clinical social worker registered with the board (hereinafter called "supervisor") within California shall comply with the requirements set forth below. • (a) Prior to the commencement of any therapy or supervision, the supervisor shall sign under penalty of perjury the “Responsibility Statement for Supervisors of an Associate Clinical Social Worker” (revised 08/07, form #1800 37A-522), which requires that: o (1) The supervisor possesses and will maintain a current valid California license as a licensed clinical social worker or a licensed mental health professional acceptable to the Board as specified in Section 1874. o (2) The supervisor has and will maintain a current license in good standing and will immediately notify the associate of any disciplinary action, including revocation, suspension (even if stayed), probation terms, inactive license, or any lapse in licensure, that affects the supervisor's ability or right to supervise. o (3) The supervisor has practiced psychotherapy or provided direct supervision of associates, or marriage and family therapist interns or trainees who perform psychotherapy for at least two (2) years within the last five (5) years immediately preceding supervision. o (4) The supervisor has had sufficient experience, training and education in the area of clinical supervision to competently supervise associates.  (A) Persons licensed by the board who provide supervision shall have a minimum of fifteen (15) contact hours in supervision training obtained from a state agency or approved continuing education provider. This training may apply towards the approved continuing education requirements set forth in Sections 4980.54 and 4996.22 of the Code. The content of such training shall include, but not be limited to: (i) Familiarity with supervision literature through reading assignments specified by course instructors; (ii) Facilitation of therapist-client and supervisor-therapist relationships; (iii) Evaluation and identification of problems in therapist-client and supervisor-therapist relationships; (iv) Structuring to maximize supervision, including times and conditions of supervision sessions, problem solving ability, and implementing supervisor interventions within a range of supervisory modalities including live, videotape, audiotape, and case report methods; (v) Knowledge of contextual variables such as culture, gender, ethnicity, and economic issues; and (vi) The practice of clinical social work, including the mandated reporting laws, and knowledge of ethical and legal issues. o (5) The supervisor knows and understands the laws and regulations pertaining to both supervision of associates and the experience required for licensure as a clinical social worker. o (6) The supervisor shall do all of the following:  (A) Ensure that the extent, kind and quality of clinical social work performed by the associate is consistent with the training and experience of the person being supervised.  (B) Review client/patient records and monitor and evaluate assessment and treatment decisions of the associate clinical social worker.  (C) Monitor and evaluate the ability of the associate to provide services at PRACTICAL APPLICATIONS IN SUPERVISION

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o

o

o

o

o

the site(s) where he or she will be practicing and to the particular clientele being served.  (D) Ensure compliance with all laws and regulations governing the practice of clinical social work. (7) The supervisor and the associate shall develop the “Supervisory Plan” as described in Section 1870.1. The associate shall submit the original signed plan for each supervisor to the board upon application for licensure. (8) The supervisor shall provide the associate with the original, signed “Responsibility Statement for Supervisors of an Associate Clinical Social Worker” (revised 08/07, form #1800 37A-522), prior to commencement of any supervision. The associate shall provide the board with the original signed form for each supervisor upon application for licensure. (9) A supervisor shall give at least one (1) week's written notice to an associate of the supervisor's intent not to sign for any further hours of experience for such person. A supervisor who has not provided such notice shall sign for hours of experience obtained in good faith where such supervisor actually provided the required supervision. (10) The supervisor shall complete an assessment of the ongoing strengths and limitations of the associate. The assessments shall be completed at least once a year and at the completion or termination of supervision. A copy of all assessments shall be provided to the associate by the supervisor. (11) Upon written request of the board, the supervisor shall provide to the board any documentation which verifies the supervisor’s compliance with the requirements set forth in this section. (b) The board shall not deny hours of experience gained toward licensure by any associate due to the failure of his or her supervisor to complete the training requirements specified in subsection (a)(4)(A). [Section 1870 of Division 18, Title 16, of the California Code of Regulations.]

WHAT IS A “SUPERVISORY PLAN?” “On and after January 1, 1999, all associate clinical social workers and licensed clinical social workers or licensed mental health professionals acceptable to the board as defined in Section 1874 who assume responsibility for providing supervision shall develop a supervisory plan that describes the goals and objectives of supervision and shall complete and sign under penalty of perjury the “Supervisory Plan”, (form no. 1800 37A-521, revised 12/05), hereby incorporated by reference.” “This supervisory plan shall be completed by each supervisor providing supervision and the original signed plan shall be submitted by the associate clinical social worker to the board upon application for licensure.” [Section 1870.1 of Division 18, Title 16, of the California Code of Regulations.] WHAT DOES AN APPLICANT NEED TO DO TO GAIN HOURS OF EXPERIENCE TOWARD THE LCSW LICENSURE? PRACTICAL APPLICATIONS IN SUPERVISION

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“A person who wishes to be credited with experience toward licensure requirements shall register with the board as an associate clinical social worker prior to obtaining that experience. The application shall be made on a form prescribed by the board.” “An applicant for registration shall satisfy the following requirements: (1) Possess a master's degree from an accredited school or department of social work. (2) Have committed no crimes or acts constituting grounds for denial of licensure under Section 480.” “An applicant who possesses a master's degree from a school or department of social work that is a candidate for accreditation by the Commission on Accreditation of the Council on Social Work Education shall be eligible, and shall be required, to register as an associate clinical social worker in order to gain experience toward licensure if the applicant has not committed any crimes or acts that constitute grounds for denial of licensure under Section 480. That applicant shall not, however, be eligible for examination until the school or department of social work has received accreditation by the Commission on Accreditation of the Council on Social Work Education.” “Any experience obtained under the supervision of a spouse or relative by blood or marriage shall not be credited toward the required hours of supervised experience. Any experience obtained under the supervision of a supervisor with whom the applicant has a personal relationship that undermines the authority or effectiveness of the supervision shall not be credited toward the required hours of supervised experience.” “An applicant who possesses a master's degree from an accredited school or department of social work shall be able to apply experience the applicant obtained during the time the accredited school or department was in candidacy status by the Commission on Accreditation of the Council on Social Work Education toward the licensure requirements, if the experience meets the requirements of Section 4996.20, 4996.21, or 4996.23. This subdivision shall apply retroactively to persons who possess a master's degree from an accredited school or department of social work and who obtained experience during the time the accredited school or department was in candidacy status by the Commission on Accreditation of the Council on Social Work Education.” “An applicant for registration or licensure trained in an educational institution outside the United States shall demonstrate to the satisfaction of the board that he or she possesses a master's of social work degree that is equivalent to a master's degree issued from a school or department of social work that is accredited by the Commission on Accreditation of the Council on Social Work Education. These applicants shall provide the board with a comprehensive evaluation of the degree and shall provide any other documentation the board deems necessary. The board has the authority to make the final determination as to whether a degree meets all requirements, including, but not limited to, course requirements regardless of evaluation or accreditation.” [Cal. Bus. & Prof. Code Section 4996.18.]

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HOW MANY HOURS OF SUPERVISION DOES THE ASW NEED? “Supervision shall include at least one hour of direct supervisor contact for a minimum of 104 weeks and shall include at least one hour of direct supervisor contact for every 10 hours of client contact in each setting where experience is gained. Of the 104 weeks of required supervision, 52 weeks shall be individual supervision, and of the 52 weeks of required individual supervision, not less than 13 weeks shall be supervised by a licensed clinical social worker.” “For purposes of this section, “one hour of direct supervisor contact” means one hour of face-toface contact on an individual basis or two hours of face-to-face contact in a group setting of not more than eight persons.” [See Cal. Bus. & Prof. Code Sections 4996.21, 4996.23.] WHERE CAN ASWS WORK? On or after January 1, 1999, “experience shall only be gained in a setting that meets both of the following: (A) Lawfully and regularly provides clinical social work, mental health counseling, or psychotherapy. (B) Provides oversight to ensure that the associate's work at the setting meets the experience and supervision requirements set forth in this chapter and is within the scope of practice for the profession as defined in Section 4996.9. Experience shall not be gained until the applicant has been registered as an associate clinical social worker. Employment in a private practice as defined in paragraph (4) shall not commence until the applicant has been registered as an associate clinical social worker. A private practice setting is a setting that is owned by a licensed clinical social worker, a licensed marriage and family therapist, a licensed psychologist, a licensed physician and surgeon, or a professional corporation of any of those licensed professions.” [Cal. Bus. & Prof. Code Section 4996.21.] CAN ASWS WORK AND GAIN HOURS OF EXPERIENCE AS AN INDEPENDENT CONTRACTOR? “A registrant shall not provide clinical social work services to the public for a fee, monetary or otherwise, except as an employee.” “A registrant shall inform each client or patient prior to performing any professional services that he or she is unlicensed and is under the supervision of a licensed professional.” [Cal. Bus. & Prof. Code Section 4996.18.] “An unlicensed person employed under Section 4996.15 of the Code to perform limited social work functions shall inform each patient or client prior to performing any such functions that he or she is not a licensed clinical social worker and is under the supervision of a licensed clinical PRACTICAL APPLICATIONS IN SUPERVISION

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social worker, a licensed psychologist or a licensed psychiatrist, whichever is applicable.” [Section 1880 of Division 18, Title 16, of the California Code of Regulations.] “If volunteering, the associate shall provide the board with a letter from his or her employer verifying his or her voluntary status upon application for licensure. If employed, the associate shall provide the board with copies of his or her W-2 tax forms for each year of experience claimed upon application for licensure. While an associate may be either a paid employee or a volunteer, employers are encouraged to provide fair remuneration to associates. An associate shall not do the following: (1) Receive any remuneration from patients or clients and shall only be paid by his or her employer. (2) Have any proprietary interest in the employer's business. An associate, whether employed or volunteering, may obtain supervision from a person not employed by the associate's employer if that person has signed a written agreement with the employer to take supervisory responsibility for the associate's social work services.” [Cal. Bus. & Prof. Code Section 4996.21.]

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SUPERVISION – CAMFT CODE OF ETHICS

 “Marriage and family therapists do not exploit the trust and dependency of students and supervisees.” [CAMFT Code of Ethics, Part I, 4.]  “Marriage and family therapists are aware of their influential position with respect to students and supervisees, and they avoid exploiting the trust and dependency of such persons. Marriage and family therapists therefore avoid dual relationships that are reasonably likely to impair professional judgment or lead to exploitation. Provision of therapy to students or supervisees is unethical. Provision of marriage and family therapy supervision to clients is unethical. Sexual intercourse, sexual contact or sexual intimacy and/or harassment of any kind with students or supervisees is unethical. Other acts which could result in unethical dual relationships include, but are not limited to, borrowing money from a supervisee, engaging in a business venture with a supervisee, or engaging in a close personal relationship with a supervisee. Such acts with a supervisee's spouse, partner or family member may also be considered unethical dual relationships.” [[CAMFT Code of Ethics, Part I, 4.1.]  “Marriage and family therapists do not permit students, employees, or supervisees to perform or to hold themselves out as competent to perform professional services beyond their training, level of experience, competence, or unlicensed status.” [CAMFT Code of Ethics, Part I, 4.2.]  “Marriage and family therapists who act as supervisors are responsible for maintaining the quality of their supervision skills and obtaining consultation or supervision for their work as supervisors whenever appropriate.” [CAMFT Code of Ethics, Part I, 4.3.]  “Supervisors and educators are knowledgeable about supervision, relevant laws and regulations, and the practice of marriage and family therapy. Supervisors and educators are knowledgeable about and abide by the laws and regulations governing the conduct of supervisors and supervisees.” [CAMFT Code of Ethics, Part I, 4.4]  “Supervisors and supervisees are aware of and stay abreast of changes in professional and ethical standards and legal requirements, and supervisors ensure that their supervisees are aware of professional and ethical standards and legal responsibilities.” [CAMFT Code of Ethics, Part I, 4.5.]  “Supervisors and educators are aware of and address the role that culture and diversity issues play in the supervisory relationship, including, but not limited to, evaluating, terminating, disciplining, or making decisions regarding supervisees or students.” [CAMFT Code of Ethics, Part I, 4.6]

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 “Supervisors and educators create policies and procedures that are clear and that are disclosed to supervisees and students at the commencement of supervision or education.” [CAMFT Code of Ethics, Part I, 4.7]  “Supervisors and educators provide supervisees with periodic performance appraisals and evaluative feedback throughout the supervisory relationship and identify and address the limitations of supervisees and students that might impede their performance.” [CAMFT Code of Ethics, Part I, 4.8.]  “Supervisors follow lawful business practices and employer policies when employing and/or supervising interns, trainees, applicants, and associates.” [CAMFT Code of Ethics, Part I, 4.9.]  “Supervisors and educators guide supervisees and students in securing assistance when needed for the supervisee to maintain or improve performance, such as personal psychotherapy, additional education, training, or consultation.” [CAMFT Code of Ethics, Part I, 4.10.]  “Supervisors shall document their decisions to dismiss supervisees.” [CAMFT Code of Ethics, Part I, 4.11.]  “Supervisors are aware of and review any trainee agreements with qualified educational institutions.” [CAMFT Code of Ethics, Part I, 4.12.]  “Supervisees understand that the patients seen by them are the patients of their employers.” [CAMFT Code of Ethics, Part I, 4.13.]  “Marriage and family therapists treat and communicate with and about colleagues in a respectful manner and with, courtesy, fairness, and good faith, and cooperate with colleagues in order to promote the welfare and best interests of patients.  “Marriage and family therapists respect the confidences of colleagues that are shared in the course of their professional relationships.” [CAMFT Code of Ethics, Part I, 5.1.]  “Marriage and family therapists are encouraged to assist colleagues who are impaired due to substance abuse, emotional problems, or mental illness.” [CAMFT Code of Ethics, Part I, 5.2.]  “Marriage and family therapists do not file or encourage the filing of ethics or other complaints that they know, or reasonably should know, are frivolous.” [CAMFT Code of Ethics, Part I, 5.3.]  “Marriage and family therapists do not agree to see or solicit the clients of other therapists or encourage clients to leave other therapists, except as addressed in Section 3.10.” [CAMFT Code of Ethics, Part I, 5.4.] PRACTICAL APPLICATIONS IN SUPERVISION

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 “Marriage and family therapists who advertise do so appropriately. Their advertising enables consumers to choose professional services based upon accurate information.” [CAMFT Code of Ethics, Part I, 10.]  “Marriage and family therapists accurately represent their competence, education, training, and experience relevant to their professional practice to patients and others.” [CAMFT Code of Ethics, Part I, 10.1.]  “Marriage and family therapists take reasonable steps to assure that advertisements and publications, whether in directories, announcement cards, newspapers, radio, television, Internet or any other media, are formulated to accurately convey information to the public.” [CAMFT Code of Ethics, Part I, 10.2.]  “Marriage and family therapists do not use a name that could mislead the public concerning the identity, responsibility, source, and status of those practicing under that name, and do not hold themselves out as being partners or associates of a firm if they are not.” [CAMFT Code of Ethics, Part I, 10.3.]  “Marriage and family therapists do not use any professional identification, including but not limited to: a business card, office sign, letterhead, telephone, or association directory listing, Internet, or any other media, if it includes a statement or claim that is false, fraudulent, misleading, or deceptive. A statement is false, fraudulent, misleading, or deceptive if it a) contains a material misrepresentation of fact; b) fails to state any material fact necessary to make the statement, in light of all circumstances, not misleading; or c) is intended to or is likely to create an unjustified expectation.” [CAMFT Code of Ethics, Part I, 10.4.]  “Marriage and family therapists correct, wherever possible, false, misleading, or inaccurate information and representations made by others concerning the therapist's qualifications, services, or products.” [CAMFT Code of Ethics, Part I, 10.5.]  “Marriage and family therapists do not solicit testimonials from patients.” [CAMFT Code of Ethics, Part I, 10.6.]  “Marriage and family therapists make certain that the qualifications of persons in their employ are represented in a manner that is not false, misleading, or deceptive.” [CAMFT Code of Ethics, Part I, 10.7.]  “ Marriage and family therapists may represent themselves as either specializing or having expertise within a limited area of marriage and family therapy, but only if they have the education, training, and experience that meets recognized professional standards to practice in that specialty area.” [CAMFT Code of Ethics, Part I, 10.8.]

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EXPERIENCE GUIDELINES

WHAT ARE THE HOURS OF SUPERVISED EXPERIENCE AN APPLICANT NEEDS TO COMPLETE PRIOR TO LICENSURE? Prior to applying for licensure examinations, each applicant shall complete experience that shall comply with the following: • A minimum of 3,000 hours completed during a period of at least 104 weeks. • Not more than 40 hours in any seven consecutive days. • Not less than 1,700 hours of supervised experience completed subsequent to the granting of the qualifying master's or doctoral degree. • Not more than 1,300 hours of supervised experience obtained prior to completing a master's or doctoral degree. • The applicant shall not be credited with more than 750 hours of counseling and direct supervisor contact prior to completing the master's or doctoral degree. • No hours of experience may be gained prior to completing either 12 semester units or 18 quarter units of graduate instruction and becoming a trainee except for personal psychotherapy. • No hours of experience may be gained more than six years prior to the date the application for examination eligibility was filed, except that up to 500 hours of clinical experience gained in the supervised practicum required by subdivision (c) of Section 4980.37 and subparagraph (B) of paragraph (1) of subdivision (d) of Section 4980.36 shall be exempt from this six-year requirement. • Not more than a combined total of 1,000 hours of experience in the following: o Direct supervisor contact. o Professional enrichment activities. For purposes of this chapter, "professional enrichment activities" include the following:  Workshops, seminars, training sessions, or conferences directly related to marriage and family therapy attended by the applicant that are approved by the applicant's supervisor. An applicant shall have no more than 250 hours of verified attendance at these workshops, seminars, training sessions, or conferences.  Participation by the applicant in personal psychotherapy, which includes group, marital or conjoint, family, or individual psychotherapy by an appropriately licensed professional. An applicant shall have no more than 100 hours of participation in personal psychotherapy. The applicant shall be credited with three hours of experience for each hour of personal psychotherapy. • Not more than 500 hours of experience providing group therapy or group counseling.

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• • •

For all hours gained on or after January 1, 2012, not more than 500 hours of experience in the following: o Experience administering and evaluating psychological tests, writing clinical reports, writing progress notes, or writing process notes. o Client centered advocacy. Not less than 500 total hours of experience in diagnosing and treating couples, families, and children. For up to 150 hours of treating couples and families in conjoint therapy, the applicant shall be credited with two hours of experience for each hour of therapy provided. Not more than 375 hours of experience providing personal psychotherapy, crisis counseling, or other counseling services via telehealth in accordance with Section 2290.5. It is anticipated and encouraged that hours of experience will include working with elders and dependent adults who have physical or mental limitations that restrict their ability to carry out normal activities or protect their rights. This subdivision shall only apply to hours gained on and after January 1, 2010. [Cal. Bus. & Prof. Code Section 4980.43.]

WHAT ARE THE HOURS OF SUPERVISED EXPERIENCE AN APPLICANT NEEDS TO COMPLETE PRIOR TO LICENSURE? “On or after January 1, 1999, an associate shall have at least 3,200 hours of post-master's degree experience in providing clinical social work services as permitted by Section 4996.9. At least 1,700 of these hours shall be gained under the supervision of a licensed clinical social worker. The remaining hours of the required experience may be gained under the supervision of a licensed mental health professional acceptable to the board as defined in a regulation adopted by the board. Experience shall consist of the following: (1) A minimum of 2,000 hours in psychosocial diagnosis, assessment, and treatment, including psychotherapy or counseling. (2) A maximum of 1,200 hours in client-centered advocacy, consultation, evaluation, and research. (3) Experience shall have been gained in not less than two nor more than six years and shall have been gained within the six years immediately preceding the date on which the application for licensure was filed.” [Cal. Bus. & Prof. Code Section 4996.21.] “All persons registered with the board on and after January 1, 2002, shall have at least 3,200 hours of post-master's degree supervised experience providing clinical social work services as permitted by Section 4996.9. At least 1,700 hours shall be gained under the supervision of a licensed clinical social worker. The remaining required supervised experience may be gained under the supervision of a licensed mental health professional acceptable to the board as defined by a regulation adopted by the board. This experience shall consist of the following: (1) A minimum of 2,000 hours in clinical psychosocial diagnosis, assessment, and treatment, including psychotherapy or counseling. (2) A maximum of 1,200 hours in client-centered advocacy, consultation, evaluation, and research. PRACTICAL APPLICATIONS IN SUPERVISION

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(3) Of the 2,000 clinical hours required in paragraph (1), no less than 750 hours shall be face-to-face individual or group psychotherapy provided to clients in the context of clinical social work services. (4) A minimum of two years of supervised experience is required to be obtained over a period of not less than 104 weeks and shall have been gained within the six years immediately preceding the date on which the application for licensure was filed. (5) Experience shall not be credited for more than 40 hours in any week.” [Cal. Bus. & Prof. Code Section 4996.23.]

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SAMPLE LETTER OF AGREEMENT FOR OFFSITE SUPERVISION It is hereby agreed that _____________________________________________________________________ (Supervisor) hereinafter referred to as supervisor, agrees to supervise the intern/trainee listed below, for __________________________________________________________________________ (Employer/Organization) Supervisor agrees to provide this service to _____________________________________________________ (Employer/Organization) on a voluntary basis.___________________________________________________ (Employer/Organization) agrees to allow _________________________________________________________ (Supervisor) to supervise the intern/trainee listed below. Supervisor agrees to ensure that the extent, kind, and quality of counseling/psychotherapy performed by the intern or trainee, is consistent with the intern or trainee’s training, education, and experience and is appropriate in extent, kind and quality. Employer is aware of the licensing requirements that must be met by the intern or trainee and agrees not to interfere with the supervisor’s legal and ethical obligations to ensure compliance with those requirements, and employer agrees to provide the supervisor access to clinical records of the clients, counseled by the intern or trainee. Supervisor agrees to ensure that the counseling/psychotherapy performed by the intern or trainee listed below and the supervision provided by the supervisor will be in accordance with Chapter 13, Division 2 of the Business and Professions Code (the MFT Licensing Law) and any regulations promulgated thereunder. The intern/trainee listed below is employed by the _______________________________________ (Employer/Organization) and performs counseling/psychotherapy services of a nature specified in Chapter 13, Division 2 of the Business and Professions Code and any regulations promulgated thereunder. ______________________________________________________________________________ Trainee/Intern (print) Supervisor (print) License

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Trainee/Intern (print)

Supervisor (print)

License

______________________________________________________________________________ Employer/Organization (print name) ______________________________________________________________________________ Street City State Zip ______________________________________________________________________________ Authorized Representative (print name and title) ______________________________________________________________________________ Dated Authorized Representative (signature)

This Letter of Agreement is to be signed and dated prior to providing services, which are to be counted as hours of experience.

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LINKS TO BBS FORMS



MFT Intern/Trainee Supervisor Responsibility Statement http://www.bbs.ca.gov/pdf/forms/mft/mfrespon.pdf



ASW Supervisor Responsibility Statement http://www.bbs.ca.gov/pdf/forms/lcs/lcrespon.pdf



MFT Intern/Trainee Weekly Summary of Hours of Experience Form http://www.bbs.ca.gov/pdf/forms/mft/mfwkylog.pdf (For Hours Gained BEFORE January 1, 2010) http://www.bbs.ca.gov/pdf/forms/mft/mfwkylog.pdf (For Hours Gained ON or AFTER January 1, 2010 – Updated)



ASW Weekly Tracking Log Form http://www.bbs.ca.gov/pdf/forms/lcs/aswlog.pdf



MFT Intern/Trainee Experience Verification Form http://www.bbs.ca.gov/pdf/forms/mft/exp-mfc-b4-2010.pdf (For Hours Gained BEFORE January 1, 2010) http://www.bbs.ca.gov/pdf/forms/mft/exp-mfc.pdf (For Hours Gained ON or AFTER January 1, 2010 – Updated)



ASW Experience Verification Form http://www.bbs.ca.gov/pdf/forms/lcs/lcs-exp.pdf



ASW Supervisory Plan Form http://www.bbs.ca.gov/pdf/forms/lcs/supplan.pdf

Additional BBS Forms can be found at the following link: http://www.bbs.ca.gov/forms.shtml.

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CRITICAL REMINDERS FOR INTERNS AND TRAINEES AND SUPERVISORS TOO! BY: MARY RIEMERSMA, FORMER EXECUTIVE DIRECTOR THE THERAPIST (NOVEMBER/DECEMBER 2009) UPDATED OCTOBER 2012

The information that follows has been compiled to assist interns, trainees, and applicants in navigating the sometimes complicated intricacies of the licensing law and regulations while pursuing licensure. Understanding the law and regulations is critical to acquiring hours of experience and subsequently qualifying for the license as quickly and efficiently as possible. Use this resource as a guide to assure the protection of your hard-earned hours of experience. This information is likewise critical to supervisors to be able to provide the most accurate information and to not lead supervisees astray. BBS’ Current Address: Board of Behavioral Sciences 1625 North Market Blvd., Suite S-200 Sacramento, CA 95834; Phone: (916) 574-7830; Fax: (916) 574-8625; Website: www.bbs.ca.gov Requests for Applications and Forms can be printed from the BBS Website, which is likely the most expeditious way to acquire the forms. Requests for BBS forms and applications may also be made in writing to the above address or by telephone. If you request by telephone or in writing, be sure to make your requests for forms early so that you are prepared with forms when you need them. Generally allow at least two weeks for requests by mail or phone to be processed. Communicating with the BBS When communicating with the BBS, especially when submitting forms and applications, it is recommended that you mail “certified, return receipt requested.” Likewise, keep photocopies of all that you submit to the Board and attach the “certified return receipt” to the copy you retain. It is to your advantage to keep accurate records, as you may need these should there be any question about your hours of experience or supervision. Retain Copies of Application Materials On another note, be sure to keep copies of any applications in perpetuity. One never knows what direction life events will take. Your application may get lost in the mail. You may need the application many years later when you, because of life events, wish to relocate to another state and need to apply for licensure within the new jurisdiction. Expecting to acquire copies of the forms from the BBS, after many years have passed, may be difficult if not impossible. Be Truthful on Applications (Even if it Hurts) PRACTICAL APPLICATIONS IN SUPERVISION

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Be careful, cautious, and truthful on applications. Do not fail to disclose a past conviction even if you believe it is no longer accessible, or has been expunged. Providing a letter describing what happened, what you have accomplished to assure rehabilitation, and enclosing a copy of any disposition would be worthwhile. Intern Registration Allow at least 60 days for processing your application for Intern Registration. Processing may be more rapid, but it could also be delayed, especially if something is inadvertently omitted from the application or not clear in the application. Unreadable fingerprinting may also cause a delay and sometimes resubmissions are necessary, which could significantly delay the processing of applications. In other words, apply as early as possible. If one submits an application for intern registration within 90 days of being granted a degree (regardless of how long it takes to process the application), the hours of experience gained post-degree will count as long as lawfully employed and not employed in a private practice. Intern/Post Degree Experience Applicants who are post-degree who did not apply for intern registration within 90 days of their degrees being granted will not be able to accrue any hours post degree until the intern registration numbers are actually granted. One should anticipate that application processing could take 60 days or in some cases even longer if there are unanswered questions, fingerprinting difficulties, or other problems. First-Time Examination Candidates The Exam Eligibility application is where you submit all hours of experience for the Board’s review to qualify for the license. Currently, LMFT exam applicants should allow a minimum of four to five months for processing. Written Examinations Applicants for the LMFT exam must take written examinations that are administered continuously. When you are notified by the BBS of eligibility to take the written examination, you will need to schedule yourself with the entity with whom the Department of Consumer Affairs has contracted to administer the examinations. Re-Examinees Candidates who do not pass either the regular written exam or the clinical vignette written exam will need to sign-up to be reexamined. Candidates being re-examined will be required to pay an additional examination fee in a timely manner. Re-examinations are required to be at least 180 days following the candidates’ most recent examination date. Re-examinees must wait until the next examination cycle to retake a “failed” examination in order to take a new form of the examination. This “waiting” period also provides ample time to study and further prepare for retaking the examination. Clinical Vignette Examination First Time Candidates

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Candidates are considered eligible for the clinical vignette examination after passing the written examination. Like the regular written examination, candidates schedule themselves to take the exams. Taking Exams When Offered is Important Caution—Generally speaking, a person who does not take an examination or re-examination within one year of eligibility of examination will have his/her application abandoned, which will require re-application. If you must re-apply, you may possibly lose hours of experience that may be too old to be countable at the time of re-application. Recommendation— Take exams whenever they are available to you even if you do not feel 100 percent prepared. There is no limit to the number of times one can take an exam. Note: Effective January 1, 2014, there will be a new exam process for LMFT applicants, which will consist of a new California law and ethics examination and a new clinical examination. These new exams will replace the standard written and the clinical vignette exams currently in place. Effective January 1, 2014, upon registration with the BBS, an MFT intern must, within the first year of registration, take the new California law and ethics exam. After completion of all the education requirements, completion of supervised work experience, and passage of the California law and ethics exam, the applicant must take the new clinical exam. LMFT applicants who have passed the standard written exam, but have not passed the clinical vignette exam by January 1, 2014 will then need to take the new clinical exam. Applicants who have not passed the standard written exam by January 1, 2014, must take both the new California law and ethics exam and the new clinical exam. Information for Trainees, Interns, and Applicants A “trainee” is a person who is in his/her graduate degree program to qualify for the license and has completed 12 semester or 18 quarter units of study.  An “intern” is a person who has been granted his/her degree to qualify for the license, has applied for and been granted his/her intern registration number from the BBS. A “post-degree applicant” is either a person who has been granted his/her degree and applies for intern registration within 90 days of being granted that degree or has applied for the license and/or is in the process of being examined to qualify for the license. Guidelines on Hours of Experience Following are requirements for collecting hours of experience for licensure as an LMFT in the State of California. These requirements are paraphrased from the licensing law and regulations governing the marriage and family therapist profession. A minimum of 3,000 hours of experience is required. Such experience may be gained in no less than 104 weeks, which spans the period from being a trainee through being a registered intern. Trainee Experience PRACTICAL APPLICATIONS IN SUPERVISION

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Not more than 750 hours of counseling and direct supervisor contact may be obtained prior to the granting of the qualifying degree. (This limitation on hours does not include professional enrichment activities such as workshops and personal psychotherapy received.) “Trainees” are unlicensed persons enrolled in qualifying master’s or doctor’s degree programs who have completed no less than 12 semester units or 18 quarter units of coursework. As a trainee, one can gain a maximum of 1,300 hours, including a maximum of 750 hours of counseling and direct supervisor contact. A minimum of 1,700 hours must be gained subsequent to the granting of the master’s or doctor’s degree. Trainees are not required to have completed 12 semester or 18 quarter units of study to receive personal psychotherapy for countable hours. These are the only hours that do not require supervision. Keep in mind, however, that such experience will only count if the psychotherapist is a licensed professional, but such licensee needs only a current and valid license and does not need to be two years licensed. These hours will be recorded on the Exam Eligibility application. Practicum Hours of Experience Hours of experience gained during the practicum, as required within the educational program, may be counted as hours of experience (i.e., hours of experience gained doing therapy, as opposed to classroom instruction). Further, up to 500 clinical hours of practicum experience is exempt from the “six-year-rule”. Even though all practicum hours may be countable as hours of experience, only 500 hours may be older than six years. Additionally, hours of experience gained as a trainee must be coordinated between the school and the site where the hours are being accrued. The school must approve each site and must have a written agreement with each site. Hours gained during practicum, like all other hours of experience, must be accounted for on the BBS Weekly Summary of Hours logs. Students who enter into a graduate program on or after August 1, 2012 or for students who are currently enrolled in a graduate program that meets the requirements of the “new curriculum,” must complete a minimum of 225 hours of experience in supervised practicum, of which 75 hours may be in client-centered advocacy. Further, these students may only counsel clients and gain these hours toward licensure when enrolled in a practicum course, with the exception of a 90 day period, if the 90 day period is immediately preceded and proceeded by enrollment in a practicum course or completion of the degree program. Maximum Hours Per Week For Interns and Trainees No more than forty (40) hours of experience may be credited for any seven consecutive days. These 40 hours are inclusive of all categories of experience (e.g., supervision, workshops, client contact hours, etc.). Minimum Hours for Couples, Families, and Children Not less than five hundred (500) total hours of experience shall have been gained in diagnosing and treating couples, families, and children. These hours may be in any combination, e.g., all children or a mix of couples, families, and children. The first 150 hours of treating couples and families are double-counted. PRACTICAL APPLICATIONS IN SUPERVISION

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Psychological Testing, Process/Progress Notes and Client-Centered Advocacy Not more than five hundred (500) hours of experience will be credited for administering and evaluating psychological tests of counselees, writing clinical reports, writing progress notes, or writing process notes and client-centered advocacy. These hours are optional. Group Counseling or Therapy No more than five hundred (500) hours of experience will be credited for providing group therapy or group counseling. Group counseling hours are optional. When counseling groups of children, you may record the hours under “children.” Telehealth Not more than three hundred seventy-five (375) hours of experience may be counted toward providing psychotherapy, crisis, or other counseling services via telehealth (telephone and/or Internet therapy). These hours are optional. Hours of Supervision— Individual and Group During each week in which experience is claimed and for each work setting in which experience is gained, an applicant shall have at least one (1) hour of direct supervisor contact or two (2) hours of direct supervisor contact in a group of not more than eight (8) persons receiving supervision. The intern/trainee shall have at least two hours of group supervision in every week in which group supervision is claimed. Group supervision is optional. Group supervision may be acceptable when gaining, for example, an hour on Monday and an hour on Wednesday, as long as the hours are both in the same seven day period making up the week. Supervision hours are actual sixty minute hours, not 45 to 50 minute therapy hours. Each hour of group supervision counts as an hour of experience. If less than two hours of group supervision are provided within the week, the supervision hours will not count and one’s hours of experience may be jeopardized. The intern/trainee shall receive at least one (1) hour of individual supervisor contact per week for a minimum of fifty-two (52) weeks. These weeks need not be consecutive. Individual supervision means one supervisor and one person being supervised. In other words, there must be 52 separate weeks within which at least one hour of individual, face-to-face supervision has been provided. Direct supervisor contact means face-to-face supervision, which also includes contact via two-way, real-time video conferencing for interns who work in a non-profit, governmental agency, or educational institution. Maximum Countable Supervision per Week Not more than five (5) hours of supervision, whether individual or group, shall be credited during any single week. Keep in mind, however, that it may be necessary to gain and record more than five hours of supervision in a week to be able to credit all hours of experience gained. Ratios for Interns, Trainees, and Applicants Trainees shall receive an average of at least one unit of direct supervisor contact for every five hours of client contact in each setting. While there must be supervision within each week, these PRACTICAL APPLICATIONS IN SUPERVISION

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ratios need not be accounted for within each week, they are calculated based upon the average gained over the entire period of time one works in a given work-setting. Interns shall receive at least one unit of direct supervisor contact for the first ten hours of client contact per week and one additional unit for any hours over ten in that same week. One unit equals one individual supervision hour or two group supervision hours. When the hours have been approved by the BBS (following the application to take the regular written examination), it is no longer necessary to meet the ratios of experience to supervision. However, at least one hour of individual supervision or two hours of group supervision continues to be required for each work setting until licensed. Supervision/Professional Enrichment Activities Not more than a combined total of 1,000 hours of experience for related professional enrichment activities will be counted. Such activities include: •

Not more than 250 hours of workshops, training sessions, seminars, and conferences approved by supervisor. Two hundred fifty hours is the maximum while as an intern, a trainee, or both. These hours are optional and do not require direct supervision in the week the intern or trainee attends the workshop, training session, seminar, or conference approved by the supervisor. Furthermore, the BBS accepts workshop, seminar, training and conference hours that are acquired through online courses, provided that the courses meet all other requirements.



Actual hours of supervision.



Not more than 300 hours (when 100 hours are triple-counted) of personal psychotherapy received from a California licensed mental health professional. These hours do not require supervision. One may not get psychotherapy from one’s supervisor. Psychotherapy hours include group, marital or conjoint, family, or individual psychotherapy received. The two year license requirement applicable to supervisors is not applicable to this experience. These hours are optional. There is no BBS form for these hours. Applicants will log these hours on the Exam Eligibility application. Have the mental health professional provide a letter or statement verifying hours.

Weekly Summary of Hours Each trainee and intern shall maintain a weekly summary of all hours of experience gained toward licensure. The weekly summary shall be signed by the supervisor on a weekly basis. An applicant shall retain all such logs until such time as the applicant is licensed by the Board. The Board shall have the right to require an applicant to submit all or such portions of the weekly summary as it deems necessary to verify hours of experience. (These logs are generally not required to be submitted to the Board with the Exam Eligibility application unless the Board audits the application or requests the logs be submitted.) Note: Make sure your supervisor signs the logs each week. These documents provide verification that you actually gained experience during the periods indicated. Additionally, we would PRACTICAL APPLICATIONS IN SUPERVISION

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recommend that you retain these documents indefinitely. You never know when you might need them. Experience Verification Each Trainee and Intern shall submit to the BBS a completed and signed Experience Verification form with his/her exam eligibility application. The supervisor must complete and sign the form. Any changes should be initialed by the supervisor and the Board may verify such changes. A separate form should be used for each supervisor verifying hours of supervised experience and for each employment setting. A separate form should be used for pre-degree and post degree hours. “Six Year Rule” All 3,000 hours of experience, with the exception of the practicum hours described above, must have been gained in the six years immediately preceding the date the application for examination is filed. Thus, the maximum amount of time for which hours may be credited, with the exception of up to 500 qualifying practicum hours, is six years (This is affectionately known as the “sixyear rule.”). This “six year rule,” provides that all experience shall be gained within the six years immediately preceding the date the application for licensure was filed, except that up to 500 hours of clinical experience gained in the supervised practicum shall be exempt from this sixyear requirement. Another way to view the six-year rule is if you want to count the first hour you have gained and that hour is not an hour gained in practicum, you would have to apply for licensure/examination within six years of that first hour. For example, if you applied for licensure on January 1, 2020, all hours except for the 500 protected practicum hours would need to be completed between January 1, 2014 and December 31, 2019. The Other Six Year Limit— Intern Registration Persons who do not complete their hours of experience within the initial six-year intern registration period must reapply for a new intern registration. Such persons may not work in private practice. Hours from one intern registration roll into another intern registration period; however, in no case may the hours submitted to qualify for licensure be older than six years, with the exception of up to the 500 exempt hours gained during the practicum. Note: The six year intern registration and the six year limitation on hours may totally or partially overlap, but they are separate and distinct periods of time that should not be confused. These two six-year periods of time are critical for applicants to understand. If the initial six-year intern registration is exhausted, one must apply for and qualify for a new intern registration number. The hours now carry forward into the next intern registration period (which was, at one time, not the case). Supervision Reminders Current Valid License Make sure your supervisor holds a current, valid license, which is not under suspension or probation by a licensing board. Sometimes licensees neglect to notify the BBS, or other licensing board, of a move—consequently, they may neglect to renew their licenses in a timely manner. PRACTICAL APPLICATIONS IN SUPERVISION

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Also, be certain that the supervisor has been California licensed for two years prior to commencing supervision. The following licensed professionals may be supervisors: licensed marriage and family therapists, physicians certified in psychiatry by the American Board of Psychiatry and Neurology, psychologists, licensed clinical social workers, and licensed professional clinical counselors (must complete additional training and education as specified in California Business and Professions Code section 4999.20(3)). Verify on the licensing boards’ website that the supervisor’s license is current, valid, and not under suspension or probation. Be sure to check again at the time of the supervisor’s next renewal to make sure that the license is subsequently renewed. A supervisor’s failure to renew his or her license will result in a loss of hours to the supervisee. Note: The only exception to the two-year license requirement is supervisors who provide supervision only to trainees at an academic institution that offers a qualifying degree program, where the supervisor has been licensed in California and in any other state, for a total of at least two years prior to commencing any supervision. Supervisor Mandatory Continuing Education Supervisors, licensed by the Board of Behavioral Sciences who supervise MFT interns and trainees, are required to complete each license renewal period, six (6) hours of continuing education in supervision. This coursework is to be taken either prior to or within sixty days after commencing the supervision of an intern or trainee. However, the supervisor’s negligence in failing to take the required coursework will not result in the loss of hours for the intern or trainee. Note: The six (6) hours of continuing education requirement does not apply to supervisors who are licensed as a physicians certified in psychiatry by the American Board of Psychiatry and Neurology or a psychologist. Payment for Supervision According to California Labor Code Section 221, an employer may not require an employee to pay for anything that is of benefit to the employer, which arguably includes supervision. Therefore, it is CAMFT’s recommendation that employers not require employed and volunteer interns to pay for supervision. Offsite Supervision or Supervision Not Paid for by the Employer It is permissible to get offsite supervision in any work setting other than private practice, but only where an appropriately executed letter of agreement exists. This letter of agreement (the original) must be filed by the applicant with his/her Exam Eligibility application. A Sample “Letter of Agreement For Offsite Supervision” can be found at the end of this article and on the CAMFT website at www.camft.org. This letter of agreement should be typed onto the letterhead of the employer as it is the employer who is permitting the “offsite supervision,” or permitting the supervisee to get supervision not provided by the employer. Who May Not Supervise Interns and trainees are not to gain any experience under the supervision of a spouse, relative, or domestic partner. Any experience obtained under the supervision of a supervisor with whom the PRACTICAL APPLICATIONS IN SUPERVISION

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applicant has had or currently has a personal or business relationship that undermines the authority or effectiveness of the supervisor shall not be credited toward the required hours of supervised experience. Additionally, interns and trainees cannot receive supervision from anyone who has ever been their therapist. Individual Supervision Individual supervision means one supervisor and one person being supervised. As regulation specifies, supervision is to be “one-on-one, individual, and face-to-face.” One hour of individual supervision means sixty minutes of supervision. Group Supervision Group supervision means a group of not more than eight persons being supervised by one supervisor. Again, the supervision, according to regulation, is to be “face-to-face.” Two supervisors for a group of sixteen supervisees would not be acceptable. Two hours of group supervision means one hundred twenty minutes of supervision. Each hour of supervision may occur on different days as long as it occurs within the same week in which the hours are being claimed. Exception to Face-to-Face Supervision An exception to face-to-face supervision is where an intern is working in a government entity, a school, college, or university, or an institution that is both nonprofit and charitable, and such intern may gain supervision by two-way, real-time videoconferencing. Other Supervision Guidance Supervisees may have some weeks where they receive solely individual supervision and some weeks where they receive solely group supervision. Separate supervision is required for each work setting in which one is gaining hours of experience. For example, intern in setting one gains three hours of experience and is therefore required to have one hour of individual or two hours of group supervision in that setting, and in setting two sees five clients and is also required to have one hour of individual or two hours of group supervision for this setting. For hours of experience to count within a given week, supervision must occur within the same week that the hours are gained. However, for trainees the ratios are not necessarily required to be achieved within the same week as the hours of experience are gained. A supervisor may supervise an unlimited number of interns and trainees in any appropriate work setting other than private practice, but is limited to supervising three MFT interns when those interns are employed in private practice. Supervisors are limited to supervising groups of no more than eight persons under supervision. A supervisor shall give at least one week’s written notice to an intern or trainee of the supervisor’s intent not to sign for any further hours of experience for such person. A supervisor who has not provided such notice would be obligated to sign for hours of experience obtained in PRACTICAL APPLICATIONS IN SUPERVISION

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good faith where such supervisor actually provided the required supervision and the supervisee actually gained experience. The supervisor is required to have practiced psychotherapy or provided direct supervision for at least two years within the five year period immediately preceding any supervision. The supervisor is required to address with the intern or trainee the manner in which emergencies will be handled. The supervisor is required to obtain from the supervisee, the name, address, and telephone number of the prior supervisor and employer. The intent is that the supervisor will address with the prior supervisor and employer issues and concerns that will benefit the supervision of the intern or trainee. The supervisor is required to verify that the site is appropriate for gaining hours of experience. Miscellaneous Reminders Employment/Volunteer/ Independent Contractor Interns, trainees, and applicants may only perform services as employees (IRS Form W-2) or as volunteers, and not as independent contractors (IRS Form 1099). Interns, trainees, and applicants who have been hired and paid on an independent contractor basis will have their hours denied. The BBS views independent contractor status as self-employment, which is the reason such hours are denied. One may only be self-employed following licensure. If employed, an applicant for the license shall provide the Board with copies of the corresponding W-2 tax forms for each year of experience claimed when applying for the license. If volunteering, an applicant shall provide the BBS with a letter from his or her employers verifying the intern’s employment as a volunteer when applying for the license. Payment for Expenses Trainees, interns, and applicants who provide volunteered services or other services, and receive no more than a total, from all work settings, of five hundred dollars per month as reimbursement for expenses actually incurred. The Board may audit applicants who receive reimbursement for expenses, and applicants have the burden of demonstrating that the payments received were for reimbursement of expenses actually incurred. Disclosure Interns, trainees, and applicants are required to inform clients, prior to performing professional services of their unlicensed status, their registration number, their employer’s information, and that they are working under the supervision of licensed marriage and family therapists, licensed clinical social workers, licensed professional clinical counselors, licensed psychologists, or licensed physicians certified in psychiatry by the American Board of Psychiatry and Neurology. Remuneration from Patients/Clients Interns, trainees, and applicants shall not receive any remuneration from patients or clients, and shall only be paid by their employers.

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Where Services May Be Provided Trainees, interns, and applicants shall only perform services at the place where their employers regularly conduct business, which may include performing services at other locations, so long as the services are performed under the direction and control of their employers and supervisors and in compliance with the laws and regulations pertaining to supervision. For example, an intern working in private practice may see a patient in the hospital. Or, a trainee may see a patient who is homebound, on behalf of the agency that employs him/her, in the home of the patient. Private Practice Interns must be “registered” at the time employment in a private practice begins. Interns must be in their initial six-year intern registration period while gaining any hours of experience in private practice. Supervision in Private Practice by Someone Other Than Employer The supervising licensee in a private practice shall either be employed by and practice at the same site as the intern’s employer, or shall be an owner or full-time employee of the private practice. Supervision when Supervisor is on Vacation or Sick Leave Alternative supervision may be arranged during a supervisor’s vacation or sick leave if the supervision otherwise meets the requirements of the licensing law. Lawful Employment Settings for Trainees A trainee may gain experience as an employee or volunteer in any setting that lawfully and regularly provides mental health counseling or psychotherapy; provides oversight to ensure that the trainee’s work at the setting meets the experience and supervision requirements required by law, is within the scope of practice for the profession, and is not a private practice. All hours of experience gained as a trainee must be coordinated between the school and the site where the hours are being accrued. The school must approve each site and must have a written agreement with each site. Lawful Employment Settings for Interns Registered interns may work in all of the settings in which trainees may work, and in addition, they may, during their initial six-year intern registration, be employed or volunteer in private practices. Lawful Employment Settings for Applicants for Intern Registration A person who is post-degree, awaiting intern registration, may work in any setting appropriate for a trainee, and may not work in private practice. Persons who are in their second six-year intern registration period may likewise not work in private practice. Ownership of a Practice or Business Trainees and interns shall have no proprietary (ownership) interest in their employers’ businesses and shall not lease or rent space, pay for furnishings, equipment or supplies, or in any other way pay for the obligations of their employers. This means that interns and trainees will not be PRACTICAL APPLICATIONS IN SUPERVISION

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signers on joint checking accounts with employers, pay remodeling costs for office space, pay advertising costs, etc. Employee vs. Volunteer The requirements of law and regulation are applicable equally to persons who are employees and persons who are volunteers. Do not presume that if you are a volunteer and law or regulation says “employee,” that it does not apply to you. You are bound by the same requirements whether you are an employee or a volunteer. Responsibility Statement for Supervisors This statement is to be signed by the supervisor prior to commencing supervision with an intern, trainee, or applicant. These forms are on the BBS website at www.bbs.ca.gov. Interns are to submit Supervisor Responsibility Statements to the Board for all supervisors upon application to take the examinations for licensure. Notification of Change of Address Licensees, registered interns, and applicants are required to notify the BBS within 30 days of a change of address. The form can be found on the BBS website.

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From Masters Degree to Licensure Trainee Enter Masters degree program

12 Semester 18 Quarter Units required to collect hours

Applicant

Registered Intern Must apply for Intern Maximum of Registration within 90 six years as a days to be able to Registered collect hours during Intern however this time. may reapply for Employment in a new intern private practice not number and permitted. hours roll -----------------------forward. Requirements for Private practice hours are the same as employment for Interns not permitted in subsequent six year intern registration periods. Supervision for 10 hours of experience one hour individual or two hours group plus one additional individual hour or two additional group supervision hours for hours over 10

Complete Masters degree program ----------------------Degree granted/ confirmed/posted

Supervision Ratios 5 to 1 individual or 5 to 2 group

Applicant

Licensed

Application pending or hours approved and in examination process or passed exams and awaiting receipt of license. -----------------------When application approved, one hour of individual or two hours of group supervision required in each work setting.

Congratulations! License granted as a Marriage and Family Therapist

Trainee Limitations Masters Program (Maximum of 1,300 total hours gained as a trainee) Must complete 12 semester or 18 quarter units of study to collect hours.

750 Hours Maximum in client contact and supervision

Minimum of six semester or nine quarter units of practicum Exception: hours for personal psychotherapy Those beginning Graduate Study prior to August 12, 2012: Those beginning graduate study on or after August 1, 2012 or who are meeting the requirements of the new law must be enrolled in a practicum course to counsel clients.



Those beginning graduate Study on or after August 1, 2012 or who are meeting the requirements of the new law: •

Minimum of 150 Hours of client contact in practicum

Minimum of 225 Hours of client contact in practicum although 75 hours may be in client centered advocacy

Up to 500 of the practicum hours of experience (depending on the number actually gained) are exempt from the “six year rule.”

Hours of Experience Requirements and Limitations at a Glance 3,000 Hours Total 250 Hours Maximum Workshops, seminars, training sessions, and conferences approved by supervisor

1,000 Hours Maximum 300 Hours Maximum Limited Maximum by 1,000 Total Hours Personal Psychotherapy received (100 x 3 = 300 hours) do not require supervision

Individual and Group Supervision (no more than five hours per week)

500 Hours Maximum

500 Hours Minimum

375 Hours Maximum

500 Hours Maximum

Hours Remaining

Administering and evaluating psych tests, writing clinical reports, writing process or progress notes

Diagnosing and treating couples, families, and children. (First 150 hours with couples and families may be doublecounted.)

Psychotherapy, crisis counseling, or other counseling by telehealth (telephone or Internet counseling)

Group counseling or therapy

May be individual, or couples, families, and children

Client-Centered Advocacy

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SUPERVISORS TWENTY-FIVE MOST OFTEN ASKED QUESTIONS BY:

MARY RIEMERSMA, FORMER EXECUTIVE DIRECTOR

THE CALIFORNIA THERAPIST (SEPTEMBER/OCTOBER 1989) UPDATED FEBRUARY 2013

1. Can the intern/trainee I supervise be an independent contractor? No. California Business and Professions Code Section 4980.43(b) states that supervised experience must be gained by an intern or trainee either as an employee or as a volunteer. Only those who can independently practice without supervision can be classified as independent contractors, such as licensed MFTs. 2. Does the intern/trainee have to work at the employer's place of business? The intern/trainee must work where the employer regularly conducts business, which means in the employer's facility or office. This does not mean that the employer/supervisor must always be present when the intern/trainee is working. It does mean that the intern or trainee cannot work out of the intern/trainee's home, an office located down the street or across town (unless, of course, the employer regularly conducts business at that site) or from an office rented by the intern or trainee. However, the employer may allow for the intern/trainee to see a client out of the client’s home when it is necessary or in other locations, such as, a nonprofit organization or a governmental agency, under the direction and oversight of the employer. 3. May I charge the intern/trainee for supervision? Under California Labor Code Section 221, employers cannot request or require employees to relinquish or payback a portion of their wages to their employers. Thus, employers cannot deduct training fees for supervision from employees’ paychecks. It is also unlawful under state law for employers to compel or coerce employees into purchasing anything of value from the business. This means employers cannot require trainees and interns to purchase supervision from the employer. Additionally, Labor Code Sections 450 and 2802 prohibit employers from charging employees for anything that is of benefit to the employer or anything that could be considered an obligation of the employer or part of the employer’s cost of doing business. The BBS has provided the following statement in regard to interns paying for supervision: “The Board’s laws generally contemplate that interns should be paid for their work as employees. To the extent that interns are paid as employees, their employer may not require such interns to pay for the required supervision.” We would suggest that employers not expect employees to pay for supervision—this recommendation is applicable to all work settings including private practice PRACTICAL APPLICATIONS IN SUPERVISION

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settings. Also suspect are employers who charge employees training fees in order to cover the costs of supervision. 4. Is there any problem if I supervise, as well as do psychotherapy, with my intern? Yes, there is a problem. First of all, the hours of psychotherapy will not count toward hours of experience. Secondly, regulations state that "any experience obtained under the supervision of a supervisor with whom the applicant has a personal relationship which undermines the authority or effectiveness of the supervisor shall not be credited toward the required hours of supervised experience." If a supervisor attempts to cross boundaries and play both roles as supervisor and psychotherapist, it would be difficult to argue that the authority and effectiveness of the supervisor is not undermined. 5. How much are interns/trainees customarily paid? Even though many interns and trainees volunteer and receive no wages, interns employed in private practice are generally paid between thirty and seventy percent of the fees they generate. Of course, lawfully, they may only be paid by their employers and after taxes have been appropriately withheld. The law does provide that interns employed in private practice are to be paid "fair remuneration." "Fair," of course, is as perceived by the parties involved and is not defined in law. One could argue that anything above minimum wage is "fair." Meanwhile, interns and/or trainees may be paid in any work setting by the employer without limitation as to the amount. Interns and trainees may be paid a salary, e.g., $12,000 per year or $200 per week. Interns and trainees may also be paid based upon a specified amount per hour, e.g., $10 per hour. Or, interns and trainees may be paid a percentage of the fees generated by the intern or trainee, e.g., fifty percent. 6. May an intern volunteer in private practice? Probably not. Private practices are set up to operate a commercial enterprise to generate income. Therefore, interns who are employed by private practices to provide professional services that benefit the private practice employer. The interns should be classified as employees and paid for their professional services. However, there may be certain circumstances where an intern may volunteer in a private practice. If the intern is truly performing pro bono services in a private practice setting, it may be allowable for the intern to be classified as a volunteer. 7. Can we charge the intern/trainee for training given at a non-profit and charitable corporation? A trainee who is working to fulfill licensing or professional experience requirements does not have to be classified as an employee if the training is part of an established course of study of an accredited school or approved institution and if the training is academically oriented and is for the benefit of the trainee. Thus, since trainees are not considered employees, they may pay training and supervision fees. PRACTICAL APPLICATIONS IN SUPERVISION

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Interns are post-graduate and are considered a part of the workforce. They are no longer a part of an established course of study of an accredited school or approved institution, and thus, if interns are providing professional services at a non-profit organization that operates a commercial enterprise, they must be classified as employees. Employees may not pay for anything that benefits the employer and are obligations of the employer, including but not limited to, training fees, supervision fees, and overhead expenses. 8. What are my responsibilities as a supervisor? For a list of the responsibilities as a supervisor for MFT interns and trainees, see the Responsibility Statement for Supervisors of MFT Trainee or Intern available on the BBS website at www.bbs.ca.gov. 9. Can the intern/trainee advertise? How? When an intern or trainee advertises, he/she may lawfully advertise that he/she is an employee and under supervision of a licensed professional. According to regulation, a marriage and family therapist registered intern may advertise if such advertisement complies with the law and makes certain disclosures required by law. These disclosures include, informing patients that he/she is a registered intern, providing patients with his/her registration number, informing patients of his/her employer, and informing patients that he/she is working under the supervision of an appropriately licensed professional. Thus, an intern employed in private practice would include on a business card the intern's name, the fact that the intern is a marriage and family therapist registered intern, the intern’s registration number, the name of the employer, and the name of the supervisor indicating that the person is the "supervisor" and the full license designation of the supervisor. 10. Do I, as supervisor, need to notify the BBS that I am supervising an intern or trainee? No. As a supervisor, you have the responsibility to fill out the required forms so that your intern or trainee can submit the forms to the BBS with his/her exam eligibility application. You are also required to take the six hours of supervision coursework or training every renewal period in which you are supervising the intern or trainee. It’s recommended that you keep the certification of the supervision coursework or training in the event you are audited by the BBS. 11. Are there any circumstances where I can supervise when I've been licensed for less than two years? Arguably, when all hours of experience have been collected by the supervisee, it would be possible to supervise with less than two years of licensure. Since the law and regulations require supervisors to be licensed two years only for purposes of gaining experience, one may argue that this mandate is not applicable when the experience requirement has been met. 12. What should I do when I, as supervisor, go on vacation? PRACTICAL APPLICATIONS IN SUPERVISION

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Alternative supervision may be arranged during a supervisor's vacation or sick leave if the supervisor and supervision meet all of the requirements of law and regulation regarding supervision. 13. How do I supervise "professional enrichment activities," e.g., when the person I supervise attends workshops and/or obtains personal psychotherapy? All professional enrichment activities, including attendance at workshops, training sessions, seminars, and conferences, as well as personal psychotherapy hours do not require the intern or trainee to receive supervision in that same week. However, supervisees must obtain the supervisor’s approval prior to attending any workshop, training session, seminar or conference. Workshop, training, seminar, and conference hours need to be logged on the Weekly logs and the Experience Verification Forms and signed by the supervisor. Personal psychotherapy hours are to be logged on the Exam Eligibility application. 14. What happens when the person I supervise has collected all required hours? The individual must still be under supervision until he or she is licensed. The BBS has recommended that the individual meet with his or her supervisor for at least one individual hour of supervision or two hours of group supervision a week. 15. Can I be held liable for the work of the person I supervise? Yes, you do assume risk when you supervise. If you are supervising an intern whom you have employed in your private practice, you assume essentially the same risk for patients seen by the supervisee as those seen by you. An employer is generally held responsible for the acts of the employee. If you are employed as a supervisor, your risk is more limited. While you do have risk, it is generally limited to the quality and appropriateness of the supervision. The employer who employs you and the supervisee assumes the bulk of the liability in such a case. If you are providing supervision as a volunteer by letter of agreement, your risk is equivalent to the risk of the employed supervisor. Supervisors can further limit their risk by being well-informed about the supervision process, utilizing effective supervision techniques, being accessible to the supervisee, monitoring adequately the work and work setting of the supervisee, recognizing and helping the supervisee to correct and improve deficiencies and maintaining a learning environment throughout the supervision process. 16. May my intern, whom I employ as a W-2 employee, assist with the increased costs of rent, telephone expenses, advertising, office furnishings, etc.? No. If the employee shares in such costs, the impression given is that the employee has a stake in the business, has an "ownership" or "proprietary" interest in the practice, which is unlawful. It does not make sense that the employer should receive all fees from patients seen by supervisees, and then, from fees collected, pay wages based upon a percentage of the fees collected, and then, expect the supervisee to contribute to the cost of running the business. This seems exploitive and inappropriate. Also of concern is the effect upon the ability of the supervisor to effectively PRACTICAL APPLICATIONS IN SUPERVISION

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supervise and control the supervisee when the supervisor is dependent upon the supervisee for contributing to the supervisor's costs of running a business. 17. Do I have to pay for workers' compensation insurance for my employee? Yes. Licensed MFTs who employ interns have the same obligations as all other employers in this state. One of those obligations is the provision of workers' compensation insurance. The failure to provide such insurance could be a very costly oversight. If the employee was injured on the job, the employer could be held personally liable for all of the employee's medical care as well as lost wages. This would apply to "psychological injuries" (stress cases) as well. 18. How many MFT registered interns can I employ and supervise in my private practice? No more than three at one time. An MFT professional corporation may employ up to thirteen interns at one time, but each supervisor employed by the professional corporation may only supervise a total of three interns at one time. Trainees may not be employed in private practice. 19. If I employ three interns in my private practice, may I also supervise other interns and trainees who work in other work settings? Yes, as long as the "other" interns and trainees are employed and work in allowable work settings other than your private practice. You may supervise an unlimited number of interns and trainees employed in non-profit and charitable corporations, licensed health facilities, governmental entities and schools, colleges and universities. Be cautious, of course, when you provide group supervision, that each group does not exceed eight persons being supervised. In addition, if you are not paid for providing supervision by the employer of the interns and trainees being supervised, be certain that each supervisee has an appropriately executed "Letter of Agreement for Offsite Supervision.” A sample of this letter of agreement can be found on the CAMFT website under Resource Center. Failure to do so will cause the supervisee to not be able to count the hours of experience gained in that work setting. 20. What should I do if the intern/trainee I supervise is not making adequate progress? The intern or trainee under your supervision is no different than any other employee. Employees are expected to work as directed by the employer. Employees are expected to abide by the direction given by the employer/supervisor. When the employee falls below the employer/supervisor's expectations, the following may occur: •

• •

The supervisor may recommend that the supervisee read a book or article, attend a workshop or conference, take a course, get psychotherapy or a combination of the above. The supervisor may work with the supervisee to remediate deficiencies, e.g. do additional training. The supervisor may lay the ground rules and inform the supervisee of actions which will be taken should the supervisee not comply with the supervisor's

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• •

requirements. The supervisor may recommend additional hours of supervision. The employer/supervisor may, just as with any other employee, terminate the employment.

21. Can I hire someone in my private practice who has received his/her master's degree but has not yet received his intern registration number? Or, may I hire a trainee? No. According to law, only licensees may engage in private practice. The only exception is that "registered" interns may be employed in private practice. In order to be considered a "registered intern," the intern registration number must have been granted, i.e. the applicant has received the registration or has been informed by the BBS that the number has been issued. However, an intern who has been issued a second registration number cannot work in a private practice settting, regardless of the fact that the intern may be done with all his/her hours of experience. 22. Can I bill for insurance reimbursement for services provided by my intern? Yes, but since insurance companies are not required under California law to reimburse for intern services, insurance plans may not reimburse. California law does not mandate that the services of interns are to be reimbursed; the "freedom of choice law" only makes reference to licensed MFTs. Thus, clients should never be led to believe that the intern's services will be reimbursed. Additionally, as with all insurance claims, the claim should not be fraudulent or misleading. In other words, it should be clear on the claim form who the provider of services was, and that the intern was working under the supervision of the licensee. . It should also contain the fee actually charged for the supervisee's services, not the fee charged for the licensee's services. Nevertheless, there are good arguments that the supervisor can make to appeal claim denials. The supervisor can argue "since the intern is employed by me and works under my direct supervision and control and since I have ultimate responsibility for the patient, the claim should be paid. I, as supervisor, initially determined that the intern was competent to treat this patient. The intern receives regular and ongoing supervision from me for treating this patient as well as all other patients seen by the intern. This is no different than a woman who goes to an obstetrician to get prenatal care. The first time the patient is seen by the obstetrician and every time thereafter she is seen by a nurse practitioner, yet the physician gets reimbursed. Since I am ultimately responsible as the employer and supervisor, and since I feel comfortable with the treatment provided by the registered intern, you should pay. Besides, the fees I charge for my intern are one-half of my hourly fees. It is to the advantage of the insurance company to reimburse based upon her fees rather than mine." The key here, is full disclosure regarding the provider of services and his/her status. 23. If my license in under suspension or probation, may I begin or continue a supervisory relationship? No. If you do supervise, the hours accrued by the person being supervised will not count. Full disclosure to the person being supervised is critical. PRACTICAL APPLICATIONS IN SUPERVISION

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24. To whom should payment be made for services rendered by an intern or trainee? Payment for services rendered by interns and trainees must always be made to the employer. Interns and trainees may only be paid by their employers, not by clients. 25. Are there any circumstances under which I can supervise in private practice when I am not the employer? The only circumstance where you may supervise in private practice when you are not the employer is when you are employed by and practice at the same site as the employer. In order to supervise interns in an MFT professional corporation, you must be the owner of the corporation or a full-time employee of the professional corporation.

This article appeared in the September/October 1989 issue of The California Therapist, the publication of the California Association of Marriage and Family Therapists, headquartered in San Diego, California. This article is intended to provide guidelines for addressing difficult legal dilemmas. It is not intended to address every situation that could potentially arise, nor is it intended to be a substitute for independent legal advice or consultation. When using such an article as a guide, be aware that laws, regulations and technical standards change over time, and thus one should verify and update any references or information contained in this article.

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TIPS ON SUPERVISION: SUPERVISOR RECORD KEEPING BY: MARY RIEMERSMA, FORMER EXECUTIVE DIRECTOR

THE THERAPIST (JULY/AUGUST 2007 & REPUBLISHED SEPTEMBER/OCTOBER 2009) REVIEWED/UPDATED JANUARY 2013

Therapists who provide supervision often ask about the records they should maintain on the persons they supervise. While law, regulation, and ethics of the professions do not generally address the need or requirement to keep records on supervisees, the practicality of doing so makes abundant sense. Especially for the therapist who is supervising a number of supervisees, records are necessary to assist with recall as to the progress of the supervisee, to know where the prior supervision session left off, and to assist the supervisor in recollecting where the supervisee’s patients are in their treatment. Additionally, consistent record keeping and documentation of supervision can provide the primary means of defense should the supervisor be implicated in a legal or disciplinary matter regarding the supervisee or supervision. This list is not exhaustive, however, the following are items that supervisors should consider having in their supervisees’ files: • •

• • • •

• • • •

If the supervisee is post-degree, a copy of the receipt showing that the intern or associate is currently registered. If the supervisee is not covered by the employer’s malpractice insurance policy, the supervisor should have a copy of the supervisee’s policy, or at a minimum, proof of coverage. A copy of the application, resume, or vitae for the supervisee. Documentation that the supervisee is hired at will. This means that the supervisee may also be terminated “at will.” Documentation that specifies who to contact in case of an emergency involving the supervisee. Notes documenting the names, addresses, and telephone numbers of the prior supervisor and employer, and notes documenting any discussions with such individuals. A copy of any written or signed contract or agreement with the supervisee, if such a contract or written agreement exists. A copy of the required signed statement by the supervisee agreeing to comply with the child abuse reporting law. Documentation regarding how fees are established for the provision of the supervisee’s services. Job description or description of the duties of the supervisee.

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• • •

• • • • • • • • •

Documentation expressly prohibiting the supervisee from engaging in any sexual act or contact with a patient, clarifying that such acts are never within the scope of employment, they are illegal, unprofessional conduct, in violation of the ethical standards of the profession and will not be condoned. Documentation informing the supervisee that it is mandatory to inform the supervisor of any sexual fantasies or sexual approaches made by patients/clients to the supervisee. A copy of the signed supervisory responsibility statement. Copies of all weekly summaries of experience (logs), if required by the licensing board for the profession. Notes as to the manner in which records of patients/clients are to be maintained by the supervisee. For example, are progress notes expected, are original journals and artwork to be returned to the patient/client, how are critical voice mail messages retained, can notes be maintained on the computer, etc. Documentation that any records maintained by the supervisee, with regard to clients/patients, are the records of the employer and not the supervisee. A log of all dates and times of supervision, with notations for supervision sessions cancelled or shortened. Periodic evaluations of the supervisee. Any written correspondence between the supervisee and supervisor. Copies of intake forms for all clients seen by the supervisee. Copies of informed consent/disclosure statements, insofar as they exist, for all clients seen by the supervisee. Notes on any instructions or recommendations made to the supervisee. Notes on any discussions of supervisee’s concerns expressed and how those concerns were addressed by the supervisor. Notes on critical issues that supervisees’ have, or any time a judgment must be made about supervisee's conduct or about critical issues with patients/clients.

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SUGGESTIONS FOR DEVELOPING A WORTHWHILE SUPERVISORY RELATIONSHIP BY MARY RIEMERSMA, FORMER EXECUTIVE DIRECTOR

THE THERAPIST (MARCH/APRIL 2009) REVIEWED/UPDATED JANUARY 2013

We often hear stories about problematic supervisors. Supervisors that do not know what they are doing. We hear about supervisors that are unethical. We hear about supervisors that do not know how to supervise. And we hear about supervisors who are "lousy" clinicians or just plain ignorant or dumb. These are the words of prelicensees who call CAMFT. And, similarly, supervisors often complain about the problems they experience with supervisees. The supervisee just doesn't get it. The supervisee is headstrong, and does not listen, or does not understand the unique qualities of the setting, or just does not do or want to do as instructed, refuses to keep records or is a know-it all. We can't judge who is right and who is wrong, but we can offer guidance to assist in surmounting the obstacles. What Can Be Done By a Supervisee to Assure that the Supervisory Relationship is the Best that it Can be? When being supervised, the supervisee must remember that supervisors are not all-knowing and they are not perfect, any more than parents or employers are all-knowing and perfect. Don't expect them to be. If you do, you will be sure to be supervised by a failure and you will feel shortchanged. Supervisors are not mind readers. If you have specific needs, you need to express what those needs are. If you, as supervisee, are not open to this experience being a true learning experience with both desirable and undesirable qualities, you will not gain the full benefit that you can from the supervisory process. Remember, there is something to learn from even the more distasteful experience. There is something to be gained by doing things you do not want to do. Even stretching your comfort level can add value to your experience. And if the supervisor is truly "bad," you may learn as much or more than you do from the best supervisor and best supervision experience. One must also consider that the supervisor who may be great for one supervisee is ineffective for anothereven if it is just because the personalities are not a good fit. As You Begin Your Experience Even though you do not often have the opportunity to interview and hire your supervisor, I would recommend that you schedule a time to "interview" your supervisor before the supervisory relationship begins. Ask your supervisor all types of questions. Here are a few to get you started and we expect you can devise others. These questions are best asked at a time prior to the existence of the supervisory relationship when they can be answered separate and apart from PRACTICAL APPLICATIONS IN SUPERVISION

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a prejudiced, heated, or adversarial discussion. • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

How does the supervisor supervise? What does the supervisor expect from the supervisee? What does the supervisor expect from the supervisee who has the amount of experience that you have? What does the supervisor do if the supervisor is not satisfied with the performance of the supervisee? What should the supervisee do if the supervisee believes he/she needs more from the supervision? In the eye of the supervisor, what is a model supervisee? What should the supervisee do if he/she is not satisfied with the supervision? What is the theoretical orientation of the supervisor? How does the supervisor work with a supervisee who shares your theoretical orientation? What is the philosophical orientation of the supervisor? Is the supervisor regularly available each week to provide the requisite supervision? What happens if the supervisor is not regularly available as anticipated? What if the supervisee is not available for some reason? When will the supervisor sign for hours of experience? What is the supervisee to do in case of an emergency? What is the supervisee to do when faced with a dilemma? Who should the supervisee go to if the supervisor is not available? When and how will the supervisee be reviewed by the supervisor? What should the supervisee do if the relationship seems to not be working as effectively as it could? How many persons has the supervisor supervised? For how long has the supervisor supervised on behalf of the employing agency? Are there any problems or pitfalls that the supervisor believes supervisees regularly face? How will the supervisor react and what will the supervisor do if he/she believes personal issues are getting in the way of the supervisee doing an effective job? Is there a contract or agreement that the supervisee is expected to sign? If so, ask if you may review it in advance? If something happens and the supervisee's services are terminated, how much notice will be given? How will the clients be informed? What happens when the supervisee decides to terminate employment? What may become of the clients he/she is seeing? Is there anything unique about this setting that the supervisee will not readily pick up? How does the supervisor stay up to date on legal and ethical issues? How does the supervisor stay abreast of the changes in the licensing law and regulations? How does the supervisor stay up-to-date on the provision of supervision?

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• • •

Does the supervisor get supervision or consultation? Does the supervisor regularly see clients? What is the supervisor's area of specialty or emphasis?

When the Interview Causes Uncertainty If the interview leads you to believe that the supervisor is someone that will be an unlikely candidate for you to work with, your choices are to: • • • • • •

Give it a try and let the chips fall where they may. Stick it out until something better comes along, and at the same time, keep looking. Diplomatically see if the employer has another possible supervisor who can provide you with supervision. Try to arrange for offsite supervision. Look for another position with a better fit. Reassess your expectations.

When Best Intentions Go Awry Often supervisees are hired and work under supervision in what appears to be a mutually beneficial situation, and somewhere along the way things change. What started out as a fair and mutually respectful relationship evolves into the "supervision from hell." Or, the good, caring, and helpful supervisor leaves or retires and the replacement supervisor is "not from this planet." With the replacement supervisor, you may find yourself in a situation where you need to start from the beginning. Try to arrange for the interview with the supervisor who is new to attempt to "get off on the right foot." Sometimes, however, if the relationship disintegrates, the only viable option is to look for a new employer and supervisor and begin anew. Recourse for a Supervisee When a supervisee is dissatisfied with the supervisor, the supervisee should begin by examining him or herself. Could he or she have handled things better or differently? Did the supervisor really do something wrong, or something unethical, or unlawful? Has the supervisee carefully listened to the supervisor's version of the story? Is the supervisee seeing the situation realistically? Has he or she consulted or engaged in research to be certain his or her opinion is the correct opinion? Has the supervisee "slept" on the issue? If the supervisee is convinced that he or she is on the right track, the next step would be to attempt to approach the supervisor and thoroughly and calmly discuss his/her concerns. Thinking through these concerns and writing them down in advance may assist the supervisee through this discussion. Be sure to arrange enough time to do justice to the issues on the table. If this discussion fails to accomplish what is intended, the next step is to go to the employer to express concerns. The employer may ask that such concerns be submitted in writing. Or the large employer may have some type of dispute resolution process. If so, the supervisee would be expected to comply with that process. Small employers are unlikely to have any formal procedure for handling disagreements. The employer, however, may not be sympathetic with the concerns of the supervisee and may "side" with the supervisor. If there is no resolution, one must PRACTICAL APPLICATIONS IN SUPERVISION

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move on. Moving on may include being supervised by a new supervisor with a new employer. Sometimes this is the only viable option. Depending upon the circumstances, an unhealthy supervisory relationship may result in the supervisee complaining to a professional association's ethics committee-like, for example, CAMFT's Ethics Committee. However, if this recourse is chosen, the Ethics Committee will be able to take action only insofar as the supervisor has violated the Code of Ethics and only if the supervisor is a member of the association. If the issues that led up to the complaint occurred during an earlier version of a code of ethical standards, the standards may have, at the time, been scant with regard to supervisors and/or supervisees, such as CAMFT's Code of Ethics. Today, they are more extensive. The ethical standards that are pertinent are those in effect at the time the matter becomes an issue. While the supervisee may feel he/she has been wronged or mistreated by the supervisor, the Ethics Committee may only act if a particular standard or standards have been violated. Depending upon circumstances, an exceedingly unhealthy supervisory relationship may result in the supervisee complaining to a licensing board for the supervisor—like the BBS or Board of Psychology. Keep in mind that action would only be taken by such a Board for a violation of law, gross negligence, or incompetence in the course of supervision. Poor or inadequate supervision, even though problematic and unhealthy, would not likely result in any disciplinary action against the supervisor. Further, it could lead to an investigation of a supervisee as well if there is fault to be found with the supervisee. Such investigation could delay an application for the license and/or the ability to take the examinations. Lawsuits are another type of recourse available to supervisees and likely the best course for some types of employer/employee disputes, such as wrongful terminations and disputes involving money. Filing a complaint with the Department of Labor Fair Employment and Housing Authority may be another opportunity for recourse depending upon the circumstances. Supervisees who are faced with difficult employer/supervisor relationships are urged to call CAMFT to consult. While the consultation may not lead to resolution of the problem, we can assist in identifying the options that are available to the supervisee. Ultimately, the supervisee must decide the best course of action for his/her circumstances. If you are a supervisor looking for ways to better work with and relate to your supervisees, we would suggest you read "Dealing with Unqualified, Incompetent, or Dishonest Interns" and/or “The Do's and Don'ts of Interviewing Interns and Trainees” that both can be accessed by visiting the CAMFT website.

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A TALE OF TWO SUPERVISEES BY: DAVID G. JENSEN,

STAFF ATTORNEY

THE THERAPIST (SEPTEMBER/OCTOBER 2004) REVIEWED JANUARY 2013

It was the best of times for the supervisor, and it was the worst of times for the supervisor. 1 Why? The BBS had accused the supervisor of committing unprofessional conduct by being grossly negligent when supervising two interns, and the Administrative Law Judge ("ALJ") who presided over the cases decided both of them on the same day. It was a good day because the ALJ ruled in the supervisor's favor in one of the cases, but it was a bad day because the ALJ ruled against the supervisor in the other one. In deciding what went right versus what went wrong during the supervision of these two interns, the ALJ helps us to understand some of the characteristics of "good" and "bad" supervision. I say some of the characteristics of good and bad supervision because these cases do not cover all of the possible events, whether good or bad, that may occur during the course of a supervisory relationship. These relationships are much too complex for that. However, these two cases create some of the pieces, albeit important ones, of a puzzle that portrays good and bad supervision. In general, good supervision is ethical and legal and contributes to the well-being of the patient and the successful maturation of a trainee or intern as a therapist; by contrast, bad supervision is unethical and maybe illegal, can harm patients, and can lead to the disciplining of a supervisor by the BBS for committing unprofessional conduct. These cases help us discern what reasonably competent supervisors do in supervision. These cases also illustrate how the internal machinery of the administrative law process works. Before we examine what went wrong in case one versus what went right in case two, let us review some key regulations and laws pertaining to the supervision of trainees and interns. A Supervisor's Responsibilities Under California Law Many laws and regulations affect supervisors, interns and trainees, but when it comes to actually supervising such individuals, there are few laws and regulations on this particular subject. In a nutshell, supervisors are required to "ensure that the extent, kind, and quality of counseling performed is consistent with the education, training, and experience of the intern or trainee. 2" This idea of consistency seems to be used in two senses. In one sense, it seems to mean that supervisors have an affirmative 1

This article is based on actual disciplinary matters that the BBS adjudicated. The names of the participants are not being used, however, to protect their identities. It is the author’s sincerest hope that each of them has learned from his or her mistakes and are successful, ethical practitioners. 2 16 CCR 1833.1(a)(8)

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obligation, what a lawyer would call a legal duty, to ensure that interns and trainees are not given cases beyond their level of competence. But, in another sense, it also seems to mean that supervisors are supposed to be monitoring the cases given to trainees and interns to ensure that the trainees and interns are rendering services at the level of their competence and not below the level of their competence. Moreover, supervisors are also required to "monitor and evaluate the extent, kind, and quality of counseling performed by the intern or trainee by direct observation, review of audio or video tapes of therapy, review of progress and process notes and other treatment records, or by any other means deemed appropriate by the supervisor. 3 This means that there are many ways to supervise a trainee and intern and a good supervisor utilizes at least some of them at one time or another during the course of the supervisory relationship. This also means that the supervisor, not the intern or trainee, is responsible for selecting the methods of supervision. Overview of the Administrative Law Process In the cases that follow, the patients alleged that they had been harmed by improper supervision. The patients felt aggrieved, and they turned to the BBS for redress of their grievances, which they initiated by filing complaints with the BBS. Once a complaint has been filed, the BBS must then determine whether the complaint merits investigation by the Department of Investigations. Not all complaints are forwarded to the Department of Investigations for investigation, however. In some cases, for a variety of reasons, including insufficient evidence of wrongdoing, the BBS decides not to forward complaints to the Department of Investigations and these matters are closed or addressed in another manner. If the BBS does refer the complaint to the Department of Investigations, such department will investigate the complaint and submit a report of the investigation to the BBS. After reviewing the report, the BBS will then decide whether to commence disciplinary proceedings by filing an accusation of unprofessional conduct against the person named in the complaint. In the cases that follow, the supervisor was accused of committing unprofessional conduct in the course of supervision. The charge of unprofessional conduct means that the supervisor has committed acts of gross negligence during the supervision, or that the supervisor has recklessly caused harm to the patient by supervising improperly. At this juncture the supervisor could have resolved these accusations by entering into a Stipulated Settlement with the BBS, which would have required the supervisor to agree to mandated discipline. However, in these cases the supervisor wanted to have his or her "day in court" so the supervisor elected to have the complaints heard by an ALJ in an administrative law hearing. An administrative law hearing is like a trial, although the more formal rules of evidence and civil procedure are relaxed. At the hearing the BBS prosecutes the case against the person named in the accusation. The BBS must prove by clear and convincing evidence to a reasonable certainty that the person accused of committing unprofessional conduct has actually done the things that constitute unprofessional conduct. If the evidence is clear and convincing to a reasonable 3

16 CCR 1833.1(a)(9)

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certainty that the person has committed unprofessional conduct, the ALJ will decide the case against that person. However, if the evidence is not clear and convincing to a reasonable certainty that the person has committed unprofessional conduct, the ALJ will decide the case in favor of that person. During the cases that follow, the central issues were whether the supervisor was grossly negligent or reckless in his or her supervision of the interns. By gross negligence, the law means an extreme departure from what a reasonably competent supervisor is supposed to do under similar circumstances. 4 It amounts to doing things while supervising that no reasonably competent supervisor would do, or failing to do things that a reasonably competent supervisor would do. It should also be pointed out that the patients filed separate accusations against the interns themselves for the unprofessional conduct that the interns committed and those accusations were separately adjudicated. The cases discussed here are concerned only with the actions of the supervisor within the course and scope of his or her supervision of the two interns. A Tale Of Two Supervisees: Case 1: What Went Wrong? In case 1, supervisor hired "Randy" as an intern and Randy was assigned "Mary" as a patient. In time, Randy and Mary's professional relationship became personal. Randy saw Mary four to five times a week, although the record is not clear about whether these were personal or professional interactions; he also saw members of her family, but again the record is not clear as to whether these were personal or professional interactions. Randy and Mary engaged in a sexual relationship, and Randy billed for therapy sessions that never occurred. Although we do not have all of the details as to why, this house of unethical and illegal cards came tumbling down and Mary was allegedly harmed by Randy's actions and supervisor's unprofessional conduct. And, what was the supervisor doing while all this was happening? Not much of anything. The supervisor did meet with Randy on a weekly basis to review the progress of his patients, but the quality of the supervision was poor. The supervisor's style consisted of simply listening to case reports from supervisees. The supervisor never reviewed Mary's clinical file; in fact, the supervisor assumed but was not sure whether Randy even kept a client file for Mary. The supervisor never had Randy audiotape or videotape a session as a way of assessing Randy's clinical skills. In fact, the supervisor had trouble recalling that Mary was ever discussed much during supervision. In deciding the case against the supervisor, the ALJ concluded that the supervisor had been grossly negligent, and hence violated the standard of care when supervising Randy by: 1. Failing to exercise "vigilant watchfulness" over Randy. The ALJ opined that although supervisors are not required to assume that their supervisees will break the law, they are required to assume that they will make errors and mistakes in judgment when counseling, after all they 4

Van Meter v. Bent Construction Co. (1956) 46 Cal. 2d 588

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are just learning to be therapists. But, supervisors need to ensure that such errors and mistakes in judgment in counseling do not lead to patient harm. A supervisor must do more than teach; the supervisor's responsibility is to oversee, to monitor, and to actively help a supervisee grow in the profession through the mistakes that they are bound to make. In this case, the supervisor also failed to realize that the intern was billing for counseling sessions that never occurred. That is something that should not occur because trainees and interns are employees, not employers. Employers should know what is going on with billing and reimbursement issues because they are the owners of practices or administrators of agencies. Thus, part of "vigilant watchfulness" includes being aware of issues involving billing and reimbursement. Moreover, it seems that the supervisor was also unaware that Randy was counseling members of Mary's family. Certainly, another part of "vigilant watchfulness" includes knowing and approving of the individuals that interns and trainees take on as clients. Did the intern think about possible dual relationship considerations? Conflicts of interest? Therapist/patient loyalty issues? 2. Failing to do more than simply listening to Randy give case reports of his work with Mary. The ALJ concluded that a reasonably prudent supervisor uses all of the supervision tools available to him or her when supervising. Such tools include direct observation, review of audio or video tapes of therapy, review of progress and process notes and other treatment records, or any other means deemed appropriate by the supervisor. 5 The ALJ also concluded that a reasonably prudent supervisor would audio or videotape at least one session to use as an analytical tool for assessing the supervisee's progress as a therapist. 3. Blindly accepting Randy's reports about what was occurring during sessions. According to the ALJ, a supervisor is supposed to pay attention and exhibit a degree of skepticism about the reports that the supervisor is getting from his or her supervisee. This does not mean that the supervisor is supposed to distrust his or her supervisees because trust is the mortar that holds the supervisor-supervisee relationship together. Rather, the supervisor should be aware that trainees and interns are inexperienced and that their perceptions can be erroneous and their methods inappropriate. Consequently, part of being a good supervisor is inquiring about the clinical perceptions of supervisees and the methods such supervisees are using in their sessions with clients. A Tale Of Two Supervisees: Case 2: What Went Right? In case 2, supervisor hired "Rodney" as an intern. Rodney had impeccable credentials, both in terms of solid academic work and personal references. Rodney conducted himself in a very knowledgeable and confident way. He was an impressive individual, and he gave others the feeling that he knew what he was doing. He radiated confidence, and he exuded competence. He seemed a perfect fit for supervisor's practice.

5

16 CCR 1833.1(a)(9); Sections 4.1 though 4.15 of the CAMFT Code of Ethics provide several ethical standards which specifically concern the conduct of supervisors and supervisees.

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Supervisor assigned "Jill" to Rodney as a patient. Jill had Borderline Personality Disorder, and, to say the least, she was a very challenging patient. But, Rodney had experience working with Borderline's and he was keenly interested in working with this population. Supervisor met with Rodney each week for a minimum of one-hour, and they discussed problems that Rodney had encountered in the previous week's session and they discussed approaches to be used in the upcoming week's session. Rodney kept chart notes, and his supervisor reviewed such notes. When difficult issues concerning Jill's treatment arose, Rodney was very persuasive in demonstrating that he had control of a challenging patient. In staff meetings with all of the agency's therapists, Rodney freely participated and he was considered to be, by his peers, very insightful into the issues affecting his patients. He was also generally thought of as someone who performed competent work. Unbeknownst to all concerned, however, Rodney had lost control of Jill's treatment. To assist Jill with remembering events from her past, Rodney and Jill began taping their sessions. Rodney did not inform his supervisor that he was taping these sessions; nor did he inquire of his supervisor about the advisability of taping the sessions. The tapes exhibited therapy that had become highly sexualized, both in terms of physical embraces and the content of discussions, although Rodney and Jill never had sexual intercourse. The tapes also evidenced that in the battle between Rodney and Jill for control of the sessions, Jill "won" and her "victory" caused her serious harm. Although it is possible for an intern to have the requisite degree of skill, education, and training to work competently with borderline patients, in light of a supervisor’s duty to ensure that the extent, kind, and quality of counseling performed is consistent with the education, training, and experience of the intern or trainee, supervisors should think about these issues before assigning a borderline patient to an intern. Interestingly enough though, in case two, despite the fact that Jill was harmed by the intern's actions, the ALJ concluded that there was not clear and convincing evidence to a reasonable certainty that the supervisor had been grossly negligent or reckless in his supervision of Rodney. To be fair, however, it must be pointed out that the ALJ believed that the successful prosecution of this case by the BBS was compromised by the extraordinary length of time, i.e., many, many years, that had passed between the occurrence of the events giving rise to Jill's complaints and the actual adjudication of those complaints by the ALJ. In other words, had Jill's complaints been adjudicated by the ALJ sooner, the result may have been different. Nevertheless, Jill's complaints are still worthy of study because they help delineate the contours of good supervision. In the accusation concerning Jill's case that the BBS filed, it alleged that the supervisor was grossly negligent in assigning her case to Rodney because Rodney was unqualified and unfit to counsel her, presumably because she was a borderline patient and he was just an intern. The ALJ concluded otherwise, however. The ALJ stated that it was not below the standard of care for the supervisor to assign the case to Rodney. However, this does not mean that supervisors have free reign to assign borderline patients, or any patients for that matter, to trainees and interns. The law PRACTICAL APPLICATIONS IN SUPERVISION

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requires supervisors to ensure that trainees and interns are not given cases beyond their level of competence. Moreover, the ALJ stated that this question would probably be answered differently today, most likely because the laws and regulations concerning these issues have evolved over time, but given the facts of this particular case as presented to the ALJ and the state of the law at the time the services were rendered, which, again, was many, many years before the matter was heard by the ALJ, the ALJ concluded that it was not grossly negligent for the supervisor to assign the case to Rodney. He did have experience with borderlines, and he was very good at creating the illusion that he was competent to handle Jill's case. In supervision, Rodney said and did all of the right things that furthered the impression that he was handling Jill's case in a reasonably competent manner. And, there was no independent evidence available that would have alerted the supervisor to the true nature of Rodney and Jill's relationship. The true nature of their relationship was being hidden from the supervisor. Although it is possible for an intern to have the requisite degree of skill, education, and training to work competently with borderline patients, in light of a supervisor's duty to ensure that the extent, kind, and quality of counseling performed is consistent with the education, training, and experience of the intern or trainee, supervisors should think about these issues before assigning a borderline patient to an intern. If the supervisor decides to assign such a patient to an intern, however, the supervisor's rationale for the decision should be documented thoroughly in the patient file. In the accusation concerning Jill's case, the BBS also alleged that the supervisor was grossly negligent because the supervisor failed to adequately supervise Rodney in his treatment of Jill, but, again, the ALJ concluded otherwise. In the supervisor's supervision of Rodney, the supervisor did all of the right things. The supervisor met with him on a weekly basis; the supervisor reviewed the case file; the supervisor discussed concepts, problems, and approaches to be used in Rodney's sessions with Jill; Rodney seemed to have a firm grasp on the particular issues of Jill's case. In short, the supervisor seemed to exercise "vigilant watchfulness" over Jill's case. I say seemed to exercise vigilant watchfulness because the supervisor was actively involved with the supervision of the appearance of Jill's case and not the reality of her case. The reality of her case was a secret, one known only to her and Rodney. The ALJ decided in the supervisor's favor in this case, in part, because there were no compelling facts to place the supervisor on notice that Rodney was lying about the nature of his relationship with Jill. Factually this is a different situation than we had with Randy and Mary. In their case, the intern was billing for sessions that never occurred and the intern entered into therapist-patient relationships with individuals that the supervisor did not know about. These are things that a supervisor should know; these are facts that were readily discoverable by the supervisor had he or she been watching the supervisee vigilantly. In Rodney and Jill's case, however, the supervisor could not readily discover the truth about their relationship because this information did not exist in the client records; it was intentionally being kept from the supervisor's discovery. Conclusions In these two administrative law proceedings two clients alleged that they had been harmed because their cases were supervised improperly; moreover, the BBS formally accused the PRACTICAL APPLICATIONS IN SUPERVISION

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supervisor of committing unprofessional conduct within the course of such supervision. However, after listening to the evidence, the ALJ concluded that in one case the supervisor had committed gross negligence and in the other case the supervisor had not committed such negligence. The unique facts of these cases are important because they help us define some of the characteristics of good and bad supervision. Again, this is not meant to be the definitive account of good supervision, but based on these cases, a reasonably competent supervisor: 1. Exercises "vigilant watchfulness" over the cases that are assigned to the supervisor's trainees and interns; 2. Is aware of who is being billed for the services that trainees and interns provide and how often the clients are coming in for treatment; 3. Is aware of who trainees and interns take on as clients and considers the potential for dual relationship and conflict of interest issues; 4. Uses the tools available for supervising trainees and interns, including occasional audio or video-taping; 5. Is clinically skeptical about the trainee's or intern's work with clients and demonstrates such skepticism by inquiring about the clinical perceptions of supervisees and the methods of treatment used by supervisees in their sessions with clients. Lastly, assuming a patient files a complaint against you for committing unprofessional conduct, whether for improperly supervising or otherwise, do not panic. Although it may seem like it, the world is not really ending. The trouble may go away, or you may be able to extricate yourself from it. For instance, the BBS may decide not to investigate the complaint, or the investigation may reveal that it would be impossible to prove beyond a reasonable certainty that you committed the acts that the patient has accused you of committing. Moreover, assuming there is an administrative law hearing, you may win because you acted as a reasonably competent supervisor and not as a grossly negligent one. Of course, should you receive any communications from the BBS regarding the possible commission of unprofessional conduct by you, you may contact CAMFT for guidance.

This article appeared in the September/October 2004 issue of The Therapist, the publication of the California Association of Marriage and Family Therapists, headquartered in San Diego, California. This article is intended to provide guidelines for addressing difficult legal dilemmas. It is not intended to address every situation that could potentially arise, nor is it intended to be a substitute for independent legal advice or consultation. When using such information as a guide, be aware that laws, regulations and technical standards change over time, and thus one should verify and update any references or information contained herein.

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DEALING WITH UNQUALIFIED, INCOMPETENT, OR DISHONEST INTERNS BY: DAVID G. JENSEN, STAFF ATTORNEY

THE THERAPIST (NOVEMBER/DECEMBER 2003) REVIEWED JANUARY 2013

Supervising interns can be a rewarding experience, professionally speaking, of course. And, in a perfect supervision world, your interns will sail smoothly through their internships and never run into turbulent waters as they make swift and steady progress towards the balmy island of licensure. Your interns will always value your insights and judgments; they will always render services in a competent manner; they will always maintain confidentiality; they will never have sex with their clients; they will always adhere to ethical and legal standards; and, they will always view supervision as an integral part of their maturation as therapists. Unfortunately, you don't supervise in a perfect supervision world. Supervising can also be a "Nightmare on Elm Street" experience, if you are supervising an unqualified, incompetent, or dishonest intern. You will rue the day you hired such an individual, and you will certainly lose sleep as you worry about potential BBS investigations and lawsuits. Hopefully not, but as you supervise interns you may come across an intern who has lied on his or her intern registration or license application; you may have an intern who propositions clients for sex; you may have an intern who is so incompetent clinically that he or she is a danger to the public; you may have an intern who engages in illegal and unethical dual relationships; you may have an intern who is suffering from severe depression, or some other mental illness; or, you may have an intern who is abusing drugs and/or alcohol. When faced with serious violations of laws, regulations, and/or ethical standards, what recourse do you have under the law, as a supervisor, to do something about such violations? Can you have your concerns redressed? If so, who has jurisdiction over such concerns? Moreover, if you do decide to do something, can the intern then successfully sue you for doing what you did? The purpose of this article is to apprise supervisors and interns of the right that supervisors have under California law to make reports to the BBS about unqualified, incompetent, or dishonest interns. Although this article focuses on the rights that supervisors have in relation to interns, the information contained herein is equally applicable to interns or colleagues who wish to complain about unqualified, incompetent, or dishonest licensees. The Problem Is it possible for an unqualified, incompetent, or dishonest intern to become licensed? Unfortunately, the answer to this question is yes. Keep in mind that all someone has to do to PRACTICAL APPLICATIONS IN SUPERVISION

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become licensed is obtain a graduate degree, submit 3,000 hours of experience, and then pass a written and oral examination. You would think that it would be difficult, or even near impossible, for an unqualified, incompetent, or dishonest intern to obtain the requisite experience and pass the examinations, but the sad reality is that it's not. Here's how it typically occurs. Intern acquires about 600 hours at setting A, but his supervisor, Supervisor Mary, then realizes the intern is dishonest because intern forged Supervisor Mary's signature on some entries for intern's weekly logs. Supervisor Mary then terminates the supervisory relationship with intern after signing off on the hours the intern has lawfully earned, which is what Supervisor Mary is required to do by applicable regulation.1 Consequently, although Supervisor Mary knows that the intern is dishonest, intern has acquired some hours towards the 3,000-hour requirement. Intern then goes to setting B where he acquires even more hours towards licensure before being fired for propositioning a female client, but he gets the hours that he did earn signed for by his supervisor. Intern is then off to setting C, where he acquires even more hours towards the 3,000-hour requirement. This mini soap opera illustrates the problem. It is possible for an unqualified, incompetent, or dishonest intern to be passed along from setting to setting, performing miserably at each one, but at the same time being allowed to acquire hours of experience towards licensure. So, if that's the problem, what can supervisors do to derail this train of incompetence and dishonesty once it has left the station? The Solution? Section 43.8 of the California Civil Code provides immunity from liability to any person, including any supervisor, who communicates information in the possession of that person to the BBS, or any other licensing board, when the communication is intended to aid the BBS, or a committee or panel of the BBS, in evaluating the qualifications, fitness, character, or insurability of an intern. Section 43.8 reads, in pertinent part: …there shall be no monetary liability on the part of, and no cause of action for damages shall arise against, any person on account of the communication of information in the possession of that person to any … professional licensing board or division, committee or panel of a licensing board, … when the communication is intended to aid in the evaluation of the qualifications, fitness, character, or insurability of a practitioner of the healing or veterinary arts. Consequently, Section 43.8 of the Civil Code provides immunity to supervisors when they notify the BBS about interns who are unqualified, dishonest, or incompetent as long as the communication is intended to aid the BBS in evaluating the qualifications, fitness, character, or insurability of the interns. Section 43.8 seems to provide supervisors with a blanket of immunity, but is such blanket thick and expansive enough to completely protect supervisors from the icy winds of a lawsuit brought by an aggrieved intern?

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Absolute or Conditional Immunity? In Hassan v. Mercy American River Hospital, 2 the California Supreme Court ("hereinafter Court") recently considered the extent of the liability provided for those persons who make reports to licensing boards and other such overarching organizations pursuant to Section 43.8 (hereinafter "Section 43.8 Notification"). The issue before the Court in the Hassan case was whether the immunity afforded by Section 43.8 is absolute or conditional. 3 The answer to this question is important because if the immunity is absolute, no supervisor could be sued successfully by an intern for making a Section 43.8 Notification; conversely, if the immunity is conditional, there is a chance of a supervisor being sued successfully by an intern for making a Section 43.8 Notification, assuming, of course, that the supervisor has done something to defeat the conditional or qualified immunity. In Hassan, the Court concluded that the immunity afforded by Section 43.8 is conditional, not absolute.4 Obviously, in light of what I just stated in the previous paragraph, this is not good news for supervisors, or anyone making a Section 43.8 Notification. The Court in Hassan opined that the information conveyed in a Section 43.8 Notification must be given with the intent of aiding in the evaluation of a person's qualifications, fitness, character, or insurability.5 But the Court distinguished valid Section 43.8 Notifications from ones that have been made maliciously.6 Malicious communications will defeat the conditional immunity afforded by Section 43.8 of the Civil Code. So, what would constitute a malicious communication for the purpose of making a Section 43.8 Notification? Fortunately, the Court in Hassan answered this question as well. A malicious communication for the purpose of a Section 43.8 Notification is one that the communicator knows is false or is made when the communicator lacks the good faith intent to aid in the evaluation of the intern that is the subject of the Section 43.8 Notification.7 In Hassan, the Court stated that, "Because false information of any sort has no value in evaluating a medical practitioner, the communication of information known to be false cannot be intended to help or assist in that evaluation, or, in other words, an intent to deceive is inconsistent with an intent to aid. Thus, proof that the communicator knew the information to be false when it was conveyed establishes malice sufficient to defeat the qualified Section 43.8 privilege."8 I cannot stress enough that the information communicated in a Section 43.8 Notification must be true. There is no place in a Section 43.8 Notification for false information. Including false information in a Section 43.8 Notification will likely expose you to liability because such information will destroy the conditional or qualified immunity that you have when making a Section 43.8 Notification. Moreover, information given to the BBS in a Section 43.8 Notification should only be given to the BBS to aid the BBS in evaluating an intern's qualifications, fitness, character, or insurability. The Court in Hassan points out that to "aid" means ordinarily to "assist or help," and that to "intend" means to have in mind a purpose or goal. Given the dictionary definition of these words, the Court concludes that a communication is intended to aid in the evaluation of someone "when the communicator acts with a subjective purpose or goal to help or assist in the PRACTICAL APPLICATIONS IN SUPERVISION

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evaluation" of the person who is the subject of the Section 43.8 Notification.9 Interestingly enough, the Court in Hassan states that the information given within a Section 43.8 Notification does not actually have to aid the BBS in evaluating an intern; the information just has to be communicated to the BBS with the intent of aiding it in the evaluation of an intern.10 For your use, should you desire to make a Section 43.8 Notification to the BBS, CAMFT has prepared the letter below as a model to follow when making such notification. What About Notifying the BBS About An Unqualified, Dishonest, or Incompetent Licensee? Although this article has focused on the relationships between interns and supervisors, you should also note that a Section 43.8 Notification could also be used by an intern or a licensee to notify the BBS about an unqualified, dishonest, or incompetent licensee. A Section 43.8 Notification about a licensee would be made in the same way and with the same caveats that such notifications are made about interns. The information provided to the BBS about a licensee must be given to assist the BBS it in its evaluation of the qualifications, fitness, character, or insurability of the licensed person and the information contained in the Section 43.8 Notification must be true. Within the spirit of CAMFT's Code of Ethics, however, colleagues should attempt to resolve their concerns with other licensees before filing a Section 43.8 Notification. Pursuant to Ethical Standard 5, licensees are supposed to respect the confidences of colleagues, are encouraged to assist colleagues with their personal problems, and are to avoid making frivolous complaints. The spirit of the Code of Ethics calls for respect, courtesy, fairness, good faith, and cooperation in these situations. Hopefully, consulting with a colleague will lead to the offending licensee agreeing to make certain changes in his or her personal or professional life to address the legal and ethical concerns raised by the colleague. If not, then the Section 43.8 Notification process remains as a mechanism for having the colleague's legal and ethical concerns about an unqualified, dishonest, or incompetent licensee addressed by the BBS. However, the Section 43.8 Notification process should only be used for serious violations of legal and ethical standards. Are Communications Between Interns and Supervisors Confidential? In California, communications between interns and supervisors are not confidential so generally there is not a problem with forwarding information communicated from an intern to a supervisor on to the BBS for the purpose of making a Section 43.8 Notification. However, if an intern does convey information to you as a supervisor about a personal or professional problem, that information should not be the basis for making a Section 43.8 Notification. Although, technically, you could relay the information to the BBS pursuant to a Section 43.8 Notification because the information is not confidential, the better approach is to counsel and work with the intern to help him or her address his/her problems or refer for therapy if warranted. But, suppose you do discover that one of your interns has committed a serious breach of legal or ethical standards. Most of the time you will be reporting acts that the intern has committed, or has failed to commit, that violate legal or ethical standards. You will be reporting your PRACTICAL APPLICATIONS IN SUPERVISION

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observations of what occurred and not information reported to you by the intern so the information is not confidential. On the other hand, confidentiality would come into play if you, as a supervisor, learn of ethical or legal violations committed by an intern or licensee from a patient. If you then forward such information to the BBS you would be breaching the patient's confidentiality if the patient has not authorized the disclosure. Patients, of course, may file their own complaints about interns or therapists with the BBS. And, patients will be asked to waive confidentiality so that the BBS can investigate such complaints. But, what if the patient does not want to make a complaint, but you, as the supervisor or colleague, think that one is warranted? If the only information that you have about an intern's or colleague's violation of legal or ethical standards comes from the patient, then you would have to have patient authorization before making a Section 43.8 Notification. Conclusions Although the Section 43.8 Notification process is available for anyone to use to contact the BBS about information that the BBS can use to evaluate the qualifications, fitness, character, or insurability of interns and licensees, such process should only be used to address serious violations of legal or ethical standards. If at all possible, supervisors should work with their interns and colleagues should work with one another to address and correct legal and ethical concerns. Making a Section 43.8 Notification should be the exception and not the rule. However, if you are considering making a Section 43.8 Notification, you need to be aware of the following four things: You do not have to make a Section 43.8 Notification; in other words, you are not mandated to make a Section 43.8 Notification if you discover that one of your interns has committed ethical or legal violations. Making a Section 43.8 Notification is a purely voluntary act. In lieu of making a Section 43.8 Notification about an unqualified, incompetent, or dishonest intern, you could suspend or fire the intern and then sign the hours that you are legally obligated to sign off on and be done with that particular intern.

If you do decide to make a Section 43.8 Notification, be aware that the conditional or qualified immunity available for making a Section 43.8 Notification will not insulate you from being sued by an intern; rather, the immunity will provide you with a defense to a lawsuit when and if one has been filed against you.

A Section 43.8 Notification should only be made after an intern or a licensee has committed a serious breach of ethical or legal duties. A Section 43.8 Notification should not be used to address personality or financial differences or other such minor issues. These types of issues need to be addressed and handled in a professional manner between interns and supervisors or colleagues.

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Pursuant to the Hassan case, an organization can be a "person" within the meaning of Section 43.8 of the Civil Code.11 This means that entities, and not just supervisors, can make Section 43.8 Notifications. Consequently, an executive director of a nonprofit corporation could make a Section 43.8 Notification on behalf of such corporation.

1 18 CCR 1833.1(c) 2 Hassan v. Mercy American River Hospital, 3 Cal. Rptr. 3d 625, (2003) 3 Hassan, p. 628 4 Hassan, p. 625 5 Hassan, p. 630 6 Hassan, p. 632 7 Hassan, p. 632 8 Hassan, p. 632 9 Hassan, p. 630 10 Hassan, p. 632 11 Hassan, p. 632

This article appeared in the November/December 2003 issue of The Therapist, the publication of the California Association of Marriage and Family Therapists, headquartered in San Diego, California. This article is intended to provide guidelines for addressing difficult legal dilemmas. It is not intended to address every situation that could potentially arise, nor is it intended to be a substitute for independent legal advice or consultation. When using such information as a guide, be aware that laws, regulations and technical standards change over time, and thus one should verify and update any references or information contained herein.

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THE DO'S AND DON'TS OF INTERVIEWING INTERNS AND TRAINEES BY: MARY RIEMERSMA, FORMER EXECUTIVE DIRECTOR

THE CALIFORNIA THERAPIST (MAY/JUNE 1992) REVIEWED JANUARY 2013

Questions often arise among supervisors/employers about how best to conduct interviews to screen MFT interns and trainees. Conversely, interns and trainees often ask, was this an appropriate question for me to be asked when seeking a position as an MFT intern or trainee. While much of what will be addressed here is not limited to interns and trainees—it is the same for any employee—I will address some of the more common questions that we receive from both supervisors and supervisees. Questions follow which are generally considered to be inappropriate: • • • • •

"What was your maiden name?" "Are you married?" "Do you live with anyone?" "Are you divorced?" "Are you single?"

While it would be considered okay to ask, "have you ever used any other name?," the questions above are unacceptable because they inquire about a person’s marital status. While you may have no intent to discriminate against marital status when employing an intern or trainee, the intern or trainee may believe that you are being discriminatory. The consequences to the supervisor of such an allegation are many. • • • • • •

"What is your age?" "When were you born?" "How old were you when you started/completed your education?" "What year did you graduate from high school?" "How old are your children/grandchildren?" "Do you have difficulty working with young people?"

Whether intended or not, any of the above questions could be considered by the applicant to be age discrimination. The only age concern that you can lawfully express are questions to assure that the applicant is over the age of eighteen, which of course, is generally a given in this profession. •

"Do you have children?"

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• • • • • • •

"How many children do you have?" "Are you currently pregnant?" "Do you plan to have children?" "When do you plan to have children?" "Who takes care of your children when you work?" "Will your children interfere in your ability to be available to patients?" "What do you do when your kids are sick?"

You may be concerned that family issues may affect the performance of the intern or trainee that you hire, however, questions asked in the above manner are not appropriate. Questions need to be phrased to determine potential job performance, without showing bias or prejudice. For example, "do you see any problems in your being able to perform the duties of this position? If so, what are the problems?," or "will you have any difficulty being available for the hours that we need an intern or trainee? If so, please explain the difficulties as you see them." • • • • •

"Are you currently in psychotherapy?" "From whom are you getting (have you gotten) psychotherapy?" "What have you learned from the psychotherapy you have received?" "What issues have you addressed in your personal psychotherapy?" "How has your psychotherapy helped you to be a better therapist?"

While the above questions may tell you a lot about the person you are considering for an intern or trainee, they are inappropriate to ask of a potential supervisee. In fact, such questioning is not appropriate even during the course of supervision. Probing into such issues, besides being intrusive, could also be considered harassment and outside the ethical and legal boundaries of the supervisor. It is the supervisor’s role to oversee the quality and performance of the intern’s or trainee’s work; it is not the supervisor’s role to become the psychotherapist for the intern or trainee. • • •

"Where were you born?" "Are you a U.S. citizen?" "What is your nationality/national origin/race/color/lineage/descent/parentage?"

These questions are inappropriate during the interview. However, it is okay to say, "If we should decide to hire you, will you provide us with verification of your legal right to work in the U.S?" It would also be appropriate to ask whether or not the applicant speaks, writes or reads any other languages. • • • •

"Do you own or rent your home?" "Have you ever filed bankruptcy?" "Have your wages ever been garnisheed?" "What are your current or past liabilities?"

Any questions which delve into the personal financial affairs of the intern or trainee are unacceptable. PRACTICAL APPLICATIONS IN SUPERVISION

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"Please give me a list of all organizations to which you belong."

While you may ask if the applicant is a member of any job related organizations or professional societies, it is considered inappropriate to ask such a question in the above manner. The reason is that the applicant would feel compelled to disclose "all" organizations which could indicate race, religious preference, color, national origin, ancestry, sex or age. For example, such a person might feel compelled to disclose that they are a member of the AARP, which of course, would be an indicator of age. The applicant might later charge that you were prejudiced against the elderly and thus did not hire him/her. The best way to avoid such an allegation is to not ask the question. • • • • • •

"How much do you weigh?" "How tall are you?" "Why are you obese/so thin?" "Do you have any illnesses or any medical condition that we should be aware of?" "Are you receiving any disability or workers’ compensation?" "Do you have any physical disabilities or handicaps?"

All of the above questions are intrusive and inappropriate to be asked in an interview, and frankly, would be inappropriate reasons for refusal to hire an intern or trainee. However, it would be okay to ask, "do you have any condition or disability that may limit your ability to adequately complete the duties of an intern or trainee? If so, please explain." • •

"Have you ever been arrested?" "Has anyone ever complained about you to a licensing board or a professional association?"

If addressed, such questions should be phrased as, "have you ever been convicted of a crime substantially related to the duties of this profession?" or "have you had disciplinary action taken against your license/certification or registration in any state?" or "Has a mental health professional association ever taken disciplinary action against you/your membership?" Any question about a conviction should be followed with a statement that "a conviction will not necessarily disqualify the applicant." • • •

"What is your religion?" "Does your religion prevent you from working certain days?" "What religious holidays do you observe?"

If you are concerned about an intern or trainee being able to work the hours that you want them to be available, provide the intern or trainee with a statement of the days, hours and shifts to be worked. Then ask if he or she has any problems with the hours or days to be worked. Additional tips to keep in mind when interviewing: •

Don’t talk too much. Ask questions to draw as much information as you can from the intern or trainee. You want to find an employee that is compatible with you as

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• • •







supervisor and the employer (when the employer is someone other than the supervisor). Ask questions that are open-ended to draw out the intern or trainee. You want to learn about their skills, theoretical orientation, philosophy for doing therapy, ability to take and follow directions, compatibility with the employer and colleagues, etc. Ask questions in an unbiased manner. Ask questions in a non-projective way. Don’t set the intern or trainee up to answer the question with what they think you want to hear. Use general probes, when necessary, to draw additional information from the intern or trainee. For example, "tell me more about. . .," "what do you mean by. . .," "what are your reasons for. . .," Be sure to honestly explain the job, the employer’s philosophy, the theoretical orientation of the employer, etc. Don’t promise the intern or trainee more than can be delivered. If the intern or trainee will be asked to agree to a contract or agreement, disclose this contract/agreement at the outset. Also disclose personnel policies at the time of hire, then stand by the rules as they have been disclosed to the intern or trainee. Don’t hesitate to check references. Verify that the intern is registered (if required to be registered) with the BBS.

Questions that can assist you in drawing out the intern or trainee: • • • • • • • • • • • •

"What aspects of being a therapist do you enjoy most/least?" "What would you like to be doing five years from now?" "What experiences, qualifications, or interests do you have that you believe are beneficial to your work as a therapist?" "If you were just beginning your education to become an MFT, what are the things you would like to do differently?" "Which courses in your educational program did you like most/least?" "How did you become interested in becoming a therapist?" "What would your supervisor say your strongest/weakest traits are?" "Give me an example of a patient that you worked with that you found most rewarding?" "Give me an example of a patient that you worked with where you felt you were unsuccessful?" "Do you have any questions?" or "Is there any aspect of this position that I can clarify for you?" "Tell me what there is about you and your experience that indicates that you will be successful working as a therapist here?" "How do you handle situations in which you believe you are not treated in the manner you expect to be treated?"

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INTERNS/TRAINEES - EMPLOYEES, NOT INDEPENDENT CONTRACTORS BY: MARY RIEMERSMA, FORMER EXECUTIVE DIRECTOR

THE THERAPIST (JANUARY/FEBRUARY 2002) REVIEWED JANUARY 2013

A question often asked by licensees, interns and trainees is, "Can an intern or trainee work and gain hours of experience as an independent contractor?" The answer is clearly NO. The licensing law never permitted trainees and interns to be independent contractors. Any references in the law to a working relationship have always referred to "employment." Many people, of course, have been either unaware of the law or have chosen to ignore the law. Many felt that the change from independent contractor to employee status came as a result of the licensing law revision effective January l, l987. Such is not the case. Others believe that the change came about when regulation clarified this issue on January 1, 1990. There are specific reasons for the "employee" status, which will be discussed later in this article. First of all, let's look at the differences between an independent contractor and an employee: •



An employee works primarily for your business. In contrast, an independent contractor, a lawyer, for example, works independently for a number of people or entities. An intern or trainee may be employed by you and even others, but does not work independently with the clients he/she sees. The employee is subject to your control and you have the right to direct how the work is done, not just demand a particular result. Employees are under the direct control and supervision of the employer. Employees work the hours directed by the employer, are given the necessary space, equipment and facilities to do the job, have specific tasks to accomplish and are judged on the results of those tasks. On the other hand, independent contractors are given a job to do, then they basically complete the job on their own. There are no set hours, space and facilities are generally not provided and there is usually no supervision. In other words, an independent contractor is generally an outside provider of services who is basically in business for himself/herself. The general principle is that an independent contractor is subject to the control or direction of another person only as to outcome of the finished product, not the means and methods for accomplishing the finished product. Since law and regulation state that "all experience shall be at all times under the supervision of the supervisor who shall, with the person being supervised, be responsible for ensuring that the extent, kind and quality of counseling performed is consistent with the training and experience of the person being supervised, and who shall be responsible

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to the board for the compliance of all laws, rules, and regulations governing the practice of marriage, family and child counseling," it is impossible to construe that independent contractor status was intended or would provide sufficient supervision. The employee works in your office or establishment and does not have his own place of business or business name. Of course, interns and trainees are required by law to "perform services at the place where their employer regularly conducts business and shall not have any proprietary interest in that business..." This means that the intern or trainee may not have an office or business of his/her own. In addition, the intern or trainee may not have his/her own business or business name, and any advertising that includes the name of the intern or trainee would only promote the business of the employer. In contrast, an independent contractor who is in business for himself/herself, would likely have his/her own office, would probably have his/her own business name and would advertise his/her business. The licensing law is quite clear that this is not the intent for interns and trainees. The kind of work the employee does for you is the type of work normally done by employees. The licensing law states that "no person may for remuneration engage in the private practice of marriage and family therapy...unless he or she holds a valid license..." This means that one must be licensed to engage in the practice of marriage and family therapy for a fee. There are, of course, exceptions for certain professions and for marriage and family therapy performed in certain exempt work settings. There is also an exception for interns "employed" in private practice and interns and trainees "employed" in other permissible work settings. Regardless of these exceptions, law and regulation provide that, "Trainees and interns shall not receive any remuneration from patients or clients, and shall only be paid by their employer." Thus, interns and trainees may do marriage and family therapy as long as the fees paid by the clients are made payable to the employers. The employers are expected to pay employees as in any other employer-employee relationship.

Generally, employees are not licensed professionals even though licensed professionals may be employed. Licensed professionals, e.g., psychologists, CPAs, attorneys, architects, engineers, etc. may operate as independent contractors. Non-licensed persons in these professions may never work as independent contractors. This is also true with licensed marriage and family therapists. Some mistakenly believe the intern registration is a license and may even call it an "intern license." There is no intent, and there has never been any intent by the BBS to grant interns a license. The "intern registration" merely means what the name indicates; the intern is registered with the BBS as someone who does not yet meet all of the qualifications of licensure. The main purpose for registering is to continue to accrue hours of experience post-degree to eventually qualify for licensure. Clearly, from the viewpoint of the IRS, employees and independent contractors are two very different kinds of workers. Just because you may agree to hire someone as an independent contractor does not make it so for tax and other legal purposes. Besides, you will be in clear violation of the licensing law. Thus, before you decide to hire an intern or trainee or anyone else for that matter, you need to take a long hard look at whether the IRS or a court of law would consider that person to be your employee, rather than an independent contractor. And, if after PRACTICAL APPLICATIONS IN SUPERVISION

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reading this article you are still not convinced, I would encourage you to submit an SS-8 form to the IRS for their position on your "employee." This form asks a number of pertinent questions upon which the IRS can issue an opinion. Unless you are quite certain that a work relationship will be considered that of an independent contractor, be very careful about hiring in this manner. The consequences of poor judgment can be very severe. Besides, if you are in violation of the licensing law if the employee is an intern or trainee, you may be liable for the employer payroll taxes you failed to pay and either a portion of or all of the employee taxes you failed to withhold. In effect, you could end up paying the taxes that are owed by your employee. What's more, if your intern is hurt on the job and you have not provided workers' compensation insurance coverage, you could be liable for extensive legal and medical expenses as well as lost wages. On a final note, if you have a qualified retirement plan and you have not contributed to the plan on behalf of the employee, the retirement plan could be disqualified. The consequences of poor judgment for the intern or trainee are loss of hours and possible disciplinary action by the Board of Behavioral Sciences. The consequence to the supervisor, in addition to the consequences identified above, is subjecting oneself to disciplinary action by the licensing board for "aiding and abetting unlicensed practice." When one becomes an employer, he/she assumes all federal and state employer obligations. These include federal and state income tax withholding, FICA, state disability, federal unemployment tax' and workers compensation. Obviously, arrangements where interns and trainees are responsible for their own withholding taxes and social security are improper since they would be acting as independent contractors. It is usually the added costs for the variety of payroll deductions and taxes combined with the added burden of such calculations and their respective reporting forms to which most potential employers object. Indeed, it is a hassle to complete those forms, withhold taxes and pay taxes. But, getting caught on the wrong side of this issue can be much worse. Many who employ interns and trainees are reluctant to realize that hiring an employee causes them to assume the responsibilities required of every other employer in this country. However, there are ways, for a nominal fee, to lessen this burden. There are many small accounting and bookkeeping firms that specialize in handling payroll accounting. There are also other firms and banks that provide payroll accounting for a nominal fee. Wells Fargo Bank offers what is known as a "small business package" where they provide payroll accounting for a fee. ADP (Automated Data Processing) and Paychex are two businesses that specialize in payroll accounting and can easily be found in most telephone directories. Fees generally are approximately $50 per month. For this service charge, they calculate all of the withholdings, issue the payroll, and complete both quarterly and annual reports. All you supply are the funds to pay the checks, the hours worked by each employee and the amount to be paid per hour. This option, while it does not remove the burden, does make it much more acceptable. Besides, it frees the employer to do what the employer does best, which is likely not payroll accounting. Meanwhile, do not be wrongly persuaded by friends, colleagues, business associates, and some accountants into the independent contractor game. They will tell you how easy it is to avoid all of those taxes and reporting forms. Listen to their advice only after you are confident that the PRACTICAL APPLICATIONS IN SUPERVISION

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person you plan to employ indeed qualifies for independent contractor status. And, if you are uncertain, get well-qualified, competent advice; or submit an SS-8 form for an IRS opinion. Keep in mind that even though the hiring of an intern or trainee is clear in the licensing law, not every other situation can be so clearly defined. Two different CPAs may even give differing opinions; and in such a situation it is probably better to err on the side of caution. Employees or Independent Contractors? The Internal Revenue Service uses 20 legal criteria to determine whether workers are employees or independent contractors. Workers are generally employees if they: 1. Must comply with employer's instructions 11. Must submit regular reports to the about work. employer. 2. Receive training from or are at the direction 12. Receive payments or regular amounts at of the employer. set intervals. 3. Provide services that are integrated into 13. Receive payments for business or traveling the business. expenses. 4. Provide services that must be rendered 14. Rely on the employer to furnish tools and personally. materials. 5. Hire, supervise and pay assistants for the 15. Lack a major investment in facilities used to employer. perform the service. 16. Cannot make a profit or suffer a loss from 6. Have a continuing working relationship with their the employer. service. 7. Must follow set hours of work. 17. Work for one employer at a time. 18. Do not offer their services to the general 8. Work full-time for an employer. public. 9. Do their work on the employer's premises. 19. Can be fired by the employer. 10. Must do their work in a sequence set by 20. May quit work at any time without incurring the employer. liability.

This article is intended to provide guidelines for addressing difficult legal dilemmas. It is not intended to address every situation that could potentially arise, nor is it intended to be a substitute for independent legal advice or consultation. When using such information as a guide, be aware that laws, regulations and technical standards change over time, and thus one should verify and update any references or information contained herein.

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TERMINATION OF EMPLOYMENT: WHO "OWNS" THE PATIENT? BY: RICHARD S. LESLIE, J.D., OF COUNSEL

THE THERAPIST (JANUARY/FEBRUARY 1992) REVIEWED JANUARY 2013

One of the more troubling aspects of practicing therapy often occurs upon termination of an employment or contractual relationship. At that time, questions arise like: a) Who "owns" the patient? b) Can I take patients with me? c) What if I take patients with me in violation of a contractual clause that attempts to prohibit me from taking patients? d) How can we (the agency or employer) protect our economic interests? e) Can we ask that the departing therapist pay a percentage of future fees in order to compensate us for the loss of patient revenue? These questions arise in many different kinds of relationships. For instance, the therapist who is leaving a setting may be licensed, or may be a registered intern or trainee. The setting may be a nonprofit and charitable corporation, a private practice or clinic setting. The answer to these questions are difficult, and reasonable minds can differ. I offer below my views on the subject and advise those facing similar situations to seek their own legal advice. First, I must confess that I have dealt with this subject, on and off, for over a decade and my opinion has not changed. I have talked with a number of lawyers about this issue (those who represent the agency/employer and the departing therapist) and they have generally agreed with my approach, although we usually also agree that there is no certainty how a court might rule. To the best of my knowledge, neither the BBS, nor the attorneys who staff the board (either from the Department of Consumer Affairs of the Attorney General’s office), have ever issued a formal written opinion on this subject. Second, it is my experience that this issue is often met with confusion by those involved in the process, and that termination of the employment or contractual relationship is an emotionallycharged occurrence. Sometimes the parties threaten each other with lawsuits, and sometimes they complain or threaten to complain to the licensing board. I believe that the observance of a few basic rules, and the consideration of a few basic questions, can assist all involved in an amicable PRACTICAL APPLICATIONS IN SUPERVISION

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and ethically appropriate termination. It must be remembered by all parties concerned that the patient has the right to terminate treatment at any time, and that the patient has the right to choose the therapist of his/her choice. Additionally, it goes without saying (but I’ll say it anyway!) that all parties concerned are supposed to act in the best interests of the patient, not in their own best (economic) interests. I am often amused when I hear an agency director claim that the reason he/she doesn’t want the terminating therapist to take patients with him/her is because of the concern about the practitioner’s competence. Often, however, there is no documented employee records that support such concern, even though the employee may have been employed there for a year or more. This "concern" is often nothing more than an excuse for trying to prevent the patient from leaving the agency. In the event that there does exist a good reason for termination, I will offer some suggestions later in this article. In making decisions in the best interests of the patient, it should also be remembered that the patient has options, and that the patient should, within a reasonable period of time prior to having to exercise those options, be fully informed of the options. Hiding options from patients, or cajoling patients into further treatment with one or the other, is clearly inappropriate. Continuity of care is also an important concept, and those involved in the decision making process should keep that concept well in mind. When an employee or independent contractor has decided to leave an agency, or when the contract expires, I believe that the "ethically correct" action is for the employee/contractor to inform the employer of his/her intention to leave and to discuss the plan of action vis-a-vis patients. It would, in my opinion, ordinarily constitute negligence for the therapist to leave the agency without first discussing termination issues with the patient. At the time of that discussion, the therapist should let the patient know of his/her options. This is the point where the employer usually gets concerned. Some employers have developed written statements that patients are given that carefully and neutrally describe the options available to the patient. Other employers seek to meet with the patient, either alone or in the company of the treating therapist, so that they can be sure that the options are fairly presented. Care must be taken to protect the patient by not letting the patient know that there is a "tug of war" or an economic battle going on between the therapist and the employer. I’m not certain as to what method is the best way to proceed, but obviously it would be good if there existed some trust between the employer and the employee. Unfortunately, all too often such trust is not present, and thus the problems begin. When the departing therapist is an intern or trainee, it must be remembered that such unlicensed persons cannot practice independently and must be appropriately employed and supervised. Such employment must be in a private practice (for interns only), a nonprofit and charitable corporation, specified licensed health facilities, a school, college or university, or a governmental entity. A condition precedent to interns or trainees "taking patients with them" is that they have a new and proper employment setting lined up. Additionally, the intern or trainee should have obtained permission from the new employer to bring the patients into the new work setting and PRACTICAL APPLICATIONS IN SUPERVISION

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to continue to charge the patient the same fee as the patient was paying at the other agency. All fees are, of course, paid to the employer, and not to the intern or trainee. Several ethical and legal issues arise with respect to the fee, since sometimes the new employers will want to charge the transferring patient their usual fee, and will not want to accept the fee set by the previous employer. In other situations, the new employer may set the fee below that of the previous employer. It is, of course, true that the patient can agree upon a new contractual arrangement if he/she is given reasonable notice, but, in my opinion, a lower or higher fee can present problems. A higher fee may put the patient in an awkward position (wanting to continue in therapy, but having to pay a higher fee to do so) and a lower fee may trigger a complaint from the former employer that the lower fee is intended to improperly manipulate or entice the patient to leave. While it certainly can be argued, and would appear that a lower fee is good for the patient, I think one has to consider the situation. For instance, what if a licensed person is leaving the XYZ Agency and tells the patient that if he/she decides to leave the agency the fee will be $60, as opposed to the $80 the patient is currently paying. Allegations can be made, even by the patient, that this substantial reduction in fee was deliberately made to influence the decision. I therefore think it best that the amount of payment, as well as the terms and conditions of payment, be as close to that which existed at the prior employer’s business. I think that such an arrangement does not unnecessarily raise collateral issues. Proceeding smoothly through such situations is itself a difficult task. The less complicating issues, the better! Having mentioned the principles of patient choice and continuity of care, it also must be remembered (primarily by the departing therapist) that patients may want to stay at the XYZ Counseling Center and may feel safe and secure being treated at a particularly well-reputed agency. Furthermore, it also must be known that some employees (e.g., licensees as well as prelicensed people) do not perform well and ultimately may be appropriately terminated by the employer. Sometimes, like in the case where an employee steals from the employer or has sex with a patient, the employer may terminate employment abruptly. It will then be necessary for the employer to make contact with the patient and to let the patient know of the termination of employment and that another therapist will be assigned to the case. This situation is particularly troublesome because the patient may want to continue to see the therapist, or because the terminated therapist may be tempted to contact all of his/her patients to let them know what happened and what their options are. Although each situation must be judged by its own facts, I generally believe that terminated therapists should not reach out and try to contact patients. I believe that to do so creates the appearance of overreaching and may thrust patients into the usually bitter dispute which exists between the employer and the terminated employee. It is my belief that upon a sudden termination it becomes the employer’s responsibility to care for the patients and protect the patients’ interests. If the terminated therapist wants to express concern for the patients, I usually advise that a letter be written to express that concern to the former employer and to make any requests for action or access directly to the former employer. PRACTICAL APPLICATIONS IN SUPERVISION

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Employers who terminate employees "for cause" face difficult dilemmas. They need to explain to the patient that the therapist no longer works there and the patient usually wants to know why. The patient may want to continue in treatment with the terminated therapist and the employer may be concerned about allowing the patient to see an unethical or dangerous practitioner (sexual involvement with patient, or other grossly negligent conduct). The employer often fears that being too specific will either alarm the patient, or will result in retaliatory action by the terminated therapist, or both. Again, the particulars of each situation must be thoroughly examined before specific advice can be offered, but generally I suggest that the employer inform the patient that the employee was terminated (or no longer works there). The employer should be ready to assign another therapist, or if necessary, to refer the patient elsewhere. If the patient wants to know the particulars of the termination or the reason why the therapist is no longer there, I often advise the employer to tell the patient that it is not appropriate to discuss the details of employer-employee relations. The patient is, of course, free to contact the terminated therapist to ascertain whatever information he/she desires. There is a legitimate concern on the part of employers that failure to tell the patient the details of the termination, and possibly allowing the patient to decide to continue in a bad or dangerous therapeutic relationship with the terminated employee, does not constitute "acting in the best interest of the patient." In aggravated cases, and depending upon the patient’s mental condition, I have advised therapists to carefully describe the reasons for the termination. It is important for employers to carefully document employee records so that the reasons for any terminations are preserved and recoverable (another article!). It is also important to let the patient know, in certain circumstances, that allegations may have been made, but not yet proven. For instance, what if the BBSE has filed an Accusation against a therapist for "sex with patient," but the administrative hearing has not yet taken place? The patient could be informed of this information, but should also be told that the therapist has not yet been proven to have acted unprofessionally. Agencies and employers are often legitimately concerned with protecting their business and with not suffering unanticipated and significant economic losses. They will often draft contracts which provide for remuneration of the employer by the employee in the event that the employee "takes patients with him/her." Some contracts provide that the departing therapist will pay the employer a percentage of fees generated by future treatment. I am concerned that such an arrangement may constitute a violation of Section 4982 (o) of the Business and Professions Code. That section prohibits the following conduct: Paying, accepting, or soliciting any consideration, compensation, or remuneration, whether monetary or otherwise, for the referral of professional clients. All consideration, compensation, or remuneration shall be in relation to professional counseling services actually provided by the licensee. Nothing in this subdivision shall prevent collaboration among two or more licensees in a case or cases. However, no fee shall be charged for that collaboration, except when disclosure of the fee has been made in compliance with subdivision (n). I believe that if an employee sued to enforce such a contractual provision, an argument could be PRACTICAL APPLICATIONS IN SUPERVISION

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made, in defense of nonpayment, that such a clause is against public policy since it violates the above-referenced section. I think such a defense would not be as strong with a contract that provides for compensation of the employer which is not based upon future fees to be earned, but is based upon past services rendered or one which specifies a fixed sum of money to be paid for each patient who decides to leave the agency. The contract should contain language that clearly spells out the reasons why the employer is being compensated. The departing therapist is not buying patients, but rather, is compensating the employer for the expenses incurred by the employer for advertising and the other usual and customary costs of doing business. As mentioned earlier, I am not aware of any rulings by the relevant licensing boards that relate to these issues. Nor am I aware of any judicial decisions that discuss these issues. We may, in the near future, seek to obtain an opinion from the Attorney General’s Office with respect to the issue of payment of money and whether or not, and under what circumstances, it may constitute a violation of Section 4982 (o) of the Business and Professions Code. It should be obvious that this area of practice is fraught with problems and concerns, many of which do not have clear and unambiguous answers. It is therefore important for those involved in such situations to obtain their own legal advice. I am always willing to discuss these issues with attorneys representing either side in the dispute. I realize that this article may raise some questions and concerns, and does not cover definitively all of the situations that may arise. However, I think it is important that these issues be aired and discussed. Hopefully, with more awareness of the problems, the parties involved will be able to handle these situations more professionally, with a minimum of controversy, and in the best interests of the patient.

This article appeared in the January/February 1992 issue of The California Therapist, the publication of the California Association of Marriage and Family Therapists, headquartered in San Diego, California. This article is intended to provide guidelines for addressing difficult legal dilemmas. It is not intended to address every situation that could potentially arise, nor is it intended to be a substitute for independent legal advice or consultation. When using such information as a guide, be aware that laws, regulations and technical standards change over time, and thus one should verify and update any references or information contained herein.

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TRAINEE HOURS MAY BE IN JEOPARDY MARY RIEMERSMA, FORMER EXECUTIVE DIRECTOR THE THERAPIST MARCH/APRIL 2010 REVIEWED/UPDATED JANUARY 2013

We are regularly told by trainees, supervisors, educational institutions, and employers that they are unaware of the section of law that requires there to be a written agreement between schools and work settings for the hours of experience gained by trainees outside of their practicum assignments. The pertinent section of the Business and Professions Code is: 4980.42. (a) Trainees performing services in any work setting specified in subdivision (d) of Section 4980.43 may perform those activities and services as a trainee, provided that the activities and services constitute part of the trainee's supervised course of study and that the person is designated by the title "trainee." (b) Trainees subject to Section 4980.37 may gain hours of experience and counsel clients outside of the required practicum. This subdivision shall apply to hours of experience gained and client counseling provided on and after January 1, 2012. (c) Trainees subject to Section 4980.36 may gain hours of experience outside of the required practicum but must be enrolled in a practicum course to counsel clients. Trainees subject to Section 4980.36 may counsel clients while not enrolled in a practicum course if the period of lapsed enrollment is less than 90 calendar days, and if that period is immediately preceded by enrollment in a practicum course and immediately followed by enrollment in a practicum course or completion of the degree program. (d) All hours of experience gained pursuant to subdivisions (b) and (c) shall be subject to the other requirements of this chapter. (e) All hours of experience gained as a trainee shall be coordinated between the school and the site where the hours are being accrued. The school shall approve each site and shall have a written agreement with each site that details each party's responsibilities, including the methods by which supervision shall be provided. The agreement shall provide for regular progress reports and evaluations of the student's performance at the site. If an applicant has gained hours of experience while enrolled in an institution other than the one that confers the qualifying degree, it shall be the applicant's responsibility to provide to the board satisfactory evidence that those hours of trainee experience were gained in compliance with this section. Thus, hours gained by trainees, that are outside of practicum assignments, must be approved by schools where the trainees are enrolled and these schools are to have written agreements for each site where trainees are working. The agreement is to provide regular progress reports and PRACTICAL APPLICATIONS IN SUPERVISION

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evaluations of the student’s performance at the work sites. Some schools do not permit hours to be gained outside of practicum. Some schools charge a fee to allow for the hours to be gained and to provide the requisite oversight. And, it appears some schools may be oblivious to this requirement. We would encourage schools, supervisors, employers, and trainees to be aware if this important requirement that could affect the hours gained by trainees. Arguably, if these written agreements do not exist, the BBS could disallow the hours of experience gained by the trainees who are gaining hours of experience outside of their practicum assignments. While the BBS may not always require the submission of these documents, they may decide to regularly request them and can certainly request them if looking into a questionable situation. Please note that, currently California Business & Professions Code Section 4980.42(b) allows trainees to gain hours of counseling experience outside of a practicum course if the trainee’s school approves the site and has a written agreement with the site. However, Section 4980.42(c), requires that trainees who enter into a degree program on or after August 1, 2012, or for those who enter a degree program that meets the requirements of Section 4980.36, may only counsel clients while not enrolled in a practicum course if the period of lapsed enrollment is less than 90 calendar days and if that period is immediately preceded and immediately followed by enrollment in a practicum course or completion of the degree program. Meaning, all trainees gaining counseling hours of experience must be enrolled in a current practicum, or fall under the exemptions mentioned above.

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RETHINKING PRIVATE PRACTICE INTERNSHIPS BY: MARY RIEMERSMA, FORMER EXECUTIVE DIRECTOR THE CALIFORNIA THERAPIST (JANUARY/FEBRUARY 1997) REVIEWED/UPDATED JANUARY 2013

Some may recall an article previously published in The California Therapist called, "Interns: To Have or Have Not—How an Internship Ought to Be" (Sept./Oct. 1995). The article posed several key points, i.e., it can be very rewarding to supervise interns in private practice; it provides a significant opportunity for interns to gain valuable experience; it takes time, energy, commitment and money to build a profitable private practice which includes interns; yet licensure of the intern(s) generally means that the return is markedly diminished when the intern(s), upon licensure, leaves the practice and takes his/her clients. According to the author and others, a great deal is missed when an intern is not exposed to a private practice internship. In such settings, there is a different type of clientele, and interns miss out on observing how a private practice is built, managed and maintained. This article will focus on what is necessary to succeed when employing interns in private practice and what is required when one is a supervisor in a private practice. Believe it or not, it is possible to succeed; and it is possible to succeed when fully complying with the requirements of law and regulation. There are several situations where employing interns in private practice are destined for failure, including 1. The licensee contemplating employing the intern has difficulty sustaining a "full" practice. 2. The intern has no skills, or is reluctant to develop skills, in marketing, e.g., the intern is expecting the private practitioner to supply their client-load 3. The intern is in the exam process, and is seeking a licensee to "work under" only until licensed. 4. The licensee has only a limited interest and desire to provide supervision. 5. The licensee lacks skills in providing supervision and/or managing employees. Generally, when any of these situations exist, the result will be an unsatisfactory experience for either the intern, the employer/supervisor, or both. In such case, it would be preferable to the licensee, if he/she desires to be a supervisor and has the competence to supervise, to contract to provide supervision with a non-profit and charitable corporation, a licensed health facility, a governmental entity, or a school, college or university in need of a supervisor for their interns or trainees. This is an excellent supplement to a practice without the added liability, responsibility and commitment required to also be an employer. If the supervisor is not paid by the employer, a letter of agreement between the employer and supervisor must exist, whereby the supervisor agrees to provide service for the organization on a voluntary basis. This letter of agreement, PRACTICAL APPLICATIONS IN SUPERVISION

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besides indicating the various parties to the agreement, includes language from Section 1833(b)(4) of California Code of Regulations. How to Make it Work—The Long-Term Commitment One of the best ways to ensure success is to make sure that the relationship can grow into a longterm commitment. By that we mean that the relationship should not be destined to terminate upon licensure of the intern. If the relationship, following licensure of the intern, could evolve into a partnership, it is likely that both the supervisor and the employee would benefit. From the supervisor’s perspective, having a partner whom the supervisor has had the opportunity to groom and prepare for licensure is an advantage. From the supervisee’s perspective, having a supervisor whom you have grown to trust and respect lays the foundation for a worthwhile partnership. When the supervisor and supervisee are both committed to a long-term relationship, the supervisor can more realistically commit the time, energy and money necessary to assure the practice’s success. The supervisee, likewise, has a vested interest in the success of their longterm goal. In many circumstances, an intern seeks a private practice placement as a place to gain experience while awaiting licensure. Most often, when the intern is licensed, he/she leaves in order to commence independent practice. As long as this reality exists, licensees will be less inclined to employ interns, since the inevitable departure creates a serious disruption to the licensee’s practice, as well as the licensee’s income. This scenario results in the licensee feeling exploited and reluctant to, in the future, employ other interns. In order for the employment to be worthwhile and profitable to the employer, the employer needs the assurance of a longer term commitment. The intern who wishes to successfully market him or herself to potential private practice employers, needs to sell him or herself as a long-term, profitable addition to the private practice, and should be willing to make a long-term commitment. How to Make it Work—Marketing is not Solely for Employers Given today’s marketplace, it is the rare private practitioner that has excess clients for the employee to treat. Thus, the intern who hopes to succeed in private practice will likely not succeed unless there is, not only a willingness, but a commitment and desire to market the private practice. Without substantial marketing by the intern, the intern will have insufficient clients to sustain a practice and may become disenchanted; and certainly his or her employer will become disenchanted as insufficient income is generated to sustain the costs of having an employee. If the relationship is not profitable for the licensee, the relationship will usually fail. Employers generally only hire employees because it is good for their businesses. If there is no return on the investment, the savvy employer will rid itself of whatever is not profitable, including interns. If marketing is foreign to the intern, the intern should look for ways to improve his/her marketing skills, e.g., attend courses or workshops in marketing, read books and articles on marketing, and put the acquired good ideas to work. What are the Positives? PRACTICAL APPLICATIONS IN SUPERVISION

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Providing supervision can provide an opportunity to return something to your chosen profession. If you are so inclined, this experience can be immensely rewarding. Providing supervision can be a learning experience. There is an axiom that the best way to learn is to teach. Supervision is much the same, because in many ways it is a "teaching" experience. When sharing knowledge, it is important to have an understanding of that knowledge at a different level than is necessary to merely apply the knowledge. Providing supervision can be a challenge which causes the supervisor to expand his/her way of thinking. This experience generally causes persons to do what they do better. Providing supervision can provide a welcome diversion to a practice that may have become mundane. Having a supervisee can reduce the feelings of isolation that sometimes occurs when therapists engage in a sole, independent practice. It is also possible for licensees to learn from their supervisees. If planned correctly, the employment of one or two interns can be profitable. For a comparison of what may and may not work financially, note the following hypothetical situations: Situation #1 The intern, on average, sees only three patients per week at an average of $50 per hour. This translates to monthly income for the supervisor of approximately $645. The supervisor, nevertheless, incurs the following (see below) monthly expenses by having an intern and suffers a net loss. Situation #2 The intern, on average, sees fifteen clients per week at an average of $50 per hour. This translates to monthly income for the supervisor of approximately $3,897. In this case, the supervisor still incurs monthly expenses by having an intern, yet the result is a net gain of $475 per month or $5,100 per year. This is a reasonable amount by which to supplement the practice’s income. At the same time, it likely increases the exposure of the practice (marketing) and expands the referral base. Hypothetical Costs Added telephone costs Oversight for the intern’s work Increased costs for advertising Added office expenses Additional risk for intern* Wages for intern Employee benefits Additional rent -Total costs for intern Profit before taxes

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Situation #1

Situation #2 $25 400 100 10 100 65 20** 0*** 720 (75)

$50 800 100 50 100 1,400 300** 150 2,950 947

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*risk is an arbitrary figure to account for the supervisor’s increased liability while employing an intern. **employee benefits include FICA, workers compensation, Medicare, and state and federal unemployment taxes. ***no additional rent is added for this situation since it is assumed that no additional space is necessary in this scenario.

Obviously, this arrangement cannot work in the supervisor’s best interests if the intern is seeing an insufficient number of clients, or if the intern’s services are under-valued, e.g., only low-fee patients are seen for $10 or $15 per session. Thus, it behooves the supervisor and intern to devise a fee schedule that is fair and reasonable given the intern’s education, training, experience and special expertise. Keep in mind that the private practice need not operate like a non-profit venture. Situation #2 demonstrates that when developed carefully, the employment of the intern can be a profitable and worthwhile venture. An often-asked question by both interns and potential supervisors is how much should an intern in private practice be paid? There are no limits to the amount an intern may be paid, however, the floor for a less experienced intern is minimum wage. There is no ceiling, but generally those who are more productive (see a greater number of patients) earn higher wages. Interns may be paid a fixed amount per hour or per week, or they may be paid an annual salary. Interns are also paid on a percentage basis. These percentages generally range between thirty and seventy percent of the fees generated by the intern. Customarily, an intern with fewer clients is going to be on the lower end of the scale, while an intern with a greater number of clients is going to be paid a higher percentage. In any case, the intern must be paid as an employee, and not as an independent contractor. Additionally, when one is an employee, he/she must be paid within the pay period for the hours worked, not paid at the time reimbursement is received from third party payers. "Within the pay period" generally means that the employee is paid at least semi-monthly. Moreover, fees generated by interns are the income of the employer. The employer is responsible, as indicated above, for all of the costs of running the practice and for paying wages to the intern-employee. It is never appropriate for the intern to contribute to the costs of running the practice. Not only would this be exploitive of the intern, it would be unlawful. What are the Negatives? The negatives may or may not occur, however, following are some of the pitfalls that can arise when hiring an intern to work in a private practice: You may hire the wrong person. For example, you may have prepared and done everything in an exemplary manner, however, if the wrong person is selected the relationship is doomed. Thus, to avoid this pitfall, select carefully. It is much easier to turn someone down for the position than it is to terminate them once you later ascertain that you made the wrong choice. You will have to become an employer. While this is an easily surmountable task, many licensees avoid providing supervision in private practice because they perceive this task as daunting. Like in any other situation when one becomes an employer, he/she assumes responsibility for all federal and state employer obligations. These obligations include federal and state income tax PRACTICAL APPLICATIONS IN SUPERVISION

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withholding, FICA, state disability, federal unemployment tax and workers’ compensation. It is usually the added costs for the variety of payroll deductions and taxes combined with the added burden of such calculations and their respective reporting forms to which most potential employers object. However, there are ways, for a nominal fee, to lessen this burden. There are many small accounting/bookkeeping firms and banks which provide payroll accounting services for a nominal fee. Firms such as ADP (Automated Data Processing) and Paychex are businesses which specialize in payroll accounting and can easily be located in most major cities. For a fee that is likely much lower than the value of the employer’s time, they calculate all of the withholdings, issue the payroll, complete both quarterly and annual reports, maintain payroll records, etc. All the employer supplies are the funds to pay the checks, the hours worked by each employee, and the amount to be paid per hour or pay period. While this option does not eliminate the burden, it does make becoming an employer much more palatable. You are sure to have struggles from time to time. Working with someone else is never as easy as working alone, however, the benefits of a good relationship may outweigh the detriments of working in isolation. You will likely forfeit some freedom. When someone is relying upon you for guidance and direction, it is often more difficult to be in complete control of your own hours. However, your diminished freedom by having to be accessible, is often offset by additional freedom when you have another responsible therapist upon which to rely. Having an employee may bring to light your own shortcomings. It is sometimes easy to overlook shortcomings when there is no one to whom you are responsible. However, when you have an employee whose respect you value, you are placed in a position of needing to be "beyond reproach." You may lose money. It is quite common that when a new business is begun or a business is expanded, it will initially lose money. However, if the business or the expanded venture is worthwhile, it will begin to be financially rewarding and result in a profit after a while. If it is not meant to be, it may never turn a profit. In other words, you must put something into it to get something worthwhile out. You may have to pay more personal income tax. Of course, this is not all bad. If you are so unfortunate to end up paying more in personal income taxes, it is likely that you are making more net income, which means that the venture is worthwhile. You may have to work on improving your supervisory skills. This responsibility may mean that you need to participate in courses, workshops, trainings, consultations, etc. to upgrade your ability to provide supervision. Of course, this costs both time and money.

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You may sacrifice privacy. Just like your freedom, when your supervisee is depending upon you, it is difficult, if not impossible, to have complete privacy. If everything else about the relationship is working, however, the benefits exceed the sacrifice. What are the Legal Considerations? Intern Registration Required A person must be registered as a intern to be employed in a private practice [B & P Code Section 4980.43 (e) (2)]. This also means that if the period has expired within which one may be a registered intern, that person would no longer be eligible to be employed in a private practice. Persons in a second registered intern period (is in his/her second six year) registration may not work in private practice. Interns Shall Only be Paid by Employers Interns in private practice, as with other work settings, may only be paid by their employers and may not be paid by patients [B & P Code Section 4980.43 (h)]. Interns May Not be Independent Contractors As is true in other work settings, interns employed in private practice may not be independent contractors [B & P Code Section 4980.43 (b)]. An independent contractor is one who essentially is self-employed. The law never intended that interns could be self-employed. Thus, interns, like other employees, complete W-4s, have withholdings taken from their wages by their employers, and receive W-2s at the end of each year. An independent contractor receives a Form 1099 at the end of each year and is responsible for reporting and filing his/her own taxes. If a supervisor hires an intern as an independent contractor rather than as a employee, that supervisor may be accused of "aiding and abetting unlicensed practice," since the supervisor is assisting the intern to be "self-employed/an independent contractor." Interns are to Receive Fair Remuneration An intern may be paid as an employee or may be a volunteer in a private practice setting. The Law provides that, ". . .While an intern may be either a paid employee or a volunteer, employers are encouraged to provide fair remuneration." [B & P Code Section 4980.43 (e) (3)] The intent is that interns employed in private practice are to be treated fairly and are not to be financially exploited. Additionally, whether such interns are volunteers or employees, their employers have the same responsibilities. Interns Shall Have No Proprietary Interest Interns are to have no ownership interest in their employers’ businesses [B & P Code Section 4980.43 (i)]. This means that interns will not pay for rent or the other costs of running the employer’s business, will not pay for advertising, will not be a signer on a lease, will not be a signer on a joint checking account, and will not pay for supervision or be responsible for the employer’s share of payroll taxes. Interns are to Work Where The Employer Conducts Business PRACTICAL APPLICATIONS IN SUPERVISION

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"Interns shall only perform services at the place where their employer regularly conducts business, which may include performing services at other locations, so long as the services are performed under the direction and control of their employer and supervisor, and in compliance with the laws and regulations pertaining to supervision. . ." [B & P Code Section 4980.43 (i)] This means that interns are expected to work in their employers’ offices. It could mean, in addition, seeing a patient when the patient is hospitalized, or performing services in the patient’s home in the case of disability or other good cause. Some supervisors conduct business in multiple sites, which means that the intern may also see patients in these various locations, as long as the supervisor regularly sees patients at each location. The intern may not, however, work from an office located separate and apart for the supervisor (down the street or across town), unless the supervisor regularly does business at that site. Likewise, interns may not rent their own office space. Supervisors are Required to have a California License for Two Years A licensee must have been California licensed for two years in order to employ and supervise an intern [CA Code of Regulations 1833.1 (a)(1)] Supervisors are Required to have Actively Practiced In order to supervise, the supervisor must be actively seeing clients or providing supervision, at least within the recent past, i.e., The supervisor has practiced psychotherapy or provided supervision for at least two years within the five year period immediately preceding any supervision. [CCR 1833.1 (a)(5)] Private Practice Supervisors Limited to Three Interns A person supervising MFT interns in private practice may employ and supervise no more than three MFT registered interns [B & P Code 4980.45 (a)]. Regardless of the number of interns supervised within the private practice, the supervisor may supervise an unlimited number of interns and trainees for work settings other than private practice. Supervision by a Licensee Other Than the Employer If an intern is supervised by someone other than the employer of the private practice, the supervisor "shall be employed by and practice at the same site as the intern’s employer." [B & P Code Section 4980.43 (e) (4)] The BBS interprets this section literally, which means that the supervisor is to be an employee of the employer and may not be an independent contractor. In this case the number of interns permitted to be supervised within the practice is still limited to no more than three MFT registered interns. Supervision in an MFT Professional Corporation In the case of an MFT professional corporation, the corporation could employ up to fifteen MFT registered interns, as long as each of the persons who is qualified to provide supervision supervises no more than three interns, i.e., “A marriage and family therapy corporation may employ, at any one time, no more than a total of three individuals registered as a marriage and family therapist intern, clinical counselor intern, or associate clinical social worker for each employee or shareholder who

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has satisfied the requirements of subdivision (g) of Section 4980.03. In no event shall any marriage and family therapy corporation employ, at any one time, more than a total of 15 individuals registered as a marriage and family therapist intern, clinical counselor intern, or associate clinical social worker. In no event shall any supervisor supervise, at any one time, more than a total of three individuals registered as either a marriage and family therapist intern, clinical counselor intern, or associate clinical social worker. Persons who supervise individuals registered as either a marriage and family therapist intern, clinical counselor intern, or associate clinical social worker shall be employed full time by the marriage and family therapy corporation and shall be actively engaged in performing professional services at and for the marriage and family therapy corporation. Employment and supervision within a marriage and family therapy corporation shall be subject to all laws and regulations governing experience and supervision gained in a private practice setting.” [B & P Code Section 4980.45 (b)] Duty of Intern to Disclose Unlicensed Status The supervisor has a duty to ensure that each intern fulfills his or her responsibility to "[i]nform each client or patient prior to performing any professional services that he or she is unlicensed and under the supervision of . . ." [B & P Code Section 4980.44 (c)] Supervision by a Prior Therapist Prohibited Like other supervisorial relationships, experience in a private practice ". . .shall not be gained under the supervision of an individual who has provided therapeutic services to that applicant." [B & P Code Section 4980.03 (g)] Interns and Advertising Interns may be included in the advertising of the private practitioner as long as certain disclosures are made. These disclosures require the intern to, in the advertisement, state that he or she is a marriage and family therapist registered intern, his or her intern registration number, his or her employer, and his or her supervisor’s information [B & P Code Section 4980.44 (d)]. Thus, the intern’s business card or other advertisement would include the intern’s name, the fact that the intern is a marriage and family therapist, registered intern (and provide the IMF #_____), the name of the employer, and the name of the supervisor identifying the person as the supervisor, with the license title (and license number) of the supervisor. Permitting an intern to advertise in any manner that does not comply with the requirements of law or regulation may be grounds for disciplinary action against the supervisor as well as the supervisee. Supervisor Responsibility Statements All supervisors are required to sign "supervisor responsibility statements" prior to commencing supervision. These statements are signed under penalty of perjury and set forth many of the supervisor’s responsibilities, including, among other things, that the supervisor is appropriately licensed, the license is valid and not under suspension or probation, the supervisor is competent to provide supervision, the supervisor is knowledgeable about marriage and family therapy, and is knowledgeable about the laws and regulations that govern supervision. Further, this statement provides that the supervisor will give the supervisee a week’s written notice of his/her intent to not certify any further hours of experience [CCR 1833.1].

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The supervisor has the duty to ensure that the ". . .extent, kind, and quality of counseling performed is consistent with the training and experience of the person being supervised. . ." and the supervisor ". . .shall be responsible to the board for compliance with all laws, rules, and regulations governing the practice of marriage and family therapy. . ." [B & P Code Section 4980.43 (b)] There are many considerations when contemplating the decision to have or to not have an intern working for you in your private practice. As indicated, there are many things one first needs to know, and many legal considerations to give thought to. Regardless of these seeming obstacles (anything new seems formidable at the outset), being a supervisor can be a worthwhile, rewarding and profitable venture. Like anything else, it takes careful planning, preparation and nurturing. Selecting a candidate for the long term who is compatible and who has similar or complementary goals is key. Selecting an intern who is adept at marketing is also a plus, especially given current market conditions. Reconsider including an intern as an employee in your practice--the benefits can surpass the negatives.

This article appeared in the January/February 1997 issue of The California Therapist, the publication of the California Association of Marriage and Family Therapists, headquartered in San Diego, California. This article is intended to provide guidelines for addressing difficult legal dilemmas. It is not intended to address every situation that could potentially arise, nor is it intended to be a substitute for independent legal advice or consultation. When using such information as a guide, be aware that laws, regulations and technical standards change over time, and thus one should verify and update any references or information contained herein.

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MYTHS AND REALITIES OF SUPERVISION BY: MARY RIEMERSMA, FORMER EXECUTIVE DIRECTOR THE THERAPIST (SEPTEMBER/OCTOBER 2001)

REVIEWED/UPDATED JANUARY 2013

Therapists who take on the role of supervisor incur considerable responsibility. In assuming this responsibility, therapists need to be informed and knowledgeable about what this role entails. This article is written to provide reminders to therapists about their legal and ethical responsibilities of supervision and to dispel some of the rumors and myths that may accompany supervision. Laws and Regulations Regularly get updated licensing laws and regulations that govern the professionals for whom you will be providing supervision and carefully review the pertinent sections that address supervision issues. Whether an LMFT or other licensee, you may from time to time provide supervision for aspiring clinical social workers or psychologists. When these situations occur, you need to be knowledgeable about the laws and regulations for the other professions as well as your own. The laws and regulations for each of the professions can be obtained on the Internet, go to www.bbs.ca.gov for the licensing law and regulations for MFTs and LCSWs, and go to www.dca.ca.gov/psych for psychologists. These laws and regulations are amended regularly. Responsibilities of the Supervisor • Sign and adhere to the attestations on the Supervisor Responsibility Statement. • Ensure that the supervisee works within his/her scope of practice. • Ensure that the supervisee works within his/her scope of competence. • Ensure that the supervisee provides services in compliance with the law. • Ensure that the supervisee provides services in compliance with the ethical standards of his/her profession. • Ensure that the work setting that the supervisee is in is appropriate. • Ensure that the supervisee signs the mandatory statement acknowledging his/her child abuse reporting duties. • Monitor and evaluate the diagnosis and treatment decisions of the supervisee (social work profession-monitor the welfare of clients/psychology profession-monitor clinical performance and professional development). • Review client/patient records. • Provide some-left to your discretion-direct observation by one-way mirror, videotape, audiotape, as deemed appropriate by the supervisor. • Advise or encourage your supervisee, when appropriate, to get personal psychotherapy while being careful not to take on that role. • Develop a plan with your supervisee to address emergencies. PRACTICAL APPLICATIONS IN SUPERVISION

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• •

Obtain the name, address, and telephone number of your supervisee's prior supervisor and employer-and then use this information to learn of the supervisee's strengths, weaknesses and areas to work on. Prior to refusing to sign hours of experience, willingly give a week's written notice of your intent to not sign for hours of experience to the intern or trainee. A supervisor who has not provided such notice must sign for hours of experience obtained in good faith where such supervisor actually provided the required supervision. In fact, psychologists are subject to disciplinary action if they fail to sign hours of experience.

When supervising trainees, make sure that there is a written agreement between the school, employer and supervisor setting forth each party's responsibility. When supervising social work associates, it is necessary, annually and at termination, to assess the ongoing strengths and weaknesses of the supervisee. Additionally, supervisors of social work associates must develop a supervisory plan that defines the goals and objectives of the supervision. This plan is to be submitted by the supervisee to the BBS within thirty days of commencing supervision. When supervising persons pursuing the psychology license, one is required to file an annual report that addresses specific criteria. Mandatory Continuing Education Supervisors of MFT interns and trainees are required to regularly (during each license renewal period or within the first sixty days of commencing supervision) get six-hours of continuing education in supervision. The content of the required coursework is left to the discretion of the supervisor. Your supervisee will not be penalized should you fail to take the workshop or fail to take it timely; you could, nevertheless, be disciplined by a licensing board for failing to fulfill your obligation. If you are supervising a social work associate you must, prior to commencing supervision, complete 15 hours of coursework with specified content in supervision. The content includes: familiarity with supervision literature, facilitation of therapist-client and supervisortherapist relationships, evaluation and identification of problems, structuring to maximize supervision, knowledge of contextual variables, and the practice of social work including legal and ethical issues. Finally, persons supervising aspiring psychologists are also required to obtain six hours of training in supervision, however, one has various options including workshops, courses, supervision of supervision, or grand rounds. Make sure your interns and trainees inform clients, at least verbally and possibly in writing prior to performing professional services, that they are unlicensed and working under supervision. Persons who supervise persons pursuing the psychologist license are, as supervisors, required to notify patients that the supervisee is unlicensed and working under supervision. Make sure your interns and trainees do not receive any remuneration directly from patients or clients. Supervisees may only be paid by their employers and may only be paid as employees and not as independent contractors. PRACTICAL APPLICATIONS IN SUPERVISION

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Only licensed mental health professionals (licensed marriage and family therapists, licensed clinical social workers, licensed psychologists, and licensed physicians certified in psychiatry by the American Board of Psychiatry and Neurology) can supervise interns and trainees. The supervisor must have held a valid California license as a mental health professional for at least two (2) years and practiced psychotherapy or directly supervised trainees, interns, or associate clinical social workers that perform psychotherapy as part of their clinical practice for at least two of the past five years immediately preceding supervision. Should you be disciplined by a licensing board, you have a duty to immediately notify your supervisee(s) and cease providing supervision. Psychologists are required to notify supervisees at the time an accusation is rendered against them. Good Things to Do Give your supervisee a copy of the brochure, Therapy Never Includes Sex, and explain how it is to be used and where to get additional copies. Ask, prior to hiring your supervisee, if he/she has ever had a personal relationship or fantasies of a personal relationship with a patient. Impress upon your supervisee that personal relationships with patients will not be condoned. Inform the supervisee that you are to be apprised of any fantasies he/she may have about a patient. Impress upon your supervisee the need to maintain the confidences of patients. Inform the supervisee that patient files are not to be removed from the office-if permissible, photo-copies of records may be removed as long as properly safeguarded. Make it clear in writing and verbally that the supervisee employed in private practice is hired "at will." "At will," means he/she can likewise be fired "at will," or for any reason whatsoever, with or without cause. Encourage supervisees to join CAMFT and to regularly utilize CAMFT's services to get telephone consultation of a legal, business or practice nature. Provide each supervisee with a copy of CAMFT's Code of Ethics. Myth—"Working Under Someone's License" We regularly hear interns say that they are "working under someone's license," or likewise, we hear supervisors say, "she is working under my license." Unlicensed people do not work under another's license. Only the licensee can use his/her license. When a supervisor employs an intern, the supervisor becomes the employer and the intern becomes the employee; the supervisor uses his/her license to engage in practice, and the supervisee uses his/her intern registration number, PRACTICAL APPLICATIONS IN SUPERVISION

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which permits him/her to be employed in the private practice. When the supervisor provides supervision on behalf of another entity, the supervisor is responsible for providing supervision, but the intern likewise does not work under the supervisor's license. Myth—The Supervisor is "liable" for the Intern's Acts While it is true that the supervisor is responsible for the acts of the intern when the intern is employed in private practice, such liability does not rest with the supervisor when speaking of work settings other than private practice. In the state of California, the employer is liable for the acts of the employee. Interns who word in a private practice are employees of that private practice. It is the supervisee's status as an "employee" that creates the liability for the private practitioner/employer, not his/her status as an intern. Supervisors who are not also employers are responsible for the quality of the supervision he/she provides. Myth—Patient Records belong to the Intern The patients' records are the property of the employer. If the supervisor is the employer, in the case of a private practice, the records are the property of the supervisor. Interns should not be permitted, when terminating employment, to take the patients' records to the new employer. However, it may be permissible and appropriate to allow the intern or trainee to take a photocopy of the records to the new employer if the intern or trainee will continue to provide therapeutic services to the patient. Myth—Offsite Supervision is Unlawful Offsite supervision, or supervision not paid for by the employer, is lawful in all work settings other than private practice. To be acceptable, however, the supervisor must have a written agreement with the employer. It must contain specific language that comes directly from regulation [California Code of Regulations Section 1833(b)(4)]. Offsite supervision is lawful for marriage and family therapists and clinical social workers as long as there is an appropriately executed letter of agreement. Myth—The Supervisor Must Be Present 50% of the Time This provision was from the psychology licensing law and regulations, and has recently been somewhat revised. However, there is no minimum amount of time the supervisor must be present when the MFT intern, trainee or social work associate is working. Myth—Because the Supervisee is a Volunteer, Workers Comp Insurance is Unnecessary Employers of supervisees, where the supervisees work on a voluntary basis, may be required to provide workers compensation insurance. Regardless of whether the employer is or is not required to provide workers compensation insurance, it should be considered and makes good sense. The failure to provide such insurance could be very costly. If the supervisee is injured on the job, the employer could be held personally liable for all of the employee's/volunteer's medical care as well as lost wages. This would apply to "psychological injuries" (work-related stress cases) as well. Myth—The Patient "Belongs" to the Employer PRACTICAL APPLICATIONS IN SUPERVISION

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Patients don't belong to either party-employer or employee. Patients have free will and may go where they wish, which means the patient can stay with the employer and be referred to another therapist, the patient can be referred elsewhere to a therapist independent of the employer or supervisee, or, the patient can follow the supervisee to the supervisee's new employment setting, providing the supervisee is going to be appropriately employed and presuming the supervisee is not being terminated for having engaged in some heinous act. All parties, in this situation, should choose to operate in the patient's best interests. Generally speaking permitting the patient to follow the supervisee to his or her new employment setting may be in the patient's best interests, as the supervisee is the one with whom the patient has developed a therapeutic relationship. Regardless, therapists who are concerned about operating in the patient's best interests will offer the various alternatives to the patient and will let the patient decide what is best. Keep in mind, however, that the employer is responsible for the patient. If the employer is a licensed therapist in private practice, the licensed therapist has responsibility for that patient, whether the supervisee leaves voluntarily or is terminated for cause. Such a supervisor has a duty to make sure that the patient is not abandoned in such a circumstance. Reminders Make sure your license is current and valid and not under suspension or probation. Remember, if you neglect to notify the BBS, or other licensing board, of a change of address, your license will lapse and your supervisee will not be able to count his/her hours during the period the license is Myths and lapsed. In such a case, you could be subjecting yourself to disciplinary action by a licensing board and/or the possibility of a lawsuit brought against you by your supervisee. With one exception, you are required to be licensed in California for two years prior to providing supervision to MFT interns and trainees. Note: The only exception to the two-year license requirement is supervisors who provide supervision only to trainees at an academic institution that offers a qualifying degree program, where the supervisor has been licensed in California and in any other state, for a total of at least two years prior to commencing any supervision. Persons other than psychologists who are supervising aspiring psychologists, are required to be licensed for three years prior to commencing supervision. When an intern employed in private practice is supervised by someone other than the employer, the supervisor must be employed by and practice at the same site as the intern's employer. A supervisor may not supervise a spouse, relative, or domestic partner. The supervisor may not supervise anyone with whom he or she has a personal or business relationship. The supervisor may not do therapy with his/her supervisee, and may not supervise anyone who has previously been his/her patient. Effective January 1, 2010, the supervision ratio for Marriage and Family Therapist Interns and Associate Clinical Social Workers (ASWs) are as follows: One hour of individual supervision or two full hours of group supervision must be received during each week, in each setting in which experience is gained. There must be one additional hour of individual supervision or two additional hours of group supervision received during any PRACTICAL APPLICATIONS IN SUPERVISION

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week in which more than 10 hours of client contact is gained, in each setting. Individual supervision means one supervisor and one person being supervised. As regulation specifies, supervision is to be “one-on-one, individual, face to face.” One hour of individual supervision means sixty minutes of supervision. Two hours of group supervision means one hundred twenty minutes of supervision. Although it is permissible to provide two hours of group supervision in two, one-hour segments, both one-hour segments must be held during the same week in which the experience is gained. Group supervision means a group of no more than eight persons being supervised by one supervisor; two supervisors for a group of sixteen supervisees is not acceptable. Separate supervision is required for each work setting and in each week in which an intern or trainee is gaining hours of experience. Supervision must occur within the same week that hours of experience are gained. A supervisor may supervise an unlimited number of interns and trainees in any appropriate work setting other than private practice, but is limited to supervising three interns when those interns are employed in private practice. Also effective January 1, 2010, an intern working in a governmental entity, a school, a college, or a university, or an institution that is both nonprofit and charitable may obtain the required weekly supervision via two-way, real-time videoconferencing. Videoconferencing has not been defined other than it must be two-way and occur in real time (live). It may not be utilized predegree or prior to the issuance of the intern registration. Interns and trainees may only perform services as employees (IRS Form W-2) or as volunteers, and not as independent contractors (IRS Form 1099). Interns and trainees who have been hired and paid on an independent contractor basis will have their hours denied. The BBS views independent contractor status as self-employment, which is the reason such hours are denied. One may only be self-employed upon licensure. When an intern or trainee provides volunteered services in any lawful work setting other than private practice, and receives no more than a total, from all work settings, of five hundred dollars per month as reimbursement for actual incurred expenses, the hours will not be denied even though no W-2 is issued. According to law, the board may audit applicants who receive reimbursement for expenses, and the applicant has the burden of demonstrating that the payments received were for reimbursement of expenses actually incurred. Make sure your trainees and interns only perform services at the place where their employer regularly conduct business, which may include performing services at other locations, so long as the services are performed under the direction and control of their employer and supervisor and in compliance with the laws and regulations pertaining to supervision. For example, an intern working in private practice may see a patient in the hospital or a trainee may see a person who is homebound on behalf of the agency that employs him/her. Make sure your interns are "registered" at the time employment in your private practice begins. Make sure your trainees and PRACTICAL APPLICATIONS IN SUPERVISION

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interns have no proprietary (ownership) interest in your or the employer's business. This means that interns and trainees will not pay rent, be a signer on a lease, be a signer on a joint checking account, pay the costs of running the business, pay for advertising, etc. For all hours gained as a marriage and family therapist trainee, the school must have a written agreement with the employer where the hours are gained. If no agreement exists, such hours cannot be counted by the trainee, no matter how good the work setting or supervision is. All supervisors of trainees and interns must sign the Responsibility Statement for Supervisors of a Marriage and Family Therapist Trainee or Intern. The supervisor is required to provide the trainee or intern with the original signed Responsibility Statement prior to the commencement of any counseling or supervision and the intern/trainee must submit the original signed form to the Board upon application for examination eligibility. Supervisors of social work associates are required to sign a similar form entitled, Responsibility Statement for Supervisors of an Associate Clinical Social Worker, and shall provide the Associate with the original signed Responsibility Statement prior to the commencement of supervision and the Associate must submit the original signed form to the Board upon application for licensure. For psychologists in training, as of January 1, 2005, a Supervision Agreement must be completed and signed by the supervisor and trainee prior to accruing supervised professional experience. Once the supervised professional experience has been completed, a Verification of Experience Form must be completed and signed by the primary supervisor or, if the experience is part of a formal internship, completed and signed by the Director of Training and submitted with the Supervision Agreement Form directly to the Psychology Board by the primary supervisor or Director of Training. The Agreement Form is not to be sent to the Psychology Board until the Supervised Professional Experience has been completed and the Verification of Experience Form has been completed. All primary supervisors of psychologists in training shall be licensed psychologists, except that board certified psychiatrists may be primary supervisors of their own registered psychological assistants. Delegated supervisors shall be qualified psychologists or those other qualified l mental health professionals listed in section 1387(c) of the California Code of Regulations. The delegated supervisor(s) shall be employed in the same work setting as the trainee. A psychological assistant accruing Supervised professional experience in a private setting is required to submit a plan for such experience to the Psychology Board for approval as provided for in section 1387(b)(11). The proposed supervision plan submitted by the psychological assistant for approval must be signed by all participants involved and must describe the qualifications and responsibilities of the supervisor and/or the delegated supervisor. The plan shall also be developed for, and demonstrate, appropriate preparation of the psychological assistant to practice effectively within the specific private practice setting. Issues to Consider in Advance of Commencing Supervision How will you handle the supervision of your supervisee(s) when you are on vacation, ill, or unable to provide supervision for the week? Alternative supervision may be arranged during a

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supervisor’s vacation or sick leave if the supervision otherwise meets the requirements of the licensing law. Remember, if there is no supervision within the week, hours will not accrue. How will supervisee fees charged to clients be established? In an agency or setting other than a private practice, the fees are likely set by the employer and are not an issue. In a private practice, the fees should be set by the supervisor/employer, while there may be input from the supervisee. Remember, this is the employer's business, and the supervisee is an employee of the employer. How will you, the supervisor/employer, handle a termination-either initiated by the employer or initiated by the supervisee? Who "owns" the patients? Can the patients follow the supervisee to his/her new employer? What if there is no new employer? An article was previously written on this topic and can be found on the CAMFT website in the Resource Center. The article is entitled, "Termination of Employment: Who owns the Patient?" Should you have a contract/agreement with the new supervisee? If you are supervising on behalf of an entity other than in private practice, whether or not there is a contract/agreement has likely already been determined by your employer. If you are supervising in a private practice, you may want to consider a contract or an agreement. Whatever way you decide to go, it may be a situation of being "damned" if you do or "damned" if you don't. Contracts or agreements may have unintended consequences, such as, limiting your ability to terminate "at will," causing you to have to give warnings or notice that may not feel appropriate at the time you need to take action, or obligating you to provide benefits that, upon reflection, do not work. What will be included in disclosure/informed consent statements that your supervisee(s) will use with clients? What will be included in authorization forms that you will want to provide for your supervisee(s)? It will be difficult to adequately advise your supervisee(s) if you have not developed such documents for your personal use. Supervisors have many issues to consider prior to providing or during the course of providing supervision. This overview addresses some of the concerns that a supervisor should consider during or prior to commencing a supervisorial relationship. It does not and cannot address every situation that could potentially arise in the course of providing supervision, nor is it intended to be a substitute for independent advice or consultation. When using such an article as a guide, be aware that laws, regulations and technical standards change over time, and thus one should verify and update any references or information contained in this article. Keep in mind that members of CAMFT may always call the Association to get answers to questions of a legal, ethical or business nature. You will find CAMFT staff ready to assist you and informed about your questions about supervision. For other resources on supervision, refer to the CAMFT website in the Resource Center section. For example, "Critical Reminders for Interns and Trainees and Supervisors Too!" will provide useful information on required hours of experience, work settings and supervision concerns. This article appeared in the September/October 2001 issue of The California Therapist, the publication of the California Association of Marriage and Family Therapists, headquartered in San Diego, California. This article is intended to provide guidelines for addressing difficult legal dilemmas. It is not intended to address every situation that could potentially arise, nor is it intended to be a substitute for independent legal advice or consultation. When using such an article as a guide, be aware that laws, regulations and technical standards change over time, and thus one should verify and update any references or information contained in this article.

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TEN ADVERTISING MISTAKES MADE BY THERAPISTS BY: ANN TRAN-LIEN, JD, STAFF ATTORNEY THE THERAPIST MARCH/APRIL 2012

Advertising is a great way to promote your business and inform the public of the services you provide. It is one of the fundamental aspects of building a business, a career, and a name for yourself in your profession. Therapists are free to advertise, but they must do so in a manner that is truthful and accurate. The topic of advertising may seem simple enough, but California law mandates specific advertising requirements that licensed therapists, registrants, and trainees must follow. Generally, it is unlawful for therapists to disseminate any form of “public communication” containing a false, fraudulent, misleading, or deceptive statement (Cal. Bus. & Prof. Code 651(a).) The CAMFT Code of Ethics also provides clear guidelines on ethical advertising, and states that LMFTs, interns and trainees may not use any professional identification if it includes a statement or claim that is false, fraudulent, misleading, or deceptive.1 The Board of Behavioral Sciences (BBS) may take action against your license or registration if you fail to comply with California law on advertising.2 Keep in mind that the overall theme is to avoid any advertising that is, or can be reasonably construed as false, fraudulent, misleading, or deceptive. The omission of important information, as well as the inclusion of certain words and phrases, can render an advertisement false, misleading, or deceptive. To assist you in ensuring that your advertisement is in accordance with California law and the CAMFT Code of Ethics, this article will discuss how to avoid ten advertising mistakes that therapists regularly make. 1. Not recognizing that letterheads, e-mail addresses, or other public communications distributed to clients and the public are considered advertisements under California law. Many therapists may be surprised to know that the law considers, among other forms of public communication, e-mail addresses, letterheads, and websites as advertisements, along with communications by means of mail, television, radio, motion picture, newspaper, book, list or directory of healing arts practitioners, business cards, and office signs.3 Believe it or not, the BBS has taken action (usually in the form of a citation) against licensees and registrants because of a misleading or deceptive e-mail address, website address, etc. For example, an LMFT was recently disciplined for using an e-mail address with the word “doc” within the address when she did not have a doctorate degree or a license to practice medicine. Thus, it is prudent to remember that any public communication you make, including a letterhead or an email address, must comply with the advertising requirements and not be false, fraudulent, misleading, or deceptive. On occasion, you may find inaccurate information about you, your license, and/or your business in a directory or mentioned on television or radio that was not PRACTICAL APPLICATIONS IN SUPERVISION

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approved by you. In these circumstances, it would be wise for you to immediately, or when reasonably practicable, correct or attempt to correct the erroneous information. Keeping a paper trail documenting your attempts, or the process it took you to correct inaccuracies is advisable in the event you are challenged by the BBS at a later date. Your good faith efforts to correct any inaccuracies will be your best defense to any potential BBS inquiry. 2. Including the words “psychotherapy” or “psychotherapist” in an advertisement without following the BBS policy. Example of Inappropriate Advertisement: John Doe, MA. LMFT #123456. 7901 Raytheon Road, San Diego, CA 92111. Psychotherapy with individuals, couples, and families. The BBS adopted a policy (Policy # E-95-2) in 1995 that mandates the following: If a licensee, registrant, or trainee uses the words “psychotherapy” or “psychotherapist” in an advertisement, the advertisement must also include his/her full name and complete title of his/her license or registration. Additionally, the individual referenced in the advertising must be competent to perform the professional services advertised or be able to act in the professional capacity as advertised. Example of Appropriate Advertisement: John Doe, MA, Licensed Marriage and Family Therapist. 7901 Raytheon Road, San Diego, CA 92111. Psychotherapy with individuals, couples, and families. 3. Advertisements for unlicensed persons that do not disclose important and relevant information required by law. Example of Inappropriate Advertisement: ABC Counseling Center. John Doe, MA. MFTI. Under supervision of Jane Bee. Registrants and trainees may advertise their services, but they should do so under the oversight and control of their supervisors and employers. Since registrants and trainees are required by law to be employees or volunteers, and not independent practitioners, it is recommended that the supervisor and employer approve any advertisements for registrant and trainee services. The law requires advertisements for MFT Interns, trainees, ASWs, and PCC Interns to include certain information to ensure that the advertisements do not give the impression that the registrant or trainee has his or her own practice. Advertisements for MFT Registered Intern services must include all of the following information: 1) he or she is an MFT Registered Intern; 2) the Intern’s registration number; 3) the name of his or her employer; and 4) he or she is supervised by a licensed person (including the supervisor’s license information). In addition, if the acronym “MFTI” is used in an advertisement, the title “Marriage and Family Therapist Registered Intern” must also be written in the advertisement.4 Advertisements for MFT Trainee services must include all of the following: 1) he or she is an

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MFT Trainee; 2) the name of his or her employer; 3) the supervisor’s license designation or abbreviation, and the supervisor’s license number; and 4) that he or she is supervised by a licensed person.5 Advertisements for ASW and PCC Intern services must include all of the following: 1) he or she is an ASW or PCC Intern; and 2) the supervisor’s license designation.6 Websites and letterheads advertising unlicensed persons’ services need to adhere to the advertising laws (see #1). Also, e-mail addresses that are misleading or deceptive are unlawful (e.g. [email protected]com when John Doe is an MFT Registered Intern). It is also required that all unlicensed persons inform clients, prior to the outset of treatment, of his or her unlicensed status (see #5). Examples of Appropriate Advertisements:  ABC Counseling Center. John Doe, MA, MFT Registered Intern #67890. Under supervision of Jane Bee, LMFT #123456 

ABC Counseling Center. John Doe, MA, MFTI, Marriage and Family Therapist



Registered Intern #67890. Supervised by Jane Bee, Licensed Marriage and Family Therapist



John Doe, MSW, ASW #987654. Supervised by Jane Bee, LCSW #123456



John Doe, MA, Professional Clinical Counselor Registered Intern. Supervised by Jane Bee, LPCC #123456

4. Using the acronym or abbreviation of the license (“LMFT”; “LCSW”; “LPCC”) or registration (“ASW”; “PCCI”) in an advertisement without including the license or registration number. Example of Inappropriate Advertisement: John Doe, MA, LMFT. 7901 Raytheon Road, San Diego, CA 92111. Licensed therapists, Registered ASWs, and PCC Interns who advertise their services must include their license or registration number in the advertisement unless such advertisement contains the individual’s full name and full title of his or her license. Therefore, if you spell out the title of your license or registration in your advertisement, you are not required to include your license or registration number. (16 C.C.R. §1811.) Also, as previously mentioned, therapists cannot advertise the words “psychotherapy” or “psychotherapist” without including the complete title of their license or registration (see #2). This regulation is not applicable to MFT Interns as their registration number must always appear in their advertisements (see #3). Examples of Appropriate Advertisements:  John Doe, MA, LMFT #12345 PRACTICAL APPLICATIONS IN SUPERVISION

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 

John Doe, MA, LCSW. Licensed Clinical Social Worker John Doe, MA, PCCI. Professional Clinical Counselor Registered Intern. Supervised by Jane Bee, LPCC #1234565

5. Failing to provide clients with accurate information regarding an unlicensed person’s unlicensed status and supervision. Prior to performing any professional services, a trainee, MFT Intern, ASW, and PCC Intern must inform each client of their unlicensed status and provide their supervisor’s information.7 The law also requires trainees and MFT Interns to provide their employer’s information and interns to provide their registration numbers.8 It would be a good idea to include this information in the disclosure statement or professional service agreement so that there is written documentation that the client was accurately informed. 6. Including information about fees in an advertisement that is not exact and includes words that are prohibited by law. Example of Inappropriate Advertisement: Providing therapeutic services for as low as $60 a session! Call for more information! Although you do not have to include your fees in your advertisements, any advertisement that includes your fees must be exact, without the use of words or phrases, including, but not limited to, “as low as,” “and up,” “lowest prices,” or other similar words or phrases. The law specifically states that price advertising must not be fraudulent, deceitful, or misleading, including statements or advertisements of discounts or premiums, or any statements of a similar nature. The fee for each service must also be clearly identifiable. (Cal. Bus. & Prof. Code §651(c).) Prior to beginning treatment, therapists are also required to disclose to the client or prospective client the fee to be charged for the services. If there are any variables, such as charges for missed or cancelled sessions, that information should also be made known to the client at the outset of treatment.9 Example of Appropriate Advertisement: The fee for service is $100 per therapy session. A session is 50 minutes long. To cancel an appointment, please contact the therapist 24 hours in advance of your scheduled appointment. Cancellations made less than 24 hours in advance of the scheduled appointment and missed sessions will result in a $25 charge. 7. Using a fictitious business name or a “DBA” that is false, misleading, or deceptive. If you choose to do business under a name different from your full legal name, you must file a “Fictitious Business Name Statement” otherwise known as a “DBA” (doing business as) with the registrar-recorder/county clerk office in the county where your business is located. LMFTs, LCSWs, and LPCCs conducting a practice under a fictitious name must not use any name that is false, misleading, or deceptive, and must inform the client, prior to rendering treatment services, of the name and license designation of the owner(s) of the practice.10 PRACTICAL APPLICATIONS IN SUPERVISION

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Additionally, the CAMFT Code of Ethics specifically states, “LMFTs do not use a name that could mislead the public concerning the identity, responsibility, source, and status of those practicing under that name, and do not hold themselves out as being partners or associates of a firm if they are not.” (CAMFT Code of Ethics Part I, §10.3.) Thus, therapists who are sole proprietors should avoid using words in a fictitious business name that may give the impression that the sole proprietorship is a joint venture comprised of more than one owner. Such inappropriate words to include in a fictitious business name of a sole proprietorship are, “Center,” “Associates,” “Group,” etc. For an in-depth reading on joint advertising, see David Jensen’s article, “Joint Advertising: Profits or Peril?” (The Therapist, July/August 2006.) 8. Using the words “psychological” or “psychologist” in an advertisement when the practitioner is not a Licensed Psychologist. Example of Inappropriate Advertisement: John Doe, MA, Licensed Marriage and Family Therapist. Providing psychological services to individuals, couples, and families. Unless you have a license as a psychologist, it is unlawful to include in your advertisement words that could lead one to believe that you are a psychologist. According to California law, an individual is representing themselves as a psychologist when the person holds himself or herself out to the public by any title or description of services including the words “psychology,” “psychological,” “psychologist,” “psychology consultation,” “psychology consultant,” “psychometry,” “psychometrics” or “psychometrist,” “psychoanalysis,” or “psychoanalyst,” or when the person holds himself or herself out to be trained, experienced, or an expert in the field of psychology.11 You may advertise your degree in the area of psychology, such as, “clinical psychology” or “counseling psychology,” but it must be done in a manner that is not misleading or deceptive. Example of Appropriate Advertisement: John Doe, MS in Counseling Psychology. Licensed Marriage and Family Therapist. Providing psychotherapy to individuals, couples, and families. 9. Making a scientific claim in an advertisement that cannot be substantiated by reliable, published scientific studies. Example of Inappropriate Advertisement: John Doe. Licensed Marriage and Family Therapist. I specialize in treating anxiety by watching stand-up comedy. Advertisements that include a scientific claim must be capable of being substantiated by reliable, peer-reviewed, published scientific studies should the advertisement be challenged.12 If you are interested in including a scientific claim in your advertisement and would like to reference peerreviewed, published scientific studies, a good resource is EBSCO Host, which is available to CAMFT members, free of charge. For more information, log on to www.camft.org or call Membership Services at (888) 892-2638. Example of Appropriate Advertisement: John Doe. Licensed Marriage and Family Therapist. I have specialized training in Cognitive Behavioral Therapy to treat anxiety and related disorders. PRACTICAL APPLICATIONS IN SUPERVISION

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According to extensive studies, Cognitive Behavioral Therapy has yielded significant and large improvements concerning symptoms of anxiety and depression. 10. Soliciting testimonials from clients to include in an advertisement. Including testimonials in your advertisement does not necessarily fall under the overall theme of this article, which is to avoid advertising in a false, fraudulent, misleading, or deceptive manner; nevertheless it may be considered unethical conduct and may lead to issues of unprofessional conduct and/ or negligence. The CAMFT Code of Ethics Part I, Section 10.6 specifically provides that solicitation of testimonials from clients is unethical. Therapists and clients have a unique professional relationship, much different from the relationships the other professionals have with their clients. In a therapeutic relationship, the client is typically vulnerable and dependent upon the treating therapist. Accordingly, therapists must avoid behaviors and actions that could reasonably result in exploitation of the client. Since therapists can benefit monetarily from including client testimonials in their advertisements, it may lead to allegations of client exploitation. The client may feel obligated to provide the testimonial to the therapist, and/or feel as if he or she deserves favorable treatment from the therapist since the client has done a significant favor for the therapist (assisted in getting the therapist’s good word out). The client may feel hurt or rejected if he or she perceives that the therapist is ungrateful for the testimonial. It is also not recommended that the therapist solicit testimonials from former clients. While termination has taken place and a reasonable amount of time has passed, there may be a possibility that the client may wish to come back to therapy at a later time.

Ann Tran-Lien, JD, is a staff attorney for CAMFT. Ann is available to answer member calls regarding business, legal, and ethical issues.

Endnotes 1. CAMFT Code of Ethics Part I, § 10. 2. Cal. Bus. & Prof. Code § 4982(p). 3. Cal. Bus. & Prof. Code § 651; CAMFT Code of Ethics Part I, § 10.4. 4. Cal. Bus. & Prof. Code § 4980.44(d). 5. Cal. Bus. & Prof. Code § 4980.48. 6. Cal. Bus. & Prof. Code § 4996.18(e); § 4999.45(c). 7. Cal. Bus. & Prof. Code § 4980.44(c); § 4980.48(a); § 4996.18(e); § 4996.18(h); § 4999.36(d); § 4999.45(c). 8. Cal. Bus. & Prof. Code § 4980.44(c); § 4980.48(a). 9. Cal. Bus. & Prof. Code § 4982(n); CAMFT Code of Ethics Part I, § 9.3. 10. Cal. Bus. & Prof. Code § 4980.46; § 4992.10; § 4999.72. 11. Cal. Bus. & Prof. Code § 2902(c). 12. Cal. Bus. & Prof. Code § 651(b)(7).

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ON ETHICS: AVOIDING PROBLEMS WITH FEES, PAYMENT AGREEMENTS AND HEALTH INSURANCE BY: MICHAEL GRIFFIN, JD, LCSW, STAFF ATTORNEY THE THERAPIST MARCH/APRIL 2012

Over the past few years, the CAMFT Ethics Committee has received a number of complaints from consumers alleging that a therapist may have acted unethically because he or she either misrepresented, or failed to accurately represent, some fee-related issue. As you might expect, when a therapist discovers that a former client has made such a complaint, it tends to be a very unsettling experience. In some cases, the therapist is surprised that the client has made such a complaint. But in many instances, fee-related problems were evident during the course of treatment but never resolved. In fact, a dispute involving the client’s fee, health insurance benefits, or some other payment-related issue may have precipitated the termination of the client’s treatment. It is hard to overstate the need for LMFTs and pre-licensees to maintain clear communication with clients regarding the issue of health insurance and fees. There are numerous reasons for saying this, not the least of which is the likelihood that a fee or payment-related dispute will disrupt a client’s treatment. Such a dispute can also lead to an ethics complaint or a disciplinary action against a therapist by the Board of Behavioral Sciences. Problems concerning fees and insurance can often be avoided by the exercise of due care by the therapist. The following precautions may be obvious to most therapists, but they are necessary, if a therapist hopes to minimize the likelihood of a fee-related complaint. Take care to thoroughly discuss the issue of fees and responsibility for payment before treatment begins It is understandable that a therapist may struggle in meeting this requirement. The therapist may be uncomfortable discussing the issue of money with the client, or the client may resist talking about the subject of fees, preferring to engage the therapist in a discussion of his or her immediate concerns. The therapist may also feel a sense of urgency in responding to the client’s emotional distress before doing anything else. But, the issue of fees must be appropriately addressed before providing services to the client. This includes all aspects of the fee arrangement, including missed appointment or cancelation fees, health care insurance arrangements, etc. Take the time to identify and discuss health care plan benefits and limitations The importance of clear communication with clients regarding fees and payment agreements is especially true when the client is utilizing his or her health insurance to pay for therapy. Considering that there are multiple types of insurance plans, with varying benefits and eligibility PRACTICAL APPLICATIONS IN SUPERVISION

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rules, it is quite easy for misunderstandings to occur. That doesn’t mean that every problem which involves the client’s health insurance is necessarily the therapist’s fault. A client may be angry when “discovering” the insurance plan has a large deductible, even though it was the client who purchased the plan. Or, the client may state that he or she didn’t realize that the insurance plan would not reimburse the cost of services provided by an “out of network” therapist. Ultimately, it is recommended that the client record contain a clear written fee agreement, which contains the relevant office policies regarding the topic of health insurance. When, and if, problems arise concerning the client’s fee, the therapist should attempt to address the issue at the earliest possible opportunity. Clients who are covered by Medicare should be informed that services provided by marriage and family therapists, are not currently reimbursed by Medicare. Services provided by Interns and Trainees A client may be unfamiliar with the distinction between an LMFT and a Registered Intern and fail to recognize that his or her health insurance benefits probably don’t apply to treatment rendered by the Intern. While it is possible that the health care plan may cover services provided by Registered Interns it is unlikely. Consequently, when services are to be provided by an Intern or Trainee, it is extremely important that the client be informed of the fact that his or her health insurance may not provide reimbursement for the treatment provided. The Bottom Line: It is important to maintain clear communication with clients on any issue concerning fees, insurance and payment agreements Regardless of whether the therapist or client is ultimately determined to be “at fault” for the problem, the bottom-line is that almost any fee-related dispute is upsetting to the client and to therapist. Although it is probably impossible for a therapist to eliminate the possibility of encountering a problem in this area, it is possible to reduce the likelihood of having such problems by thoroughly discussing any and all fee-related issues from the start and by maintaining clear communication with clients as issues arise.

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SECTION II

PRACTICAL APPLICATIONS IN SUPERVISION

TABLE OF CONTENTS

SECTION II TEACHING PSYCHOTHERAPY: THE PROCESS OF SUPERVISION AND CONSULTATION CLAIRE ALLPHIN

II- 3

LIVE SUPERVISION OF LIVE SUPERVISION: A MULTI-LEVEL APPROACH JENNIFER ANDREWS AND DAVID J. CLARK

II-10

HOW PERSONAL CAN TRAINING GET? HARRY J. APONTE

II-20

THE ROAD TO BECOMING A CAMFT CERTIFIED SUPERVISOR CATHERINE AUMAN

II-33

SELF-DISCLOSURES AND SUPERVISION: THE USE OF SELF-DISCLOSURES WITHIN SUPERVISION RICKI BODEN

II-41

SELF-DISCLOSURES AND SUPERVISION: GUIDELINES FOR TEACHING INTERNS THE USE OF SELF-DISCLOSURE WITH CLIENTS RICKI BODEN

II-47

THE INTERACTIONAL NATURE OF SUPERVISION: A PSYCHODYNAMIC PERSPECTIVE SUSAN BOULWARE

II-54

RELATIONSHIP AND SUBJECTIVITY JUDITH R. BROWN

II-62

TEACHING AND LEARNING PROBLEMS IN SUPERVISION JANE BURKA

II-69

THE SOUL OF SUPERVISION PETER H. COSTER

II-79

INTERACTIVE EVALUATIONS: SOME PROCESS-ORIENTED QUESTIONS FOR THE SUPERVISOR LAUREL J. COX

II-84

MUSINGS OF A SUPERVISOR SHARON DUFFY

II-89

TRAINING TO THINK CULTURALLY: A MULTIDIMENSIONAL COMPARATIVE FRAMEWORK CELIA JAES FALICOV

II-95

INDIVIDUAL AND GROUP SUPERVISION OF LMFT INTERNS IN AN AGENCY SETTING: PRACTICAL APPLICATIONS IN SUPERVISION

A TRAINING MODEL BARBARA FARBER

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DEVELOPMENTAL STAGES IN SUPERVISION: IMPLICATIONS FOR SUPERVISORS AND ADMINISTRATORS TAD GOGUEN FRANTZ

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DIFFERENT TYPES OF COUNTERTRANSFERENCE AND THE IMPORTANCE OF ADDRESSING THEM IN SUPERVISION SARAH GILLEN

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SUPERVISION OF INTERNS: BALANCING ALL THE HATS LYNDA HARBERT

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THE SUPERVISORY EXPERIENCE: AN OBJECT RELATIONS PERSPECTIVE HAROLD JARMON

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PRACTICAL AND CULTURAL ASPECTS OF SUPERVISION DOLORES S. JENERSON-MADDEN

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SUPERVISION: AN HONOR AND A GIFT OF BOTH GIVING AND RECEIVING FOR BOTH SUPERVISORS AND SUPERVISEES STUART KAPLOWITZ

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SCHOOL OR APPROACH SPECIFIC MODELS OF TRAINING AND SUPERVISION HOWARD LIDDLE

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MULTIPLE THEORETICAL APPROACHES TO SUPERVISION: CHOICES IN FAMILY THERAPY TRAINING SUSAN H. MCDANIEL, TIMOTHY WEBER, JAMES MCKEEVER

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IN TREATMENT JULIE OLSON

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AN INTEGRATIVE APPROACH TO FAMILY THERAPY SUPERVISION WAYNE F. REGINA

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GENDER IN SUPERVISION/TRAINING IN MARRIAGE AND FAMILY THERAPY ELIZABETH J. REGISTER

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OVERCOMING OBSTACLES TO LIVE SUPERVISION LYNNE SHOOK

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ENHANCING LIVE SUPERVISION WITH CREATIVE LEARNING ENVIRONMENTS IN AGENCY AND UNIVERSITY SETTINGS H. DAN SMITH

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COLLABORATIVE TRAINING TOOLS FOR SUPERVISORS AND SUPERVISEES NANCY STEINY

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THE USE OF ROLE-PLAY IN PSYCHOTHERAPEUTIC TRAINING PRACTICAL APPLICATIONS IN SUPERVISION

MOLLY MERRILL STERLING

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PROBLEM-FOCUSED SUPERVISION: RATIONALE, EXEMPLICATION, AND LIMITATIONS CHERYL L. STORM, ANTHONY W. HEATH

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THE WAY OF THE SUPERVISOR ROBERT TAIBBI

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SOLUTION-ORIENTED SUPERVISION: THE COAXING OF EXPERTISE FRANK N. THOMAS

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GOING ABOVE AND BEYOND THE REQUIREMENTS: CAMFT CERTIFIED SUPERVISOR PROGRAM

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PRACTICAL APPLICATIONS IN SUPERVISION

TEACHING PSYCHOTHERAPY: THE PROCESS OF SUPERVISION AND CONSULTATION CLAIRE ALLPHIN

THIS ARTICLE WAS PUBLISHED IN THE PSYCHOTHERAPY INSTITUTE JOURNAL. BERKELEY, CA; 1982, PP. 17-22.

There has not been a great deal of interest among psychotherapists in theories about supervision and consultation, and when I first began supervising I did what I think most supervisors do: relied on my own experiences as a supervisee and psychotherapist. Since that time, I have read as much literature as I could find on the subject, and have also developed some concepts of my own. As will be apparent from this paper, I have come to realize that it is very important to recognize and understand the differences (as well as the similarities) between teaching psychotherapy and doing psychotherapy. I hope the ideas and concepts presented here will help to make the teaching/learning process more understandable and hence more effective for supervisors and consultants, and supervisees and consultees as well. Difference Between Supervision and Consultation Effective supervisors and consultants must consider themselves primarily educators, not psychotherapists. I see only one difference between supervising and consultation, but it is important and needs to be acknowledged at the outset. The therapist is required to be in supervision, whereas the therapist chooses consultation. When an agency or licensing board requires that a therapist be supervised, the supervisor is responsible for the practice of the supervisee. It is therefore important that the supervisor be given authority by the agency to supervise; otherwise the supervisor has responsibility but no authority to carry it out. For example, an agency which does not value teaching and has student-therapists only to serve more clients with less cost to the agency, the supervisor may not be given the authority to deal with a student-therapist who is not acting responsibly with patients, or who chooses not to come to regularly scheduled supervisory sessions. The requirement that the therapist be supervised affects the relationship with the supervisor. There is more likelihood that a parent-child pattern will occur in the transference and countertransference relationship, or at least that the intensity of this pattern will be greater than in consultation. Difference Between a Therapist in Supervision or Consultation and a Patient in Psychotherapy The relationship between supervisor/consultant and therapist is of crucial importance in teaching psychotherapy, just as the relationship between therapist and patient is in practicing psychotherapy. A therapist comes to a supervisor/consultant in order to learn how to use himself or herself in the psychotherapeutic process, wanting change in that part of the self which makes up the professional helping function. A patient, on the other hand, presents all of his or her life experiences to a psychotherapist, to be examined in the interest of change (Ekstein, 1958). Often there is development beyond the narrowly professional realm for therapists, but in my view this PRACTICAL APPLICATIONS IN SUPERVISION

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should be secondary to the aim of professional development. In the supervision/consultation situation, the focus is on the relationship between the therapist and patient. What the therapist brings of his or her personal life can usually be related to the work the therapist is doing with the patient. Concepts Specific to the Teaching Process Parallel Process One especially useful concept in the teaching of psychotherapy is parallel process, which occurs when the relationship between the therapist and patient is re-enacted in the relationship between supervisor/consultant and therapist. The supervisor/consultant may experience reactions and feelings that the patient experiences, or reactions and feelings that the therapist experiences in working with the patient; or the therapist may treat the patient as the supervisor/consultant would treat him or her. The latter situation is more likely to occur when there is a problem between supervisor/consultant and therapist that is not being acknowledged. Parallel process occurs unconsciously and is especially useful in discerning the basis of a problem in the therapeutic relationship. The learner is communicating the difficulty to the teacher unconsciously, in order to get help. An example is a therapist who presented to me the case of a man who had told her in a very casual tone that his girlfriend had just had an abortion. The therapist was angry at her patient for not having compassion for his girlfriend. I found myself feeling angry at the therapist for not trying to understand her patient. When we talked about this, we could see that I needed to have compassion for the therapist so she could have it for her patient, who would in turn be able to have compassion for his girlfriend. The therapist’s presentation of her reaction helped me to help her understand her patient, so she could be with him as he needed her to be. In the parallel process which occurred, I, as supervisor/consultant, experienced toward the therapist what the therapist experienced toward her patient. Unconsciously, the therapist was acting like her patient in the relationship with me in order to learn from me how to work with her patient more effectively. My experiencing what the therapist experienced helped me to understand and help her to relate in a therapeutic way toward her patient. Learning Patterns Patterns develop that show how a person learns and what difficulties there are in learning effectively. A pattern is the way a person learns and the way he or she resists learning. People exhibit different learning patterns — some learn by protesting and arguing about new ideas, while others are submissive, taking in new information, but not using it until it becomes more familiar (Ekstein, 1958). One therapist whose pattern was to quietly accept new ideas finally complained that too much was being presented to her, and she could not make sense of it. I was surprised because she did not question any ideas until several supervisory sessions had taken place. Knowing this about her learning pattern helped her to work more effectively. After we discovered her learning pattern, she could consciously regulate her intake of new information, and I could be more sensitive to her capacities.

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Change is both wanted and feared; in learning there will be desire for change and resistance to it. In the above example the therapist learned by being submissive, but she also resisted learning by seeming submissive while not taking in what was offered in the teaching process. Learning patterns are unique to each individual. Ekstein and Wallerstein (1958) point out that categorizing learning patterns is useful for illustrative purposes but does not do justice to the complexities involved in the nuances through which the learning patterns manifest themselves. Here are a few of the examples Ekstein and Wallerstein (1958) list: “learning by vigorous denying” in which the student denies anything new can be useful; the “mea culpa” attitude in which the student magnifies his or her own failings in order to avoid anyone else’s finding fault; and the pattern in which the student has a “problem finding a problem.” In this last pattern, the student sees the teacher as having the responsibility of pointing out problems, rather than himself or herself taking responsibility for finding problems. Learning Problems Ekstein and Wallerstein (1958) call learning patterns that occur in the relationship between therapist and patient learning problems. In this situation, the therapist is reacting to the patient according to the therapist’s own idiosyncratic patterns, without regard for the patient’s needs. Discussion of these learning problems in the supervisory or consulting situation enhances the therapist’s learning the practice of psychotherapy. In other words, it is via the difficulties the therapist has in relating to the patient that teaching and learning take place. The unique difficulties in the therapist/patient relationship will reflect learning problems that have their basis in the therapist’s learning pattern. Problems About Learning Learning patterns will occur in the relationship between supervisor/consultant and therapist, and are called by Ekstein and Wallerstein (1958) problems about learning. The therapist reacts to the supervisor/consultant in his or her characteristic pattern of learning. This reaction needs to be viewed as the therapist’s effort to learn and also as his or her resistance to learning. Here is an example differentiating the learning pattern, the learning problem, and the problem about learning: the therapist’s learning pattern was to act as though she knew everything and did not need help. The pattern became a learning problem when she insisted on telling her patients what to do instead of helping them to discover for themselves what they wanted to do. The pattern became a problem about learning when the therapist did not bring problems about her work to the supervisory sessions because she needed to present herself as knowing everything. Concepts Common to Teaching and Practicing Psychotherapy Initial Comments I find the initial comment or comments a therapist makes about the patient very important in deciphering the problem in their relationship. For example, a therapist’s saying, “I feel bored,” or “angry,” or “anxious” with the patient provides a clue to understanding the dynamics of the therapeutic situation. The patient may be acting in a way to evoke certain feelings in the therapist in order that the therapist can understand what the patient has felt when treated similarly by, for example, a parent.

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I have frequently found it useful to return to the initial comment or question when, later in the supervisory or consulting session, I find myself puzzled or stuck in trying to understand the process between the therapist and patient. Attention to the initial comment of the therapist is similar to attention given to the initial session or the beginning of the session in practicing psychotherapy. The difference is that, in teaching, I hear what the therapist says as a comment about what the patient is trying to communicate about himself or herself, whereas, when I am with a patient I hear the patient talking about himself or herself, or about our relationship. Tension in the Relationship Experiencing tension in the relationship between myself and the therapist tells me something is happening which needs to be discussed or attended to in some way. For example, one therapist I supervised talked for several sessions about her patients leaving therapy and her concern about what she was doing to provoke this. During these sessions the thought occurred to me that the therapist was dissatisfied with supervision and was thinking of stopping or changing supervisors. I felt particularly tense before the last session, when, indeed, the therapist said she wanted to stop working with me and to work with someone else. In retrospect I think it would have been helpful for me to have raised the question I had about whether the therapist was feeling dissatisfied. There was a parallel process occurring which I overlooked. Since I did not bring up the negative feelings at the first opportunity, i.e., when I thought the therapist was having negative feelings about me, she acted them out by leaving supervision rather than talking about her feelings; this was the process that had occurred with her patients. She was not open to hearing their indirect or implicit complaints about her, so the patients acted out their feelings by leaving. My second opportunity to bring up the question about the supervisory relationship was when I experienced the tension, but again I did not take the opportunity to do so. I was newly in full-time private practice and did not want to hear criticism about my supervisory work. So we see in the process between supervisor and therapist the essential ingredient of the work between the therapist and her patient. In both dyads there was an absence of dealing with negative feelings, which I believe could have been remedied if I had realized that a parallel process was occurring and had talked about this process, or if I had later found a way to discuss the tension I was experiencing. I think there is a difference between tension which arises in the supervisor/consultant as a result of the parallel process, and tension which arises as the result of a problem or undiscussed issue between the supervisor/consultant and therapist. The above example illustrates a combination of the parallel process and tension in the supervisory relationship. An example of a situation in which the tension in the supervisory relationship was not related to the parallel process is a therapist who came late to several supervisory sessions. I began to feel tense and uncomfortable about this, and my asking the therapist about his coming late so frequently led him to reveal his feeling envious of me for being experienced and having an established practice. His training was near end, and he was just about to begin to be on his own, to develop his own practice, and to start paying for private consultation. Identification with the Therapist In teaching psychotherapy, I usually identify with (or put myself in the shoes of) the therapist, rather than the patient. In this way, I can help the therapist deal with what he or she is feeling PRACTICAL APPLICATIONS IN SUPERVISION

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about the patient so the patient can then have a therapist who is clearer about what he or she is doing. In other words, when the therapist is clear about himself or herself in relation to the patient, he or she can then listen and understand the patient more clearly. Identifying with the therapist when I am teaching is the same as identifying with the patient when I am practicing psychotherapy. The difference is that I comment about, or ask questions about, the therapist’s relationship with the patient, not with me, as I do in the therapeutic situation. Use of Transference and Countertransference This is another area of similarity between teaching and practicing psychotherapy. Supervisor/consultant and therapist experience something of the parent-child pattern of relationships, as do therapist and patient. In the former case, this relationship does not usually need to be interpreted, but does need to be recognized and accepted. In teaching, I use the therapist’s countertransference reactions to help him or her understand the patient; just as in the therapeutic relationship, I use my countertransference reaction to help me understand the patient. For example, when a therapist feels a strong reaction toward a patient, especially if this particular reaction is unusual, often the therapist has introjected, or taken in, a projection that the patient has made onto him or her. One therapist was describing why he wanted to push his patient to make a decision about a career although the patient had just begun to talk about this after recently leaving another profession. The therapist was surprised at himself, and, as we talked about the patient and her mother’s reaction to her, the therapist realized he had introjected the patient’s projection of her mother onto him. This helped the therapist understand what the patient needed from him — i.e., not to be pushed into making a premature decision, as she had done in the past to satisfy her mother. This illustrates using the therapist’s countertransference reaction in order to help him or her understand the patient, just as I use my countertransference reaction to understand my own patient in the therapeutic situation. Phases in the Teaching Process I now want to describe what occurs in the teaching of psychotherapy that is unique to the supervisor/consultant-therapist relationship. There are phases in the teaching process that are not a function of the relationship between therapist and patient that are specific to the relationship between supervisor/consultant and therapist. In my experience, I have seen three phases in the teaching process (something like those that Heinz Kohut sees in the psychotherapeutic process): mirroring, idealization, and internalization of the idealizing functions, i.e., separation-individuation. The mirroring phase occurs initially, when the therapist is ambivalent about change and needs the supervisor/consultant to reflect empathically his or her experience in order to strengthen the uncertain, anxious learner. During the idealizing phase, the therapist experiences the supervisor/consultant as all-knowing and uses the supervisor/ consultant’s strength to bolster his or her own. In the third phase, the therapist internalizes the functions he or she formerly attributed to the supervisor/consultant. In supervision/consultation, these phases are not discrete entities, just as they are not in the psychotherapeutic process. They overlap, occur PRACTICAL APPLICATIONS IN SUPERVISION

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simultaneously, and in various orders throughout the teaching process. Initially, the therapist needs the supervisor/consultant as a self-object in the Kohutian sense: an important person or object in one’s life who provides affirming, approving, and tension-regulating functions and also serves as a model to idealize (1971). The beginning learner does not have tension-regulating functions internalized with regard to being a therapist. For example, he or she may be unable to evaluate compassionately his or her work as a therapist, and needs the supervisor/consultant to provide this function. One young beginning therapist came to a supervisory session very depressed because he had not known what to say when his patient asked if she were abnormal, after telling the therapist that she had three children, each by different fathers, all of whom she had known only casually. In this instance, I talked with the therapist about his reactions to the patient so he could learn to sufficiently separate himself to help the patient talk about her own feelings about herself. As a supervisor, I identified with the therapist, mirroring his feelings of helplessness. The therapist, in turn, was then able to mirror the patient’s feelings so she could become accepting of her own feelings. This occurred as a result of the therapist’s being able to have compassion for his reaction to the patient, after he recognized the source of his own feelings toward the patient. I think the therapist can benefit from knowing something of the foibles the supervisor/consultant has. I let more of myself be known to therapists than to patients in order to help therapists be more compassionate about themselves and to dilute the idealizing transference. In the relationship between the supervisor/consultant and the therapist, as compared to that between the therapist and patient, the two participants are more dependent on each other for feedback about how each is doing his or her job. Margaret Rioch (1976) summarizes this notion: Teachers of psychotherapy have no reliable way of measuring what their students have learned. They rely on impressions and anecdotes, most of which are supplied by the very students whose learning they are trying to evaluate ... The teacher who is in despair at not being able to communicate anything of value to a particular student may, the next day, become exaggeratedly cheered by evidence of improved therapeutic skill. The reverse occurs equally often. (p. 233) Finally, it is important for a supervisor/consultant to be able to let go of the need to be idealized. Supervisor/consultants need to feel good enough about themselves not to need therapists’ idealization of them beyond the point of the therapists’ own needs. Conclusion Learning to teach psychotherapy should be an ongoing process, just as learning to practice psychotherapy should be. This paper’s bibliography suggests a number of sources for concepts and techniques helpful to supervisors and consultants. Consulting with more experienced teachers is, of course, a very useful learning device which allows teachers to present their work with students just as psychotherapists present cases to supervisors and consultants. Peer consultants can also be used in a similar way. I hope that better-developed ideas and methods will accrue from continued examination of the process of teaching psychotherapy, and that PRACTICAL APPLICATIONS IN SUPERVISION

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before long there will be more extensive literature on the subject. References Ekstein, Rudolf & Robert S. Wallerstein. The Teaching and Learning of Psychotherapy. New York: Basic Books, 1958. Kohut, H. The Analysis of the Self. New York: International Universities Press, 1971. Rioch, J. Margaret, Winifred R. Coulter, David M. Weinberger. Dialogues for Therapists. San Francisco, Washington & London: Jossey-Bass, Inc., 1976.

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LIVE SUPERVISION OF LIVE SUPERVISION: A MULTI-LEVEL APPROACH JENNIFER ANDREWS, M.A. DAVID J. CLARK, PH.D.

It still happens that therapists with more experience are expected to become supervisors of other therapists. This, more often than not, is done with a view that the process of therapy, and perhaps an apprenticeship contain all the training that is necessary to produce a skilled clinical supervisor. This article reflects a movement within the field of marriage and family therapy (MFT) that views the roles and objectives of supervisor and therapist as different. Although the same person can play both roles, each has different technical skills and a distinct professional identity. The American Association of Marriage and Family Therapy (AAMFT) Commission on Supervision Bulletin (Heath, 1989) notes, “there are five books on family therapy supervision and/or training, six special issues of journals, 26 review articles, and hundreds of other articles and chapters on specific aspects of marriage and family therapy supervision and/or training” (p.3). This literature provides almost no information about this MFT training subspecialty that can be used in practice. This article attempts to fill the gap by presenting an example of our experience as MFT supervisors/trainers. Pragmatic and Conceptual Considerations For many years, we have been involved with a training program which uses an integrated gestalt/systems therapy approach. Although our primary focus is upon live supervision, we utilize videotape supervision, didactic/experiential supervision, directed readings and the use of training tapes for vicarious learning and gaining conceptual ideas. Our program goal is enhanced professional development for both marriage and family therapists and supervisors. There are four assumptions in our framework for the practical description of our supervision of the supervisor. 1.

2.

We assume that an integration of a non-pathology seeking intrapersonal model such as gestalt therapy (Andrews & Clark, 1985; Andrews, Clark & Zinker, 1988; Greenberg, 1983; Kaplan & Kaplan, 1982, 1987) is congruent with systemic theory and practice. We assume that the resulting approach is appropriate for training supervisors since it contains relational skills and recognition of “internal processes” (Breunlin, Karrer, McGuire & Cimmarusti, 1988) for the close work between the training-supervisor (TS) and the supervisor-in-training, (SiT), as well as the similar, close work between the SiT and the therapist-in-training.

We extend our relational focus, using a wide angle lens for the traditional “I-Thou” relationship so that it may include the systems on both sides of the mirror. The therapist system consists of all the people that are involved in administering treatment to the patient system, while the patient system is made up of all the human systems that are or may be involved in the maintenance or resolution of the presenting problem (Pinsof & Catherall, 1986). Similar to other practical methods (Greenberg & Webster, 1982; Harman & Tarleton, 1983: Williams, 1988), we systematically integrate experiential work from gestalt therapy into PRACTICAL APPLICATIONS IN SUPERVISION

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our program. Both individual training sessions and the training group allow for experiential methods and exercises such as empty chair work, role playing and focusing (Gendlin, 1978). 3.

We also believe that a truly integrative model, in contrast with “undisciplined eclecticism” (Liddle, 1982) prepares the supervisor to think critically, question the literature, and remain open to new ideas (Lebow, 1987).

Our typical SiT is licensed as a marriage and family therapist and is in a work situation which requires that he/she provide supervision for other therapists or trainees. He/she usually has the professional goal of obtaining the AAMFT-Approved Supervisor designation. At the beginning of supervisory training we evaluate the SiT’s level of competence in the particular model of family therapy (i.e., structural/strategic) with which the SiT identifies. The new therapist-trainee is presented with an approach that incorporates goal-oriented models with the ability for direct communication and creative experimentation. With regard to reliance on a particular family therapy model, we agree with Breunlin, Liddle and Schwartz (1988) that “models are viewed as partial realities of the field of family therapy, and as the training program progresses, supervisor/trainees are encouraged to expand their systemic thinking through careful integration of compatible models,” (p. 215). Our format and structure appear similar to that described by the above authors as, “concurrent training of supervisors and therapists,” (Ibid. pp. 207-224). This position holds that a therapist/trainee best learns to do family therapy by actually working with live families. Similarly, the SiT learns to do family therapy supervision by doing the supervision while being closely monitored and receiving feedback often from the TS. This concurrent training allows for simultaneous change and learning to occur at multiple levels which include the family system, the therapist-in-training, the SiT, the observing team of therapists-in-training and the TS. 4.

We further assume that learning at each of the different levels is “isomorphic,” that is, the changes of the same form occur as a ripple effect at the different levels. If the therapist is irritated with the family, the SiT can become irritated with the therapist, the team becomes irritated with the SiT and the TS can become irritated with the entire group. There is considerable recognition in the professional literature of psychotherapy and counseling and clinical supervision for the similar concept of “parallel process” (Stoltenberg & Delworth, 1987). So it is commonly observed that when growth or change takes place at any level of a system, other levels are affected.

However, the learning which takes place in the family system or the therapy system does not teach supervision skills. Jay Haley suggests that we examine the “parallels” between supervision and therapy and the corresponding consequences of a training approach. “It is different if the trainee is to become a teacher and supervisor. In that case, he or she must learn the conceptualizations in order to pass them on and so the process of how to teach is itself a learning situation,” (Haley, 1988, p. 366). We can agree that some change is happening at each of the MFT therapy training levels, but there is a difference among these subsystems. Providing marriage and family therapy, training MFT therapists and training MFT supervisors involves different goals and attitudes. These can be classified as different categories or levels of learning. There is a difference between doing marriage and family therapy, training marriage and family PRACTICAL APPLICATIONS IN SUPERVISION

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therapists and the training of MFT supervisors. We agree with current research (Kniskern & Gurman, 1988) which suggests that three components which are fundamental for the development of good clinical skills are: structuring skills; relationship skills; and experience over time. Kniskern and Gurman (Ibid.) point out that level of experience is “an indirect criterion for training success.” Generally, with the more experienced therapist, the chances are better for a successful outcome for the family in therapy. Though time is not a variable that can be taught to trainees, the other two factors that relate to training success can be effectively taught and it is important for the supervisor to teach these well. Structuring skills include directness, clarity and self-confidence, information-gathering and the skill of stimulating interaction. Relationship skills include warmth, humor, affect and behavior integration. These skills appear to be related to positive outcome, regardless of therapeutic orientation (Ibid. p. 370). Cleghorn and Levin (1973), discuss three objectives related to these skills. We agree with these objectives as goals to increase both the supervisor and therapist trainees’ conceptual skills; those which relate to the ability to formulate problems and solutions systemically and allow them to make interactional predictions, perceptual skills; those which relate to the ability to evaluate a particular family-system or therapist-client-system; and executive or technical skills. These skills relate to the ability to act in a family-system or therapist-client-system in ways that are consistent with the training program. The stages of development (Hess, 1986), which reflect growth in supervision, are an exciting experience for all involved. As the process of observing, giving directives and giving feedback progresses, the quality of each of these changes. As the SiT becomes more competent and takes over more, it is possible for the TS to intervene less. The process of intervening less is an active process and represents a stage of growth for the TS. So the process of maturing happens at each level of the system.

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The Multilevel Training Context The formal organization of the overall training program creates specific roles, functions, and goals related to each training subsystem. Each author functions as the TS for one SiT. Each SiT functions as the supervisor for a group of four (4) therapists-in-training. Each therapist-in-training rotates from therapist to team member. On alternate weeks there is live MFT supervision for four (4) hours. On the other training weeks, the four (4) hour sessions include individual consultations, group and videotape supervision, as well as experiential/didactic sessions. During the first phase (3 months) the TS is a “participant-observer” in both the live therapy supervision and alternate supervision sessions. The TS and SiT meet separately, although briefly for pre-session, pre-intersession and post-postsession supervision during the live therapy supervisory process. However, the “behind-the-mirror” and other supervision “meetings” are videotaped for possible continued supervision of supervision on the alternate weeks. This enables the TS to discuss micro moves in the supervisory relationship between the SiT and the therapist-trainees. Attention is paid to details of how directives are given and received such as accuracy of perceptions, attention to themes and nuances which cannot be attended to when an ongoing live therapy/supervision/supervision of supervision block is in progress. You cannot put the family, therapist or supervisor on pause, while the team builds alternate hypotheses. This careful examination of the bits and pieces of the process of therapy and supervision also continues at the day long meetings which occur on a weekend, once every two months. Both training groups meet together for a formal presentation by a TS and as the training progresses, one/both of the SiTs take responsibility for presenting to the therapist-trainees. This is also a time when role-playing of the families that are stuck can take place. The teams enjoy the luxury of the presence of the other group who lend additional bodies for experiential work. Novel feedback adds to the interest and variety of the day. The SiT is encouraged to take charge of this day as he/she becomes capable of doing this competently. The TS is functioning best when the therapist-trainees are least aware of their presence. The ability to have others participate in our experience through writing is frustrating. The reader doesn’t get the sense of excitement, energy, tension or satisfaction that exists “in vivo.” We don’t get the feedback that is automatic and built into the live training model. We hoped that presenting some material written about the SiT experience will bring some life to this paper. The application process for Approved Supervisor designation involves written descriptions of the training setting, a philosophy statement and a case history with one therapist/trainee. We thought the last of these would serve to illustrate how the SiT sees the training situation. The following passage was part of a successful application for the supervisor designation. This is a typical supervisory experience that may be found in our training program. One of the authors, Jennifer, served as the Training Supervisor for this case. The Supervisor in Training (SiT), Virginia, was an experienced family therapist who worked with the therapist/trainee, Betty. The real success for both Betty and Virginia happens when each of them stop being on stage and become more of who they really are. This process of forgetting their roles and becoming themselves took place over twelve sessions. PRACTICAL APPLICATIONS IN SUPERVISION

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Summary of Supervision with Betty (therapist-in-training) • Initial screening and contracting between Virginia and Betty Following a beginning course in family systems, Betty entered the advanced training in October. Our contract was to meet every Monday evening from six to ten p.m. with a group of four trainees. At least two families would be seen every other week. Betty would receive live supervision from me, through a one-way mirror, each time she saw a family. We would also periodically review portions of the videotaped sessions, individually or within the group. •

Contracted Supervisory Goals Betty and I agreed, and Jennifer concurred, that a reasonable goal for her would be to build understanding and skills of structural/strategic family therapy. I would provide live supervision for her cases as well as review videotapes. My supervisory goal was to assist her in moving from an experiential-psychodynamic based family therapy model to a systemic model. Correspondingly, I hoped to expand her view of therapist as facilitator to include the therapist as an “agent of change,” one who plans the therapy, rather than following the client’s lead (Haley, 1976). We agreed to evaluate her progress through ongoing feedback with the team and individual evaluative sessions as we needed them.



Supervisory/training setting All sessions took place at the teaching setting of our training program where viewing room and therapy room are separated by a one-way mirror. All sessions were videotaped with written consent of the clients. The “Bailey Family” was self-referred by responding to an article about the training which appeared in a local newspaper.



Methodology Supervision, as I conduct it, consists of several phases resembling Ferrier’s model (Ferrier, 1984). Since these are “supervision of supervision” sessions, modifications exist to accommodate conferring with the Training Supervisor. The TS (Jennifer) is present with me behind the mirror, as an observer, throughout the session. We have agreed that I will be in charge of all sessions, responsible for all communication by phone-ins, walk-ins, interactions with the team and for the total supervision of the therapy that Betty is conducting with the Baileys.



The pre-session phase In the first part of this phase, Jennifer and I briefly review the last session. Then I meet with the therapist and review the intervention from the preceding session and the hypotheses upon which it was based (intake application in the case of a first session). The therapist also reports any “between session” contact with the client-system. The goals for the session are set at this time. Alternative responses to the intervention are discussed and the therapist response is planned.



The therapy session During this phase the trainee/therapist rejoins the family, checks on the task assignment given during the last session and proceeds to implement the plan for the session.

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The mid-session break I step out of the room with the TS, before the therapist returns to the observation room. We quickly review the session and goals and then return to the team. The therapist has reviewed the session alone for a few minutes and now rejoins me with the team. We reconnect and give feedback to the therapist. They evaluate the feedback from the previous intervention and re-evaluate the previous hypotheses. The team discusses compliments for the family and the therapist notes these to read to the family as a message from the team. A new intervention is designed and the next appointment or termination with follow-up is planned. The team is a part of this planning discussion.



Delivering the intervention The therapist discloses selected messages from the team to the family, usually starting with the words, “the team is impressed” and reads the list of compliments to the family. Then she presents the agreed upon directive and concludes the session, setting the next appointment.



The post-session wrap-up The therapist is reintegrated into the team, allowed to debrief from the session and feedback is offered. The team is instructed to punctuate positive aspects of the therapist’s functioning. As too often happens in our zeal to assist, we criticize what we want changed, but take for granted his/her competency or growth. Following the post-session conference, I confer with the TS once more. We discuss the case and the supervision issues. She talks with me about my experience with Betty. I generally follow the live supervision/consultation format as defined by Liddle and Schwartz (1983), thus formal evaluation with Betty takes place during brief individual sessions every sixth week.

Significant Stages of Development Betty worked with a family with a five year old boy during the Advanced Family Therapy training. They were having marital as well as parenting problems. Since Betty also has a young child, it was easy for her to identify with the couple and their problems. I had some concern about her identifying too closely and we discussed that, including what signs she should look for to know when she was becoming less objective. Early in the therapy, much of the focus was on verbal communication between the parents and the parents and the child. It took a few sessions to teach Betty to pay as much attention to analogous behaviors as verbal behaviors. With her previous bias that clear communication and shared experience were the most sought after values, it was difficult to wean her from her favorite expression, “would you please share...” Initially, I would call in an intervention and find my words parroted. If they were not well received by the family, I would call in again, and found that she did not like receiving information from me a second time. In the process of reviewing “micro moves” on the videotaped sessions with the TS, I began to appreciate the isomorphic nature of my relationship with Betty and her relationship with the family (Liddle, et al, 1984). If I called twice, she felt punished, and consequently her tone of voice changed when she spoke to the family who then felt punished by her. My relationship with the TS was a further instance of this isomorphic process. This cycle was broken when, upon her PRACTICAL APPLICATIONS IN SUPERVISION

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suggestion, I began to reassure her when I called in, punctuating what was going well before making a suggestion. I also contextualized my interventions, so that she had a framework for them and they could make more sense to her. When an intervention failed to be well-received by phone after several call-ins, I learned to call Betty out of the room. It was a unique process to grasp that sometimes, if a message failed by phone, she might readily understand the content in a face-to-face exchange. I never walked in during a session. Jennifer and I talked about this and we agreed that my walking into a session would seem a rude interruption to Betty. A significant and unexpected change occurred for Betty, when one day she spontaneously started carrying a clipboard and recording notes and calls during the session. She reported that she finally felt confident enough not to be ashamed of taking notes. This also freed her to use her own language and the language of the client more than my language, since she captured the ideas in writing and didn’t have to expend energy remembering them. As the weeks went by, we developed a shorthand for directives and she could carry out an intervention with less instruction on my part. Betty has a very dry and enjoyable sense of humor. As she became less frightened and more comfortable, this became a major asset to use with the family. When asked to unbalance in favor of the peripheral father/husband, she successfully chose to praise his selection of ties and shoes, more to the delight of the team than his wife. She also developed her own ways of de-escalating, using her clipboard and her humor. If an argument got too heated, she learned to cool it quickly by requesting that the family slow down, so that she could take better notes. “You have to go slower, I can’t remember all of this. I think I have Youngheimer’s disease. That’s what you have when you can’t remember and you’re not old enough for Alzheimer’s disease.” Betty did not initially recognize the interactional patterns between the family members. However, within three sessions she began to notice and comment upon the self-initiated activities of the child in response to the discomfort of the parents. Since this family responded positively to task assignments and some rapid changes occurred, she was much encouraged, as we all were. The chronically unemployed father found a job and kept it for the full term of the therapy. Betty grasped the art of making paradoxical interventions and enjoyed restraining change, predicting relapses and wondering aloud what could be causing the change. The father, compliant with tasks, also became more involved in parenting his son while giving his wife a rest from this job. The family was seen for twelve sessions between October and June, and terminated therapy by mutual agreement since they had met and maintained their goals. Our improving supervisor-therapist relationship, concurrent with her development of structural/strategic skills, facilitated our verbal shorthand. As time went on, the team’s communication with each other matured and they supported each other as therapists as well as the families in therapy. The completion of the compliance-based strategies by the family was also important to the successful experience that Betty had with this family and our supervision. I found that my relationship with her improved as she stopped worrying about being criticized. At that time I noticed that I stopped worrying about the TS finding fault with my supervision of the case. Current Directions and Guidelines Professional organizations on a national level have recently become proactive in promoting the PRACTICAL APPLICATIONS IN SUPERVISION

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need for formal courses and training in the area of supervision. In addition, specific to the field of marriage and family therapy (MFT) and designation as an Approved Supervisor of the American Association for Marriage and Family Therapy (AAMFT), the Commission on Supervision (Feb. 1989) announced supervision course guidelines, as well as six learning objectives for acceptable courses. These guidelines and objectives are intended to allow course sponsors to tailor course content and to allow for differing educational philosophies and contents. An integrated approach to supervising the supervisor in a multilevel context could also include learning objectives of an SiT with the goal of achieving some professional recognition, such as an Approved Supervisor designation. With the continued research in the area of supervision and clinical experimentation by marriage and family therapists, our field may set the pace for other clinicians and disciplines in the helping professions. In contrast to the considerable research on the outcome of family therapy (Gurman, Kniskern & Pinsof, 1985) little has been done to evaluate training effectiveness of a particular school or approach which has more empirically validated training methods. This evaluation has not been done for therapists or supervisors-in-training. However, it seems apparent, as noted by Kniskem and Gurman (Ibid.), “that trainees representing the more technique-oriented family therapies are working more actively in evaluating their methods,” (p. 37 1). Since many of the methodological problems of outcome versus process MFT research have been resolved (Gunnan, Kniskern & Pinsof, 1985; Greenberg & Pinsof, 1986) the potential for evaluating these approaches seems greater. The subspecialty area, “supervision of supervision” for marriage and family therapists is just part of the important direction within the field. One of the authors (David) has been involved in similar multilevel training programs in community mental health and chemical dependency agencies. These public agency experiences were similar to those reported by Wade Lewis (1988). In fact, his comments seem appropriate to conclude this paper: The supervision model presented here may appear to be overly detailed in its procedures and the components of the model likewise seem to be merely semantic exercises. However, it is believed that this supervision model contains important conceptual distinctions that are translated into concrete practices which “fit” the structures of many public agencies. (P.91).

References Andrews, J. & Clark, D.J. (1985, November). The Gestalt integrated family therapy training program. Paper presented at the meeting of the Tenth Anniversary International Conference on Family Therapy, Washington, D.C. Andrews, J., Clark, D.J., & Zinker, J. (1988) Accessing trans generational themes through dreamwork. Journal of Marital and Family Therapy. 14,(1), 15-27. Breunlin, D., Karrer, B., McGuire, D., & Cimmarusti, R.A. (1988). Cybernetics of videotape Supervision. In H. A. Liddle, D.C. Breunlin, & R.C. Schwartz (Eds.) Handbook of family therapy training and supervision. (pp. 194-206). New York: Guilford Press. Breunlin, D., Liddle, H. & Schwartz, R. (1988). Current training of supervisors and therapists. In H. A. Liddle, D.C. Breunlin, & R.C. Schwartz (Eds.) Handbook of family therapy PRACTICAL APPLICATIONS IN SUPERVISION

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training and supervision. (pp. 207-224). New York: Guilford Press. Cleghorn, J., & Levin, S. (1973). Training family therapists by setting learning objectives. American Journal of Orthopsychiatry, 43(3), 439-446. Commission on Supervision of the American Association for Marriage and Family Therapy. (1989). Marriage and family therapy supervision. Course guidelines and a marriage and family therapy supervision bibliography. Washington, D.C. Ferrier, M.J. (1984, Spring). Teamwork: Process, problems and perspectives. Journal of Strategic and Systemic Therapies, 3(l), 1724. Gendlin, E. (1978). Focusing. New York: Everest House. Greenberg, L.S. (1983). Toward a task analysis of conflict resolution in Gestalt therapy. Psychotherapy: Theory, Research & Practice, 20, 190-201. Greenberg, L.S., & Pinsof, W.M. (1986). Process research: Current trends and future perspectives. In L.S. Greenberg & W.M. Pinsof (Eds.) The psychotherapeutic process: A research handbook, (pp 3-20), New York: Guilford Press. Greenberg, L.S., & Webster, M. (1982). Resolving decisional conflict by means of a two chair dialogue: Relating process to outcome. Journal of Counseling Psychology, 29, 468-477. Gurman, A.S., Kniskern, D.P., & Pinsof, W.M. (1985). Research on the process and outcome of marital and family therapy. In S. Garfield & A. Bergin (Eds.), Haley, J. (1988). Problemsolving therapy, New York: Harper & Row. Haley, J. (1988). Reflections on supervision. In H.A. Liddle, D.C. Breunlin & R.C. Schwartz (Eds.) Handbook of family therapy training and supervision (pp 358-367). New York: Guilford Press. Harman, R.L., & Tarleton, K.B. (1983). Gestalt therapy supervision. The Gestalt Journal, VI(l), 29-38. Heath, A.W. (Ed.) (1989). Commission Urges Citation of MFT Supervision Literature. COS Bulletin, II(1), Washington, D.C. Hess, A.K. (1986). Growth in supervision: Stages of supervisee and supervisor development. In F.W. Kaslow (Ed.) Supervision and training: Models, dilemmas and challenges. (pp.51-67). New York: Hawthorne Press. Kaplan, M.L., & Kaplan, N.R. (1982). Organization of experience in the immediate present: A gestalt/systems integration. Journal of Marital and Family Therapy, 8, 5-14. Kaplan, M.L., & Kaplan, N.R. (1987). Processes of experiential organization in individual and family systems. Psychotherapy: Theory, Research & Practice, 24, 561-569. Kniskern, D.P., & Gurman, A.S. (1988). Research. In H.A. Liddle, D.C. Breunlin, & R.C. Schwartz (Eds.) Handbook of family therapy training and supervision. (pp.368-378). New York: Guilford Press. Lebow, J.L. (1987). Developing a personal integration in family therapy: Principles for model construction and practice. Journal of Marital and Family Therapy, 13(l), 1-14. Lewis, W. (1988). A supervision model for public agencies. The Clinical Supervisor, 6(2) 85-91. Liddle, H.A. (1982). On the problems of eclecticism: A call for epistemologic clarification and human scale theories. Family Process, 21, 243-250. Liddle, H.A., Breunlin, D., Schwartz, R. & Constantine, J. (1984). Training family therapy supervisors: Issues of content, form and context. Journal of Marital and Family Therapy, 10, 139-150. Liddle, H.A., & Schwartz, R. (1983). Live supervision/consultation: Conceptual and pragmatic guidelines for family therapy training. Family Process, 22, 477-490. PRACTICAL APPLICATIONS IN SUPERVISION

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Pinsof, W.M., & Catherall, D.R. (1986). The integrative psychotherapy alliance: Family, couple and individual scales. Journal of Marital and Family Therapy, 12(2) 137-151. Stoltenberg, C.D., & Delworth, U. (1987). Supervising counselors and therapists: A developmental approach. San Francisco, CA: Jossey Bass. Williams, A.J. (1988). Action methods in supervision. The Clinical Supervisor, 6(2), 13-27.

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HOW PERSONAL CAN TRAINING GET? HARRY J. APONTE, MSW FAMILY THERAPY TRAINING PROGRAM OF PHILADELPHIA THIS ARTICLE IS REPRINTED WITH PERMISSION FROM THE JOURNAL OF MARITAL AND FAMILY THERAPY, 1994, VOL. 20, NO 1, 3.15.

Training on the person of the therapist calls for trainees to deal with their personal issues in relation to the therapy they do. Growing controversy about dual relationships has the field wondering where to draw the line between training and therapy. This paper offers a distinction between dual qualities and dual relationships to clarify the issue. An illustration of clinical training with qualities of therapy demonstrates an effort to maintain proper boundaries in training on the person of the therapist. The basic premise of person of the therapist training is that therapy is a personal encounter within a professional frame. Although theory and technique are essential to the professional practice of therapy, the process is affected wholly through the relationship between therapist and client. This means that to fathom the therapy relationship, one must understand its components, both personal and professional. The professional aspects of the relationship define the roles of the participants vis-à-vis one another. The personal component of the therapy relationship viscerally relates the therapist to the client’s life. The Personal Training of Therapists Therapy challenges clinicians to use their personal selves effectively within the professional relationship. The personal component of this relationship is not about some generic liking and acceptance of clients. It is specific to the goals and means of therapy. Thus therapists need training that both opens them to themselves and teaches them vulnerability, discipline, and freedom within the relationship. One approach, the person/practice model (Aponte & Winter, 1987) attempts to integrate intensely personal work on the self with clinical practice. It illustrates well some of the dilemmas over boundaries that confront trainers and trainees who pursue this personal focus in professional training. The Personal Practice Model Training is organized around year-long programs. Trainees work in groups of around 12, led by two-person teams. Trainees meet monthly for two days at a time and present their material to the trainers individually on a rotation schedule. They use one hour to discuss personal issues or clinical material. They use two-hour periods for live interviews with client families and occasionally with their own family members. In the program, trainees seek to: 1. Understand and conceptualize issues from their lives by: (a) identifying and interpreting themes in their histories and current relationships through PRACTICAL APPLICATIONS IN SUPERVISION

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their genograms and personal family sessions; (b) accessing emotionally their own personal struggles, past and present; (c) articulating templates for themselves for how they have succeeded and failed with their personal and family issues; (d) making explicit for themselves personal values, philosophy, and social factors that drive their lives and affect their therapy. 2. Gain mastery over their personal issues through: (a) taking into personal therapy unresolved issues, especially those experienced in the professional context; (b) learning to think about, feel, and live with unresolved issues in order to facilitate working with them in therapy; (c) pursuing limited understanding, resolution, and management of their issues through their clinical practice. 3. Learn to use themselves in therapy by: (a) developing the capacity for personal intimacy, mutuality, and commitment with clients inside professional boundaries; (b) discovering their clients in themselves and themselves in their clients through empathy (Margulies, 1989); (c) differentiating self from their clients within the shared experience of the therapy process (Kerr, 1981); (d) developing the skill to work with the connections between their own and clients’ values and personal philosophy; (e) integrating their personal work with a professional model of therapy to achieve theoretical and practical congruity of the use of self in their therapy. In summary: 1. Therapists develop the capacity to assess their personal emotions and reactions within the therapeutic transaction, 2. They learn how, in light of their own life experience, to interpret what these reactions tell them about their clients. 3. Clinicians learn how to forge interventions out of their model of therapy plus develop an understanding of client needs. Training the person of the therapist not only opens therapists up to themselves but also delves into the boundaries between therapist and client. The touching of therapists’ and clients’ lives in therapy beckons therapists to gain mastery of their personal selves in their clinical relationships. The Question of Dual Relationships This kind of work with the personal issues of therapists has raised questions about possible violations of subprinciple 4.2 of AAMFT’s Code of Ethics (2001) which prohibits provision of therapy to current students or supervisees. There is growing controversy about the boundaries between professional training in the use of self and family-of-origin work and psychotherapy for the trainee (AAMFT, COS Bulletins Vol. IV, No. 3, pp. 1-2, 199 1, and Vol. V, No. 2, p. 4, 1992). The need to clarify the thinking of the field is becoming more urgent: The notion that the trainee needs both to understand and resolve her own family-of-origin issues is integral to the PRACTICAL APPLICATIONS IN SUPERVISION

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philosophy of particular family therapy models . . . Ryder & Hepworth, 1990, p. 284) The question of where to draw the line between training and therapy is sufficiently complex that it is unlikely that anyone can develop a simple boundary that will win universal agreement. One would have to answer the question of how to be therapeutic without being a therapist. Training programs that aim at producing personal change in therapists for the sake of improving their therapy will struggle with this question. In the person/practice model, work done directly with trainees about their personal issues aims to identify personal life patterns. In the process, trainees attempt to develop new perspectives on their lives and may even attempt new ways of addressing their personal issues. These efforts provide them with perspectives and approaches to their issues that become useful reference points in their therapy with clients. Their personal work is meant to be therapeutic, not therapy, which is essentially an effort to resolve personal issues. Trainers commit to trainees’ personal issues primarily to improve their performance as therapists. This point is lucidly illustrated in the help trainees receive to work with their unresolved issues. Even with personal issues that become resolved, the ultimate goal is not achieved until trainees learn to use the original struggle and the journey to resolution as resources for their work with clients. We can suggest here some principles which will lessen the likelihood of a conflict of interest between training and therapy. However, we need to keep in mind the spirit behind the concern about dual relationships, which is to prevent exploitation by persons who have professional power over supervisees, trainees, students, and patients. Unless we do this, we can become ensnared in purely legalistic distinctions that burden professional relationships rather than nourish and protect them. Dual Quality versus Dual Relationship Relationships in the fields of therapy and counseling can be quite complex. This is particularly true in the arena where training or education interfaces with what is therapy or therapeutic. Classes in school that have students discuss their families of origin, supervision that touches on personal issues of therapists, training that focuses on the personal issues of therapists, and therapy that is considered primarily training or didactic are all in this borderline area. Most of these examples are not inherently dual relationships. They are relationships with dual qualities in contrast to a dual relationship in which a trainer paid to train a therapist simultaneously accepts payment from the trainee as patient. The complex examples are relationships of one nature that have qualities of another. There are situations involving training and therapy that are inherently wrong, such as a supervisor for any reason pressuring a supervisee to reveal personal family history. However, more instances of dual qualities in the relationship between training and therapy fall into the murkier “conditional” zone. Conditions There are a variety of conditions which determine whether the dual qualities of a relationship are an exploitation of student/supervisee/trainee. 1. Abuse of power: Does the trainee understand the implications of the dual qualities of PRACTICAL APPLICATIONS IN SUPERVISION

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the relationship and have the freedom to enter into or refuse any aspect of the relationship? 2. Intent to exploit: Is there intention to take advantage of a trainee? Is there personal gain that motivates the trainer to enter into the dual qualities of the relationship? 3. Harm done the trainee: Has the trainee been hurt by the dual qualities of the relationship? How much and in what ways? Some Guidelines The concern of this paper is the training of the person of the therapist. In the person/practice model the dual quality can be thought of as professional training that may be personally therapeutic. It is impossible to anticipate all potential ethical violations in the dual qualities inherent in the person/practice model relationship, but much can be done to protect against violations and promote a constructive association between the two qualities of the training program. For one, trainers using this model would do well to spell out how the program is both personal and clinical and to obtain explicit acceptance from trainees, even in writing. Trainees and trainers would agree that: 1. Trainees will be presenting their personal histories and information about their current life circumstances. 2. Although trainers may inquire about what they believe is relevant, trainees are free to volunteer only what they wish to reveal. 3. Trainers and fellow trainees are bound by confidentiality for all personal information revealed by a trainee. 4. Trainers and trainees are not to assume a treatment contract (with all that implies) under the guise of training. 5. Trainees will pursue personal treatment outside the training program, and trainers will assist this pursuit, when appropriate. The person/practice model is so supportive of trainees seeking their own personal therapy that trainees frequently search for therapy on their own initiative. They generally receive the recommendation by the trainers to pursue personal therapy. To assure the essential nature of the person/practice model, the ruling principle should be that it is aimed primarily at the professional development of the therapist. Some general conditions are advisable: 1. Trainees will bring in their professional work for supervision on a regular basis through live session, video or audiotape, and clinical discussion. 2. Whatever personal work is done is ultimately related to the trainee’s professional performance. Bringing the clinical work of trainees into the training context helps keep everyone’s eyes on the purpose of the training. Making consistent, deliberate efforts to relate all personal work to its clinical application will also keep people focused. Some practical steps a program can take to insure appropriate boundaries while also being PRACTICAL APPLICATIONS IN SUPERVISION

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personally supportive to trainees are: 1. Use co-trainers to lead the training in order to help trainers with their countertransference in this intensive work. 2. Use the training group actively to provide program feedback to trainers and personal support to trainees. 3. Have a back-up to the training program for personal consultation to trainees who need special help between training sessions. This paper cannot begin to address the full range of principles and practical measures needed to support the integration of the personal with the technical in our clinical work. CASE EXAMPLE The following case of Elaine, a trainee, is presented in detail to give the reader an opportunity to form some judgments about a situation in which training at times looked a lot like therapy, but which the trainers thought to be primarily professionally enhancing while also being therapeutic. Did they maintain appropriate boundaries? The author believes that they did. The program made it possible for this therapist to: (a) examine in live supervision her personal issues as they appeared in a clinical session, (b) look with her mother, also a therapist, at the session’s videotape to explore her own mother/daughter issues, and (c) follow up these two experiences with an interview by the trainer of her and her mother. The author believes that Elaine came out of this process with more freedom to use her personal life experience in her clinical work and her personal power in her clinical relationships. In her training Elaine also took a step toward further differentiating from her mother. She had been in personal therapy which she felt was successful prior to the training program. Nonetheless, the work with the client family lanced open old issues that she hoped to deal with not only for the sake of her work with her clients, but also for herself personally. She chose to address these issues where she was currently experiencing them most acutely, in the context of her clinical work. Presented here are excerpts from three training sessions: (a) the live supervision of the trainee with a client family, (b) a discussion with the trainee of the interaction between her clinical work and personal life, (c) an interview by a trainer of the trainee and her mother. Live Supervision The training program is based upon the person/practice model and is conducted within a structural framework (Aponte, 1992). In preparation for live supervision, the trainers, together with the training group, spend about 30 minutes preparing the trainee for the session. The trainers supervise the hour-long session from behind an observation mirror, calling in as well as inviting the trainee out to talk. One of the supervisors may join the trainee in the session. The trainee and trainers jointly decide ahead of time how they will work together. There is a debriefing after the session to make explicit the linkages between the work with the family and the therapist’s personal issues.

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The trainee, Elaine, whose personal and clinical work is being presented in this paper is an experienced clinician in her mid-30s. The family she brought in for supervision consisted of a married couple, Sherry and Dan, adoptive father to Sherry’s two daughters, Dina, 16, and Nancy, 15, the identified patient. Nancy had been hospitalized for depression and a suicidal gesture. For this supervisory session, Elaine did not ask for help dealing with any particular pathology of the family as much as with how she related to the family in therapy. In Elaine’s initial statement she said: There is a way I collude in the power Nancy has in this family. I may treat her as too adult . . . I just know that when I have had sessions where Nancy is present, I start to feel the boundaries get a bit soft. It’s an experiential kind of thing that I know is reflecting something internally in me. As Elaine talked further with the co-trainers, A (T-A) and B (T-B), her issues with the rest of the family became apparent. About Sherry: Maybe it’s my mother’s face going on . . . I’m thinking I’m afraid of her [Sherry], too. She’s withholding, and I’m the point of her anger. Elaine was in touch with her fear of coming up directly against her mother’s anger in Sherry. In contrast, she thought of how comfortably she confronts Dan, the father. Trainee: T-A: Trainee:

T-B: Trainee: T-A: Trainee: T-A: Trainee:

Right. So I tested that out with Dan anyway, because I called Protective Services [when he struck Nancy and caused her nose to bleed]. He was pissed at me. You can afford to do it with Dan for some reason. Yeah, I could afford to do it with my father [too]. The combination [of Sherry and Dan] is somewhat like my parents. I think in some ways I sort of started calling my relationship with my father a covert incest, emotional incest. I was a companion. I was his partner. There is definitely that here. And, although my mother has changed a lot, she was like how Sherry is with her kids And you say, she distances herself from her husband and maybe you feel she distances herself from what you’re feeling. Yep. And I had these separation issues . . . You know, can I be separate and will you still love me? So, Nancy is you? Is that what you are saying? Yes, I was probably the powerful daughter. The question is — where does that leave us for today . . . ? What do you need to be able to do today . . . ? I need to be able to challenge Sherry. I have been very cautious. But, then if I’m Nancy, then it complicates it.

After some discussion about how she could stay related to Sherry in their interviews, Elaine remembered that although Sherry is reserved in session, she writes “very emotional letters” to Elaine between sessions. The trainers then offered Elaine two strategies to use with herself. They suggested that Elaine focus herself on the hidden emotional side that Sherry reveals in her letters. That would allow her to feel the caring mother that is Sherry and hold on to the reality of Sherry versus the fantasy of her mother. They also suggested that Elaine use Sherry to help her PRACTICAL APPLICATIONS IN SUPERVISION

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relate to Nancy in the session. This would help Elaine support Sherry’s taking charge of Nancy, while keeping herself from overidentifying with Nancy, The pre-session completed, Elaine was prepared to see the family. Present in the session were the parents, Dan and Sherry, along with Dina and Nancy. Elaine began the session by trying to find out where the family was at that moment. Apparently they were still reacting to an incident that had occurred that morning as they were preparing to come in. The girls had gotten into an argument, and Dan had tried to help only to aggravate the situation further. Dina made a comment about “hating” the family, which hurt the father. His mother had died when he was quite young, and his father subsequently abandoned him and his younger brother. He was sensitive to family loyalty. Sherry felt he should have stayed out of the incident and let the girls work it out between them. Trainee:

Dan: Trainee:

You know, it just sort of clicked with me . . . that you really lost your family and so family is really important to you. Now, with Dina’s comment like that in anger, it really calls on you because of your history. Yeah, that’s true. I think it’s important to me. So how are these girls going to be able to do their thing in the family without it ripping you apart?

(Elaine continued with Dan along these lines for a while. The trainers then invited her to join them and the group behind the observation mirror.) T-A: Trainee: T-A: Trainee: T-A:

Okay. How are you feeling? A little anxious. I don’t feel like I’m grounded in there . . . . . . you are . . . taking care of Dan . . . , your accustomed place. . . . this is really a repeat of my family, taking care of my dad. . . . like [Dan felt that] nobody else [in the family would] handle [the girls’ conflict] . . . (The trainee returned to the family and invited the test of the family into a discussion of the incident. the family proceeded to review what happened. The trainee then engaged Sherry.)

Trainee: Sherry:

What do you make of this whole thing? This quibbling between the kids—I’m getting used to it . . . Comments like that by Dina don’t worry me. If the comments were from Nancy, it would have probably been another story. Trainee: Why? Sherry: Dina gets angry and over it, and I understand where Dina is coming from . . . I guess I worry about Nancy’s anger level . . . She’s run away twice already . . . Trainee: Sherry, see what’s going on with your daughter. She seems a little upset. Sherry: . . . Tell me what’s going on, Nancy. Nancy: That comment Dina made —You and Dad would have taken it more seriously if I would have said it. Sherry: . . . I worry a little bit more about you. Do you know why? Because I can’t read you like I can Dina . . . (The trainee got mother and daughter talking about their relationship. Both soon began to PRACTICAL APPLICATIONS IN SUPERVISION

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cry. Suddenly, the trainee broke off and told them she was going back behind the mirror to talk with the trainers.) T-B: She [Sherry] gave you what you asked for, and in the middle of that is when you got up. Trainee: I just think it must be getting into some of my old stuff with my mother and I feel like I’m pushing again and I don’t know where these feelings are coming from . . . T-B: Something happened. Trainee: And it feels so awful, like leaving Dan out. You know, I’m so aware of him there. T-A: You’re taking care of him by letting [Sherry] take care of her daughter. Trainee: Yeah. It’s true. I mean I was sort of getting that, like Dan is really going to benefit from this. But, on an emotional level . . . I want to keep checking back with him… T-B: Is there something [we can do to help you] tolerate what is happening to you? Trainee: I think I just can’t be crying out there . . . Trainee: Well, I would like you [T-A] to come in now . . . I need some support . . . (In the safety of the supervisory relationship, Elaine allowed herself to access a level of emotion that she might not otherwise have permitted herself. She then asked for the help she needed, that is, for T-A to join her in the session as a consultant. The trainer entered with Elaine and engaged with Sherry about how vulnerable she was feeling with Nancy, which had just set off Elaine’s affective memories about her parents.) T-A: (To Sherry.) Elaine was talking about how sensitive you are to what we’re talking about . . . how deeply you feel, and that you don’t always express it, but sometimes do in a letter. Sherry: Sometimes I write better than I talk. T-A: . . . You get very private at those moments where you don’t feel so competent, and . . . instead of turning to Elaine . . . you stay all by yourself . . . when [Elaine reaches for you], then you blow up . . . like “leave me alone,” “I’ll do it myself.” Sherry: (To Elaine.) It’s not that I don’t trust your advice. You’ve been right every time. It’s not that I don’t want the help—a lot of times I just don’t know how to ask for it. And then when I do, I don’t know what to do with it. T-A: (To Elaine.) Somehow, you are going to have to convince Sherry that she can be incompetent in here, that she can ask you for help in the wrong way. Nancy: That’s what it is. She thinks she is gonna mess up and say the wrong thing. And that’s gonna damage her forever. Sherry: (To Nancy.) What if I said something to hurt your feelings? And I didn’t mean it that way. T-A: The question is whether the two of you [Sherry and Nancy] . . . [when] you are both kind of hurt . . . can you stay in the same place and talk to each other? Nancy: Cause we’re both too much alike. T-A: (To Dan.) I see what happens to you if I were in your shoes, I’d want to go in there and fix it up. Dan: Yeah, I don’t like it. T-A: . . . when you feel like that, [Elaine will help you] . . . walk over to [Sherry] . . . not to Nancy, and be a little supportive to her. Dan: Yeah. T-A: She [Sherry] needs to learn how to take a little support from you when she is PRACTICAL APPLICATIONS IN SUPERVISION

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Dan: T-A:

Sherry: T-A: Trainee: Trainee:

feeling a little nervous and a little scared. Which is hard sometimes ‘cause she tightens up with me. It’s all right for her not to be able to relax and do it all. Because you love her that way, and Elaine cares about her that way. So nobody is expecting her to be someone else. Except me. (To Elaine.) You’ve got to let these people be human and make a few mistakes and see that they still love each other. Yep. So, I will see you a week from Monday then, the regular time.

Elaine allowed herself not to be so competent that she needed no one else. T-A worked with Sherry’s parallel issue pulling family and Elaine around her, asking her to let them support her. Elaine wrote a follow up to T-A about her subsequent meeting with the family: I felt more empowered in the session to . . . keep Nancy from being therapist; push Sherry a little beyond her comfort level; stop myself from overfocusing on Dan; create a stronger boundary around Sherry/Dan. Presentation for Discussion In her next turn to present, Elaine talked about how the dynamics of her family of origin were so close to her struggles during the family session. She spoke about how during her childhood, her mother, Ruth, devoted much of her attention to Elaine’s developmentally handicapped brother. However, because Elaine had considered her mother overwhelmed with the care of her brother, she could not ask for more for herself. At the same time, Elaine had been protective of her father, now deceased, who seemed lonely and unable to take care of his own emotional needs. After Elaine’s brother, as an adult, was placed in a group home, her mother became a social worker and therapist like Elaine. However, there still existed between Elaine and her mother the strain of whether Elaine would eventually inherit responsibility for her brother. The trainers felt Elaine had confronted her issues so graphically in the family session that she would profit from showing the videotape to Ruth. She did with her clients’ permission and reported on the experience in her next presentation. . . . Your assignment to me was to watch that family tape . . . see myself . . . and . . . my mother . . . in terms of the work. I decided to address that issue with her on the phone, and the first thing was that I told her I felt like Dad’s emotional caretaker — and [that] she was . . . wrapped up in my brother . . . She validated it. She said, “I could see that I was distracted and so [your caring for Dad] felt good. [We watched] the tape . . . And then once we started watching, it was great . . . We stopped the tape several times, and I talked about ways that I thought like the daughter. And she was really relating to the mother, . . . But what I got that was really powerful and the point of the whole thing was that I saw my mother sitting there with her mother . . . they didn’t have a great relationship either. Her mother . . . was pretty closed. So, I really got it. And we cried together. And she told me a very painful story about . . . my father . . . [who] took [my brother] to a work-out place, and in the locker room my father was helping my brother get dressed . . . and there were some men noticing that . . . he was a little too old to be PRACTICAL APPLICATIONS IN SUPERVISION

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getting help from my father, and my father came home and said how embarrassed he felt . . . that was one of the few times she said that he ever talked about his pain. He always held his pain . . . It is really sad. I just sat there and we both cried. I felt better about this family. I felt better about Nancy and I felt better about tackling the nurturing part with [Sherry] the Mom. Watching the videotape with her mother affected Elaine. Yet she wanted more clarity. She needed to take it further to free herself for doing therapy. The trainers suggested that she invite her mother to Elaine’s next training session, T-A would see Elaine and her mother while T-B, along with the trainee group, would serve as consultants to T-A. Elaine ran with the idea and her mother immediately agreed. Interview of Trainee with Her Mother In the pre-session preparation for Elaine, she told the trainers: Trainee: That’s my fear . . . she’s going to want something from me . . . around [my brother], and I [won’t] want to do it, and she’s going to be angry or disappointed… T-B: How are you worried about this? What is happening? Trainee: I’m just not going to be a good girl . . . because I’m not going to be here for her the way she wants me to be there for her . . . (With that, Elaine set the theme of the meeting with her mother, individuating and identifying with her.) T-A: (To Ruth.) Is there a way you’d like to improve it [the relationship]? Mother: Yes . . . about my son, Bill . . . I think that she feels sometimes that I’m encroaching on her, and all I need is a comforting word, and I’ll be glad that she is there for me. Trainee: So I guess I don’t know what you want, and I have all these fantasies that you want something, but you’re not saying it. Mother: How about checking it out? Trainee: Well, I could check it out, but I don’t, Mom. Mother: What is it that you want me to do? (They tried earnestly with one another. Neither wanted to expect too much of the other or be critical. Each felt guilty about what she needed.) T-A:

Mother:

Trainee: Mother:

It’s interesting . . . before you came in, Ruth, Elaine and I were talking about the parallels between the two of you . . . You were each the oldest of three. You both lost a father at about the same age . . . You were both good girls, and today you are both good social workers . . . Elaine is wondering . . . was she trying to please her mother the way I’m trying to please my mother? . . . This whole thing is to hear a little bit about that today from you. It was very hard for me to say “no” to Grandma and . . . I did want to meet all of her expectations of me . . . It’s almost like it’s a genetic kind of thing. My mother did that with her own mother and I did that with my mother . . . Why couldn’t you say “no” to her? I was afraid she wouldn’t love me.

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Mother:

I was afraid of the anger. She would become angry and I was afraid that she would reject me. And I guess there is probably more to that. My mother used me at a very young age as her confidant . . . [when] she was upset with my father . . .

(Elaine’s mother vividly described the family legacy of daughters feeling obligated to their mothers. Moreover, Elaine could see her mother not just as her mother, but as a daughter and woman with her own fears.) T-A: Mother: T-A:

Mother: T-A: Trainee: T-A: Trainee:

(To Ruth.) I’m going to try something cause you are struggling with this. Yes, I am struggling. Could you two exchange chairs — (Then addressing Ruth.) If your mother were sitting there [where Elaine was sitting] . . ., and you wanted to tell your mother you loved her, and you wanted to feel a little less of this burden [to please], what would you want to say to her? I would tell her that I love her very much but [that] I have my own life to lead, I have my family and my issues . . . (To Elaine.) If you were her mother and she said that to you, how would you reassure her that it’s okay . . .? I would say that I love you no matter what and that I know sometimes you need to separate from me . . . but I’m always here for you . . . Well, what would you do with the part of you that would say, “But I will also need my daughter sometimes?” . . . I would say something similar . . . , I want to tell you what I need . . . when I want something from you . . . , [and] even if you say “no” I want to have the freedom to do that.

(This reversal of roles proved to be a jolt for them. It was followed by an intense discussion between them about Elaine’s relationship to her brother. Mother finally accepted that Elaine had her own independent relationship with her brother and could trust that Elaine would be there for him in her own way, The session ended with an obvious sense of relief and freedom for both Elaine and her mother. In the post-session discussion Elaine reported to the trainers and the group.) Trainee:

This was powerful for me . . . I mean, just the experience of changing chairs after my mother had said all those things and me being in her chair. Literally, I was in her chair in her same position. I started to cry as soon as I did it . . . So we were really running a parallel line and we just really intersected . . .

Results of the Training In a subsequent written communication Elaine stated: My task with the family seemed to be in seeing Sherry’s (mother’s) vulnerabilities; to see myself in her to identify with her. Up to that point in the work, I vulnerabilities. The session with my mother laid the foundation to do the work with Sherry. With my mother, I was able to be freer with my thoughts, feelings as well as see her in a different light . . . I identified with my PRACTICAL APPLICATIONS IN SUPERVISION

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mother, I had a breakthrough with Sherry when I could identify with her as a mother. At that point I challenged her with Nancy. I don’t think I would’ve gotten that far on my own without doing the bit I did with my mother. (Of course, watching the tape with my mother . . . helped a lot—continued to give me a way to individuate from her AND identify with her.) Maybe that was the key simultaneously individuating from AND identifying with Sherry . . . I don’t think I could’ve done it without . . . individuating from my mom around the main issue (Bill). At the end of this, her last year in the training program, Elaine also summarized what she had personally gained from 3 years in the program: 1. “I am an emotional adult with my mother.” 2. “I am out of the triangle with my mother and my brother.” 3. “I am better able to allow for mutuality in relationships.” 4. “[I am] feeling more entitled to be taken care of by others . . . A corollary is that I felt more generous when I take care of others.” The personal gains have far-reaching professional implications. Being an “emotional adult” with her mother will help her use her personal power in her interactions with client mothers. Being out of the triangles with her mother, father, and brother will help her in triangles with client families. Allowing for more mutuality will facilitate her sharing with clients responsibility for the therapy process. The feelings of entitlement and freedom to be more generous will enable her to take from clients and give more of herself to them. Moreover, what Elaine learned for herself will serve her as a guide for what her clients can do for themselves. Discussion How else except through such a training program can a therapist allow herself the freedom to be as personally vulnerable as Elaine was in a professional context? As clinicians, we must perform professionally. The training context allows a trainee, like Elaine, to feel all the personal emotions operating in her in a therapy session because the trainers and group take care of her while watching out for her clients. It opens up the doors between the personal and the professional while strengthening boundaries. It helps achieve permeability while maintaining clarity and control. It helps achieve integration with differentiation. Conclusion This article offered a description of a training experience that touched on the dual qualities, professional and personal, of person training. The training also gave a trainee the opportunity to further personal growth through a clinical experience while helping her professional performance. Was this proper training of the person of the therapist, or was this a crossing of boundaries into dual relationships of trainer/therapist vis-à-vis a trainee? This is an issue which has assumed growing importance with more training relating to family of origin and use of self for therapists. It cries out for further exploration, but also for active guidance for clinicians. Today, professional associations need to be in a position to advise and guide trainers/ teachers/supervisors who in good faith are trying to tackle difficult questions related to dual PRACTICAL APPLICATIONS IN SUPERVISION

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relationships. For professional associations to limit their activities to catching and correcting wrong is counterproductive. It instills fear and inhibits creativity and flexibility. Recognizing the complex reality of mentoring relationships, professional associations need to invest as much energy in assisting the integration of the professional with the personal as in correcting wrongful boundary crossing. References AAMFT Code of Ethics (1991). Washington, DC: Author. Aponte, H. J. (1992). Training the person of the therapist in structural family therapy. Journal of Marital and Family Therapy, 18, 269-28 1. Aponte, H. J., & Winter, J. E. (1987). The person and practice of the therapist: Treatment and training. Journal of Psychotherapy and the Family, 3, 85-111. Kantor, D., Mitchell, E., Pillemer, J. T., & Slobodnik, A. (1992). Letter to the editor. The Supervision Bulletin, 5 (2), 4. Washington, DC: AAMFT. Kerr, M. E. (1981). Family systems theory and therapy. In A. S. Gurman & D. P. Kniskern (Eds.), Handbook of family therapy (pp. 226-264). New York: Brunner/Mazel. Margulies, A. (1989). The empathic imagination. New York: W. W. Norton. Ryder, R., & Hepworth, J. (1990). AAMFT an ethical code: Dual relationships. Journal of Marital and Family Therapy, 16, 127-132. Storm, C.L.(1991). Changing the line: An interview with Edwin Friedman. The Supervision Bulletin, 4 (3),1-2. Washington, DC: AAMFT. My thanks for her ideas and editorial help to Theresa Romeo-Aponte.

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THE ROAD TO BECOMING A CAMFT CERTIFIED SUPERVISOR BY: CATHERINE AUMAN, MFT THE THERAPIST JANUARY/FEBRUARY 2008

My first reality check was that there would be no “grandparenting.” I had been supervising clinicians for almost twenty years in hospital and community settings; MFTs, psychologists, social workers, unlicensed folks, and even a few novice MDs, but that doesn’t count in the quest to become CAMFT certified. I wanted to achieve certification to have recognition of my previous experience, to add another certificate to my wall, but also to learn more to improve my skills and be a better teacher and mentor to incoming therapists. The first order of business to become a CAMFT Certified Supervisor was to get the twenty‐one hours of specific coursework. CAMFT offers this training frequently and it is now available online. I highly suggest taking it through CAMFT, as I took six hours through another provider only to find that it did not meet CAMFT’s criteria and had to take it over. The coursework is interesting and well‐organized, and you will need the notes to write your final paper. The next task was to find a place to provide supervision, which much to my surprise, was not as easy as one would think. I ran ads stating that I would provide supervision for free or low fee and received no response. I announced it at professional meetings and through email listserves to no avail. Finally, I found an ad in the back of The Therapist announcing that one of the local graduate programs was looking for Supervisors for interns, and I interviewed and was accepted. A word of advice: the time to apply is in early fall when students are looking for supervisors: at other times you will be considered redundant. The requirement is to provide supervision for an intern or other clinician for 52 weeks, which does not need to solely be done in one placement. You must also arrange for a CAMFT approved consultant for your own work, meet with this person monthly, and have the hours signed for. You can find someone at your placement, or you can hire a CAMFT Certified Supervisor whom you can find on CAMFT’s website. Finally, after the hours of education, supervision, and being supervised are completed, you will complete a written supervision case summary. I am including mine here as I have been contacted by other MFTs who have had trouble with this part of the requirement. Although it was daunting to write, it was a pleasurable experience to review and organize my thoughts and experience. As with all writing projects, it was much more pleasurable to have written it than to write!

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Written Supervision Case Summary to Fulfill the Requirement for the CAMFT Certified Supervisor Program: Theory of therapy and philosophy of supervision Briefly state the major tenets of your theory of therapy. Briefly describe your philosophy of supervision. Demonstrate the consistency of your thinking in these two areas throughout the case summary. In my more than twenty years of working in the psychotherapy field, I have developed my own eclectic approach that was first based in the psychodynamic perspective, then transpersonal, then systems theory. Then there came years of working in hospitals fully immersed in the medical model utilizing the cognitive behavioral interventions favored there. In the last few years, I have become increasingly enamored of Solution Focused and other brief therapies and have received additional training in these modalities. The tenets of Solution Focused therapy will ultimately have a major impact on the system. Minimal historic exploration is required in most cases. The therapist helps by the encouragement and validation of small changes and by the identification and amplification of exceptions, the presupposition of good intentions, and the use of the client’s own language. I disagree with the strong stance against the importance of insight. I believe that it takes a variety of viewpoints and skills to be a good therapist. Although I do not particularly subscribe to the medical model, I find it useful, as I find CBT effective with some patients, postmodern interventions with others, and long‐term psychodynamic therapy with others. I believe that the more tools we have in our therapeutic toolbox, the more likely we are to be helpful. Just as a great painter such as Van Gogh studied all the artists who had preceded him before he developed his own style, so must a future master therapist. My theory of supervision is similarly eclectic. The supervisor inhabits a variety of roles: that of teacher, counselor, collegial peer, and gatekeeper of the profession. We also must think beyond teaching what we do, and focus on preparing supervisees for today’s world. It is a way to give back and to ensure that well trained persons are entering the profession. My model of therapy differs from that of supervision in that I see myself as more of a teacher when acting as a supervisor than as a therapist. For a novice supervisee, I see the task of the supervisor is to find the positive for the supervisee as she has greater narcissistic vulnerability, lower tolerance for ambiguity, and greater dependence needs than will a later stage student. It is good to point out what the supervisee is doing well, to compliment that, and act as a cheerleader. Setting

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Describe the setting in which supervision took place. Discuss the type of setting, administrative structure within the setting, facilities for conducting supervision (e.g. private practice, nonprofit and charitable), trainings/workshops offered, methods regarding supervisee selection, and any other significant factors which impacted your supervision. The setting for this case study was Phillips Graduate Institute. My supervisee was a trainee whose placements were at the LA Free Clinic where she saw mostly low‐income clients of various ethnicities, and Camp Gonzales, a locked probation facility for boys ages 16‐18, most of whom were gang members. My supervisee and I met in a consultation room on campus. The student was also involved in weekly postmodern group supervision as part of her coursework. During my interview, I spoke about my varied background and various theoretical orientations, and how in the last few years, I had become increasingly excited about Solution Focused Brief Therapy due to my work with managed care clients and the several trainings I had taken. Due to this, Phillips staff decided I was ‘postmodern’ (being considered postmodern was news to me!) and I was assigned my supervisee who was in the postmodern track at the Institute. It created some conflict later on in the supervision and proved to be a great growth opportunity for me. Other contextual issues Indicate how awareness of contextual issues such as gender, age, culture and sexual orientation of the supervisor and supervisee influenced the supervisory relationship. Describe methods used to work effectively within these contexts. My supervisee and I discussed how the fact that both of us were middle‐aged (albeit a 15‐year age difference), middle‐class, white women brought up issues of trust, and difficulties in establishing rapport between the supervisee and the poor and ethnically different clients at her placements. We also had the opportunity to notice differences in the expectations of the therapist in Asian and Hispanic cultures, and that the expectation of a more hierarchical role was at odds with the supervisee’s preferred postmodern stance. The supervisee was visibly upset with the father of one of her clients who was not supportive of his daughter’s lesbianism. The supervisee disclosed that she had bisexual experiences in the past, and that her anger was countertransference and that she needed to explore her own unfinished business in this area. The fact that my supervisee was younger may have had an impact on the supervision as she appeared to have a beginner’s chip on her shoulder at times that was perhaps hiding fear and insecurity. I know that when I was doing my internship, I often thought older therapists were dinosaurs and didn’t know as much as those of us with the up‐to-date knowledge. Of course, I lost this rather quickly in the real world, but with my supervisee, I often felt I was getting my just reward for my previous arrogance.

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Legal and ethical issues Identify relevant legal and ethical issues specifically related to the supervision. Describe how you addressed them. I taught my supervisee that therapy with court‐ordered individuals, such as her clients on probation, is like a three‐legged stool: the client and the therapist are triangulated with the legal system. Her documentation had to meet the facility’s standard and I helped her formulate her treatment plans and documentation, then reviewed her work. During our time together, the supervisee took coursework about assessing for risk, so we were able to review that for her patients presenting with depression, substance abuse, anxiety, and so forth. A patient at the Free Clinic was suing her former employer for sexual harassment, so we discussed the potential that the patient might be using the treatment for legal purposes to show damage, rather than using it therapeutically. I taught the supervisee how to chart with an eye to a possible subpoena for records, reviewed all her documentation, then signed the charts as her licensed supervisor. Assessment Describe the supervisee’s diagnostic and treatment planning skills, theoretical base, stage of professional development and skill level, and interpersonal style. The supervisee had many of the characteristics expected at the novice level: confusion between textbook knowledge and practical application, insecurity about the ‘doingness’ of therapy, and lack of therapeutic techniques and case management skills for a variety of issues. She needed to become comfortable with client sessions, learn how to conduct an intake, take session notes, and how to present a case. She didn’t know how to identify when a client might have an Axis II diagnosis, and as novices often do, tended to under‐diagnose. She needed to learn to research issues online and elsewhere. My supervisee was very much in awe of skill and technique that had taken twenty years to develop and measured herself against that. She wanted to be able to do Narrative Therapy as well as Michael White, and when this didn’t happen, she blamed herself. I worked with her to broaden her view and to be able to honor the personal strengths she brought to the therapy setting, such as her previous career as an educator. On the plus side, my supervisee had a very pleasant, engaging demeanor and self‐presentation helped her establish a good bond with most clients. She has an innate sense of how to help, and good clinical instincts.

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Goals List specific supervisor goals for supervisee development. List specific supervisee goals. The supervisee identified her goals as: to become comfortable with the intake process, to know how to recognize and deal with a crisis, to have confidence when sitting with a client, and to ‘learn something about treatment planning although we don’t call it that.’ She said she might have transference issues during supervision due to growing up with a highly critical authority figure. During the course of our work together, it became apparent that she also had the goal of being able to do Narrative Therapy as well as Michael White (while still in her traineeship). My goals were: to help her develop counseling skills, to learn the rudiments of case conceptualization, and to increase her professional role development and her ability to self‐evaluate. I also wanted her to learn the benefits of an eclectic approach, to be able to enjoy this beginning stage of ‘not knowing,’ and that she honor the particular strengths that she brings to therapy, i.e., her background as a teacher, instead of trying to eradicate it. I wanted to help her be easy on herself for her learning curve, and to understand that she may someday be as good a clinician as Michael White. Methodology Identify monitoring methods (role‐play, one‐way mirror, video/audio tape, records review, self report, etc.) and describe interventions used to assist the supervisee with case conceptualization and management. Describe how your interventions facilitated the supervisee’s development. A variety of methods were used to help the supervisee develop counseling skills, case conceptualization, her ability to self‐evaluate, and professional role development. Along with monitoring and evaluating, advising and instructing, I tried to support her and her professional growth, and to share my experiences with clients, including mistakes I made. We worked on developing treatment plans, as she needed this skill for her work in agencies. We went to the bookstore and she purchased one of the excellent treatment planning guides, and I helped her walk through choosing the long‐term goals, short‐term objectives, and therapeutic interventions. She was resistant to this process because of her postmodern orientation, but as I helped her learn that she could choose the goals, objectives, and interventions that she was comfortable with and disregard the others, she became more open to the process. I reviewed her charts throughout our work and am happy to report that she developed the ability to write good treatment plans. Each week she would self‐report on cases about which she had questions, and I would attempt to help her conceptualize the cases. I helped her with the DSM‐IV, which she also was adverse to due to her theoretical orientation. But I persisted in helping her understand the efficacy of starting with the descriptive indicators to formulate a case. I used supportive teaching PRACTICAL APPLICATIONS IN SUPERVISION

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interventions, working to increase her self‐confidence at knowing who was sitting in the room with her. We role‐played working with one of her conduct disordered teens, trying out different interventions and watching some of them fall flat. I gave her clinical articles on working with antisocial personality disorders, and on how to know which therapies are effective with which clients. I had her research DBT on the Internet. I gave her advice on professional development when she had questions about whether or not to develop her bilingual skills (yes!). We discussed countertransference and some of the supervisee’s family of origin issues. At one point, she became demoralized, questioning if she was even cut out to be a therapist, and I highlighted her strengths and normalized this as part of the process. Her use of self was restricted as she tried to turn herself into Michael White, and I attempted to help her understand that she would develop her own way of being a therapist based on her authentic self, including her background as an educator. Unfortunately, her interpretation of postmodern therapy left her alienated from herself as she did not believe in psychotherapy as psychoeducation. I shared research with her that psychoeducation is the preferred treatment for certain populations, e.g., anger management clients. I also had to use confrontation to encourage her to try harder with the court‐ordered boys and not just shrug and wait until her time was up. Evaluation Evaluate supervisee’s progress and describe methods used for evaluation. The methods used for evaluation were self‐report, records review, and self‐evaluation. I had the supervisee complete several written evaluations of her progress in acquiring clinical skills and of the supervisory experience. The supervisee gained a great deal during the time I knew her. She became increasingly comfortable with diagnosis, treatment planning, case management, legal and ethical issues, and note taking. She understood the dictum, ‘First do no harm’ and was careful and alert to issues of client safety. She exhibited a good sense of how to help, and bonded well with most clients. She developed in her ability to observe interactions, choose and implement interventions, and assess their effectiveness. She began to learn to identify personality disorders and to devise treatment strategies for working with them. As noted several times, the supervisee struggled with non‐postmodern strategies. She was resistant to treatment planning and documentation (as are most therapists), and had unrealistic expectations of progress. She will need to increase her willingness to be confrontive with patients without the need to be liked at all times.

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She was being taught by her supervisor at school to learn one theory completely and only later to venture into other theoretical work, and this clashed with my view. We agreed to disagree, and I helped her develop in ways outlined above. I had some good feedback, although it came from the supervisee somewhat grudgingly. One day she told me she realized she couldn’t use Narrative Therapy with all clients because, ‘Sometimes the clients think the narrative questioning is just being weird. They don’t like it.’ Then one day toward the end, she came in very proudly to tell me she had done the best in her class on the Mock Orals and said, ‘Thank you, that was directly due to the work you did with me that the other students didn’t get.’ Her parting comment to me was, however, ‘You’re modern,’ said like it was an insult. I felt like I was just not hip enough, even though I had never cared before. I enjoyed the supervisory experience and see my major strengths as a supervisor as my breadth of experience and love of mentoring. Perhaps my biggest weakness is that I enjoy taking over and formulating and theorizing a bit too much, instead of encouraging the supervisee to do it. I will watch for this in the future.

Catherine Auman, MFT (MFT30784) is in private practice in Los Angeles, California. Her 20+ year career has included working in psychiatric hospitals, chemical dependency treatment centers, residential and community facilities, and consulting nationally with mental health organizations. She has taught psychology and counseling at JFKU and for the University of Phoenix. Catherine has made frequent appearances as a mental health expert on the national TV show ‘Extra’ and her writings have been published in journals, magazines, and books in the US, Finland, and Norway. Please visit her online at www.catherineauman.com.

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SELF-DISCLOSURES AND SUPERVISION: THE USE OF SELF-DISCLOSURES WITHIN SUPERVISION RICKI BODEN, LCSW, MFT, BCD

Psychotherapy skills are very difficult to teach. Psychotherapy supervisors struggle with the question of how to teach a skill that will best come to be known through the intimacy of direct experience. While students may arrive with all sorts of recent theoretical training and varying degrees of life experience, it is through the path of apprenticeship that they will actually begin to learn from doing. Students and supervisors alike may be wondering if they have what it takes. Can they co-create a working alliance? How will the supervisor balance the need to create a safe and creative learning environment with the need to ensure quality care? Will the supervisor be able to bring alive a complex and often contradictory profession that is always changing? Will the student be open to what is taught? Or will he or she be like an already full cup—so brimming with preconceptions that there is no room for new ideas? Given all there is to teach and learn, supervision can feel overwhelming and exposing at times for both parties. Transparency is required of each, in different forms. As a Continuing Education provider of online courses and in-person groups and classes, the question of the effective use of self-disclosure is always a hot topic. We explore our expectations of supervisees and our willingness, as supervisors, to self-disclose. How do we know what is useful and what is not, enough or too much? I always return to two basic guiding principles (Gabbard 2005): • •

Is it in the best interests of the client or the supervisee? Does it further the process of the treatment or the supervision?

Supervisee’s Self-Disclosure within Supervision Self-disclosure is an essential aspect of any supervision. It is imperative that supervisees be willing to examine their own process and develop strategies for how to use their insights to further therapeutic outcomes and to facilitate the supervisory exchange. Self-disclose is one part of effective “use of self.” Self-disclosure can create transformative moments in therapy and within supervision, provide important information that can be used to sculpt interventions, and enrich the learning experience. I remember a supervision in which the supervisee discussed the impact that her working class background was having on her professional identity development; questioning her ability to succeed in a profession her family viewed as “not real work” and something they didn’t really understand. I chose to speak about my background and that after thirty years of doing this work, I still find myself explaining to my working class family that “Yes, I talk to people and give them advice” for a living. We shared a laugh and began a profound dialogue of how her background enriched the potential of her work as a therapist. PRACTICAL APPLICATIONS IN SUPERVISION

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While students may arrive with all sorts of recent theoretical training and varying degrees of life experience, it is through the path of apprenticeship that they will actually begin to learn from doing. Yet, there is an unequal power balance in supervision; the supervisor writes evaluations, signs for hours of experience toward licensure, and is the acknowledged teacher or mentor. There are many schools of thought that emphasize, recognize or minimize this power differential based on beliefs about what provides the best training experience, and therefore, ensures the best service to clients. Supervisee self-disclosure requires careful monitoring to ensure its purpose is for better client care and supervisory learning. Overexposure of Supervisees in Supervision Supervisees experience pressures to self-disclose in supervision. Evaluations typically have a section assessing the intern’s use of supervision, which implies self-reflection and disclosure. A commonly held view by both trainees and supervisors is that the intern will only get out of supervision what he/she puts into it. Furthermore, interns are usually aware of a professional consensus that the hallmark of a good therapist is his or her willingness to be non-defensive, self-reflective, and open to feedback. Supervisors have an ethical responsibility to ensure that supervisees are not being pressured to disclose too much personal information regarding sexual history, history of abuse and neglect, psychological treatment, and familial and other personal relationships (Behnke 2005). Such information can be part of supervision, if specifically named in the supervision agreement or if discussion is necessary to deal with “impaired supervisee” assessment. Less experienced supervisors or supervisors with little training are at risk for blurring the boundaries between supervision and psychotherapy. Supervisors typically have more experience providing therapy than supervision and may inadvertently revert to a therapist mode in supervision. A common supervisee complaint is feeling overexposed in supervision. A supervisee phoned an agency’s training director to say she wanted a new supervisor. When the director asked why the intern complained that the supervision felt more like therapy than supervision. Basic questions of diagnosis, assessment, and technique were going unattended, since the supervisor seemed to only value “exploration of countertransference.” Not only did the intern not know how to address this situation with her supervisor, she also didn’t want to appear defensive or unwilling to self-reflect. She ended up concluding they weren’t a good match. Clearly, the power imbalance of supervision was a factor in this case. The supervisee needed support for taking the risk of talking with her supervisor. The supervisor needed help in reassessing the developmental level of the supervisee and in understanding her ethical responsibility to ensure that the supervisee’s rights were being protected, i.e., protected from boundary blurs and overexposure.

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Countertransference reactions by a supervisor to an intern may also lead to overexposure of the intern. If the supervisor feels devalued, challenged, or dismissed by the supervisee, he or she may retaliate out of a sense of narcissistic injury. The supervisor may need to be “right” or in control. Unconscious expression of unclaimed aggression may lead to putting the supervisee into a vulnerable position and treating the supervisee as a client. The supervisor may feel more empowered as a therapist than as a supervisor. Unclaimed competition or envy may lead to a misuse of power. There continues to be debate about what could be called the “teach or treat” dilemma (Ganzer and Ornstein 2004). How much exploration of countertransference, unconscious process, and the relational matrix of supervision is appropriate? How much selfdisclosure should be requisite for a supervisee? To some degree, supervision will ideally reflect the treatment modality being used with clients. Relationally oriented approaches to supervision emphasize the need to establish a co-created agreement addressing the content of supervision. Frawley-O’Dea and Sarnat (2001) state that these more personal interactions and self-disclosures in supervision are for the purpose of furthering the supervision process and client treatment. The focus of any self-disclosure should not be the content of any personal history but rather the supervisee’s countertransference reactions to the client’s clinical material or to supervision. The amount of discussion and selfdisclosure needs to be negotiated between the supervisor and supervisee and authorized by the supervisee. The supervisee must have the power to limit self-disclosure. The supervisor has the ethical responsibility to respect such limits and to make sure that the focus of supervision ensures optimal client care not personal therapy for the supervisee. Supervisors Self-Disclosures to Supervisees Supervisory style can be located on a continuum from the most hierarchical modes to the most collaborative. Emphasis on a didactic teaching approach is typically more hierarchical while other models value a co-creation of the supervision. Feminist, relational, and strength-based theories favor the latter. Relational theories emphasize “the importance of modeling self awareness, a multi-cultural perspective, and conceptually-informed, ethically-guided use of self-disclosure” (Wells & Pringle p. 1). No matter what theoretical model is used, supervisors must disclose certain professional information, e.g., fees, policies, emergency contact plan, in order to meet ethical and legal standards. Supervisors’ self-disclosures must meet a similar litmus test to therapists’ self-disclosures, i.e., self-disclosure must be nonexploitive and in the service of client care or supervisee learning. Levels of supervisor self-disclose are influenced by many factors. These include the context of the supervision (e.g., agency based or private practice), the theoretical bias of a context, and the theoretical orientation of the supervisor. Cultural style or context is an important factor shaping disclosure. Individual personal style is another variable and represents a conglomeration of both demographic characteristics and life experiences.

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Constructive Use of Supervisors’ Self-disclosures Supervisors’ self-discloses can help create an optimal learning environment for supervisees by using self-discloses to: 1) 2) 3) 4) 5) 6) 7) 8) 9)

normalize supervisee anxieties normalize typical countertransference responses humanize the process reduce shame model learning from mistakes encourage non-defensive self-disclose give examples of how to handle difficult situations expose supervisees to differences in clinical understanding and style model a collaborative and mutually constructive way of traversing an asymmetrical relationship, with parallels to the therapy relationship

Ethical Considerations Supervisor self-disclosure must be used appropriately and ethically. The reason for the selfdisclosure and the impact on the supervisee are critical factors in determining what is professionally appropriate and useful. Peterson (2002) suggests questions for therapists to ask themselves before self-disclosing; they can be easily extrapolated to supervisors: •

• • •

Is this information necessary to ensure that the supervisee can make an informed decision to commence supervision (fees, policies, licenses, emergency plan, supervisory contact, means of evaluation, etc.)? Is my purpose in disclosing this information to benefit the supervisee or myself? Is this supervisee likely to use this information in a way that is helpful? Do I know the supervisee well enough to speculate about the potential impact or consequences of this self-disclosure?

These questions can help provide an ethical guideline when making decisions regarding supervisors’ self-disclosure. Cultural factors should also inform decisions about whether or not to disclose. Supervisors who address cultural sameness and difference in the supervisory relationship create a welcome mat for discussing the impact of culture, including race, religion, gender, disability, and sexual orientation, in client cases as well. Dominant culture supervisors can admit they are not as competent in multiculturalism as a minority supervisee, if that is the case, and open opportunity for dialogue and mutual learning (Cook 1994). By so doing, supervisors can both model how to traverse multicultural relationships, and create a safe, effective learning environment that is uniquely attuned to the supervisee. PRACTICAL APPLICATIONS IN SUPERVISION

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Contraindications for Supervisor Self-Disclosure Both over-disclosing and underdisclosing have ethical implications in supervision, as each may derail the task. Underdisclosing mandated professional information is unethical. So is the failure to provide adequate direction and critical feedback, as it compromises the learning experience of the supervisee. Under the is guided impression that a supervisee is too anxious or vulnerable, a supervisor may only give palliative feedback. Or, seeking to avoid conflict, the supervisor may withhold his or her thoughts and reactions to supervisee’s work. Uncomfortable topics such as diversity issues may be sidestepped, with no information being directly provided. Sometimes, withholding a direct response to a question posed by a supervisee is harmful to the supervisory relationship. It is important to remember that the supervisee is not a client, supervision is not therapy, and therefore, the boundaries are different. Supervisor self-disclosure is contraindicated when: 1) it is a conscious or unconscious way of getting your needs met 2) it does not address the task of supervision, which is to provide optimal client care and supervisee training 3) it is an attempt to manipulate the Supervisee 4) it is a guilt-driven or shamebased attempt to ward off criticism, confrontation, or accountability for a mistake or a deficiency 5) it is being used to push a supervisee to make an intervention that he/she is not ready for or doesn’t agree with (caveats to this are in situations when an intervention would be legally or ethically mandated) 6) it is being used to push supervisees to make an intervention that violates cultural imperatives of the supervisee or the client 7) it is being used to build a “special relationship” with the supervisee, e.g., to aggrandize one’s self, to align with the supervisee to avoid being devalued, to initiate a romantic or sexual fantasy or relationship (This is professional misconduct and unethical.) Self-disclosure by supervisors is much less controversial than self-disclose by therapists. Benefits in the form of anxiety-reduction, trust-building, and role-modeling are well documented. Different theoretical models also more easily embrace it. Still, the power imbalance in the supervisory relationship requires a constant review of the ethical considerations in any self-disclose.

Ricki Boden, LCSW, MFT, BCD, has been in private practice in San Francisco since 1976 and was the Director of Women’s Mental Health Services and Internship training at New Leaf Services for Our Community for 20 years. She has extensive experience supervising graduate interns, registered trainees, and licensed clinicians in private practice and agency settings, PRACTICAL APPLICATIONS IN SUPERVISION

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using both individual and group formats. As a Continuing Education provider (PCE #538) she offers online and Home Study courses at www.supervisionCEU.com that meet BBS supervision and Law and Ethics requirements, as well as workshops, ongoing classes and individual consultation. References Behnke, S., (2005). The supervisor as gatekeeper: Reflections on ethical standards 7.02, 7.04, 7.05, 7.06, and 10.01. http://www.apa.org/monitor/ may05/ethics.html. Cook, D., (1994). Racial identity in supervision. Counselor Education and Supervision, 34,(2), 132-141. Frawley-O’Dea, M. G., & Sarnat, J. E. (2001). The supervisory relationship: A contemporary psychodynamic approach. New York: Guilford Press. Gabbard, G. O., (2005). Patient-therapist boundary issues. Psychiatric Times, Vol. XXII, 12. Ganzar, C. & Ornstein, E. D., (2004). Regression, self-disclosure and the teach or treat dilemma: implications of a relational approach for social work supervision. Clinical Social Work Journal, 32,431450. Peterson, Z. D., (2002). More than a mirror: The ethics of therapist self-disclosure. Psychotherapy: Theory, Research, Practice/Training. 39 (1), 21-31. Wells, M., & Pringle, V. B., (2004). Use of self in supervision model: Relational, ethical and cultural issues, 1-10. http://www.appic.org/NewsOnLine/ Articles/Supervision12-8-04.html.

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SELF-DISCLOSURES AND SUPERVISION: GUIDELINES FOR TEACHING INTERNS THE USE OF SELF-DISCLOSURE WITH CLIENTS BY: RICKI BODEN, LCSW, MFT, BCD THE THERAPIST MARCH/APRIL 2009

As a Continuing Education provider of online courses, day-long workshops, and ongoing CE classes with 30 years of supervising experience, whenever the topic of self-disclosure arises, the room heats up and the level of engagement increases. I feel this reaction reflects the essence of the use of professional self-disclosure. It requires an authenticity and presence that brings the relational aspect of both therapy and supervision to the foreground. It enlivens the exchange and often makes for the most memorable, as well as transformative moments of a therapy or supervision. Supervision requires a therapist to be able to articulate his or her work; to move beyond “doing it” to teaching it to another. One must gauge when to keep your thoughts to yourself in favor of mirroring, confirming, or admiring a budding ability. One must respect a student’s need to make his or her own mistakes at times while also navigating ethical, legal, and quality-of-care quagmires. Theoretical orientations, settings, and patient characteristics each influence a trainee or supervisor’s view of how to meet those moments in therapy when our boundaries are challenged or stretched, either because of external pulls or forces within ourselves. At best, the “use of self” required in both treatment and training is offered in service of another— the client or the supervisee. The therapist or supervisor may also derive benefits, but those benefits are secondary side effects rather than the primary purpose of the relationship. Because of the asymmetrical nature of both therapy and supervision, a commitment to rigorous self-reflection and authenticity is required. How can a supervisor and supervisee use self-disclosure with each other and with clients in a way that is ethical and optimal for both contexts? When is “use of self” skillful and in the service of the defined purpose of the relationship? When is “use of self” a narcissistic, unskillful or harmfully unboundaried intrusion, or even exploitation? Self-disclosures that are experienced as intrusive, abusive, and burdensome or change the focus of treatment to the provider rather than the client or supervisee, are boundary violations. Supervisors need to be able to help supervisees learn how to experience and modulate their impulses and intuitions to self-disclose according to strategic guidelines and ethical considerations. Two questions can serve as basic rules (Gabbard 2005) regarding self-disclosure:

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• •

Is it in the best interests of the client or supervisee? Does it further the process of the treatment or supervision?

Personal Authenticity and Professional Authenticity Self-disclosure is an ordinary but crucial way that authenticity is determined in the personal realm; it is understandable that it would arise as an expected, useful, and also complicated medium in the professional domain. Most clients want their therapists to have a genuine interest in their well-being and to feel that their therapists understand and appreciate their unique individualities. As they struggle to speak from their own experiences, clients would like to be met in their efforts by an honest voice rather than routinized “psychobabble.” I am reminded of a client asking, “But really, am I the kind of person you would be friends with?” her poignant stare and all the possible responses that filled my mind to such a heartfelt question. Self-disclosure is one behavioral manifestation of professional authenticity. Beginning therapists need help in establishing their own unique sense of what should remain inside personal and private boundaries and what could be shared professionally. This boundary will vary from person to person and hopefully be somewhat flexible to allow optimal therapeutic attunement to each individual client. The goal is to have full use of one’s professional self and maintain the focus on client needs while reserving the expression and gratification of personal needs. Supervisors can help supervisees develop their professional authenticity and express it in forms of self-disclosure that are a fit, both personally and theoretically, with empathic attunement to each client. Strategic Self-disclosure I use the concept of strategic self-disclosure in my continuing education trainings. Strategic selfdisclosure is the conscious, planned use of self-disclosure that reflects the confluence of many variables. The overriding intention of the intervention is to further therapy or supervisory goals. Hesitancy to discuss a disclosure must be labeled as a red flag at the beginning of supervision. This hesitancy should be communicated to supervisees at the onset of supervision when discussing how to best use supervision. Any disclosures that make the therapist desire secrecy or feel ashamed must be discussed in supervision. Ethically informed strategic self-disclosure represents a therapeutic use of self, the fullest engagement of the authentic professional self. However, as with many interventions, clinicians usually understand their fullest meaning in retrospect. Often strategic self disclosure also has an unconscious, seemingly unplanned component. It is important to review these disclosures as well, because many times they reflect an effective, ethical use of the same variables as elective disclosures. The unconscious and the intuitive have an awareness of their own that is often very useful in clinical work. Still, whether elective or unconscious, guidelines for teaching self disclosure are useful.

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Sample Case Vignette A supervisee in private practice supervision presents that his favorite client was threatening to quit therapy. The client accused him of not really caring about him, of only seeing him for the money and because he needed to practice on someone. The therapist was stunned—the client’s feelings were so discordant with his own. When the therapist asked why the client was so angry, the client said he was tired of watching the therapist squirm around in his chair each session. Such obvious signs of restlessness were hurtful and insulting. The client said he wanted a therapist who would enjoy working with him. The therapist replied he did enjoy working with him, but the client refuted this, saying he wouldn’t reschedule so many sessions if he did. The therapist had periodically rescheduled sessions to accommodate fluctuations in his health and unavoidable medical appointments related to a disability which he had chosen not to disclose to clients. Now, in supervision, he was questioning his decision. Chronic pain, worse on some days than others, required him to frequently shift in his chair. Realizing that his client had noticed, the supervisee felt both very exposed and distressed that his disability was having a clinical impact. Previously, he had informed his supervisor of his disability and had decided the he didn’t want to share this information with clients because it still felt too personal and emotionally charged. He worried that he wouldn’t be able to contain his own pain and that this would derail the focus on the client’s needs. He was addressing his concerns in his personal therapy. However, he now felt that in order to repair the empathic break, he should tell the client why he needed to shift around in his chair and reschedule appointments. At the same time, he also wanted to make sure that his disclosure of his medical condition wouldn’t burden the client or silence his expression of discontent. He worried: was his medical condition impairing his work? As the supervisor in this case, I would greet a dilemma like this as an opportunity to not only address a particular issue of self disclosure, but to also create a general strategic framework for deciding other questions of self-disclosure with the supervisee. Self-disclosure Guideline Below is a guideline that can be employed by the supervisor and the supervisee in formulating a plan for the use of self disclosure. It provides the supervisee with a blueprint that he or she can use in other clinical situations. • • • • •

Diagnosis Content of disclosure Transference themes Countertransference themes Ethical considerations

Diagnosis PRACTICAL APPLICATIONS IN SUPERVISION

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Diagnosis can be a useful conceptual tool in decisions regarding self-disclosure. On occasion my supervision students have questioned the concept of diagnoses, finding it to be pathologizing and objectifying. I believe, if used well, diagnosing can assist us in not re-inventing the wheel and actually attuning to unique client needs. Characterological disorders or traits provide broad guidelines of potential transference themes. For example, a borderline process may alert the therapist to boundary pushes by the client yet there is also a need for authentic contact. A narcissistic style may require finely attuned client attention that precludes much self-disclosure. Mood disorders provide information of affect states that may need either containment or amplification. Severe mental illness may require more self-disclosure in order to make contact or extremely restricted disclosure because of the blurring of self-other and reality boundaries. If diagnoses are used to further individualize an intervention, they are helpful tools. In the sample case, a borderline diagnosis might suggest that focusing on the client’s feelings of abandonment would be more useful than disclosing the supervisee’s disability. A diagnosis of depression might sway the therapist to encourage more expression of anger and disappointment, after which an acknowledgement of the distressing impact of the rescheduling that might or might not include a contained statement regarding the therapist’s health. Content of the Self-Disclosure The content of a self-disclosure might include the supervisee’s emotional response to a client or client’s statement, a comment on the impact of the supervisee on the client, or information about the supervisee. Discussing the use of a specific self-disclosure or potential self-disclosure is essential. Supervision is the place to discuss the difference between personal and professional authenticity. It is the place that supervisees can develop a language of self-disclosure that is different than the social language they bring from their personal lives. For example, if a client asks, “Have you ever had this problem—are you a recovering alcoholic, an incest survivor, etc.?” the supervisee needs to frame a professionally authentic response whether that is a simple “Yes, I am in recovery too,” or “It sounds like you want to know if I can understand your problem.” In the sample case, the supervisee has many possible levels of disclosure to consider. Given his preference to maintain the most boundaried stance possible regarding his disability, he might choose to focus on the impact of his actions on the client without disclosing his disability. He could perhaps disclose his feelings regarding the impact of his actions, e.g., “I felt sad when you said you were hurt and insulted by my actions and that you feel that I don’t like working with you.” On the other hand, he might use this as an opportunity to try a limited disclosure regarding his health: “I have to sit a lot in this job and it’s hard on my back, so I do frequently reposition myself.” He could then acknowledge the impact on the client and explore this more or assure the client he is paying attention. Again, all factors need to be considered in addressing the intervention.

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Transference Themes The use of the concept of transference is intended to raise awareness of the process between the therapist and client—to expand beyond content to a mutual understanding of what the process says about the underlying roots of an exchange and what about it may still need working through. Decisions regarding self-disclosure need to be attuned to the client’s needs and need to be theoretically syntonic with the form of therapy. In the sample case, transference themes would help shape self-disclosure. If the client has a history of a non-responsive family where needs were ignored by overburdened parents, the client may best benefit from a deeper understanding of his experience of misattunement, and from some acknowledgment of how the therapist’s behavior contributed to the client’s reactions. This acknowledgement might open a way to enter the past and other current relational experiences that feel like a repeat of this lack of responsiveness. If the client is depressed and doesn’t typically directly express his needs, the intern therapist might focus on that. In supervision, the supervisor might note the parallel between the client’s difficulty expressing his needs and the therapist’s discomfort with expressing his own needs regarding accommodation. Countertransference Themes Regardless of the theoretical language used, therapists, supervisees, and supervisors are both contributing and reacting to the clinical exchange. These feelings and actions may be based on the person’s past experiences, reactions to the present interpersonal exchange, or reflect a feeling state that the client or supervisee is unable to directly express, e.g., disavowed affect states, projective identification, or parallel process. In the sample case, countertransference is a major influence. It is important that the therapist is addressing his vulnerabilities regarding his disability. He needs to be careful to not reactively disclose more than he can tolerate, and thus lose his grounding in his authentic professional self. This loss would de-skill him and not be in the best interests of the client. Supervision can be a safe place to develop professional containment of emotionally charged material. Ethical Considerations Identifying the ethical considerations in a self-disclosure or potential self-disclosure is imperative. It is important to differentiate potential boundary violations from boundary crossings. What is the purpose of the self-disclosure, does it serve the needs of the client, or is it self-serving? Is the therapist consciously or unconsciously misusing the therapy relationship for personal gratification or gain? In the sample case, the therapist is inexperienced and just beginning to develop his professional identity. He is at risk of self-disclosing health issues for the wrong reasons and in the wrong way. For new therapists, caution is often the best approach. On the other hand, some self-disclosure PRACTICAL APPLICATIONS IN SUPERVISION

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may be in the best interests of the client and the supervisee; both treatment and learning could be facilitated. Exploring the question of whether the therapist’s disability is impairing his clinical effectiveness may be uncomfortable in supervision but ethically necessary. The therapist could benefit from having his worst fear named and addressed to its conclusion, while also maintaining effective treatment. However, without further work on this countertransference issue, the therapist is limiting his professional use of self. Wrong Reasons to Self-Disclose • • • • • •

to avoid being rude to make a client like you to avoid a client's anger at your nondisclosure to meet your own needs for healing, gratification, or gain to identify with the client and assume he or she will either feel the same way you do or benefit from your solutions to a problem if, self-disclosure would be in violation of agency policy or a supervisor's directive

Self-disclosures are inadvisable if you are not willing to discuss the impact of the disclosure on the client with the client. The intentional use of self-disclosure is to have a positive therapeutic outcome. It’s difficult to self-disclose if it feels inconsistent with your theoretical frame and yet positive outcomes may still occur from disclosures. Self-disclosure is inadvisable when experiencing a strong countertransference reaction or if it fuels a feeling of engaging in a “special relationship” with a client that you do not want others to know about. If you are not willing to talk with a colleague or supervisor about a self-disclosure, either because you want to keep it secret or feel ashamed, be alarmed and seek consultation. \ In addition, if the client has poor boundaries or limited reality testing, therapist self-disclosure is contraindicated since the disclosures may be distorted or over stimulating. If the client is overly caretaking with others, therapist disclosures may be ill advised. And if the client fears intimacy or any strong affect, disclosures may be overwhelming. (Goldstein 1994). In closing, I find having guidelines to teach self-disclosure a helpful tool. As we examine our relationships to the use of self-disclosure, both in therapy and supervision, we become more prepared to guide novice therapists struggling with their own questions about it. I believe the dialogue that ensues is a learning experience of great depth and is mutually beneficial to both supervisor and supervisee. Ricki Boden, LCSW, MFT, BCD, has been in private practice in San Francisco since 1976 and was the Director of Women’s Mental Health Services and Internship Training at New Leaf Services for Our Community for 20 years. She has extensive experience supervising graduate interns, registered trainees and licensed clinicians in private practice and agency settings, using both individual and group formats. As a Continuing Education provider (PCE #538) she offers PRACTICAL APPLICATIONS IN SUPERVISION

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online and Home Study courses at www.supervisionCEU.com that meet BBS supervision and Law and Ethics requirements, as well as workshops, ongoing classes and individual consultation. References Gabbard, G. O., (2005). Patient-therapist boundary issues. Psychiatric Times, Vol. XXII, 12. Goldstein, E. G. (1994). Self-disclosure in treatment: What therapists do and don’t talk about. Clinical Social Work Journal, 22, 417-433.

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THE INTERACTIONAL NATURE OF SUPERVISION: A PSYCHODYNAMIC PERSPECTIVE SUSAN BOULWARE, PH.D.

Abstract This article reviews and discusses contemporary psychoanalytic and psychodynamic perspectives on supervision. Supervision in the intersubjective paradigm views supervision as an interactional process between all participants involved: supervisor(s), supervisee, patient, and training institution. Transference, countertransference, projective identification, and parallel process are reformulated and broadened. Examples are discussed which illustrate the multiple dyadic and triadic transference/countertransference configurations in each supervisory process. The paradigm shift in science in this century from a positivist to a relativist position has also encouraged a shift in the perspective of the psychotherapist from authoritarian and objective stance to one founded in co-participation. The therapist is no longer a blank screen or mirror but a person who is subject to projective identifications, countertransference, counterresistances, and feelings. In a similar way the conception of the role of the supervisor has shifted, albeit more slowly, from one of teacher and overseer, to an idea that she is part of a system where she is influencing the trainee, but is also influenced by he and his patients. The classical position posited that the supervisor should use a diagnostic perspective towards the learning process. Not only is this judgmental but it sets up the supervisor to be the arbiter of a considerable portion of the reality of the supervisory and therapeutic processes. Descriptions of supervision that address the mutual interactional influence that all participants have on each other began to appear in the mid-eighties. The new paradigm, generally called intersubjectivity, views supervision as the shared creation of the supervisor and the student and assumes the student is active in the learning process and aware of his needs and requirements. Within the intersubjective paradigm the most constructive stance for the therapist is not a carefully controlled persona, but authentic responsiveness and honest disclosure (Mitchell, 1995). Therapy is understood not as the unfolding of the contents of the patient’s mind, but as an interaction between two people, each brings their own dynamics, affects, ideals, and conflicts into the encounter. By the same token, supervision in the new paradigm should be an egalitarian and relational process emphasizing the mutuality of the processes of influence. Supervision becomes a sort of analytic process centering on the subjective experiences of all the participants; supervisor, trainee, and patient. The patient, trainee, and supervisor will act in terms of their respective transference/countertransference configurations. The optimal and dysfunctional triadic combinations in the supervisory process are discussed by Marshall (1997). Greenberg (1995) has described an “interactive matrix” that includes the beliefs, commitments, hopes, fears, needs, and wishes of the participants in a therapeutic dyad, each bringing his/her unique personality into the encounter. The interactive matrix of the supervision process is at minimum a three-person situation, with other influences affecting the system: insurance policies, confidentiality, PRACTICAL APPLICATIONS IN SUPERVISION

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professional evaluation, traditions and beliefs of the training institution, and administrative issues. Berman (1997) has written: . . supervision is the crossroads of a matrix of object relations of at least three persons, in which each person brings her or his psychic reality into the bargain. It is a crossroads of actual interpersonal encounters (involving also social issues such as authority, power, gender roles, economic stratification) and of less visible intersubjective realms (p. 162). A focus on what is happening in the relationship necessitates a reformulation of traditional constructs such as transference, countertransference, projective identification, and parallel process not only for psychotherapy, but also in regard to the supervisory process. Parallel process. Parallel process has commanded the literature on supervision since its introduction by Ekstein and Wallerstein (1958). The traditional view of parallel process holds that the supervisee identifies with aspects of the patient’s resistance and then acts this out with the supervisor. While this undoubtedly occurs, placing this scenario as the focus of the supervisory process obscures the supervisor’s responsibility for any difficulties. A contemporary view of parallel process sees it as universal in the supervisory process but defines it more broadly: it is an empathic process where one participant unconsciously enacts aspects of another’s personality. It is not simply the student’s neurotic conflicts or resistances that are occurring. Parallel process involves projective identification and the relocation of the patient’s, supervisee’s, and supervisor’s self states among themselves (Caligor, Bromberg, & Meltzer, 1984). Searles (1955) wrote about a “reflection process” where the supervisory interaction is influenced by the transference/countertransference situation in the therapy relationship. Clarification of the difficulties in the supervision then removes obstacles to the learning for the supervisee and precipitates a shift in the therapy relationship. For example, an intern felt pressured by her supervisor to delve more deeply into her patient’s material and experience. The supervisor felt guarded about the intern’s ability and impatient with her progress. She would role-play for the student how she would conduct the therapy. While the interventions the supervisor proposed made complete sense to the intern, it left her feeling hopeless and in despair. Shortly after this session with her supervisor, she met with the patient, who proceeded to express hopelessness and despair about ever being able to change. A parallel process is at work; it is not at all clear where the experience of hopelessness about competency originated but it seems to be finding its way into all the participants in this triad. It could be that the parallel process is from the “top down” rather than the “bottom up.” Transference/countertransference. A modern view of transference refers to the patient’s experiences of the therapy relationship that are constructed, continually and interactionally, with the patient’s primary organizing patterns. Transference combines projected elements with realistic perceptions. Countertransference is seen as the totality of the therapist’s reactions to the patient and combines issues from the psychic reality of the therapist and elements that are particular to a specific patient. Transference and countertransference are constantly activating and shaping each other and are parts of a whole process that does not comply with cause and effect rationale. In fact, from an intersubjective perspective, transference could also be termed, counter-countertransference.

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The literature on countertransference in supervision has focused on the student’s countertransference to the patient, or on parallel process. The transference/countertransference phenomena between supervisor and supervisee and its consequences both for the supervisory relationship and therapeutic relationship, have not been examined extensively. In a supervisory hour, the trainee is doing more than merely relating to the supervisor events in the therapeutic hour. He is interacting with the supervisor and vice versa. It is the nature of this interaction that is a large part of the supervisory information. When the irrational aspects of the supervisory relationship are left unattended, inarticulated, or dissociated, there will be an impact on the therapeutic relationship by affecting the student’s understanding and use of supervisory information. The supervisor has a countertransference to both the supervisee and the patient that can be constructive for the supervisory process; it can be a significant source of data about the process of supervision and the therapy. Extending the concept of signal affect in the therapeutic relationship (Tansey & Burke, 1989) to the supervisory one, a supervisor’s awareness of her own affective response to the supervisee signals the appearance of a transference/countertransference enactment in this relationship. Exploration with the supervisee will often lead to parallel issues being played out in the therapy. Additionally, articulation of the supervisor’s countertransference to the patient may offer the trainee new insights. A relationship that has rarely been addressed in the literature is the one between the supervisor and the patient. While there is no direct contact between them, a relationship may develop in fantasy and have a powerful impact on all concerned. The patient may learn who the supervisor is, develop fantasies about her, and/or develop a transference to her separate from the transference to the trainee/therapist. The supervisor may develop an autonomous countertransference and fantasies to the patient which may or may not be conscious. She may feel curiosity, affection, or contempt for the patient, and/or attempt to “jump over” the student to treat the patient. This becomes entwined with the supervisory relationship and various transference and countertransference dyadic and triadic patterns can emerge. Projective identification. It is in the context of transference/countertransference that the construct of projective identification can be articulated. Melanie Klein (1946) originally conceptualized projective identification as occurring only in the fantasy of the child to expel bad parts of the self onto the internal mother. Contemporary views hold that projective identification has both intrapsychic and interpersonal dimensions. It is an interactional process that has several functions: communication, defense, object relatedness, and as a pathway for psychological change (Ogden, 1979). From a control mastery perspective, projective identification is also a way to turn passivity into activity. Just as a patient may locate aspects of herself into a trainee, the trainee may then locate aspects of the patient and himself into the supervisory process as a way to understand and manage them for himself and the patient. An intern I was supervising related to me an interaction with her patient in which the patient revealed, with extreme anxiety and fear, some illegal activity in which he was engaged. He was quite concerned that his therapist would turn him in to the police. She reassured him that she had no such intention and expressed her concern about how he was being manipulated by others. I had a visible countertransference response to this situation, which was actually in PRACTICAL APPLICATIONS IN SUPERVISION

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alignment with the trainee/therapist. In exploring her perceptions of my reaction, she too felt that I would want him to be turned over to the police. A split-off aspect of the patient was relocated first into the trainee/therapist, then into me, and we both enacted a role that kept the patient in the position of being passive and compliant. This in fact, reenacted two contradictory and dissociated experiences of his mother as being either extremely critical and intolerant (being reported to the police), or protective and infantilizing (guarding him from those who would manipulate him). The supervisory stance. Excluding the supervisory relationship from mutual inquiry endangers both the therapy and the supervision. It is important that there is a recognition that difficulties in the supervision process result from the interaction between two personalities with a contribution from the patient. This decreases the hierarchical distance between the supervisor and supervisee, minimizes blaming, and creates a space for open disclosure and exploration. Difficulties in the supervisory relationship can result in significant problems in the therapeutic relationship. The supervisee will often enact with a patient the difficulties experienced with the supervisor, but with the roles reversed. In addition, training institutions can resemble difficult aspects of the family situation and can be evocative of enactments around rivalry, dependency, power, loyalty, separation and individuation (Thompson, 1958). Research has indicated that supervisees believe that the timely exploration of countertransference issues in the supervisory relationship to be the mark of effective supervision. The longer problems are not discussed, the more negative the impact on the supervision (Rock, 1997). For the most part, the supervisory process should focus on the here and now experience of the encounter between the patient and supervisee. However, if the supervisor has the sense that the supervision is not going well, or there is a feeling of anxiety or inhibition, then the focus should be shifted to the supervisory relationship. If a parallel process is noticed between the therapy relationship and the supervisory one, it should be addressed. When the conflicts in the supervisory relationship are mutually explored, they provide the supervisee with a model and experience for confronting difficulties in the here and now. If this can be done constructively with the supervisor, then it can be done with a patient. It is also helpful to consider that a disagreement between a supervisor and supervisee may indicate that they are each listening to two different voices of the patient. Supervisees value experiences that promote autonomy and the development of a professional identity. They need an active, task-focused and involved supervisor, which seems to be essential for the development of autonomy (Rock, 1997). The supervisor needs to attend closely to the supervisee’s sense of self, especially his sense of competence. The supervisor’s empathic listening stance enhances self-cohesion in the supervisee: to be listened to, to have one’s experience acknowledged, and to be taken seriously enhances a sense of self. But, there can be a developmental tension in the supervisee’s process, reflecting a need to maintain autonomy at the same time as there are needs for identification with and recognition from the supervisor (Benjamin, 1988). The student needs to be professionally held in the same way that the patient requires holding in the therapeutic environment (Winnicott, 1965). This needs to be by an experienced person who believes in the supervisee’s capacity to help the patient (Casement, 1993). It is in this context that a supervisee can find a style of working with patients that is compatible with his personality. PRACTICAL APPLICATIONS IN SUPERVISION

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Qualities associated with good supervisors are flexibility about theory, knowledge of technical principles, respectful attitude towards the trainee and the patients, ability to be supportive and non-judgmental, humility toward knowledge, curiosity, a relaxed and patient manner, thoughtfulness, and the ability to communicate concepts clearly. Additionally, it is important that the supervisor has the capacity for self-reflection and self-monitoring of the emotional and interpersonal processes between herself and the supervisee, and to be able to alternate between identifying with and observing the experience of both the trainee and the trainee’s patients (Binder & Strupp, 1997). In the traditional perspective, the trainee’s personal issues were never addressed in supervision and he was speedily sent to his psychotherapist or analyst if any of the personal issues appeared in the supervision. However, in the contemporary paradigm, in order to be effective in the therapeutic process, the trainee must learn to use countertransference effectively. Therefore, the supervisor must inquire about the trainee’s personal concerns. An environment which is open, tolerant and curious allows the trainee to feel some comfort in sharing personal information and feelings as they are relevant to the supervisory process. Certainly the extent, direction and style of exploration are very different in therapy and supervision. In the former, the therapist tries to reach the deepest understanding without any immediate goals. Supervision is much more selective and goal-oriented, with the focus on issues of the trainee that are directly related to his work with patients. Supervision is not therapy; the goals are different but the process is similar. The interpersonal process that occurs in therapy also occurs in the supervisory relationship. The goal of supervision is to assist the trainee in developing his cognitions, affects and conduct in the therapeutic relationship (Hess, 1997). The role of the supervisor is that of supporting the student as therapist to the patient which entails believing in and fostering the potential for the student to become a competent therapist. The process of learning is mutative, and in a general sense, therapeutic. The supervisee learns through instruction, affective experience, and identification. In listening to and making formulations about patients, the trainee consciously as well as unconsciously, self-reflects, associates, and deepens his self-awareness. This requires, on the part of the supervisor, a basic trust in the supervisee’s capacity for maturation and professional development, which creates an atmosphere of safety. The supervisor’s willingness to acknowledge her role in difficulties in the supervisory relationship is crucial in creating this environment. It is then possible for the supervisor to be honest about feedback and limitations in the therapist’s work. From this perspective, the issue of standard technique in both supervision and therapy become irrelevant and obsolete. There is no technique that one can learn and apply correctly. What needs to be learned are not fixed rules but an introspective and empathic sensitivity to the sources and impact of our actions and inactions. The task is rather to follow in minute detail the therapeutic and supervisory interactions and to consider the interpersonal and intrapsychic implications of each verbal and non-verbal interaction. The basic ideas about boundaries and frame in the supervisory and therapeutic relationship still apply—without these clarity is lost. The supervisor is the authority and is more knowledgeable, but this does not mean she has all the relevant data. It is the supervisee who sits with the patient and the supervisor must PRACTICAL APPLICATIONS IN SUPERVISION

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realize that the first-hand knowledge of the patient, on which therapy is based, is in the possession of the supervisee. The basic principle should be that the supervisee is the therapist and the therapy is his responsibility. The supervisor possesses another perspective of the process that may be helpful, since she is not embedded in it. It is important to keep in mind that it is a different perspective, not necessarily a better one. Clinical example Elkind (1997) discusses the concept of “primary vulnerability,” an area of psychological sensitivity that one defends against experiencing. This can happen in a supervisory dyad, as well as a therapeutic dyad. Following is a detailed example of supervision where an area of primary vulnerability, authority and vulnerability to devaluation, was activated in all participants. It also illustrates the influence institutions can have on the process and the responsibility that both the trainee and the supervisor have in resolving difficulties. I had been working with a student for approximately a year and a half who was very empathic and supportive, and had a tendency to resort to educational lectures with her patients when she was not sure how to proceed in the sessions, or when a patient’s experience aroused her own difficult emotions. One session, she confronted me with how she had felt over the previous two weeks about our interactions. She felt I had been critical, directive and not attuned to her, and she experienced herself as incompetent and worthless. She also realized that she had treated a patient in the same way I had treated her. The therapy of this patient was supervised by another staff member. The patient had then canceled her session the following week. Fortunately for all the participants, the trainee and I were able to discuss this difficulty and view it from the perspective of enactments and interactional pressures. Her propensity to educate and “fix” her patients when she felt unsure or uncomfortable was “relocated” into me and I tried to “fix” her. Or alternatively, I had in the past resorted to “lecturing” when I felt stymied in my supervision of this student, which she then enacted with her patients when she felt stuck. Exploring the roles being passed around this triad (actually there were four participants involved, including the other supervisor) allowed her to realize how she affected her patients and the mutual influence of all participants. My willingness to openly explore the situation and my participation in it was the supervisory information that she could then use to adopt a more patient and tolerant stance with her patient. The patient resumed treatment and there was no disruption in the supervisory process. There are several transference/countertransference configurations or parallel processes active in this scenario. The obvious ones are those between my supervisee and myself and between the supervisee and the patient. The three of us share a primary vulnerability to devaluation and criticism. Less obvious are ones between me and my analyst and consultant, between the trainee and her other supervisor, between the trainee and her therapist, and between myself and my own patients during this time period, that paralleled the supervisory process. Over the months of working together I had been able to create with this student an open and safe environment where she could bring up difficulties. To her credit, she was mature and competent enough to confront me when necessary. The values and attitudes of the institution about psychotherapy and supervision also allowed such an exchange. Searles (1955) has noted the extraordinary emotional impact of the supervisory process on both supervisor and trainee. As part of his learning process, the supervisee internalizes the supervisory process, for better or worse. Doing supervision gives the supervisor the chance for deeper self-inquiry through contact with the supervisee and his patients. This deeper PRACTICAL APPLICATIONS IN SUPERVISION

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self-awareness extends her capacity to listen to herself and to her patients. This perspective on supervision is a maturational one—there should be no more pressure put on a trainee to progress in supervision than is placed on a patient in therapy. If a supervisee is the recipient of a stream of communications about his limitations and mistakes, he may find himself in the position of being a bad and deficient child, thereby impairing the learning process. Therapeutic and supervisory interactions are structured, enriched and limited by each participant’s relational patterns, vulnerabilities, defenses and sensibilities (Rock, 1997). Tact and sensitivity on the part of the supervisor are essential. As well, the receptivity of the supervisee and the willingness of supervisor and supervisee to question themselves and their assumptions is also essential. The goal is not to purify the process of the participants’ conflicts, but to stimulate curiosity, self-awareness, and clarity. Psychotherapy and supervision are best facilitated when both therapist and supervisor are willing to be used as servants in the process and willing to consider all data, especially the interactional data. Each therapeutic and supervisory dyad is unique and the freedom to raise any issue for exploration is likely to result in a relationship that is open, generous and effective, rather than abusive, intolerant or unsatisfying. References Binder, J., & Strupp, H. (1997). Supervision of psychodynamic psychotherapies. In Watkins, C. (Ed.). Handbook of Psychotherapy Supervision. New York: John Wiley & Sons, Inc., 44-62. Benjamin, J. (1988). The Bonds of Love: Psychoanalysis, Feminism and the Problem of Domination. New York: Pantheon. Berman, E. (1997). Psychoanalytic supervision as the crossroads of a relational matrix. In Rock, M. (Ed.). Psychodynamic Supervision. Northvale, New Jersey: Jason Aronson, Inc., 161-186. Caligor, L., Bromberg, P., & Meltzer, J. (Eds.) (1984). Clinical Perspectives on the Supervision of Psychoanalysis and Psychotherapy. New York: Plenum. Casement, P. (1993). Towards autonomy: some thoughts on psychoanalytic supervision. Journal of Clinical Psychoanalysis. 2:389-403. Ekstein, R. & Wallerstein, R. (1958). The Teaching and Learning of Supervision. New York: Basic Books. Elkind, S. (1997). Resolving impasses: including patients and supervisees in consultation. In Rock, M. (Ed.). Psychodynamic Supervision. Northvale, New Jersey: Jason Aronson, Inc., 361-398. Greenberg, J. (1995). Psychoanalytic technique and the interactive matrix. Psychoanalytic Quarterly. 44:1-22. Hess, A. (1997). The interpersonal approach to the supervision of psychotherapy. In Watkins, C. (Ed.). Handbook of Psychotherapy Supervision. New York: John Wiley & Sons, Inc., 63-83. Klein, M. (1946). Notes on some schizoid mechanisms. International Journal of Psychoanalysis. 33:433-438. Marshall, R. (1997). The interactional triad in supervision, In Rock, M. (Ed.). Psychodynamic Supervision. Northvale, New Jersey: Jason Aronson, Inc., 77101. Mitchell, S. (1995). Interaction in the Kleinian and interpersonal traditions. Contemporary Psychoanalysis. 31:65-91. PRACTICAL APPLICATIONS IN SUPERVISION

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Ogden, T. (1979). On projective identification. International Journal of Psychoanalysis. 60: 357-373. Rock, M. (1997). Effective Supervision In Psychodynamic Supervision. In Rock, M., (Ed.). Psychodynamic Supervision. Northvale New Jersey: Jason Aronson, Inc., 107-131. Searles, H. (1955). The informational value of the supervisor’s emotional, experience. In Collected Papers on Schizophrenia. New York: International Universities Press, 1965. Thompson, C. (11958). A study of the emotional climate of psychoanalytic institutes. Psychiatry. 21:145-151. Winnicott, D. (1965). The Maturational Process and the Facilitating Environment. New York: International Universities Press. Acknowledgments I am most grateful to David Wallin, Ph.D., for his thoughtful and helpful reviews of this manuscript.

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RELATIONSHIP AND SUBJECTIVITY JUDITH R. BROWN, PH.D.

Abstract The personal development of the supervisee is an essential aspect of the supervisor’s task, specifically fostering awareness of self and others, creating presence and responsiveness, and enhancing the capacity for relationship between therapist and clients. To engage the supervisee personally requires the supervisor to model and provide practice in relationship skills. Metaprocessing — consisting of metacommunication, self-disclosure and feedback — brings into focus the ongoing relationship experiences of supervisor and supervisee as they interact, not at the expense of clinical learning but as an integral part of it. It is instrumental in bringing about new meanings, self-understanding, and deeper levels of trust and contact, both in the supervisor-supervisee relationship and, subsequently, the therapist-client relationship. Leaving “subjectivity” out deprives supervision of its flesh and blood. The last decade has seen a burgeoning of literature on MFT supervision and qualifications for supervisors. Although the relationship between the supervisor and supervisee is seen as crucial to the course of supervision, little has been written or researched about this relationship. At the same time, research into successful psychotherapy indicates that a therapist-client alliance is probably a good indicator of successful outcome of therapy (Horvath & Greenberg, 1989). This would seem to point to the supervisor-supervisee relationship as especially important on two counts: first, to model and practice skills that strengthen and enhance the capacity of the supervisee to facilitate such an alliance through contactful interaction, and second, to promote an optimum learning experience in the practice of therapy for the supervisee. In writing this article I intend to focus on two fundamental and related aspects of supervision that are, strangely, rarely mentioned in the literature: first, the person of the supervisor and the person of the supervisee and their relationship, and second, the skills of metacommunication and metaprocessing. My purpose in this undertaking is to present the potential benefits of including and making explicit the on-going interaction of the supervisor and the supervisee in helping to enrich the continuing learning experience, model and provide practice for supervisees’ skills and foster the presence and engagement of the supervisees. Relationship and subjectivity are inseparable. They are both manifested in dialogue. Jourard ( 1994) defines dialogue as “catching someone’s attention so he or she listens to what is being said, giving evidence that he (sic) hears and understands.... Then, ... for the listener to speak truth in relevant response... the wish is to understand and make the self understood, so each participant shares in the world of the other’s truth.” (p. 225). It is “participatory consciousness,” (Heshusius, 1994, p. 16), the open perspective that leads to true meeting. As important as dialogue is, it is the person behind the words who makes possible the human encounter. Although the path or the method of arriving at contact may be beyond detailed study, we do know when we are involved in contactful moments of interaction. We know by what we feel. We experience something: we are touched — emotionally touched. Moments of contact are instantaneous and usually ephemeral. They depend on presence, trust and openness, both in PRACTICAL APPLICATIONS IN SUPERVISION

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relation to others and to ourselves. These qualities are not listed as subject matter in curricula for supervisors-to-be nor in supervision itself. There are clients to discuss, issues, topics, approaches to therapy, and all the business involved in the undertaking of teaching and learning about treatment. Such topics may serve as distractions from the people themselves — the supervisor and the supervisee(s) — and from the extent of their presence, trust and openness. Yet the people, their contact, and creative relationship are central, they are the basis of the whole enterprise of supervision and therapy, We are humans first, before we are therapists. Interaction as learning experience Metacommunication and metaprocessing are ways to temporarily bring into focus and highlight the current experiences of people and their interactions. These practices, which involve the ability to extricate oneself from the level of the content or subject matter and attend to the experiences of the people and the process — what is actually transpiring, are notably absent from the literature. Therefore, I must assume they are also generally absent from the agenda and behavior of supervisors and supervisees. Consequently, interactions in which supervisees can be introduced to ways of using themselves more fully, consciously and productively in their work are passed over. The most valuable personal learning experiences do not occur. The work of supervision, in addition to expanding the professional skills and abilities of the supervisee, also includes the development of the person, strengthening her or his beingness — that is, substance, essence, and presence. It has become conventional wisdom that dealing with problems is the work of therapists, and so they spend much time in supervision learning to identify, name, and treat problems. Dealing with people, while setting aside the problems for a time, seems an indefinable task. To do this, we must cast aside our crutches in the form of theories, techniques, teaching and providing answers, and rely only on ourselves. When supervisors include the human encounter in the training and supervisory process, they not only model this essential aspect of supervision but they deal explicitly with presence and responsiveness, prerequisites of supervision and therapy. Difficulties of being “in relationship” are experienced as a problem for the vast majority of the individuals, couples and families we meet in therapy, yet it would seem to be neglected as a direct point of intervention. Perhaps it is too obvious, or maybe it is an issue that we therapists and supervisors also share. It would seem the most important level at which to work is to deal directly with relationship, presence, and personal response. Inviting, even encouraging such experiences of our supervisees, as well as clients, may seem demanding, for it requires supervisors to use themselves as their instrument. It demands their presence and responsiveness, which can only exist in the now. So rather than talking about what happened in the past, or what may happen in the future, they must bring themselves to the present moment, with awareness of themselves and the other(s). It means attempting what may be the ultimate achievement dealing with what is actual, in the present moment, and being genuinely responsive. The concept of self-awareness is so foundational to presence and responsiveness, it may need some explanation. Perhaps most of us imagine we are aware, that we know what our existential state is at any moment. However, “thinking about yourself is not the same as being present to yourself” says a character in a novel called, of all things, Therapy, (Lodge 1995:100). The author cites Kierkegaard, “the unhappy man ‘is always absent to himself, never present to himself.’” I use the expression “self-awareness” to describe perception, primarily through the senses, in the moment. We may have directed perception. For example, when someone says, PRACTICAL APPLICATIONS IN SUPERVISION

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“Do you smell smoke?”, we sniff and become focused on what we smell. Another example would be a supervisor asking a supervisee, “What goes on physically for you now as you speak of your client?” The supervisee draws a breath and says, “I wasn’t breathing, was I?” Undirected awareness is when, without anyone prompting, we seem to wake up to what is going on. “Oh, I feel so frustrated trying to get through to that client! I feel it now as I talk about him. Angry, too, although I guess I shouldn’t be.” “Trying to figure out,” is not awareness. In a word, awareness is not what you think. It seems we all spend a good deal of our time distracting ourselves from ourselves, in thought — and by keeping “busy.” Awareness of ourselves does not mean shutting out the world. In fact, awareness of oneself and others goes hand in hand. I believe that only to the degree that we are in touch with ourselves can we also be in touch with others. When we sit with supervisees, or when, as therapists, we sit with clients, it is starting out where there is no path, like riding a new wave. We have skills and experience, to be sure, and we have learned how to look for patterns of behavior and interaction in couples and families; but how will we use ourselves to meet and be with this particular person or family on this particular day? That, we cannot know in advance. The client-therapist relationship is, above all, a human relationship. It provides the ideal opportunity for the therapist to model a responsive, contactful interaction. The supervisor-supervisee relationship is a perfect arena for the therapist to be initiated into the practice of reaching deeper to be part of such a relationship, with the supervisor setting the tone, prompting supervisees, not at the expense of clinical learning, but as an integral part of it. Dealing with their interaction as an inherent aspect of the supervisory experience will elicit more expansive engagement and enhance the opportunities for further development of the supervisees. Supervisors have the important task of facilitating a process orientation by “intensifying an experience through focusing on here and now interaction, emphasizing awareness, and stressing connection with self and contact with the environment — including other people” (Brown 1996, p, 34). Thereby, they provide their supervisees the opportunity to open themselves to their actual experiences in the moment, to pay attention to physical sensations such as their breathing and posture, to recognize their emotions. Such procedures can vastly enrich whatever other approaches are employed in the supervision experience. Engagement and expression replace talking about, and bring liveliness to, what might otherwise be static and stale interaction. As a consequence, supervisees can evolve as true partners in their personal growth, becoming more of themselves, through an interactional and developmental experience. They are challenged at every turn to meet, according to their level of readiness, the expectation of contactful dialogue, to discover more of themselves, not by talking about, but through, the experience of responding and being responded to. At the same time, they learn how to genuinely engage and affirm their own clients as human beings worthy of spending time with, rather than as walking problems needing to be fixed. A shift in focus Supervisors are products of the prevailing therapy culture, and as such are often concerned with analyzing, figuring out, fitting, matching, judging, and comparing facts and ideas. These areas of knowledge and skills, after all, are generally those emphasized in courses and examinations in the field of individual, marriage and family therapy. With some intelligence and time spent studying, we become adept at dealing with diagnoses and treatment plans, and describing the symptoms of psychopathology. We succeed in passing tests and feeling competent. Of a radically different order, is the ability to deal with feelings, emotions, intuition, and unconscious PRACTICAL APPLICATIONS IN SUPERVISION

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processes. Relating in a caring and creative way with others and with ourselves is learned, not from reading books, but gradually over years of (sometimes painful) self-scrutiny and living experience. It is understandable that we gravitate to the more cognitive domain in supervision. It is so much easier to grasp than our subjectivity, ourselves and our visceral responses. We tend to ignore this territory. Yet it is where pain and joy, love, fear, courage — all essentials in the human condition — reside. Demands on supervisors Supervisees, like clients in therapy, may hold their cards close to their chest, but it behooves supervisors to put their cards on the table, make explicit what is going on for them in the immediate context, and to engage their supervisees interpersonally. Following is an example of metaprocessing between a supervisor and supervisee. Supervisor: “This is what is going on for me night now. I sense we are on different wave-lengths. I realize I am wanting more engagement from you. And I wonder what is going on for you now. You have been talking about your concerns for your clients but I am speaking to what is happening between us now.” Supervisee: “I have mixed feelings about what you just said. Uum, I’ve picked up some hints that you are not satisfied with me. I guess I’ve been protecting myself in here. So I am caught. How much can I trust? I’m afraid you want something of me I can’t give.” The self-disclosure of the supervisor is like priming a pump. It tends to bring forth self-disclosure from the supervisee, revealing important relationship information. At this point, it might be very easy — indeed second nature — for the supervisor to slip into a therapist role: “You don’t know how much to trust me.” Or, “I wonder whether you felt the same toward your parents that they wanted something of you that you feared you couldn’t give.” This is a trap to avoid, both for the quality and aim of supervision, and for a lost opportunity to create a different kind of relationship, one of trust and mutual respect. The supervisee deserves the best the supervisor has to give, and in this case it is a personal response. For example, "What you have just told me is important for me to know. I appreciate very much that you trust me enough to say what you did. It seems we’ve put some juicy topics on the table. In terms of my wanting more engagement from you, you are giving me this right now. I’m open to hearing whatever else you may want to say.” The supervisor-supervisee relationship "Anxiety is a fact of life for the supervisee” (Case, 1995, p. 15). Whatever the source of the supervisee’s anxiety, the relationship between the supervisor and the supervisee can do much to increase or alleviate it. The more one knows about what is going on with the other, the less one relies on imagination, the less energy is wasted on negative projections. Metaprocessing, as the above example demonstrates, helps to make clearer what is happening at the relationship level. It is communication about the present process, instrumental in facilitating new understandings, new meanings, and deeper levels of contact. “It is a deliberate kind of communication with specific characteristics. [It consists of ] metacommunication, feedback, and self-disclosure. It involves “processing the process” (Brown, 1996, p. 72). Such interactions can be beneficial in many respects. For example: to puzzle out the events that have been taking place; to clarify motivations and social dynamics behind an event, to reflect on and reveal values, experiences and observations, PRACTICAL APPLICATIONS IN SUPERVISION

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to allow conflicting views to surface and to highlight relationships, informal rules, and covert alliances, to share what has been learned and explicate the steps and operations that facilitated or interfered with the learning or the task; to show when there has been no closure to the interaction; and to create the possibility to come to resolution and closure and proceed with new pursuits (Brown, 1996, p. 73). In the supervisory context, there are other advantages to add to this list. The ability of supervisees to engage in a metaprocessing session is an excellent indicator of their abilities to be present, aware of themselves and another person, and able to listen and respond appropriately to the situation. It is a way to assess their sense of self, their interpersonal abilities, their growth and maturity over a period of time. Jourard (1994) makes a connection between the healthy personality, growth, and self-disclosure. In addition, the inclusion of metaprocessing provides supervisors with important feedback on both the content and the process of their sessions. A major benefit is the carry-over of metaprocessing by the supervisee to the therapy situation. This is a relationship-building skill that is both appropriate and enormously useful for the therapist/client interaction, providing safety and opportunities for progress toward the health of the client. In an interview, Eve Lipchik states: “I believe that clients have to feel respected and comfortable in order to benefit from the collaborative experience and it is the role of the therapist to establish and maintain that climate” (Storm, 1995, p. 2). Lipchik continues, “Techniques by themselves are not enough. The same goes for the supervisory experience. Supervisees have to feel safe in their relationship with supervisors in order to profit from it.” Seeing, hearing and responding are present-focused activities, They help our clients rest from their incessant sub-vocal babbling and the voices from the past that continue to haunt them. Clients can, with the help of the therapist, take a vacation from figuring out, from repetitive, self-hypnotic words and phrases that keep them in their stale, left-over, unfinished situations from the past. They may dare to wake up from their nightmares of negative projections and come to a few minutes of contact with themselves and another. Metaprocessing may be one of the most important skills for therapists to pass on and practice with individuals, couples and families in therapy. The questions of subjectivity and relationship exist in a different sphere from cognitive knowing and rationality. They are often disregarded in the literature and practice of supervision, (a noteworthy exception is Yontef 1997), to the detriment of the personal and professional development of supervisees. Addressing these topics, not by discussion, but by actively engaging in the creative process of intra- and interpersonal discovery, can be the best experiential training for supervisees, who, in all of their meetings with clients, must address issues of meaning, identity and self-realization. These issues go beyond purely cognitive approaches. They naturally engage the whole person. Supervisors might find four basic questions facilitative in getting in touch with themselves and their supervisees: What (am I) are you doing now? What is happening with (me) you now? What (am I) are you experiencing now? What (am I) are you feeling now? By including their own experiences, supervisors model metaprocessing. Clarification of terms There has been, for some time, an espoused interest in feelings and emotions, accompanied by much misuse of the word “feel.” Supervisors can set an important example by avoiding such phrases as, “I feel that you...,” which generally means I imagine that you...” Such statements are not about the speaker, although they may erroneously be considered self-disclosure since they PRACTICAL APPLICATIONS IN SUPERVISION

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begin with “I feel...” “I feel that...” These statements are thoughts, not feelings, and should be understood as such. (Thoughts are fine.) When supervisees (or clients) speak in “feeling” terms, it is beneficial to help them come down from the heights of abstraction to what is actual in their experience, focusing their attention to their senses, body sensations and breathing. For example, “something’s uncomfortable” is abstract. “I’m uncomfortable, I’m hardly breathing and I am tightening the muscles in my abdomen,” is a statement that arises directly from experience. Another popular idea is the concept of “reflection.” Examples given are often limited to primarily cognitive —or intellectual — activity. For example, “Let’s reflect on (think about) this problem and come up with some possible solutions.” The following description may be helpful in expanding the notion to encompass a more total exercise: “a process of reflection that [leads] from thinking to feeling and from feeling to thinking again — no longer thinking ‘about’ something, but rather a kind of reflection within a field of experience” (von Schlippe, 1993, p. 2 10). Summary There is no substitute for genuine person-to-person interaction in the supervisory relationship. The supervisor-supervisee relationship, as manifested in their interaction, is instrumental in the vitally important development of subjectivity in supervisees: enhancing their capacity for relationship, fostering awareness, creating presence and the ability to be responsive. Whether the art or the science of supervision is emphasized, it is necessary to deal explicitly with the present moment, with me, with you, with us. This is a difficult challenge, to be sure, and perhaps the ultimate achievement. It bears fruit also by serving as a model for supervisees to follow in their work as therapists. Contact and response evoke all that is human in us, our feelings, unconscious processes, our cognitive functions, our heart and our spirit. We are touched even as we evoke emotions in others. It is fitting that supervisors share their knowledge; but we need also to share our selves and connect with others. The development of the supervisee is grounded in such moments of meaningful connection where the marvelous power of human interaction is manifested. References Brown, J. R. (1996). The I in science: Training to utilize subjectivity in research. Oslo Scandinavian University Press. Case, P. ( 1995). An anecdotal exploration of the supervisor-supervisee relationship in marriage and family therapy and supervision. Unpublished dissertation. Heshusius, L. (1994). Freeing ourselves from objectivity: Managing subjectivity or turning toward a participatory mode of consciousness? Educational Researcher 23 (3). Horvath, A. 0., & Greenberg, L. S. (1994). The working alliance: Theory, research, and practice. New York- Wiley. Jourard, S. M. (1994). The failure of dialogue. In M. Lowman, A. Jourard, & M. Jourard (Eds.), Sidney M. Jourard: Selected writings. Marina del Rey: Round Right Press. Lodge, D. (1995). Therapy. New York- Penguin Books. Storm, C L. (1995). Solution-focused ideas guide supervision: An interview with Eve Lipchik. AAMFT The Supervision Bulletin, Vol.VIII, No. 1. von Schlippe, (1993). “Guilty!” Thoughts in relation to my own past: Letters to my son. In B. Heimannsberg & C. J. Schmidt (Eds.), The Collective Silence: German identity and the Legacy of Shame. (G. Wheeler & C.O. Harris, Trans.). San Francisco: Jossey-Bass. PRACTICAL APPLICATIONS IN SUPERVISION

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(Original published in 1988.) Yontef, G. (1997). Supervision from a gestalt therapy perspective. In C.E. Watkins, Jr., (Ed.), The handbook of psychotherapy supervision. New York: Wiley.

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TEACHING AND LEARNING PROBLEMS IN SUPERVISION JANE BURKA, PH.D. THIS ARTICLE WAS PRESENTED AT THE SUPERVISOR’S CONCLAVE AT THE PSYCHOTHERAPY INSTITUTE IN BERKELEY, CA, 1993 AND IS PRINTED WITH PERMISSION FROM THE AUTHOR.

Supervision used to be viewed as a simple, didactic two-person relationship. Certainly, supervision is not simple. It is a very complex task in which as supervisors we have a lot of responsibility—professional, ethical, and legal—to teach and to help. Our goal is to help the therapist become more of a therapist—by increasing his or her theoretical knowledge, by broadening and sharpening the therapist’s technical skills, and by helping the therapist to increase the introspective and creative use of the therapeutic self. This is not a simple task. Neither is supervision only didactic. While explicit teaching about theory and technique have a place in the supervisory process, so do a lot of other things like setting the boundaries of the teaching environment, creating a safe space in which learning can occur, examining the process between therapist and supervisor, exploring the parallel process with the therapy relationship, and supporting the ongoing self-examination of both participants. We no longer think of supervision as purely didactic, but as part of a triadic relationship. There would be no supervision without a patient. So there are three pairs in the triangle of supervision: the therapist and patient, the therapist and supervisor, and also the relationship between the supervisor and the patient. As a supervisor, you do have a connection to the patient, imagining this person, trying to understand him or her, wanting to help the patient, and even having emotional reactions to the patient elicited by what you are presented from the therapist. Especially early in training, when patients are likely informed that their therapists are in supervision, the patients also have a relationship with the unseen supervisor. The supervisor imparts information, but the supervisory relationship is not the same as the supervisory information. How the information is received or used by the therapist is shaped by the nature of the relationship. I will focus on how to use the relationship between the supervisor and the supervisee to increase the learning experience of the therapist. But this emphasis on the relationship is only one aspect of all that takes place in supervision, and I want also to put this focus on the supervisory pair in a larger context. When I think about supervision, I consider five main ways of thinking about what is going on. I will detail two categories. The first is the traditional model of supervision as a straight teaching experience, where the supervisor demonstrates how he or she thinks about the patient. Essentially, the supervisor is monitoring the therapy; teaching the therapist to create and maintain a stable framework, to recognize unconscious material, to put the patient’s history to use in understanding him or her and in understanding the transference, to be attuned to countertransference, and to set limits PRACTICAL APPLICATIONS IN SUPERVISION

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when necessary. The supervisor may have to teach theory or technique in order to fill gaps in the therapist’s education. For example, I was supervising a new trainee at the Psychotherapy Institute. She told me that she took a phone call on intake of a patient who said he was depressed. He said he couldn’t talk more then, and wanted the therapist to call back, and gave his phone number at a motel phone. When the therapist called back at the agreed-upon time, and at several other times, the patient didn’t answer. The therapist was irritated, and did not feel that she had to do any more. I had to talk to her about the danger signals in a phone call from a depressed person in a motel, and had to tell her how to do a suicidal assessment before letting someone get off the phone. I directed her to call the motel front desk and try to find out if the person was still there, and was okay. Later, I talked with her about why her own alarm bells hadn’t gone off in this encounter. In this experience of supervision, I was intervening directly, teaching explicitly, and also raising questions about the therapist’s internal responses which minimized the apparent danger. This kind of didactic or management supervision occurs most frequently with newer psychotherapists. The second category for consideration is the therapist’s developmental level. A supervisor should always take into account where the therapist is in his or her experience as a therapist, (not just the person’s age or experience at other jobs or personal maturity). When working with a newer therapist, the goals are somewhat different than the goals with an experienced clinician. With a less experienced therapist, you are careful to create a safe space for the therapist in which to bring up problems and tolerate feedback, suggestions or even criticism. The newer therapist is less likely to be aware of his or her characteristic issues, or his or her impact upon patients. On the other hand, newer therapists are likely to be more open to learning and may not yet be fixed on one theoretical approach, or wedded to a particular style of working. Although anxiety, vulnerability, insecurity, and self-esteem issues are always present in supervision, no matter what the therapist’s level, newer therapists are especially worried about their adequacy—not just whether they understand the patient, but whether they’re in the right field! Depending on the therapist’s level of experience, the supervisor focuses on their skills, their strengths and their weaknesses. As therapists are more experienced, the focus shifts from the patient to the therapist, and also broadens to include the supervisory relationship. There is a shift from teaching about the patient to helping the therapist improve his or her therapeutic ability, to learn to recognize and facilitate the therapist as an “analyzing instrument.” The third category that addresses the context for the supervisory relationship is the organizational environment in which the supervision is taking place. The supervisor has a great deal at stake in the conduct of the psychotherapy performed by the supervisee. In agency settings, the supervisor may have real power over the therapist’s career, in keeping a job or getting a raise. In a school placement, an evaluation is being made that will go back to the school. In an advanced training program, evaluations will determine the therapist’s progress through the program. All of these factors will implicitly or explicitly affect what takes place within supervision, and may have serious consequences on how much freedom each person feels, and therefore on how much learning takes place. There are also traditions and beliefs in organizational settings which affect how supervision is conducted. Some organizations, like psychoanalytic training institutes for example, are enamored of theory and may overlook process PRACTICAL APPLICATIONS IN SUPERVISION

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in the therapy or especially in the supervision. On the other hand, institutions like the Psychotherapy Institute emphasize process more than teaching, and so in supervision one may see that trainees are more comfortable discussing their feelings and less comfortable devising theoretical formulations. Although we recognize the necessity for didactic teaching, the assessment of the developmental level of the therapist, and the influences of the organizational setting, essentially supervision is a relationship. Because supervision is a relationship, it cannot always go smoothly. When there is a focus on the presumed wish to learn of one participant, and on the presumed expertise of the other, anxieties about competence and exposure are inevitably stirred up in both participants. These vulnerabilities trigger problems in the teaching/learning relationship. There are two issues in the learning process for therapists who are in supervision. One is called “learning problems” (Ekstein & Wallerstein, 1958). These are the issues which arise between the therapist and his or her patient. The other is called “problems with learning.” These are the issues which occur between the therapist and the supervisor. While learning problems and problems about learning are called “problems” in the literature, they are not insidious problems in the sense of being wrong or avoidable. These “problems” are the inevitable and necessary responses to the learning situation, and they can be understood and welcomed as tools with which to work in supervision, much like transference in psychotherapy. Learning Problems Learning problems in the therapist occur between therapist and patient. Learning problems refer to the particular ways the therapist has of reacting in the therapeutic relationship that determine and possibly limit the kind of help and the extent of help the therapist can offer. In other words, learning problems are the idiosyncratic patterns of the therapist that occur automatically in working with patients and that can affect and limit learning. (In essence, these learning problems are the result of the therapist’s own psychology—where the therapist’s own issues show up, once or more often, in the conduct of therapy.) For example, a therapist worries every time a patient talks about leaving that the patient is in fact going to quit. So she anticipates the end of therapy, feels rejected and unappreciated, and starts to detach from the patient, even to wish him gone. She does not inquire about the wish to leave, or encourage the patient to continue, but accepts the leaving as a fact, which contributes to the patient’s ambivalence and may actually hasten the end of the therapy. This anticipation of rejection and loss would be considered a learning problem. Although it is obviously a part of the therapist’s psychological make-up, in supervision it is not treated as the subject of exploration as much as it is brought to the attention of the therapist so that she can change her understanding of the patient and behaviors with her patients. You can teach this therapist that the expressed wish to leave may be symbolic rather than actual; that it can be an expression of something the patient is communicating to the therapist, like retaliation, or asking for reassurance; and that the therapist’s task is to decipher the meaning, conscious or unconscious, of this communication, and to use this understanding in the therapy. How well the therapist is able to use the information will depend on several things. New therapists may simply need the experience of living through patients’ threats to quit to see that it PRACTICAL APPLICATIONS IN SUPERVISION

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doesn’t always happen. People who have been abandoned in their personal lives and therefore expect to be abandoned by their patients may be surprised and relieved by the strength of the attachment that patients make to their therapists. The point is that a supervisor tries to bring to light what the therapist is exaggerating or overlooking in response to the patient. You try to bring the dissociated aspects of the therapeutic relationship into the therapist’s awareness. There are as many learning problems as there are therapists, but here are some of the most common issues and themes that can become characteristic distortions. 1. The therapist does not feel competent enough, or that she has enough to offer the patient. This is especially true of newer therapists. She may hesitate to say what she is thinking to the patient because she is not certain that her ideas have any value. She may keep quiet when it would be beneficial to the patient to share her thoughts. For example, a therapist primarily reflected back to the patient what she was hearing, even though she had private thoughts that the patient was sometimes being unrealistic or overreacting to events in her life. The therapy didn’t seem to be going anywhere, which made the therapist feel even more inadequate. Eventually, the patient said that she might as well be talking to a friend, she didn’t see the point of therapy. The therapist was crushed, her worst fears confirmed. The supervisor suggested that the therapist could communicate to the patient some of the ideas she was developing about the patient; the patient seemed to be inviting this—why not experiment and see if it would help? This freed the therapist to tell the patient more of what she was thinking, and the therapy progressed. 2. The therapist lacks knowledge about theory or technique. She may be quite successful with some patients, but at a loss with others who are less familiar. Some therapists are very skilled at following the patient’s affect, but lack the experience of knowing how to make an interpretation when necessary. Therapists who are accustomed to making transference interpretations may not have yet acquired the skills of silent holding. An experienced therapist who has learned a lot about neurotic states or high functioning patients may not have the theoretical knowledge to recognize more primitive states, and so has a tendency to underdiagnose more severe disturbances. In these cases the supervisor can try a more didactic approach, filling in gaps in knowledge of theory or making direct suggestions about technique. A therapist came to me for consultation on a case that had been a long term therapy, about which she now felt stuck. When the therapist heard the details of the patient’s breakup with her boyfriend, and saw how the patient distorted things so that he was always wrong and she was always right, the therapist started to question the truthfulness of many things the patient had said about life, work, and friends. As we talked, it appeared that the patient was much more disturbed than the therapist thought, and that the patient’s experience of reality was severely compromised by splitting and grandiosity. Although the therapist was quite experienced, she was not so experienced with this type of patient, and she was also compelled by the experience of a patient who was very convincing. I talked both about the perverse relation to reality and about the technique of addressing this process rather than staying with the patient’s feelings.

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3. The therapist tends to feel pulled into power struggles under many circumstances with different patients. This does not refer to a countertransference response to a patient who is provoking power struggles, but to a characteristic wariness on the part of the therapist. For example, a therapist reacted to a patient’s request to change his therapy session as a manipulation, and refused the request without hearing why the patient was asking for a change. This therapist also heard a patient’s ambivalence about therapy as a challenge to her authority, and saw the discussion of setting the fee as a win/lose experience. Here the supervisor is in difficult territory, because this is a characteristic response which is likely to be repeated in supervision. There is often an overlap of problems in therapy and problems in supervision, which will be discussed later. But the supervisor can give a different point of view about the psychological intentions of a patient making a request for a change, and see how well the therapist integrates a more cooperative perspective. 4. The therapist’s use of self is restricted in her work with patients; that is, a particular aspect of the full range of emotions is limited or unavailable to the therapist. A typical example is the therapist who is not free to use her own aggression in her work. This may mean that she is unable to set limits or boundaries with demanding patients, or that she feels helpless in the face of a patient who is being contemptuous or demanding. She may not be able to mobilize her own activity enough to intervene with a patient who is hard to interrupt, or she may miss the aggressive elements in the patient or in the negative transference. The supervisor can point out the overlooked aggressive elements in the patient or in the transference/countertransference; give permission for the therapist to be more assertive; or may model the acceptability of aggression by making sure to elicit and address the therapist’s negative feelings about the supervision. There may be other kinds of restricted self-expressions: therapists who hesitate to use their own creativity and stick too closely to the rules; therapists who do not allow their own vulnerability to be touched; therapists who see only the pain and not the joy. Whatever is the characteristic bent of the therapist that is interfering with the work with a patient, the supervisor can identify it and try to encourage a broadening of the therapist’s range. 5. The last learning problem I want to mention is the therapist’s fear of getting inside the patient’s internal world, whether this means getting immersed in chaos, in pain, in rage or whatever. When a therapist sticks to giving advice or offering support, or tries to get the patient to be more rational and mature, it may represent a fear of getting caught up in the power of the patient’s world view. As an example, a therapist has a patient who is not very attractive and has few friends; yet the patient feels like a femme fatale and believes herself to be irresistibly seductive. The therapist is very impatient with the unrealistic self-image of the patient, and feels distant and critical whenever this comes up, but keeps silent so as not to hurt the patient’s feelings. When she presents the patient in supervision, her attitude toward the patient is somewhat condescending. It became clear that this therapist was unnerved by the extent of distortion and self-deception in her PRACTICAL APPLICATIONS IN SUPERVISION

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patient, and tried to distance herself from this level of craziness. She was holding back from entering the patient’s internal experience, and this interfered with her ability to think about why the patient has to hold such an exaggerated view of her attractiveness. The supervisor can help the therapist understand what the patient’s internal experience might be that creates the need for such a grandiose self-image, and give an understanding of the disturbance which may make it seem less dangerous. (It is interesting to me to see how much people can work around their own issues in doing treatment, even though these issues are not necessarily resolved in their own psychologies. You can say to a supervisee, go in and raise your fee in a manner that suggests that you feel professional and entitled, and they can do it, even though they don’t feel one bit more professional that day than they did the day before.) Problems About Learning The therapist supposedly comes to supervision to learn, but learning is a transitional state. It means shifting from the place of knowing what you know up to now, to a new place of knowing something else. This implies a new integration. Integration, especially in our field, carries a very positive connotation as something mature, evolved, and ultimately desirable. Yet integration, for patients in therapy and for therapists in supervision, by definition causes an upheaval, a realignment of what was in place. Integrating new ideas means a change in perspective on old ideas; it means having to rethink, alter, or even un-learn what one thought one knew. So genuine learning is more likely to be an experience of “de-integration,” to use Michael Fordham’s term. If learning implies change, then with the wish to change comes a resistance to change. There is an unavoidable struggle in the therapist about wanting to know more and at the same time wanting to protect oneself and to feel competent. There is bound to be a struggle against learning, a particular characteristic way of limiting learning. This is called a “problem about learning.” This struggle against learning takes place within the therapist —within any learner—but in supervision, the conflicts about learning also take place within the context of a particular supervisory relationship . As the therapist tells the supervisor about the patient, and the supervisor listens and comments, a relationship is created. These two people bring to their relationship different characters, different cognitive styles, different styles with patients, different theoretical viewpoints, different professional experiences, and each is under different institutional pressures. This particular relationship with this particular pair of people will determine how learning takes place—the relationship will shape what is learned and what cannot be learned, and even to some extent how what is learned is used by the therapist. For example, I worked with a therapist who was not very confident about her ability to make management decisions with her patients—decisions about fees, canceled appointments, and offering extra sessions. This would be considered a learning problem—her sense of inadequacy with patients around these issues, even though she did have her own ideas about what to do. In supervision, she wanted me to tell her how to handle these moments. While she was willing to first consider what she might do, her thoughts were expressed more as a necessary first step to hearing what I would do rather than her own problem-solving. This would be considered a PRACTICAL APPLICATIONS IN SUPERVISION

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problem about learning. Her way of learning was to idealize me and undervalue herself, and to pretty much do what I told her. This problem about learning contributed to problems in her therapy, because she put off answering patient’s questions unti1 she could talk to me. This both frustrated patients and undermined her own authority in therapy, adding to her sense of inadequacy. The therapist had a dream that depicted her problem about learning. In the dream, her patient came to her house for dinner, but she had nothing to feed the patient and had to leave her there hungry while she went to the grocery store to get food. I think that at first, when she was quite inexperienced, it was okay for me to solve these dilemmas for her, but it fed into my own need to be admired and important and it ultimately interfered with her confidence in her ability to stand on her own. Her problem about learning intersected with my own narcissistic needs as a supervisor, and my complying with her requests for direction limited what she was doing with her patients. Some of the most common learning problems include: 1. When you read about problems with learning, perhaps the most frequently mentioned are issues of narcissistic vulnerability and need, whether expressed directly as this therapist did, or defended against so that little is asked of the supervisor. When supervisees are submissive to authority, it can be viewed as a pleasure rather than a problem about learning, but an overly cooperative therapist in supervision may be learning through imitation rather than through his or her own struggle. Of course, some part of supervision is offering the experience and confidence of the supervisor with whom the therapist identifies and joins, but this foundation can become a problem if it interferes with the therapist learning for herself. When a therapist defends against the narcissistic vulnerability of being in a learning situation, she may have a need to prove how much she already knows, and does not leave much room for a supervisor to contribute. This problem about learning is more easily recognized, because it can be unpleasant for the supervisor, but it may also be the only way the therapist can learn, that is by first demonstrating how much she knows. I have noticed with one of the people I recently consulted that she used consultation as an opportunity to think through and talk about her work with each patient being presented. I am used mostly as a 50-minute silent witness. I provide the frame, but little else. Occasionally I ask a question or make an observation, but in short sentences: she is not interested in my pontifications. Within this limited relationship, she has noticed that her patient is much more disturbed than she had thought, and is rethinking the case, so learning is taking place, but not directly from me. Eventually I hope to bring this to her attention. Unlike learning problems, which the supervisor tries to address explicitly in supervision, problems about learning are observed by the supervisor and thought through, perhaps maneuvered around or adjusted to, but not necessarily verbalized, at least not for some time. 2. The second major issue that is identified as a problem about learning involves power struggles—overt or covert defiance. A therapist may have a strong need not to submit to the authority of the supervisor or the institution, and so may be competitive with the supervisor, derogatory of supervision, try to impress the supervisor, or deny or ward off the impact of supervision. This problem about learning can limit what the therapist can absorb from the PRACTICAL APPLICATIONS IN SUPERVISION

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supervisor, and avoids the “de-integration” that comes with new learning. Some supervisees are overtly defiant—the therapist who is critical of the supervisor, who blames supervision when the therapy doesn’t go well, who argues with suggestions or observations made by the supervisor. But subtle defiance also represents a problem about learning. For example, a therapist’s schedule changed and she wanted to stop coming to consultation because the drive would be longer and less convenient. This might seem a reasonable decision, but it might also represent something about the supervisory relationship. As this decision was explored, it came out that the therapist’s practice had dropped significantly. She felt embarrassed to admit how few patients she had. She felt competitive with the supervisor, but felt she was losing the competition. She didn’t want to feel less successful than the supervisor, and so was thinking of quitting partly as a way to hurt the supervisor’s practice. The supervisor encouraged the revelation of these competitive feelings, asked questions about the embarrassment and the wish to retaliate, but didn’t get too caught up in the therapist’s decision about continuing. Not only did the therapist decide to continue, but she later considered this exchange to be a model for how she could deal with negativity and hostility from her patients (this does not mean that the competitive issues went away, but that they can be handled as the teaching relationship continues). 3. Another problem about learning frequently encountered is called the “mea culpa” style. The therapist blames herself for her mistakes before she can be accused of making mistakes. Here guilt and self-blame are not only used by the therapist as an intrapsychic self-attack, but the self-reproach is used within the supervisory relationship as an attempt to ward off criticism by the supervisor. In this mode of preoccupation with her mistakes, the therapist can spend more time talking about her psychology and her personal problems than about the patient and the therapy. There is a fine line between accepting responsibility as an element of self-observation, which increases learning, and using the mea culpa style as a way of guilt is being used. For example, a therapist came for consultation because of a case which felt out of hand. The therapist had allowed the patient to call her at home and the patient had been calling drunk at all hours. The therapist was quick to say that she knew this was a mistake and she recounted all the other mistakes so the supervisor didn’t have to point them out. The supervisor had a hard time getting the therapist to see why these “mistakes” occurred. The therapist appeared to have insight into her role by acknowledging her errors. But it became clear that the therapist had difficulty with further self-exploration about why she had allowed things to go so far. Her admissions were ways of warding off the criticism of the supervisor. They did not lead to curiosity about what was going on with the patient, herself, or between the two of them that allowed these breaks in the frame to become so extreme. 4. Although therapists need highly developed intuitive powers, reliance on intuition can become a problem with learning. Therapists who rely on their intuition to help their patients may see their patients getting better, but may not be able to articulate why the improvement has occurred. Therefore, their learning is limited if they have not consciously increased their skills or added to their awareness about what has taken place. It is up to the supervisor to help the PRACTICAL APPLICATIONS IN SUPERVISION

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therapist reflect on and express what is taking place in the therapy. This is done by asking, for example, “what did you have in mind with that intervention?” or “where do you see the therapy headed?” or by trying to tease out what is the theory of change implicitly held by the therapist. 5. A related problem about learning occurs when the therapist presents her work, but waits for the supervisor to do the work of formulating and theorizing. The supervisor is admired, perhaps even considered omniscient, but the therapist remains passive in not evaluating for herself the issues in the therapy. Sometimes therapists have a cognitive style that makes it difficult for them to abstract, and this difficulty may remain hidden if the supervisor continues to carry the role of formulator. How does a supervisor deal with problems about learning? First, the supervisor can always be thinking about the therapist’s problems with learning, starting with an initial period of making a learning assessment. The supervisor can notice how the therapist presents material, what kinds of questions are asked, how much self-reflection is used, and where the therapist’s vulnerability seems to emerge in supervision. Is this someone who is hesitant to admit mistakes or who leads with her mistakes? Is this someone who presents questions along with possible answers or who waits for the supervisor to provide the answers? Which areas seem to make the therapist feel sensitive to criticism? Second, the supervisor can use the supervisory countertransference, feelings as a supervisor in this particular relationship. From the beginning of supervision, when the relationship is being established, and continuing as an ongoing process, the supervisor can think about how she is related to as an authority figure, how she is being used or not used as a teacher, and what kinds of feelings are aroused in response to this particular therapist. Does she feel like a big sister? like a mean mommy? like a brilliant clinician? She can use the supervisory countertransference to help identify what kind of learning environment is being established. Of course, the supervisor makes a major contribution to the kind of learning environment that emerges. While making an effort to create a safe place to stimulate therapeutic curiosity and address learning problems, the supervisor brings his or her own biases to bear on the therapist in a way that limits what the therapist can learn. It is important that the supervisor’s self-analysis continue in supervision as well as in the work as therapist: what are his theoretical biases? does he usually address the same kinds of issues in the therapy, like transference, or history, or affect? How willing is he to tolerate differences in supervisees, who may not want to clone themselves after the supervisor? What needs does he satisfy by doing supervision—the need to be admired, the need to talk, the need to be liked, the need to exercise authority? What kind of impact does the supervisor have on the therapy—is the therapist acting more like the supervisor than like herself? Is the therapist treating the patient the way the supervisor treats the therapist, or the way the therapist wishes to be treated? Is the supervisor’s optimism or pessimism about the case being transmitted to the patient? Whatever the qualities of the therapist, it is up to the supervisor to create a safe space for learning. Supervision can be viewed as a mutual play space, in which the teacher and learner PRACTICAL APPLICATIONS IN SUPERVISION

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gradually become collegial so that there are two teachers and two learners. References Ekstein, R., & Wallerstein, R.W. (1958). The Teaching and Learning of Psychotherapy. New York: Basic Books. Fordham, M. (1978). Jungian Psychotherapy. New York: John Wiley & Sons.

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THE SOUL OF SUPERVISION BY: PETER H. COSTER, PHD THE THERAPIST NOVEMBER/DECEMBER 2009

With the publication of Thomas Moore’s Care of the Soul: A guide for cultivating depth and sacredness in everyday life, the word “soul” began to find its way back into the field of psychotherapy where it belongs. The spiritual and religious wisdom traditions describe soul as neither spiritual nor physical, but the realm that lives between earthly and heavenly existence by participating in them both. To engage in “the search for one’s soul” is not so much a religious enterprise as a human one. According to Moore, soul is not found in some divine realm, but in the common ordinary experiences of everyday life, which are the source of both pleasure and pain. Whenever we attempt to navigate the duality of black and white thinking, which is the cause of much suffering in ourselves and our clients, we advocate for the middle way by means of creativity and imagination. This “middle way” is the soulful and human way of being in the world. Soul is that which mediates all experiences and embodies the variety of qualities, emotional states, and feelings that comprise our true nature as human beings. Soul is central to who we are as humans, and soul is central to our work as psychotherapists. Psycho-therapy is the art of attending to the psyche or soul by means of loving attention. How we lovingly attend to the soul is as varied and diverse as the theories that guide our work and the techniques we practice with those who come to us for help. How we care for soul depends in part on the way that we orient ourselves theoretically to the work we do. We need to ask ourselves what image of the human person guides our work with others. Our answer to this question reveals our relationship with soul. Jungian psychologist, James Hillman, defines soul as “the imaginative possibilities in our nature.” The life of soul is the life of the imagination as it gets lived and embodied in the particulars of everyday existence. We care for soul in psychotherapy whenever we are giving soul our loving attention. It is this loving attention that awakens the soul to the imaginative possibilities lying dormant within each of us. Caring for soul means honoring the images produced by the psyche as having a life of their own. When we work with the images of the psyche, as in dreams or memories, or with the disturbing fantasies that get spoken in the safety of the psychotherapeutic relationship, we are working with PRACTICAL APPLICATIONS IN SUPERVISION

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soul. The soul is endlessly producing images says Hillman, and these images reflect our heart’s longings, our creative aspirations, our unfulfilled hopes, and dreams. To work with them in psychotherapy or in supervision is to attend to soul and to engage in soul making. These images may be fragmented due to trauma or disembodied through neglect; they may be repressed and suppressed. Nevertheless, these images are the language of soul and we as psychotherapists are trained to listen and to attend to them. How does the image producing psyche we are calling soul enter the supervisory relationship? What makes supervision “soulful?” Like psychotherapy, supervision is built upon trust, mutual respect, and the collaborative participation in a co-created “assumptive world” comprised of images and symbols that have meaning and value for both supervisor and supervisee alike. Words are the primary medium we employ in our craft to engage both the mind and the heart. We use words in our work to convey knowledge, empathy, understanding, and to impart the wisdom born from our life experiences. The work of psychotherapy lies in helping our clients find the words that convey their experiences, embody their longings, and express the deep desires of their souls. The words that have been cultivated in silence lay dormant in the clients’ sanctuary of his/her heart and mind waiting to be uttered. When we speak the word that conveys the souls’ truth, and when this word is truly heard by others, a creative transmutation is set in motion. Words create and give form while producing meaning. When the souls’ language expresses the poetry of the heart, we are in the midst of a creative and sacred act. As supervisors we work with words spoken by both the supervisee and the client; words that have been remembered and repeated within the relational field of the supervisory relationship. The supervisory relationship has the potential of becoming what Jung called the “alchemical vessel,” capable of transforming the lead from life’s everyday events into the gold of a meaningful experience. The alchemical vessel, in this case, is the supervisor-supervisee relational matrix, a rich mixture of the client’s psychological material impacting the supervisee and being communicated to the supervisor who listens and waits at times in the silence of unknowing. In supervision, my supervisee speaks about the experience of her client through the medium of words that aim to recreate the imaginative and co-constructed world of the client-therapist dyad. The “world,” being heard and received within the context of the supervisor-supervisee dyad is also mediated anew through the supervisor’s own imaginative construct. These mutually influenced and shared imaginal constructs are another way of describing the life and work of soul. I am listening for the soul’s imaginative possibilities, waiting to come forth in my supervisee, as well as in her client as they navigate the terrain of their unique healing PRACTICAL APPLICATIONS IN SUPERVISION

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relationship. The supervisee is using the container of the supervisory relationship to deepen, expand, and facilitate the soul work with her client. My supervisee is also involved in her own soul work as she explores in herself the barriers that are standing in the way of entry into this relationship of mutual influence. The questions our supervisees ask of us as supervisors, the puzzles that confound them, the enactments that are unavoidable, all impact us as supervisors. This is an experience of soul. We are engaged. We participate. We are affected. To deny this is to deny soul. We may as supervisors find ourselves, without warning, fully immersed in the “bath,” those powerful forces that comprise the transformational field where psychotherapy, as soul-making takes place. That is the soul’s way of disarming us from our fixed idea and rigid patterns, our pre-conceived notions of what to do and how to best to help everyone involved, according to the rules of the particular psychological theory that attracts us. Supervision utilizes theory, as well as concepts and communicates ideas. Our theories are best when held as metaphors, ways of speaking about the life of the soul. We may have a preference for psychoanalytic inquiry, or a taste for the existential here and now of Gestalt. We may lean towards challenging behavior and uncovering faulty beliefs. All are valid, useful, and helpful tools to have at our disposal. We must as supervisors be prepared at times to go the way of unknowing, to let go of having to know and drop into the realm of the “not known.” If we ask our supervisees to learn to tolerate ambiguity, to work with paradox, to sit with conflict, then we as supervisors must be able to sit with the untidy “mess” and not lose faith. Supervision grounded in soul takes place in a multi-dimensional universe of the intra-personal, the inter-personal, and the trans-personal realms of experience. If the aim of psychotherapy is to heal relationships by caring for the soul, then these three inter-dependent realms of experience are the focus in the supervisory hour. Clinical Case Steve is a registered intern with a moderate amount of clinical experience. His training and orientation has been a holistic, somatic based approach to working within the therapeutic alliance. In supervision, Steve discussed with me his client Ed, whom he has been seeing in once-a-week psychotherapy for several months. Ed’s issues are related to gender and sexual identity. Ed identifies as a gay man who has been trying, without success, to have a close emotional relationship with the men he is sexually attracted to. The men he chooses do not reciprocate Ed’s sexual feelings. Ed’s frustration has created a good deal of conflict and confusion. Ed believes that these men must, like him, have sexual feelings for him but are afraid to own their feelings, let alone show them. Ed has decided that his task is to awaken these men to their sexual orientation, which will then, he believes, allow him to unite his sexual preference with the affections of his heart.

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Steve is able to articulate in supervision his awareness that at some point Ed will, in all likelihood, attempt to replicate the familiar pattern of non-reciprocal sexual attraction with Steve, which may in fact already be taking place within the transference counter-transference matrix. As a part of our supervisory hour together, Steve says that he would like to address the anxiety he feels about his counter-transference feelings towards Ed. Steve wants to understand the early psychodynamics and object relations of Ed’s family of origin, which may help him better understand the split in Ed’s experience between his emotional world and his sexual feelings. Steve holds the client in a “holistic” transpersonal framework and is aware of the temptation of being reductionistic by trying to fit what is unfolding for Ed into the Procrustean bed of Freudian, Jungian, or other theoretical models. Still, Steve must be able to have a rationale based upon the combination of experience and theory to support and guide his intervention in an intelligent and soulful way. Effective supervision, like psychotherapy, is not formulaic. There cannot be a single right way of proceeding. The relationship between the supervisor and the supervisee is organic, constantly shifting based upon the needs of the supervisee, those of the client, and at times the external influences of graduate training programs, licensure, and the like. There is, I believe, a soulful and imaginative way that can be a creative and playful way of engaging the material presented during the supervisory hour that is relational, collaborative, and non-authoritative. As I listen to Steve, I attune to the way in which Steve is being affected by Ed’s unconscious conflict. Steve is working to make Ed’s unconscious more conscious. In order to do so, Steve must become conscious of his own conflict, which is the place within him that he may share a similar vulnerability with Ed around issues related to gender, sexuality, and intimacy. I look upon Steve’s anxiety as a signal that the therapeutic relationship with Ed is approaching a threshold point. What I do as Steve’s supervisor, is honor the symptom, which in this instance is Steve’s anxiety, as the place of soulful encounter. This anxiety is where soul needs loving attention and this is where we need to look first. Facilitating this type of inquiry in supervision is the juncture where supervision becomes therapeutic, while continuing to be supervision. As Steve becomes more conscious and aware, he is able to name the specifics of this mutually felt state of anxiety towards sexual relations and gender issues. Steve gains experiential insight, as he becomes more embodied and more present. As his supervisor, I am now in position to utilize theory in a manner that coincides with and supports Steve’s experience with his client. Together we may talk about the ways in which Steve’s counter-transference reactions are a product of his history as well as a diagnostic portrayal of Ed’s unconscious relational world.

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Since Steve now has a measure of experiential understanding, he has more empathic objectivity and the creative edge to think about the variety of ways he might intervene to deepen the relationship and facilitate the enfoldment of Ed’s soul. In my work as a clinical supervisor, I frequently offer the supervisee alternative ways of thinking about the clients as a way of encouraging playful and creative openness to the imaginative resources at their disposal. During the supervision hour we play with theory as metaphor. In so doing, we open the space for the transpersonal field to deepen and to expand the holding environment to include the Greater Self, the awareness that soul demands something larger than the constructed and adaptive ego in order to become fully itself and to thrive. Soul seeks to know its source. Soul longs for home and desires its own self-recognition. Steve holds Ed’s spiritual longings manifesting in his need to know and be known as the soul’s way of being fully in this world. Ed’s barriers and blocks are, in many respects, similar in kind to the defenses and barriers that Steve has utilized and similar enough in kind to my own that as his supervisor I may be able to help to identify and name them. The act of naming brings life to experiences that are seeking to become soul. Supervision is a collaborative, creative, and loving enterprise, richly rewarding and deeply humbling. Supervision, life psychotherapy, attends to soul through the loving attention we give to those we mentor.

Peter H. Coster, PhD, MDiv, LMFT Directs the Center for Psychotherapy, Spirituality & Creativity, www.CPSCTherapy.org located in Berkeley, CA. He is an adjunct faculty member at John F. Kennedy University and has been a clinical supervisor at the JFK Center for Holistic Counseling for 15 years. He maintains a private psychotherapy practice. References “Supervision as Mentoring” in The Therapist, January/February 2005.

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INTERACTIVE EVALUATIONS: SOME PROCESS-ORIENTED QUESTIONS FOR THE SUPERVISOR LAUREL J. COX, PH.D.

Both supervisors and supervisees agree that supervisee evaluation is important in supervision. Beyond the broad consensus that exists within the field, the definition of therapeutic competence is often defined by the supervisor’s theoretical beliefs (Storm, C. and Todd, T., 1997). Many training centers, clinics and private practices have designed specific forms to evaluate supervisee progress (Storm et al, 1997). This formal evaluation is typically done two to four times a year. Evaluation is also necessary and valuable on an ongoing basis. Although less formal, supervisors need to evaluate supervisee learning readiness, determine how well the supervisee has assimilated information and assess the impact of previous supervisory interventions. These tasks can be difficult for the following reasons. • Once supervisors have assimilated information it is extremely difficult for them to perceive that information in the same construct in which a supervisee perceives the information. The supervisor may be relying upon concepts while the supervisee is relying upon percepts. Once a clinician has assimilated a repertoire of carefully timed techniques it is difficult to remember the experience of not knowing, the moment of readiness to learn and the steps in learning. • Supervisors often supervise from their memories of supervision. Although supervisors may have had similar experiences when they were supervisees, it is sometimes easier to remember what went well and alter perceptions of what was difficult (Goleman, 1985). • We repeat patterns from within our families and learning institutions because they feel comfortable, familiar and therefore “right.” Those patterns may, however, not be right for others. Experiences and interventions that fit the supervisor during the training may not fit the supervisee. • Although supervisee input is helpful, supervisees may not have a map or a language with which to discuss their supervisory experience and learning needs. In addition, some supervisors are uncomfortable with the role of evaluating supervisees. Supervisees may have learned to dread the evaluation process. Other supervisees are frustrated in their need for more evaluative feedback from their supervisors. The ability to assess the supervisee’s developmental stage of supervision will facilitate the evaluation process for both supervisor and supervisee. In their comprehensive model, Loganbill, Hardy and Delworth (1982) describe developmental stages of supervision and list five categories of supervisor interventions. In an expansion of the Loganbill, et al model, Cox (1988) describes the Supervisee’s Perspective of a Developmental Model (SPDM) of supervision and adds the category of evaluative interventions and re-names them Interactive Evaluations. Interactive Evaluations are process-oriented questions which are stage appropriate to the supervisee’s level of development. The supervisor initiates this interactive process in the first supervision session and continues with a series of questions through each developmental stage. Interactive Evaluations are used to determine supervisee learning readiness, to determine how PRACTICAL APPLICATIONS IN SUPERVISION

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well the supervisee has assimilated information, to determine the impact of previous supervisory interventions and to facilitate supervisee movement from stage to stage. It is important to note that these questions are representative in type and focus and are expanded by the supervisor to meet individual learning needs and experience. A complete description of developmental stages, characteristics, issues and goals is beyond the scope of this article. The reader is referred to the Loganbill, et al (1982) and Cox (1988) models. For simplicity this text follows three main developmental stages with two transition periods between stages. I. Novice Stage Transition Period II. Intermediate Stage Transition Period III. Advanced Stage Brief statements of goals and characteristics will be included within the text for clarity. Novice Stage Early supervision sessions of the Novice Stage are concerned with providing safety and structure for the supervisee. Supervisors ask supervisees the questions listed below. Although some supervisees may not at first be able to answer certain questions, the questions will set the tone and style for future sessions and will begin to train the supervisee in the thought process necessary for self-supervision. • • • • • •

What do you need from me? What do you need to feel safe? Do you feel competent to carry out this task in the client session? If not, what do you need and how can we get that for you? Is this helpful? What works best for you? Were you able to use what we discussed in supervision?

Answers to these questions are extremely helpful to supervisors and supervisees in determining individual needs and individual steps necessary for learning. Supervisors repeat these questions at every stage of the supervisory process. Later in the Novice Stage the supervisee’s clinical interventions need to be connected to clinical issues and goals. To facilitate this process, the supervisor asks the supervisee to focus on one therapeutic intervention and asks the following questions. • • • • •

What client issue are you working on in this session? What method did you use? How did the client respond? Are you satisfied with your method? How might you have worked with this issue differently?

The dialogue resulting from these questions gives the supervisor an opportunity to give feedback on supervisee progress and aids the supervisor and supervisee in definition and PRACTICAL APPLICATIONS IN SUPERVISION

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assessment of acquired supervisory skills. By the end of the Novice Stage, supervisees are comfortable with treating a variety of client issues. Transition from the Novice Stage The transition period from the Novice Stage is an important time for reinforcing strengths, building confidence, increasing self-esteem and using integrated skills in dealing with client issues. It is also a preparation period for whatever confusion may lie in the next stage. Dialogue between the supervisee and supervisor can become a catalyst for the next stage as well as a means to begin to set new supervision goals. The supervisor uses Interactive Evaluations to help the supervisee with stalled client work and to plant seeds to the Intermediate Stage. These questions focus on close observation of not only individual clients but also the qualities of the therapeutic relationship with each client. • • • • • • • • • • • • •

What do you think may be going on for this client as a result of early childhood experiences? Where do you see this client developmentally? How come? What are some ways the client might react as a result of your last session? What do you think the client will need from you then? What was the pull for you in session when the client reported missing you between sessions? With which of your clients might you have some difficulty as a result of your personal issues? Where do you think you are in the supervision process? What have you learned so far? What are some things you would like to know more about? How will you know you have moved into the next supervision stage? How do you think that will happen? How can we do that successfully? What kind of feedback would you like from me? How can I best be of help to you?

Interactive Evaluations similar to those asked about supervisee process and experience can be asked about client process and experience. The supervisor is aware of the supervisee’s caseload and therefore familiar with which clients are also ready to move into the next therapeutic stage. New areas of growth will begin to emerge from whatever frustration the supervisee experiences in addressing these questions. These areas are the focus of the Intermediate Stage. Intermediate Stage During the Intermediate Stage work focuses on client individual differences, the timing of clinical interventions, the identification of client patterns or themes, and the supervisee’s ability to predict what may happen in the next client session. In addition, the supervisee’s personal issues may escalate as they parallel client work. Often, the supervisee shifts clinical focus from a technique orientation to a relationship/process orientation. Interactive Evaluations facilitate supervisee’s process through the overwhelming confusion of this stage. These questions deal with specifics and small steps. PRACTICAL APPLICATIONS IN SUPERVISION

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• • • • •

What is it about this client that motivated you to use this intervention? What was going on for you as your client was experiencing certain emotions? What do you think your client needs from you now? What do you think a helpful next step might be for your client? For you? What is different in your work with this client now from your work a month ago?

With integration of the Intermediate Stage the supervisee has acquired therapeutic skills in working with client emotionality and in-depth issues, is able to track client themes from session to session, is able to identify personal issues and keep those clear of client issues, and has developed the ability to be more present in client sessions. Transition from the Intermediate Stage Whatever stagnation is experienced during the second transition period, Interactive Evaluations can be useful in helping the supervisee move to the Advanced Stage. These interventions focus on theoretical concepts, begin to match theory to personal beliefs and styles as demonstrated by the supervisee’s work with clients and address the overall process of therapy. • • • • • •

What is your belief about this client and the therapeutic process that led you to choose this intervention? How long do you think this client will be in therapy? At what stage in the therapeutic process is this client? What do you believe caused change in this client? What was your role as therapist in that change? How does what you do in session reflect who you are as a therapist?

This last question is one the supervisee will “live” throughout the Advanced Stage. The supervisee’s answers will help to articulate the integration of the final stage of supervision before licensure. Advanced Stage The Advanced Stage of supervision is involved with the integration of therapeutic skills, the therapeutic self and theoretical concepts and beliefs. Interactive Evaluations are used to help supervisees define their personal counseling theory built on the foundation of their clinical work and the accepted theories in the field. Therefore, questions may begin with the specifics within a client session and move to general concepts. • • • • • •

What therapeutic issue were you working on in this session? How did you work with that issue? How does working with that issue relate to your general goals for any client? How does that work relate to what you believe about change? About your role as a therapist? What accepted theory within the field is most closely aligned with that work and goal? If you were to work with the same issue within a different theoretical model, how might your goal change and what might you do differently?

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By this time the supervisee has integrated Interactive Evaluations from previous stages and uses these questions in the process of self-supervision. At this stage, supervisees usually know when they need help, how and where to get it. When Interactive Evaluations have facilitated the supervisee’s process and respected his/her experience from the first developmental stage, the supervisee will know when it is time to launch into the professional world. As a partner on that journey, the supervisor will be capable of identifying the supervisee’s readiness for licensure. In summary, Interactive Evaluations facilitate the process of supervision for both supervisors and supervisees. From the earliest level, they foster and promote the thought process necessary for self-supervision. Within each level supervisors and supervisees work together in developing goals and methods for improvement. Attention to the supervisee’s responses can accommodate individual preferences and learning styles. These Interactive Evaluations connect progress with therapeutic and supervisory interventions and provide a method to anchor and integrate therapeutic skills and a therapist’s self. In addition, they demystify the supervision process, foster clear communication, discourage blame and shame, and encourage individuality and creativity. Significantly, Interactive Evaluations respect the experience of the individual and provide the supervisor with a means for tracking the supervisee’s experience while in the process of supervision. This process can help to create an atmosphere of care and trust with the intention of helpfulness. Rather than a necessary evil both supervisors and supervisees fear and avoid, evaluation can become a curious adventure to welcome and enjoy. References Cox, L.J. (1988). The supervisees journey through the developmental model of Loganbill, Hardy, and Delworlh. Doctoral dissertation, William Lyon University, San Diego. Goleman, W. (1985). Vital Lies, Simple Truths. New York: Simon and Shuster. Loganbill, C., Hardy, E. & Delworth, U. (1982). Supervision: A conceptual model. The Counseling Psychologist, 10(l), 3-42. Storm, C. and Todd, T. (1997). The Reasonably Complete Systemic Supervisor Resource Guide. Boston: Allyn and Bacon

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MUSINGS OF A SUPERVISOR BY: SHARON DUFFY, PSYD

I often liken group supervision to music. There is always an overarching theme, but often just one voice. Chords, instruments, timing, collaboration and audience all interweave to make something meaningful. In addition, the skills a supervisor uses in modeling, honoring, and attending to the supervisory relationship are invaluable to achieve success. They are the background music to which the singer responds. The following is an example of a segment of a group supervision session with school counseling supervisees. It is an amalgam of many instances when the issue of possible child abuse has been raised. It reflects a newer supervisee’s anxiety, the inner thoughts of the supervisor and the way in which the session was managed. At the end of this article, a few of the instances of modeling, honoring and relational aspects are listed. For ease of reading: Julie is the supervisee. Sharon is the supervisor whose thoughts are in italics and parentheses, and whose words are in bold. Julie: I want to talk about Bryan this week. Remember him? The 12 year old who almost got kicked out of school for beating up that other kid in the bathroom? I saw him this morning. Sharon: (Nods and thinks, Oh yeah, the kid who’d been so surly early on. He was coming along…hope it’s still good news. She’s got so many kids in her caseload and wow…what a caseload. She’s good with them.) Julie: Well, he’d been doing so well remember? He was following the rules at home, doing his homework, you know, really making progress. Then all of a sudden he comes in today like, really mad and all pouty. He doesn’t want to talk about anything, gives me the silent treatmentjust like he did when we first started working together. Sharon: (Hmmm…guess it’s not good news. Wonder what happened. She looks disappointed. I feel badly for her, she’s worked so hard and this looked like such a success story.) Julie: I really wasn’t expecting it, so I tried to ask him what was wrong, and he wouldn’t have any of it. Just said his life “sucked.” I asked him about school and he said it was boring. Home? “The same as always.” Friends? “ Nobody likes me.” No matter where I tried to go, he put up a roadblock. Sharon: (Why isn’t she looking at me now? She’s staring at her hands then looking at the clock above my head. Something is happening. My attention sharpens. I feel myself lean forward.)

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Julie: I was getting really, really frustrated. Finally, after twenty minutes of getting nowhere I asked him if he’d just like to play cards or something. Sharon: (Good, good. She let him rest. Can’t push a pre-teen. All about the relationship.) Julie: We played for half an hour and I felt like I was babysitting or something. I decided it wasn’t a good idea to ask him any more questions. I hope that was the right thing to do. Sharon: (Wow, she’s learning to let go of her own anxiety. No agenda. But she doubts the therapeutic value of this intervention. I don’t.) Julie: He seemed to really calm down as we played. Sharon: (Smiling. Yes. I wonder what went through her mind as she watched his process.) Julie: When it was almost time to go, he apologized to me for being such a creep. I told him it was okay, but asked him what was up. He said he’d had a fight with his dad, and his dad got really angry and pinned him against the wall screaming at him. Sharon: (NO! My body seizes. Time stands still. What? Pinned against the wall? This little boy I see in my imagination? Well, maybe it’s not abuse-go easy-“pinned” might mean just horseplay. Am I being overly protective of Julie?) Julie: Said he couldn’t breathe. Said he didn’t want to talk about it though, that it was over. Sharon: (I stiffen. My mind races. There is a sense of unreality. As my stomach tightens and adrenaline courses through my limbs my breath shortens. My attention sharpens. I’ve not spoken a word, and I wonder if my face has spoken a million.) Julie: I know this family. I know how hard they’ve been working, and I knew it was just a glitch in our work together. I didn’t report to DCFS because I’m sure they’ll come around and besides, he used to lie all the time. Sharon: (Didn’t report??? Perfectly still I listen, mind seeking equilibrium. I watch her eyes as they furtively avoid mine, the uneasy way she shifts in her chair.) Julie: I have such a good relationship with these parents. I feel so badly for them. (She silences and after a moment looks up.) So what do you think? Sharon: (I smile and shift to a more comfortable, relaxed position in the chair. Breathe.) Wow, you had some surprising session didn’t you? Tell us what you’re thinking and how you are feeling about it now.

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Julie: Well, I really like this kid, and I guess I’m pretty disappointed in myself. I really thought I was doing better. All the way home in the car I was asking myself if I really had what it takes to become a therapist. Sharon: (How many hours does she have? Oh yes, she’s not a novice, but she’s in that place of shifting from doubting her abilities as a therapist to owning her professionalism and trusting her judgment.) Well, first off, I think it’s important to acknowledge that you had a rough session there. (Don’t desert her-she needs to know I’m not judging. That sense of urgency over the crisis issue resurfaces-okay just relax it’ll come. Smiling:) Anyone else here ever doubt their abilities in this profession? Yeah? Oh me too! (Back to serious-we’ve been here before and this group knows what’s coming.) So Julie, let’s talk about this scuffle between Bryan and his Dad. When you first heard it, what did you think? Julie: Well, I was scared. I wondered if it was abuse. I know he used to lie a lot, but this is the first time I’ve ever heard of anything like this from Bryan. I hope I didn’t miss it before. Sharon: (She knows it was abuse. I’m sure.) So what elements of possible abuse did you recognize? Julie: Well, you don’t pin a kid to the wall. And he couldn’t breathe!!! (Looks up and looks very anxious.) Oh no, do YOU think it’s physical abuse? Sharon: (Relief mixed with heightened anxiety flood me: I wonder how this will go.) What are your thoughts? Julie: It is, I know it. But he’s lied so much before. Sharon: Well, we don’t have the power to decide if he’s lying or not do we? Actually, it doesn’t matter much here does it? Did you once tell us his Mom had a domestic violence charge in her history? JULIE: What does that matter? It was his Dad that did it. (Silence). Well, yeah, I guess this is sort of a violent family. Even Bryan has it at school. Maybe I should see him next week and look further into it. Sharon: (Is she feeling a little defensive? What is it I’m feeling? Anxious? This isn’t about me. Breathe, Focus. Help her access her knowledge and let her have her process.) Julie: You don’t look like you think we should wait a week. Sharon: (Guess there is something telling on my face.) Well, you’re right. I am concerned. I do think you’re onto something about the violence in this family. And it’s not okay to pin a child against the wall so hard that he can’t breathe.

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Julie: I knew you were going to say that. I’ll report as soon as we leave. Sharon: Great. I think we’re making the right decision. I need you to call me tonight after you’ve called DCFS to let me know how it went. Sharon: (Cautious, now. I feel myself softening to the journey she’s been on today.) So Julie, how are you feeling about having brought this to supervision today? Julie: Well, I have to admit I was a little afraid to. Somewhere in the back of my mind I knew I was wrong. Sharon: I can understand that. (Pause.) You know I’ve got to honor the courage it took to bring it up even though you were afraid to. As I watched you talk I thought I saw a little bit of that fear in your body language. Were you aware of that? (Julie shakes her head, “no.”) Well, I think that your “true therapist” just showed up! It seems like you just needed a little time to let it all “percolate” before you came up with clarity and your own answers. You know, even I had to check in with myself to make sure I wasn’t minimizing or overlooking anything. Julie: Well, I don’t know-I still don’t think I belong in this profession sometimes. What a mistake-(Looks anxiously at me.) What if someday I really do something wrong? Sharon: (That sense of fear and that old familiar feeling of shame. How I want to take it away!) That’s why you get 3,000 hours to get where you need to be! And remember they call this a “practice” not a “perfect!” (Fond thoughts of one of my first supervisors comes to mind as I repeat her words.) Sharon: Besides, you wanna talk MISTAKES?!! Well, never put your suicidal client in your own car at 9 PM and drive her to the hospital…..oh yeah, I did that as a trainee when I’d been left alone to lock up the clinic. GROUP: You did that?!!! What?!!! They left you alone??? SHARON: (Too much disclosure?....NO, appropriate for now.) Yep, and I made other mistakes too, although not AS bad as that! You should have heard MY supervisor!! (I revel in their disbelief and laughter. Julie will still feel her feelings, but she knows she has company now. I sense a feeling of relief on her face. Kinship?) Sharon: What say, group? Thoughts? Feelings? GROUP: I can’t believe you had to deal with that Julie!

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Poor you! How scary. I don’t know that I would have even thought abuse. You’re one of my idols-I feel better about myself knowing that even you can do something like that. Yeah, Julie, I think everybody here is going to do something like that sometime and it’s good to know that we’re not alone. Sharon: (I love group supervision-the members can be so supportive. They do my work for me!) Well, you’ve heard from the group- and they’re right. I’d also add that you’re a courageous and honest person too. Thank you for being so open and for trusting us with your feelings. (Pause, a bit of silence to let it sink in and honor the moment. It feels dramatic, but it feels important too.) How are you doing now? Julie: I feel better. I really can’t wait to get that report made, and to see Bryan next week. I hope they don’t pull him out of therapy or punish him for telling. Sharon: (Feelings of sadness and dread over the likelihood of either of those occurring.) Yep, they’re both possibilities. But you’ve worked with this family and you do have a good relationship with them. Let’s see how it goes and we’ll deal with whatever we have to. Sharon: (So interesting the parallel process going on here:) You know there’s something else I don’t want to let get away from me. When you couldn’t get a word out of Bryan, you made a very therapeutic decision: you let him have his process. You didn’t push him and you didn’t alienate him. You followed his lead. That is an advanced skill, I hope you know that. Julie: Thanks, I hadn’t thought of that. Sharon: You’re welcome. Don’t let the rest of our discussion take that away from you. It’s a real strength. So, Thank you for providing us with such a rich area of learning. (Julie’s laughing now, and looking as though she’s wishing she hadn’t had to provide us with anything today! She’s a fine therapist-in-the-making. I feel confident in her future.) Julie: I don’t know, I still want to be a therapist someday but I’m sure gonna need a lot more practice! Sharon: Wait and see, Julie, someday you’re gonna be sitting in my seat! The following are some supervisory skills that were portrayed in these musings. MODELING: non-anxious presence, containment, process, collaboration, self reflection, group inclusivity, appropriate use of self-disclosure, tracking, use of silence, transparency, attention to non-verbal behaviors, use of humor, professional boundaries, knowledge of legal and ethical parameters, attention to my own process.

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HONORING: supervisee’s thoughts and feelings, difficulty of session, processes, recognition of skill, counter transference issues, developmental stage of supervisee development. RELATIONSHIP: encouragement, respect, prompt attention to supervisee reactions, demonstrating belief in the supervisee’s ability to access his or her own knowledge of self, client, process and legal and ethical issues, acknowledgement of struggles, support and appreciation of good work, a non-judgmental stance.

Dr. Sharon Duffy is in private practice in Woodland Hills, California. She supervises interns in her practice as well as at Phillip's Graduate Institute's California Family Counseling Center. She has presented numerous workshops on various aspects of Clinical Supervision throughout California and presents CAMFT’s Supervision I and II online. She is a CAMFT Certified Supervisor and an AAMFT Approved Clinical Supervisor. Sharon is also a past-President of the San Fernando Valley Chapter of CAMFT and a member of CAMFT’s Trauma Response Network.

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TRAINING TO THINK CULTURALLY: A MULTIDIMENSIONAL COMPARATIVE FRAMEWORK* CELIA JAES FALICOV, PH.D. REPRINTED WITH PERMISSION FROM FAMILY PROCESS, VOL 34, DECEMBER 1995.

A multidimensional, comparative training framework is designed to integrate culture with all aspects of family therapy. Culture is viewed as occurring in multiple contexts that create common “cultural borderlands” as well as diversity, unpredictability and possibility, as well as regularity and constraints. The framework proposes a search for basic parameters to help therapists think comparatively and pluralistically about families’ cultural configurations and meanings. Further, the parameters chosen—ecological context, migration/acculturation, organization, and life cycle are used to heighten therapists’ awareness about the “situated knowledge” of their own professional and personal culture. This approach recognizes the potential and complexity of both the family’s and the therapist’s cultural location or ecological niche, and encourages curiosity in the therapeutic conversation rather than reliance on potentially stereotyping, ethnic-focused information. Family Process 34:373-388, 1995 * Based in part on a plenary presentation at the annual meeting of the American Family Therapy Academy, Baltimore MD. June, 1993. Like multiculturalism in the social sciences, social contexts and cultural values have gained importance in family therapy. There is renewed interest in minorities and in cultural differences that influence the practice of family therapy. A growing number of training programs are exploring avenues to include issues of cultural diversity. This article presents a framework for the inclusion of cultural concerns in family therapy training. Two conceptual approaches are implicit in this framework and the attitudes it encourages: social constructionist approaches, which go beyond the hermeneutic or interpretative analysis and make use of a critical cultural lens, and multicultural or cultural diversity approaches, which recognize cultural differences and take issue with Eurocentric assessments and practices. Culture and Family Therapy Incorporation of cultural variables in family therapy is complex and can be approached in many ways. Overall, family therapists have taken four positions on including these variables: universalist, particularist, ethnic-focused, and multidimensional. Each position has different implications for practice and training. Universalist A universalist position states that all families are more alike than they are different. Most therapists would agree that families share some basic similarities. Examples are the concepts that all children need love and discipline and that parenting everywhere involves various combinations of nurturance and control. Others go farther and assume more similarities than differences in life-cycle transitions, triangulations, or multigenerational transmission processes. PRACTICAL APPLICATIONS IN SUPERVISION

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Some therapists who believe in the universality of family processes have little use for contextual variables, such as race, gender, or ethnicity. Friedman (1994), for example, claims that these social science categories are an irrelevant distraction from the basic processes that “all emotional systems have in common with all protoplasm since creation” (p. 4), such as anxiety and differentiation from a multigenerational perspective. This extreme polarization between biology and environment merely recreates the old nature-nurture controversy. It takes an either/or position when a both-and position could help search for universal human processes and yet honor the culture-specific variations and solutions to these predicaments. The main problem with a purely universalist view such as Friedman’s is the assumption that if “standard” concepts are used, all families are intelligible and thus amenable to similar treatment. This position lacks the perception that what a particular school of thought considers universal and tacitly normative, may be “local” knowledge or beliefs based on the cultural forms developed or “invented” by specific subgroups of the U.S. professional middle class. Because universalists consider cultural issues tangential to therapy, it follows that adherents of this position have little use for cultural training. Particularist The opposite of the universalist position is the particularist position, which states that families are more different than they are alike. No generalizations are possible; each family is unique. This position reinforces the view that therapists should be aware, respectful, and inquisitive about the singularity of families and individuals. Sometimes this view adds a confusing element by extending the word “culture” to the case study of family lives, and by maintaining that idiosyncrasies make each family “a culture unto itself” (Henry, 1963). In the particularist position, then, the word culture is tied to the internal beliefs of each particular family rather than to the connection between the family and the broader sociocultural context. Some therapists believe that if they pay close attention to the family’s microworld, then a focus on the relationships between the larger culture, the family, and the therapist is unnecessary. Of course, good therapy always requires close attention to each family’s idiosyncrasies. However, insofar as this position ignores the impact of social change and social inequities on family life, it makes the family’s interior solely responsible for all of the family’s distress. As might be expected, adherents of the particularist position do not advocate any specialized cultural training. Ethnic-Focused An ethnic-focused position stresses that families differ, but assumes that the diversity is primarily due to one factor: ethnicity. This position focuses on regularities of thoughts, behavior, feelings, customs, and rituals that stem from belonging to a particular group. The tendency of Irish people to marry late, the inclination of Italians to draw tight boundaries around the biological family, and the panic disease of koro among the southeastern Chinese are examples of ethnic-focused descriptions. This position requires considerable a priori knowledge about many traits thought to be characteristic of various groups. As a way of thinking, it has been enormously influential in developing a sensitivity to cultural differences, and it is helpful in work with specific ethnic populations (see McGoldrick, Pearce, & Giordano, 1982). This position has some important limitations, however. PRACTICAL APPLICATIONS IN SUPERVISION

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One limitation is the tendency to oversystematize and stereotype the notion of shared meanings by assuming that ethno-cultural groups are more homogeneous and stable than they actually are. Ethnic values and identity are strongly modified by a host of within group variables: education, social class, religion, stage of acculturation and so forth. Furthermore, many ethnic traits are in flux, stimulated by cultural evolution and by exposure to or imposition of the dominant culture. Another limitation is the assumption that the observer, the person making the social description, is completely objective and has no effect on the conclusions about the group being observed. Information about ethnic groups is presented in a style similar to that of classic ethnographies, in which a neutral observer describes distant cultures. Modern anthropology (Bruner, 1986), second-order family therapy (Hoffman, 1990), and feminist theory (Haraway, 1991) question the notion of the “former native” or “the other” as separate from the goals and subjectivity of the observer, that is, the splitting of subject and object. With respect to training in family therapy, this position imparts specific content about ethnocultural groups. As noted elsewhere (Falicov, 1988), the information tends to be given in separate, focused lectures or courses, and neither trainers nor trainees seem to transfer it smoothly to the clinical situation. Although trainees who are exposed to a variety of ethnicfocused cases and reading materials eventually deutero-learn, that is, become sensitized and seek out ethnocultural variations, a cultural way of thinking remains marginalized relative to other issues of theory and practice. Perhaps this marginalization occurs because the separateness of culture in the structure of training unwittingly conveys the following messages: (1) Culture is an issue separate from other family issues. (2) Cultural training is supplementary: “This is something you should also know.” (3) Other information provided in training is “culture-free” or “not-cultural.” This last message emphasizes precisely the opposite of what it should, that is, the cultural relativity of most of the constructions taught. Multidimensional A multidimensional position seeks to address the complexities not covered by the previous three positions. This position goes beyond the one-dimensional definition of culture as ethnicity and aims at a more comprehensive definition of culture that encompasses other contextual variables. In previous articles (Falicov, 1983, 1988), I have offered the following multidimensional definition of culture: those sets of shared world views, meanings and, adaptive behaviors derived from simultaneous membership and participation in a multiplicity of contexts such as rural, urban or suburban setting; language, age, gender, cohort, family configuration, race, ethnicity, religion, nationality, socioeconomic status, employment, education, occupation, sexual orientation, political ideology; migration and stage of acculturation. The groups produced by different combinations of “simultaneous memberships” and “participation in multiple contexts” are much more varied, fluid, unpredictable and shifting, than the groups defined by using an ethnic-focused approach. Because of these multiple subgroups, making generalizations is also much more difficult than with the ethnic-focused approach. A multidimensional definition of culture could be interpreted as requiring analysis, knowledge, and proficiency in each and all the conceivable contexts of family diversity listed in the definition, and every combination and interrelationship of contexts, too. I believe such a piecemeal interpretation quickly overwhelms trainees with excessive detail. In a previous article (Falicov, PRACTICAL APPLICATIONS IN SUPERVISION

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1988) I have proposed the incorporation of multidimensional perspectives into all aspects of a training program. In this article, I develop this idea further by proposing an initial, cultural comparative orientation that can empower trainees to work with many diverse clients without having to become experts on specific ethnic groups. Let’s elaborate further the rationale for a cultural comparative framework. A Multidimensional Comparative Framework Rationale A cultural comparative approach depends on a multidimensional view of culture. I start with the assumption that in a multicultural society, each person is raised in a number of cultural subgroups and draws selectively from the groups’ relative influences. Cultural similarities and differences are the result of inclusion in or exclusion from various groups. Today, the reality of multiple identities and subjectivities is acknowledged by many disciplines. Syncretism, or the blending of cultural influences, has become a popular concept. Many families have two or more cultures represented within them, because parents or children grew up in different settings or because the spouses belong to different races, religions, or ethnic groups. In addition, racial classifications that separate persons into clearly defined races are increasingly being questioned (Wright, 1994; Yee, Fairchild, Weizmann, et al., 1993). In response, new terms are being coined to reflect the enormous cultural complexity of modern-day families. Attempts are made to develop concepts, such as cultural borderlands and ecological niche, that capture simultaneous interfaces of contexts. Cultural Borderlands Anthropologists (Rosaido, 1989) use the term “cultural borderlands” to the overlapping zones of difference and similarity within and between cultures. Borderlands give rise to internal inconsistencies and conflicts, but also offer many potential points of human connectedness with others. The educator Henry Giroux (1992) talks about border crossings and about a “border pedagogy” that demands understanding of how fragile identity is : “There are no unified subjects here, only students whose multilayered and often contradictory voices and experiences intermingle with the weight of particular histories that will not fit easily into the master narrative of a monolithic culture” (p. 34). Fittingly, the Chicana poet Gloria Anzaldua (1987) describes the “new mestiza” (woman of mixed Indian and Spanish ancestry, born in the United States) as a woman who “copes by developing a tolerance for contradictions, a tolerance for ambiguity. She learns to be Indian in Mexican culture, to be Mexican from an Anglo point of view. She learns to juggle cultures. She has a plural personality” (p. 79). Ecological Niche Multiple contexts and the borderlands that result from the overlapping of contexts call to mind ecological spaces where access is allowed or denied, locations of partial perspectives where views and values are shaped, and where power or powerlessness are experienced. The combination of multiple contexts and partial cultural locations can be thought of as each family’s ecological niche. The idea of an ecological niche helps therapists perceive each family and its members as a unit with a complex multidimensional location grasped all at once. This location, or ecological niche, shares cultural borderlands with the locations of families from other cultures in various degrees, and gives the family a positional relationship relative to the dominant cultural values. The PRACTICAL APPLICATIONS IN SUPERVISION

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description of a family’s ecological niche is best thought of as a narrative that encompasses multiple contexts rather than as a single label, such as Mormon, or even a composite one, such as an Afro-Caribbean-Latino. To be sure, the multidimensional comparative framework proposed in this article does not deny the value of having information about discrete contextual variables (ethnicity, social class, race, religion), but it really does not support starting by learning the special characteristics of separate and distinct groups. Rather, it advocates a search for large categories that encompass connections as well as variations across groups. The philosophy behind it supports inclusiveness with a diversified unity. In fact, it aims to avoid the potential divisiveness that may result in studying groups separately and emphasizing differences only. The generic parameters are the same for all families: the specific contents can be used to compare styles, solutions, resources, and constraints across ethnic groups, social classes, religions, and so on. Furthermore, the generic cultural comparative parameters are chosen for their relevance to the practice of family therapy. It is interesting to note that the differences in content, form, and philosophy between ethnicfocused training and a comparative position parallel contemporary debate in education. Until recently, the most popular approach for multiculturalism in the schools relied heavily on ethnic studies courses (Chicano studies, African American studies, Asian studies) and the recognition of “holidays” and “heroes” for each group. Teachers have begun to question however, whether this approach may have unintentionally isolated students from each other and fragmented and impaired rather than enhanced the students’ ability to make connections and comparisons. A new, pluralistic or comparative approach is being considered (Takaki, 1994). It presents events as they have happened as interconnected and inclusive history that changed lives in every ethnic group but was also changed by all those groups. Instead of treating each group separately, a comparative approach weaves elements of all the groups’ histories into a discussion of particular topics. The topic may be economic depression, agrarian reform, immigration, or social prejudice. The teacher and students discuss how these events affected the lives of African American slaves, Chinese and Central American immigrants, or poor whites. For family therapists, the issue to compare could be family organization or the family life cycle, or aspects of minority status, or immigration in different ethnic groups, religions, social classes, and races. Training Objectives A fundamental objective of the multidimensional comparative framework is to take culture into the mainstream of all thinking, teaching, and learning in family therapy, by doing the following: • Select key concepts or parameters for cultural comparison. The parameters selected should fit the tasks of family therapy. A comparative framework assumes that some types of cultural information are more important for family therapy work than are others. Clearly, knowing about regional festivals or foods is less relevant than understanding life-cycle norms or communication styles. A comparative framework focuses on key parameters that are thought to transcend particular models of family therapy, and then it examines these parameters with a cultural lens, generating a form of comparative maps. For example, in discussions of the family life cycle, the impact of values on developmental expectations for parent-adolescent interaction can be compared in various immigrant groups, religions, or social classes, and in combinations of these contexts. PRACTICAL APPLICATIONS IN SUPERVISION

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• Generate an attitude of interest, sociological imagination (Wright Mills, 1959), and respectful curiosity (Cecchin, 1987) that develops through a critical awareness of the role that values play for families and for therapists, and in the personal and professional encounters of the two groups. The integration of these two steps—the cross-cultural comparisons in the four key parameters, and the exploratory, self-reflexive attitudes of the therapist along the same parameters— organizes the comparative framework. The parameters become roadmaps to facilitate travel in the clients’ culturally patterned interactions. Key Comparative Parameters The differences that make a difference in my context of theory, clientele, and training group are usually included as parameters in most training curricula because they are helpful in thinking systemically about families. The four key comparative parameters are as follows: 1. Ecological context: diversity in where and how the family lives and how it fits in its environment. 2. Migration and acculturation: diversity in where the family members came from; when; how and why; how they live; and their future aspirations. 3. Family organization: diversity in the preferred forms of cultural family organization and the values connected to those family arrangements. 4. Family life cycle: diversity in how developmental stages and transitions in the family life cycle are culturally patterned. These parameters simply make explicit and systematic many categories that family therapists already use explicitly or implicitly. The addition of a cultural lens expands the usual categories and adds a critical perspective about existing theories, beliefs, and practices. Comparisons of similarities and differences in conceptions, experiences, or values are made within each parameter across social classes, ethnic or religious groups, gender or sexual orientation. The parameters that matter vary, depending on the therapist’s conceptions of therapy and therapeutic change and, perhaps, even on the therapist’s own cultural background. A possible approach that becomes a sort of critical pedagogy (Freire & Macedo, 1987) for therapists is to explore with others who share a similar conceptual orientation those categories that are likely to include cross-cultural variations. Client families can also be resources in this process. Another approach is to select the key concepts that matter to you in your conception of family therapy and submit the selected concepts to cultural scrutiny.

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Ecological Context A number of approaches that take into account the “total field” of a problem and include individual and family interactions with outside institutions are effective in multicultural work. Among these are Auerwald’s ecological systems approach (1968); Aponte’s eco-structural model (1976, 1981); Montalvo and Gutierrez’s interinstitutional perspective (1983, 1988); my ecosystemic approach (Falicov, 1988); Boyd-Franklin’s multisystems approach (1989); and network-oriented therapies (Pattison, DeFrancisco, Wood. et al. 1975; Whittaker & Garbarino, 1983). An awareness of abstract values, ideologies, and belief systems present in the workings of societal institutions is another important metaperspective (Imber-Black, 1988). Trainees learn to inquire about the interactions between the family and the communities to which the family belongs, (racial, ethnic, religious, rural-urban); between the family’s living and work conditions; and between the family and institutions such as schools, social agencies, and so forth (see Figure 1). Students learn to draw eco-maps, Hartman & Laird, (1983). While discovering the connections between personal issues and socioeconomic stresses or cultural pressures (Elkaim, 1982), trainees learn (through readings, essays, research studies, and novels) about the psychology of marginalization, that is, psychosocial and health consequences of experiencing a marginalized status. The marginalization may be due to discrimination because of race, gender, economics, or immigrant status (documented or nondocumented), or to other forms of powerlessness such as lack of entitlement or access to resources. Recent articles on gender, and on race, have drawn needed attention to issues of power and powerlessness in families’ interactions with larger systems, including therapy (Hardy, 1994: Korin, 1994), concepts such as learned helplessness and internalization of negative expectations and shame, or “chronic patienthood” because of poverty and discrimination, need to become part of the vocabulary of training. Therapists should also know about the fear of failure and the achievement demands that plague and alienate the middle classes. Participating in a Freirian pedagogical exercise to heighten awareness about issues of marginalization can help trainees experience the shifts between contexts in which they themselves have power and contexts in which they feel powerless, a process that illuminates the complexity and relativity of cultural locations. Comparisons of similarities and differences in economic class across ethnic groups illuminate connections between family and ecological context. Migration and Acculturation With increasing frequency, families who seek therapy are immigrants from other cultures. Despite important differences, immigrants experience many similar psychological and social consequences (Grinberg & Grinberg, 1989: Sluzki, 1979). Perhaps the most fundamental disruption of migration is the uprooting of meaning. Peter Marris (1980), an architect and urban ecologist, suggests that the closest human counterpart to the root structure by which a plant nourishes itself is the structure of meanings by which each person sustains relationships to others, to work, and to a soil and a culture that provides familiarity and stability. With the disruption of life-long attachments and external stabilities, meanings are uprooted. Much is being written about the consequences of these uprootings and about the differences between voluntary and forced migrations. Some studies focus on trauma and crises, on posttraumatic effects such as nightmares, phobias, and panic attacks. Others focus on grief and PRACTICAL APPLICATIONS IN SUPERVISION

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mourning or on the disorienting anxieties experienced by immigrants when faced with the shock of the new (see Figure 1). A few acknowledge the opportunities for growth provided by migrations. Additional topics of interest include family disruptions caused by separations and reunions, and the disempowerment of parents who raise children in a culture that differs from the one in which the parents grew up. Other articles present evidence of lifetime depressions that can accompany an immigrant’s failed dreams. Multicultural therapists need to learn about these aspects of a psychology of migration and to compare these various phenomena across groups. Trainees learn to engage clients in a migration narrative. This narrative aims to assign meaning to the uprooting experienced by immigrants in terms of the clients unique personal history, and it may help clients recover a continuity of personal meaning (Falicov, 1993). Disruptions of ecological “fit” between family and society for different generations of immigrant families have treatment implications, such as the therapist’s role, biases of assessment, and effective therapeutic approaches (Falicov, 1982, 1988). Other helpful tools for working with immigrants are Sluzki’s (1989) network disruption and reconstruction. Ho’s (1987) cultural transitional map, McGill’s (1992) cultural story, Comas-Diaz’s (1994) ethnocultural assessment, and Inclan’s (1992) culture-migration dialogue. Experiential exercises can be used in training to heighten empathy for the immigrants’ situations. An example is the critical consciousness work titled “Gringostroika” by performance artist Guillermo Gomez-Peña (1993) in which he creates evocative role reversals between Anglos and Latinos to highlight the impact of marginalization due to language barriers. Ethnic-focused comparisons can be included by determining the similarities and differences due to migration among various Asian groups or Latino groups. Family Organization The way family groups are organized varies considerably in different parts of the world, in urban and rural settings, in various ethnic groups, and at different socioeconomic levels. Many concepts developed for the study of family organization are potentially useful for cross-cultural comparisons. The one I use here is the concept of the dominant dyad because it is particularly promising for developing a comparative and critical theory perspective. In a simple way, it makes clear what a comparative approach can do by highlighting the values embedded in the assumption of the ideal nuclear family, which is the basis of much of family therapy, and comparing them with the values of other forms of family organization, such as the extended family, which is so prevalent in ethnic and immigrant groups. The comparison does not set up the nuclear family as the standard: rather, it legitimizes other values for the conduct of family life. The dominant dyad classifies family organizations on the basis of the central, emphasized relationship in a family system. The concept evolved from the work of anthropologist Francis Hsu (1961, 1971), was mentioned by Hoffman (1981), and was applied contextually to family therapy by me and Brudner-White (1983). The concept states that in most industrialized countries, the husband-wife dyad is the publicly valued or endorsed core family relationship, and that the nuclear family is the ideal or idealized family form, despite increases in other family forms, such as single-parent households. In preindustrial and more traditional or religious PRACTICAL APPLICATIONS IN SUPERVISION

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settings, and in working-class families, the central, emphasized relationship may still be the parent-child dyad in an extended-family setting. In Chinese and Middle-Eastern families, the most central dyad is the father-son dyad; in Hindu and Japanese societies, it is the mother-son dyad. The crucial point is that the cultural code for the organization of the family is dramatically influenced by the preferred central relationship (see Figure 1). This cultural code includes the boundaries that regulate proximity and separateness (inclusion or exclusion of others), the boundaries that regulate hierarchy (the gender and generation power balance), the values associated with personal individuation and family connectedness, and the communication styles (direct or indirect) and emotional expressivity (high or low) among family members and with outsiders. Indeed, ample anthropological evidence indicates differences between those families that give prominence to the intergenerational bond and those that favor the couple bond. These two groups differ from each other in the way the couple dyad, the parent-child dyad, and the sibling and the individual subsystem function internally and in relation to the larger networks. Even the appearance of family triangles and their connection with family dysfunction (Falicov & Brudner-White, 1983), and the cultural construction of love (romantic love, sexual love, parental and filial love, sibling love) may be influenced by the dominant dyad in the family system (Falicov, 1992). Although a comparison based on which dyad is dominant does not begin to cover the diversity of all family forms, it provides a prototype or template of cultural relativity in family organization that can be used for other observations and descriptions of cultural variations. For example, it is possible that single-parent families will be closer in form and function to the intergenerational or parent-child dyad than to the nuclear family, while reconstituted families may be functioning as two nuclear families or as a mix of the two types of dyads: the marital and the intergenerational. Determining which dyad is dominant is sometimes difficult because it is not really an either/or proposition. First, formation of a committed relationship almost always involves some rebalancing of loyalties and priorities with the family of origin. In addition, many families, especially immigrants, are part of a global transition in which the values of the extended family are being replaced by the values of the nuclear family. Thus, families often are faced with the dilemmas, the contradictory demands, the conflict of loyalties, and, sometimes, the double standard that results from trying to respond to different dominant-dyad priorities—that is, the collective values of the extended family and the individualistic preferences of the nuclear family. Families’ attempts to blend two contradictory sets of rules can cause a number of problems or a number of creative solutions, a situation that could be called the psychology of cultural organizational transition. In the cultural comparative framework, trainees learn to inquire about how a family’s present structure fits all of its members’ preferences, that is, their actual versus their ideal values, rather than imposing a particular cultural code derived from theory or from personal preference. Part of this process involves collaboration with family members to answer how much and in what way the family needs to evolve toward a cultural code that favors the dominance of the couple dyad (or other relationships), or remain loyal in reality or symbolically, to the values of the intergenerational or extended network.

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Family Life Cycle Most clinicians rely on ideas about life-cycle stages to understand individual and family age-appropriate behavior. Life-cycle transitions are also used to recognize crisis points and renegotiation of rules precipitated by additions, losses, and changes of status among family members (see Figure 1). Even experienced therapists often assume that the blueprints of the life-cycle stages and transitions are culture-free, perhaps because the cycle has some universal themes, such as birth and death, getting married, and raising children. However, the specifics of family life cycles are embedded in temporal cultural fabrics. The life-cycle framework we have used in family therapy reflects the circumstances of the urban middle class in the 1950s through the 1980s. In 1980, an attempt was made to illustrate cultural differences in the timing of stages and transitions, the constructions of age-appropriate behavior, and the change mechanisms or solutions. In this study (Falicov & Karrer, 1980), the family life cycle of the ideal, traditional Roman-Catholic Mexican family was compared with that of the ideal Protestant, Anglo-American middle-class family. Differences observed for Mexicans included a longer stage of interdependence between parents and young children, often mistaken as overprotection by therapists trained in the dominant culture; the absence of a launching period in late adolescence, probably because individuation and personal identity are achieved gradually within a context of life-long intense connectedness to the three-generational family; the absence of an empty nest, and the lack of individual or marital crises at the time of middle age, perhaps due to a less romantic view of marriage and a different conception about the meaning of middle age and old age. In the cultural comparative framework, students are taught to adopt an exploratory and curious attitude when evaluating families, to be wary of uncritically using developmental norms of clinical theories or the students’ personal maps. The transition of leaving home provides an example. Most therapists have learned theory that is based on Anglo-American middle-class values, which regard late adolescence and early adulthood as the ideal times for the development of autonomy and self-sufficiency. Failure to leave home at this “appropriate” time has been linked to schizophrenia, drug addiction, and psychosomatic problems. These conditions are said to stabilize family members so the members do not have to face the threat of separation and change (Haley, 1980). However, for many working-class or poor families, and for many ethnic or religious groups, the threat of separation is small. Moving away from home (and often not very far away), occurs much later, usually because of marriage. Understanding the functions that unity, loyalty, and communal life have for persons of rural, traditional, religious, or impoverished backgrounds may help trainees see that, in these groups, individuation and its implications for mental health differ from those given by the middle-class urban prescription. Trainees become aware that some types of transitional difficulties may be more common in some cultures than in others, and that established normative markers and processes of development may be more applicable to certain populations than to others. The impact of cultural evolution and migration also should be considered when families have contradictions or dissonances in developmental expectations. Just as one can speak of a psychology of cultural organizational transition, one can also talk about a psychology of cultural developmental transition. The latter deals with the problems that may develop through attempts PRACTICAL APPLICATIONS IN SUPERVISION

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to force, merge, ignore, or reconcile two or more asynchronous or contradictory developmental cultural codes. It also focuses on the resiliencies that may accrue with the integration of two cultural codes. COMPARING CULTURAL MAPS Family Maps/Therapist Maps The four key parameters can be used not only to understand the cultural maps the family brings to therapy, but also to become aware of the cultural maps the therapist brings. A basic training assumption we make is the notion that the observer is part of the cultural equation. Therapy is really an encounter between the therapist and the family’s cultural and personal constructions. The ethnic focused approach presupposes objectivism, that is, that reality can be grasped by all observers through direct knowledge and experience. In contrast, the multidimensional comparative approach based on a position of perspectivism (Von Bertalanffy, 1968): a person’s view of reality depends on his or her perspective that frames and organizes the observations themselves. The therapist’s views about families and family therapy are embedded in an ecological niche that includes his or her preferred brand of theory and professional subculture, that is, theory maps. These maps inevitably constrain what can be observed and what can be named (Nichols & Schwartz, 1991: Walsh, 1993). The therapist’s perspective is further organized by experiences in his or her family of origin and by personal preferences, that is, personal maps, which are also part of her or his ecological niche. Awareness about the confluence of multiple cultural contexts and partial collective identities in their own lives empowers trainees to deal with families from different ecological niches, and, most importantly, it raises therapists’ consciousness about professional and personal biases. Rather than presupposing objectivity of description, and splitting of subject and object, this approach underscores “limited location” or partial perspectives, and “situated knowledge” to account for how we see as therapists (Haraway, (1991). This idea can be depicted as families’ maps and therapists’ maps that overlap (see Figure 1). The maps will be concordant in some ways and divergent in others. This notion of overlapping maps permeates comparisons during the training process and is facilitated by a number of structured tasks. Parallel to didactic lectures and experiential exercises that cover the parameters described here, trainees develop interview questions that encompass the four areas: ecological context, migration/acculturation, family organization, and family life cycle. Trainees also explore the values of their family of origin, their present family, their life experiences with different cultures and their theoretical slants in the same four basic parameters. Awareness of class, ethnicity, and religion are increased by focusing on the trainees’ own experiences (Brislin, 1988). It quickly becomes apparent that the areas of consonance and dissonance between the family and the therapist are made much richer by looking at multiple contexts and cultural borderlands. For example, family and therapist may have different ethnic backgrounds and religions but similar education and social class; they may all have experienced prejudice and marginalization because of their race, gender, or political ideology, or have experienced relocation or migration. They may share developmental niches, as parents of adolescents. In other words, a multidimensional comparative approach opens the door for cultural bridges of connectedness between family and therapist. And in areas of difference, interest in learning about the experiences and worldview of others, unlike ourselves, can forge new understanding and respect. PRACTICAL APPLICATIONS IN SUPERVISION

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Interviewing a Nonclinical Family My colleagues and I have found it helpful to have each trainee “try out” his or her cultural learning in the four key areas by interviewing a volunteer, nonclinical family, that is, one not in family therapy, using questions co-developed with students during the didactic sessions (Falicov, 1988). The volunteer family is not searching for solutions and the trainee can explore culture more fully and with less pressure. Also, the omnipresent danger of confusing culture with dysfunction, or of ignoring dysfunction in the name of cultural respect, can be discussed. Before they do the nonclinical interview trainees are encouraged to articulate and write down all their preconceptions about the cultural group they are about to interview. This is helpful in detecting stereotypes and racial or ethnic prejudices. It is also a simple and powerful way to bring home the awareness that the observer’s values and ideas are part of the observation. A quick, holistic-evaluative scanning is then made of all the contexts the family belongs to simultaneously; the aim is to understand the resources and constraints or the cultural dilemmas provided by those multiple interfaces between contexts. The therapist may have a general knowledge acquired through essays, fiction, or other readings about the various contexts in which the family is involved. However, because families distill and draw selectively and differently from the contexts to which they belong, the therapist cannot assume that knowing the contexts is knowing the culture of the family. Knowing what the contexts are provides an avenue for raising relevant questions, which, in themselves, may stimulate reflection and new perspectives for the family. Attitudes To Be Encouraged To expand self-knowledge of their cultural borderlands, with the borderlands’ potential creative alternatives, families usually need a supportive context that communicates the value of these explorations. The multidimensional approach advocated here models a supportive, curious, and imaginative stance about the family’s own cultural constraints and untapped resources. Cultural meanings are explored and derived through dialogue and conversation rather than through unchecked assumptions or presuppositions. Precisely because culture comes in multiple versions, this approach opens up multiple ways of piecing together a story, of constructing an identity, of reinventing a view. It does not rely on only one cultural explanation or impose the description of one set of values. As a by-product of the learning experiences described, a way of thinking and a number of attitudes that insure cultural sensitivity in the broadest sense for the broadest spectrum of families become part of the identity and the modus operandi of the therapist. The first of these attitudes is paying close attention or interest. This is the opposite of assuming that one knows about the culture of the family, and it is the best antidote for stereotyping. In fact, recent empirical evidence suggests that those who pay less attention, particularly when they are in a position of power, are more vulnerable to stereotyping others (Fiske, 1993). Another attitude is curiosity, a close ally of attention (Cecchin, 1987). When involved in conversations that include cultural themes, therapists pursue the conversation with curiosity and a balance of “risk and respect,” rather than with covert judgment about customs or values (Lappin, 1983). A multidimensional comparative approach also helps trainees develop a form of “sociological PRACTICAL APPLICATIONS IN SUPERVISION

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imagination” (Wright Mills, 1959), that is, the ability to grasp the relationship between history, ideology, and biography for themselves and for their clients. The goal of sociological imagination is to be so aware of how socialization affects identity that personal problems can be approached as social issues and vice versa. The process of making cultural values and contextual connections part of the therapeutic conversation sparks trainees’ empathic understanding, and heightens the family’s awareness of the intersections of personal experience with larger social issues. Empowering narratives can evolve not because, as is usually assumed, they cast a favorable light on some strength of the culture, but because they represent a balanced perception and construction of a family’s ecological niche, that is, the constraints and resources of the combined contexts in which a family (or a therapist) is existentially embedded. Conclusions The four positions outlined at the beginning—universalist, particularist, ethnic focused, and multidimensional—are legitimate and necessary ingredients of clinical evaluation. The approaches that stress training on contextual variables, that is, the ethnic-focused and the multidimensional/comparative, need not be polarized. The comparative approach is not an either/or proposition: it is a both-and situation. I suggest, however, that training begin with this latter approach, so therapists can gain a cultural road map for understanding similarities and differences as well as develop cultural self-reflexivity. Acquiring more specific ethnic, religious, or social class information can take place in the agency where practice takes place. There, trainees can become participant-observers who learn from a present and current cultural community rather than from historically constructed descriptions only. The description of the family’s and the therapist’s ecological niche with its cultural borderlands helps tackle the multidimensionality of culture by offering a bridge to the many value- imparting contexts in the lives of families and therapists. Finally, a multidimensional comparative approach helps therapists assume a metaposition relative to current prevailing theories and techniques. Cross-cultural juxtapositions that result in cultural criticism at home, a practice supported by modern anthropology, aims “to bring the insights gained on the periphery back to the center to raise havoc with our settled ways of thinking and conceptualization” (Marcus & Fischer, 1986, p. 138). Similarly, active cross-cultural excursions stimulate questions about the applicability of concepts constructed within the particular ecology, institutional politics, and historical moment of the dominant culture. The result is a healthy perspective about the culturebound nature of theories and techniques. But, above all, through a comparative framework, a cultural lens moves from the periphery to the center and becomes a mainstream way of thinking that should always be present when anyone is learning about families and family therapy. References Anzaldua, G. (1987). Borderlands/La Frontera: The new mestiza. San Francisco: Spinsters/Aunt Lute. Aponte, H.J. (1976). The family-school interview: An eco-structural approach. Family Process 15: 303-311. & VanDeusen. J.M. (1981). Structural family therapy (pp. 310-360). In A.S. Gurman & D.P. Kniskern (Eds.), Handbook of family therapy. New York: Brunner/Mazel. Auerswald, E.H. (1968). Interdisciplinary versus ecological approach. Family Process 7: PRACTICAL APPLICATIONS IN SUPERVISION

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202-215. Bateson, M.C. (1994). Peripheral visions. New York. Harper-Collins. Bertanlanffy, L. von (1968). General systems theory. New York: George Braziller. Boyd-Franklin, N. (1989). Black families in therapy: A multisystems approach. New York: Guilford Press. Brislin, R.W. (1988). Increasing awareness of class, ethnicity, culture and race by expanding on student’s own experiences (pp- 137-180). In I.S. Cohen (Ed.). The G. Stanley Hail lecture series (Vol. 3). Bruner, E.M. (1986). Ethnography as narrative (pp. 139-158). In V.W. Turner & E.M. Bruner (Eds.), The anthropology of experience. Urbana: University of Illinois Press. Cecchin, G. (1987). Hypothesizing, circularity, and neutrality revisited: An invitation to curiosity. Family Process 26: 405--.20. Comaz-Diaz, L. (1994). Integrative approach (pp. 238-261). In L. Comaz-Diaz & B. Greene (Eds.). Women of color: Integrating ethnic and gender identities in psychotherapy. New York: Guilford Press. Elkaim, M. (1982). From the family approach to the sociopolitical approach (pp. 337-357). In F.W. Kaslow (Ed.), The international book of family therapy. New York: Brunner-Mazel. Falicov, C.J. (1982). Mexican families (pp. 134-163). In M. McGoldrick, J.K. Pearce, & J. Giordano (Eds.), Ethnicity and family therapy. New York: Guilford Press. (1983). Introduction (p. xii-xix). In C.J. Falicov (Ed.). Cultural perspectives in family therapy. Rockville MD: Aspen Systems. (1988). Learning to think cu1turally (pp. 335-457). In H.A. Liddle. D.C. Breunlin, & R. C. Schwartz (Eds.), Handbook of family therapy training and supervision. New York: Guilford Press. (1992). Love and gender in the Latino marriage. American Family Therapy Association Newsletter 48: 30-36. (1993). Continuity and change: Lessons from immigrant families. American Family Therapy Association Newsletter 50: 30-34. & Brudner-White. L. (1983). The shifting family triangle: The issue of cultural and contextual relativity (pp. 52-37). In C.J. Falicov (Ed.), Cultural perspectives in family therapy. Rockville, MD: Aspen Systems. & Karrer. B. (1980). Cultural variations in the family life cycle: The Mexican American family (pp. 383-425). In E. Carter & M. McGoldrick (Eds.), The family life cycle: A framework for family therapy. New York: Gardner Press. Fiske, S. (1993). Controlling other people: The impact of power on stereotyping. American Psychologist 48: 6, 621-628. Freire, P., & Macedo, D. (1987). Literacy: Reading the word and the world. New York: Bergin and Garvey. Friedman, E.J. (1994). Sensitivity to contextual variables: A legitimate learning objective for all supervisors? The Supervision Bulletin VII(2): 4-7. Giroux, H.A. (1992). Border crossings: Cultural workers and the politics of education. New York: Routledge. Gomez-Peña, G. (1993). Warrior for Gringostroika. Saint Paul MN: Graywolf Press. Grinberg, L., & Grinberg, R. (1989). Psychoanalytic perspectives on migration and exile. New Haven: Yale University Press. Haley, J. (1980). Leaving home: The therapy of disturbed young people. New York: McGraw PRACTICAL APPLICATIONS IN SUPERVISION

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Hill. Hardy, K.V. (1994). Deconstructing race in family therapy. Journal of Feminist Family Therapy 5(3/4): 5-33. Haraway, D. (1991). Simians, cyborgs, and women: The reinvention of nature. New York: Routledge. Hartman, A., & Laird, J. (1983). Family-centered social work practice. New York: Free Press. Henry, J. (1963). Culture against man. New York: Random House. Ho, M.H. (1987). Family therapy with ethnic minorities. Newbury Park CA: Sage Publications. Hoffman, L. (1981). Foundations of family therapy: A conceptual framework for systems change. New York: Basic Books. . (1990). Constructing realities: An art of lenses. Family Process 29: 1-12. Hsu, F.K. (1961). Kinship and ways of life: An explanation (pp. 48-65). In F.K. Hsu (Ed.), Psychological anthropology: Approaches to culture and personality. Homewood IL: R.D. Irwin. . (Ed.). (1971). Kinship and culture. Chicago: Aldine Publishing Co. Inclán, J.E. (1992). Cross-cultural perspectives and codependence: The case of poor Hispanics. American Journal of Orthopsychiatry 62: 245-255. Imber-Black, E. (1988). Families and larger systems: A family therapist’s guide through the labyrinth. New York: Guilford Press. Korin, E.C. (1994). Social inequalities and therapeutic relationships: Applying Freire’s ideas to clinical practice. Journal of Feminist Family Therapy 5(3/4): 75-98. Lappin, J. (1983). On becoming a culturally conscious family therapist (pp. 122-136). In C.J. Falicov (Ed.), Cultural perspectives in family therapy. Rockville MD: Aspen Systems. Marcus, G.E., & Fischer, M.M.J. (1986). Anthropology as cultural critique: An experimental moment in the human sciences. Chicago IL: University of Chicago Press. Marris, P. (1980). The uprooting of meaning (pp. 101-116). In G.V. Coelho & P.I. Ahmed (Eds.), Uprooting and development: Dilemmas of coping with modernization. New York: Plenum Press. McGill, D.W. (1992). The cultural story in multicultural family therapy. Families in Society 73: 339-349. McGoldrick, M., Pearce, J.K., & Giordano, J. (Eds.). (1982). Ethnicity and family therapy. New York: Guilford Press. Montalvo, B., & Gutierrez, M. (1983). A perspective for the use of the cultural dimension in family therapy (pp. 15-30). In C.J. Falicov (Ed.), Cultural perspectives in family therapy. Rockville MD: Aspen Systems. , & Gutierrez, M. (1988). The emphasis on cultural identity: A developmental-ecological constraint (pp. 181-210). In C.J. Falicov (Ed.), Family transitions: Continuity and change over the life cycle. New York: Guilford Press. Nichols, M.P., & Schwartz, R.C. (1991). Family therapy: Concepts and methods (2nd ed.). Boston: Allyn and Bacon. Pattison, E.M., DeFrancisco, D., Wood, P., Frazier, H., & Crowder, J. (1975). A psychosocial kinship model for family therapy. American Journal of Psychiatry 132: 1246-1251. Rosaldo, R. (1989). Culture and truth: The remaking of social analysis. Boston: Beacon Press. Sluzki, C.E. (1979). Network disruption and network reconstruction in the process of migration/relocation. The Bulletin, a Journal of the Berkshire Medical Center 3(3): 2-4. Steinberg, L., Dornbusch, S.M., & Brown, B.B. (1992). Ethnic differences in adolescent PRACTICAL APPLICATIONS IN SUPERVISION

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achievement. American Psychologist 47: 723-729. Takaki, R. (1994). A different mirror. San Francisco: University of California. Walsh, F. (Ed.). (1993). Normal family processes (2nd ed.). New York: Guilford Press. Whittaker, J.K, & Garbarino, J. (1983). Social support networks: Informal helping in the human services. New York: Aldine Publishing Co. Wright, L. (1994). One drop of blood (pp. 46-55). The New Yorker, July 25. Wright Mills, C. (1959). The sociological imagination. London: Oxford University Press. Yee, A.H., Fairchild, H.H., Weizmann, F., & Wyatt, G.E. (1993). Addressing psychology’s problems with race. American Psychologist 48: 1132-1140.

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INDIVIDUAL AND GROUP SUPERVISION OF LMFT INTERNS IN AN AGENCY SETTING: A TRAINING MODEL BARBARA FARBER, PH.D.

Bringing high quality supervision to interns working in an agency setting is a multi-faceted, complex process. It requires careful planning, sound research, flexibility and a willingness to experiment. It also requires a firm commitment on the part of the host agency to support and develop a clinical program of the highest caliber. The purpose of this article is to detail the implementation of the supervision process in an agency-based clinical program. Background Statement Following two years of research and development, a rape and sexual abuse center decided to add a treatment component to its victim services department. A decision was made to create a low-fee, in-house counseling center designed to bring specialized services to survivors of sexual assault and their families. Potential clients would be those individuals who, due to financial circumstance, were unable to access the private therapeutic community. Treatment would be provided by MFT interns under the supervision of licensed therapists who were themselves specialists in the treatment of sexual assault. While a program of this nature necessitates ongoing training of interns in the dynamics of sexual abuse, the supervision issues are broad based and applicable to interns and supervisors working in any kind of agency treating a specific population. Program Development Selection of Interns Of primary importance in program development is the method by which interns are selected. All prospective interns are required to submit a written application prior to a pre-arranged interview date. Thus, academic and employment backgrounds may be verified and references checked. The possession of an intern registration number and the willingness to carry student malpractice insurance is mandated. The personal interview focuses on whether the intern is able to work with extremely difficult content and process material, whether the intern possesses qualities of personal maturity and integrity, whether the intern’s life history may impact his/her ability to work with the severely abused population and, most importantly, whether the intern has a willingness to risk, grow and learn. In addition, all interns are required to complete a 50 hour training program which is both didactic and experiential in nature. Following satisfactory completion of the training, interns enter a three-month probationary period and then the formal internship begins in earnest. As the program matured, additional criteria for interns became apparent. Interns just out of school were ill-equipped to deal with the highly complex issues raised by clients with histories of repetitive, sadistic assault, ritualistic abuse and chronic post-traumatic symptomatology, including the possibility of dissociative disorders. In terms of intern selection, a decision was made to take only second-level interns; the supervision issues raised by this will be addressed in PRACTICAL APPLICATIONS IN SUPERVISION

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a later section. Newly graduated interns were asked to get at least one year of post-degree experience prior to submitting an application. Secondly, it also became apparent that an evaluation procedure was necessary. Thus, midway through the ninety-day probationary period each intern is asked to meet individually with the two supervisors. The intern is given an opportunity to identify any problems, concerns or specific areas of difficulty including transference issues they may be encountering with supervisors. The supervisors, in turn, are able to give the intern feedback with respect to areas of strength as well as those in need of improvement. If difficulties are present, potential solutions are sought and specific recommendations may be outlined. Interns may be asked to do additional reading, attend workshops, audit courses or perhaps seek personal psychotherapy. The evaluation procedure is intended to be an opportunity for two-way learning. In response to intern suggestions, many aspects of the program have been improved. In any case, the ninety-day probation gives both the intern and supervisor a “way out” should a situation prove too problematic. Selection of Supervisors In terms of supervision, a team approach was quickly selected. Two licensed therapists who had worked closely with the agency for a number of years were chosen. One therapist assumed the dual responsibility of individual supervision and program administration, while the other was the provider of group supervision. Both therapists were experienced clinicians, teachers and providers of professional training. One had prior supervisory experience. It is important to note that both supervisors are in ongoing clinical supervision themselves. While this was not a requirement of the host agency, it was a decision deemed mandatory by the two supervisors. The reasons were many. First, supervisors who are charged with assisting interns in becoming aware of their own individual processes must obviously be capable of the same. Second, supervisors have a duty to keep their own clinical skills finely tuned. And third, it is important to model for interns that supervision, of one kind or another, should be a life-long process and that there is always room for growth and additional learning. Fee Structure As the agency described in this protocol is grant dependent (a situation they are seeking to reverse), it is not possible to pay interns for their services. However, they are not charged. What is provided is high quality training and supervision and as many hours of client contact per week as they can handle without affective and cognitive flooding. The agency is fortunate in that there is a waiting list of potential clients requesting services. Thus, interns are not charged with the additional obligation of seeking clients. The supervisors, however, are paid. While the hourly rate is less than a private practice hour, it is reasonably competitive with an administration position in private industry and is reflective of the host agency’s commitment to clinical excellence. Initially, supervision salaries were paid from grant monies. Currently, efforts are underway to make the agency financially independent so that program integrity will not be threatened on a year-to-year basis. Supervision Protocol The structure and content of both individual and group supervision evolved over time. This is PRACTICAL APPLICATIONS IN SUPERVISION

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where flexibility and experimentation proved most valuable. Interns were mandated to attend both individual and group supervision on a weekly basis for a total of three supervision hours per week. In addition, both supervisors presided over a weekly staff meeting thus giving interns the opportunity to access both supervisors at the same time. Twice per month the staff meetings focus on management practice concerns (room schedules, report writing, filing of claims such as victim witness, disability and private insurance, fee collection, proper use of forms); the remaining two meetings are used for professional training, in-services on topics of importance to the practice of marriage and family therapy. Initially, individual supervision was designed to focus primarily on case management. The role of the supervisor was to address all the “nuts and bolts” issues, the “how-to’s” of being a therapist. This was easier said than done. Once the program was underway, it did not take long to discover that the concept of individual supervision, and the role of the supervisor, would have to be expanded. It was learned that supervisees go through a number of developmental stages as part of the individual supervision process and, even though most entered as second-level interns, it was not uncommon for many to lack basic, rudimentary skills. In other words, it was learned that there was absolutely no uniformity that could be expected in terms of what an in-coming intern could be expected to know. That is why the initial interview process must so carefully assess the intern’s willingness to risk, grow and learn. An extremely important issue surfaced almost immediately. At first, it was considered unique to a rape and sexual abuse agency; however, it is probably faced by supervisors in any agency which deals with a specific population. Namely, exposure to a particular client population has the potential to raise issues of personal import for the intern. This is true irrespective of whatever therapy an intern may have received in the past. Working with survivors of incest, rape and molestation frequently triggered memories, either long-repressed or fully conscious, of abuse in the intern’s past. The abuse need not have been sexual. The end result, however, was that a significant amount of time in the early stages of supervision needed to focus on the therapeutic needs of the intern. This proved beneficial for a number of reasons. First, it is a powerful reminder of how easy it is to miss, avoid, or not completely work through critical therapeutic issues. Second, it is an essential ingredient in helping interns monitor their own process. And third, it assists interns in differentiating their issues from those of the clients. Clearly, identification with victims is a countertransference issue. It very quickly brings humanistically trained interns face-to-face with psychoanalytic concepts. However, the focus in the early stages of supervision is to assist the intern to stay in tune with his/her own process; only later are the specifics of transference and countertransference taught. Introducing these concepts and the techniques of appropriate interpretation at this stage is confusing to a new intern. Related to this concern is yet another issue that surfaces in the early stage of supervision. Learning to work with a specific client population can be quite overwhelming. The content material is heavy, the psychodynamics are confusing and the intern feels helpless, out of control and inadequate to do the task at hand. Assigning clients in an age range with which the intern is comfortable (e.g., adolescents) or who have issues with which an intern has had previous training PRACTICAL APPLICATIONS IN SUPERVISION

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(e.g., chemical dependency) is one way to provide some relief. However, the role of the supervisor at this point is one of slow, patient teaching. There is no way to rush the acquisition of sound clinical skills. Interns are told that it will take at least a year before they feel like they know what they are doing. On occasion, it has been necessary to contradict the teachings of previous instructors, therapists or supervisors. Sometimes the discrepancy occurs because the needs of assault survivors differ from those of other clients and what “works” with one type of pathology is not appropriate with another. Other times the intern has simply been given misinformation. And, on still other occasions, the contradiction occurs due to differing theoretical orientations. In this latter instance, every effort is made to help the intern understand different theoretical modalities so that differing ways of approaching treatment can be discussed and explored. This issue is raised only because it has the potential of creating confusion for the intern and, on occasion, has resulted in some transference problems in that the intern may feel that their previous learning is being invalidated. In the role of case manager, the individual supervisor assists the intern to develop the necessary clinical skills to practice competently and effectively. Running as a thread throughout the entire supervision, attention is eventually focused on the following areas: • Assessment and diagnosis, including the taking of a psychosocial history and specific clinical interviewing techniques • The development of an appropriate treatment plan • Crisis interventions, including ways of handling such issues as suicidality, acting-out and self-mutilation • Boundaries and limits — time, money, telephone counseling, physical touch, inappropriate demands and the limits and uses of self-disclosure • ethical and legal issues frequently encountered by assault survivors (reporting issues; forensic evaluations; appropriate interfacing with the police, child protective services and the district attorney’s office; fear of reprisal from offenders; communication with significant others, etc.) • Adjunctive therapies — when and how to make appropriate referrals • Theoretical orientations — an eclectic model is presented; the intern is introduced to a variety of psychodynamic, behavioral, systems and humanistic approaches • Counseling process — every effort is made to fine-tune an intern’s investigative and listening skills. Interns are taught to “be curious;” so often, the train is on the right track but the engine is off. While specific methods and techniques are taught, it is the client’s process to which the intern is instructed to pay the most attention • Transference and countertransference • Clinical issues specific to sexual assault survivors and their families • Communication skills, including the writing of reports, interfacing with other professionals in the community, community presentations and participation in the training of para-professional staff. The method by which these skills are taught varies. Sometimes, it is didactic; other times it is experiential. The individual supervisor may role-play, listen, question, instruct, cajole or play devil’s advocate. The learning style of the intern often influences the way in which supervision is PRACTICAL APPLICATIONS IN SUPERVISION

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handled. Some interns avoid, others have a “need to know,” and some become quite selective in the questions and concerns they bring to supervision. The reality is that each intern will come away from individual supervision with different pieces of knowledge. Sophistication levels among interns vary since they come with differing academic backgrounds and life experiences. And, finally, the individual supervisor frequently takes on the role of mentor. This does not happen with every intern but it is an extremely important and rewarding function when it does. Each and every specialist has a duty to pass on to future clinicians what they have learned. Only then can a given body of knowledge be refined and expanded. In summation, then, the role of the individual supervisor is one of teacher and facilitator, case manager, guidance counselor, administrator and mentor. It is a tall order for limited supervision. Group Supervision Group supervision is just as critical as individual; different therapeutic issues and concerns are addressed. The role of the group supervisor is also different although it obviously overlaps individual supervision. The supervisors find that they each come to know the interns in different ways. Neither one alone has the full picture. When the observations of the two supervisors are combined, supervision blooms and the specific needs of an individual intern are fully addressed and appropriate assistance is offered. Skills that support group participation are taught. For example, the group supervisor begins each week’s session with a relaxation exercise. The purpose is to allow each intern to get in touch with his/her own process. It is a remarkably effective technique for breaching defensive barriers. It has the potential for putting certain issues on the table very quickly. An added benefit is that interns learn the techniques of relaxation and stress reduction via the Dewey method — learning by doing. The same method is employed for the teaching of guided imagery. The group supervisor can easily demonstrate the unlimited potential of imagery for scene visualization and role-enactment in fantasy. Naturally, there is an important didactic component involved. A technique such as guided imagery can be a powerful tool and, as such, should be employed with care and discretion. The supervisor is charged with teaching the appropriate use of such methods in therapy, and it is here that interns learn the importance of timing and the therapeutic utilization of containment. Another aspect of group supervision is case conferencing. Often interns find themselves treating different members of the same family. They need a place and time to share their observations, ask pertinent questions and perhaps gain a sense of direction and focus. By facilitating inter-communication between the interns, the group supervisor assists in the process of helping fledgling therapists understand that they are only working with one person’s perception of the truth. That is often quite an eye-opener for a new intern. In addition, case conferencing allows for the formulation of a coordinated treatment plan and gives interns practice in organizing their thoughts with respect to a client’s progress in treatment. Group supervision is also an excellent forum for the presentation of case studies. The PRACTICAL APPLICATIONS IN SUPERVISION

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difficulties an intern may be experiencing with a particular client are often ones the other interns are encountering in their caseloads. Here the group supervisor becomes teacher, facilitator and trainer. Information is imparted, dialogue between group members is encouraged and specific counseling techniques may be suggested. It is an excellent accompaniment to individual supervision. One hour per month of group supervision is devoted to preparation for the oral licensing examination. Interns are asked to write their own vignettes from issues in their client caseloads and they take turns responding. In this way, they learn how to organize their thoughts in terms of the areas in which they will eventually be tested in order that specific areas of weakness can be identified. Interns thus have adequate time in which to remediate the subject areas posing the most difficulty. A very unique aspect of group supervision is the writing and presentation of a body history. The group supervisor offers guidelines for its preparation and the intern is given as many sessions as necessary for its oral presentation. In terms of helping interns get in touch with the very essence of who they are — thoughts, feelings, sensations, behaviors, responses to certain stimuli — the preparation of the body history is without doubt one of the most powerful experiences encountered by the intern. It is a cornerstone of the group supervision process. Group supervision offers an opportunity to bond on common developmental ground and gives both participants and supervisor a chance to observe dynamics that are not apparent in the individual setting. More than anything else, it is hoped interns will learn in group supervision how to monitor their own process and especially, techniques of self-care. I n summation, it is the feeling of both supervisors that the training of interns requires both individual and group supervision. If only one or the other is provided, significant aspects of learning are missed. It is also important for the intern to be exposed to more than one supervisor. Everyone has his/her own style of imparting information and interns can benefit from exposure to different methods of interaction. In keeping with the belief that exposure to a number of supervisors is beneficial, another opportunity afforded interns in this agency is the chance to co-facilitate time-limited, structured therapy groups under the supervision of five additional licensed therapists who independently contract with the host agency. The two primary supervisors also facilitate these groups and interns thus have an opportunity to see their supervisors as providers of service. In this way, interns get very direct training and supervision in the dynamics of group process. Interaction Between Supervisors It is essential for the two supervisors to maintain close contact and communication with one another so that the “right foot knows where the left foot is going.” To this end, the supervisors touch base with one another at least twice a week and more often if necessary. It is also important for the supervisors to present a united front in terms of dealing with procedural issues. Should any conflict arise between the supervisors, and that is a rare occurrence, it is worked out privately.

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Interns understand that confidentiality is respected and that communication between supervisors will focus on issues related to performance. In short, the information shared is generic in nature. If personal information comes to light that one supervisor feels the other should know, permission will be obtained from the intern and reasons for sharing will be delineated. Occasionally, an intern will have a conflict with one of the supervisors. Almost always, it is a transference issue. That situation is addressed by asking the intern to meet privately with both supervisors so that the alternate therapist can facilitate communication and assist in mediation. This has proved to be a learning experience for both the interns and supervisors. It certainly is a powerful and healthy way of teaching interns the skills involved in conflict resolution and transference interpretation. Administrative Effects on Supervision As stated previously, the implementation of the treatment program was carefully designed over a two year period by the Executive Director of the agency and the individual supervisor. The individual supervisor is also the Clinical Director of the agency and, at this time, is the only licensed professional on staff. This is advantageous for a number of reasons. Foremost, it has kept the treatment program “clean.” The host agency understands that the services provided must conform with legal and ethical standards of practice and they look to the Clinical Director for such information and education. Again, the learning is two-way. The agency is learning just what the training of future therapists entails, just as the supervisor is learning the mechanics of how a non-profit agency must operate. The supervisor is also able to protect the interns from wellintended, but nonetheless inappropriate, requests from other staff members for services that may be outside the range of the intern’s expertise. Such requests created early problems and once the situation was explained to staff, full cooperation and understanding ensued. The entire treatment department enjoys a warm, congenial and respectful relationship with the other departments and staff in the agency. The host agency is fully committed to high quality service in all of its departments. Never has the integrity of the treatment program been undermined or compromised. This unqualified support has made working for the agency an absolute delight. Both the Executive Director and the Board of Directors were willing to take a risk to support this new program. This included the acquisition of additional office space at considerable expense in order to “house” the needed treatment rooms. Without the support of the administrative staff and the board, the implementation of the treatment program as it now exists, would not have been possible. Closing Statement In closing, the supervision protocol presented in these pages is still evolving and will likely continue to evolve. As the program expands, new demands will have to be met and experience will likely teach supervisors more efficient ways to communicate certain skills. To date, it has been a rich and rewarding experience for everyone — interns, supervisors and the host agency staff. It is hoped that the ideas presented and the experience gleaned thus far will be of assistance to other agencies and supervisors who are planning and developing their own treatment programs.

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DEVELOPMENTAL STAGES IN SUPERVISION: IMPLICATIONS FOR SUPERVISORS AND ADMINISTRATORS TAD GOGUEN FRANTZ, R.N., PH.D.

Family therapists frequently use their knowledge of the predictable stages of individual and family development to assess clinical problems and plan interventions. Their supervisors find that a knowledge of the predictable developmental sequences which trainees must negotiate on their way to therapeutic competence is equally useful in assessing training progress and designing appropriate supervisory interventions. Review of Developmental Models in Supervision According to Kohlberg (1975), the various developmental stage theories have acquired an empirically sound common meaning. They hold that aspects of ego maturity have a long range predictive relationship to life outcome. Common to all these theories are the assumptions that “humans move through a series of stages and developmental tasks or crises and that retardation or conflict at one stage colors task solutions at later stages,” (Kohlberg, p. 253). He calls for training models in which learning activities are designed to stimulate both cognitive and emotional development in learners. He believes that skill in understanding human behavior and engaging in interpersonal relationships is acquired via the stimulation of natural trends of ego development. Blocher (1968) contends that such developmental learning is a product of social interaction. Developing skill in social interaction is learned in social interaction. While some family therapists have conceptualized supervision as a developmental process (Ard, 1973; Cohen, Gross & Turner, 1976; Everett, 1981; Johnson, 1961; Tucker, Hart & Liddle, 1976), primary interest has focused on other aspects. Family therapy still lacks a cohesive, broadly applicable answer to the question: What specifically does a competent trainee look like across all levels of training and how can supervisors best facilitate that development? This article addresses these questions. The supervision literature of the more traditionally therapeutic approaches have more to say in answering these questions than does family therapy’s literature. Conceptual models of supervisee development have been offered by Archer and Peake (1984); Bernard (1979); Blocher (1968); Ekstein and Wallerstein (1972); Flapan (1984); Friedlander (1984); Goodyear and Bradley (1983); Grater (1985); Hart (1982); Hess (1980); Hogan (1964); Littrell, Lee-Borden and Lorenz (1979); Loganbill, Hardy and Delworth (1982); Munson (1976); Robinson (1978); Stansbury (1982); Stoltenberg (1981); Wiley (1982) and Yogev (1982). Empirical studies of developmental processes in supervision have been reported by Heppner and Handley (1981); Heppner and Roehlke (1984); Hill, Charles and Read (1981); Miars, Tracey, Ray, Cornfeld, O’Farrell and Gelso (1983); Ralph (1980); Raphael (1982); Reising and Daniels (1983); Worthington and Roehlke (1979) and Worthington (1984). These studies have begun to lend empirical validity to the notion of developmental stages in psychotherapy training. The earliest developmental model, offered by Ekstein and Wallerstein (1972) in their seminal work, identified four roles in supervision systems: trainee, supervisor, client and PRACTICAL APPLICATIONS IN SUPERVISION

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administrator. Their relationships form a “clinical rhombus” with each role in one corner. They all struggle through three phases of maturation: beginning, middle and termination. The six dyads mirror and influence each other as they, too, develop through the same three phases. Maturity and competence result as persons resolve the emotional dilemmas that inevitably arise in these dyads. Maturation is facilitated when all four components remain equidistant from each other. Administrators and supervisors are advised in this model to monitor emotional closeness and adjust their own relationships to remain involved with the others without becoming overinvolved. Supervisors who notice themselves ignoring administrators, for example, as they intimately involve themselves with supervisees and their clients are, according to the model, inhibiting the personal development of everyone in the clinical rhombus. They are advised to take a more objective stance toward supervisees and attend more closely to administration. Should they experience greater empathic understanding with a supervisee’s clients than with the supervisee they are advised to notice that and equalize their supervisory attention and efforts. Administrators should adjust their relationships so they can devote equal attention among the requirements of supervisors, supervisees and clients. Family therapists will recognize in the clinical rhombus four interlocking triangles (Bowen, 1978). Bowen theory equates maturity with the amount and intensity of the triangulation processes in interpersonal systems. Intense emotional triangulation prevents maturation, while detriangulation (exercising the freedom to equalize interpersonal distance) frees relationships of the distortions that obstruct ego development. Westheafer (1984) offered a model that integrates triangle theory (Bowen, 1978; Haley, 1976; Hoffman, 1981; Madanes, 1981; Minuchin, 1981), distance regulation theory (Byng-Hall, 1982; Madanes, 1981; Minuchin, 1981; Napier & Whitaker, 1980; Williamson, 1982) and concepts of unresolved mourning in family systems (Fulmer, 1983; Hoffman, 1981; Minuchin, 1981; Paul, 1967) with the parallel process of the clinical rhombus. He noted that live supervision, which gives supervisors direct access to supervisees’ clinical sessions, permits supervisors to identify developmental regressions in which supervisees, clients and supervisors become ineffective and confused in isomorphic patterns. The triangle pattern that disables the client family (for example, a distant father who criticizes his wife for being an over-involved mother and his son for remaining babyish) is reestablished with the therapist (who takes a critically distant posture toward the father and an overly close, empathic relationship toward the mother), disabling the therapeutic system. If the supervisor, too, is inducted into an isomorphic triangle with the therapist (criticizing the therapist, ignoring the therapist’s professional development and overinvesting himself in the family’s therapeutic outcome), the therapy may become disabled and require a supervisor for the supervisor (metasupervisor) to identify and detriangulate the “frozen” and “contagious” relationship patterns. The remedy at all levels is for one person to become aware of the pattern and equalize the emotional distance in relation to the other two. The supervisor in the example would distance somewhat from the family to attend more empathically to the supervisee. Ralph (1990) conducted a series of in-depth interviews with eight supervisors and their 36 psychotherapy trainees, and concluded that learning progresses along a continuum from relatively concrete, undifferentiated, common-sense conceptualizations of therapeutic process toward more complex, sophisticated, and abstract ideas, requiring greater degrees of PRACTICAL APPLICATIONS IN SUPERVISION

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introspection. Beginners want to know and can grasp the concrete behaviors they must carry out with their clients in order to conduct a session. They ask anxiously, “What do I do?” and supervisors must tell them. In the next phase, they concentrate on learning to understand clients and take a nondirective, Rogerian approach in their clinical sessions. In a third phase, they focus on the nature of the therapeutic relationship, asking, “What must we do together for the client to improve?” In later phases they ask, “Who am I to be in order to do something therapeutic?” and the emerging professional self of the therapist becomes more of a focus in supervision, as that self becomes increasingly trusted to be both a diagnostic and a change agent. Littrell, Lee-Borden and Lorenz (1979) describe four stages. In the first one, supervisor and supervisee establish their relationship, set goals and clarify a contract. In stage two, a counseling/therapeutic component is added (see Mueller & Kell, 1972, Rioch, Coulter & Weinberger, 1976), which emphasizes interpersonal dynamics, along with a teaching component, emphasizing instruction. As the supervisee matures and enters the third stage, the supervisor serves more as a consultant and less as either instructor or therapist. Consultation is more exploratory, reflecting supervisees’ increasing professionalization and responsibility for their own learning, which they take over completely in stage four as they become independent of supervisors and adopt a self-supervision model. Hogan (1964) also identified four levels of development through which clinicians pass in their development as therapists. At the first level, novice therapists are insecure, rendering them intensely “technique” oriented, inclined to imitate their supervisors, heavily dependent on their “methodology of choice,” highly unaware of their impact on others, clients or supervisors, and lacking insight into their own emotional process and motivations. They soon leave their method-bound proclivities and try to invest their personalities into the therapeutic relationship, thus entering level two. This is a tumultuous stage in which a dependency-autonomy conflict emerges. Trainees fluctuate between overconfidence in their new skills and becoming overwhelmed by their professional responsibilities. Ambivalent struggles with the painful emergence of self-awareness add to “the growing pains of the Journeyman” (p. 140). Hogan equates the third level with becoming a master of the trade. Increased self-confidence and self-awareness allow therapists to experience their person as foreground with method as background. Having resolved the level two conflicts, supervisees and supervisors enjoy a more collegial, less hierarchical relationship. Level four brings deepening artistry, intuitive judgment, creativity and seasoning. This transcendent level is characterized further by autonomy, insightfulness with awareness of the limitations of insight, security based on awareness of insecurity, flexibility and willingness to confront the continuing struggles of living. These levels should not be thought of as discrete or mutually exclusive. Rather, they intermingle and the level one-to-level four cycle repeats many times over a professional lifetime. Stoltenberg’s (1981) “counselor complexity” model stresses the importance of the training environment in enhancing advancement from stage to stage. What is considered an optimal environment at any stage is theorized to be a suboptimal environment for the next higher stage and superoptimal environment for the previous stage. He described his four stages as: (1) imitative, unaware dependency on the supervisor, (2) dependency-autonomy conflict with the supervisor, (3) conditional dependency on the supervisor, and (4) self-aware, interdependent PRACTICAL APPLICATIONS IN SUPERVISION

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master counselor. Everett (1981), a family therapist, synthesized developmental ego psychology with family therapy’s differentiation concept into a three-stage developmental model, each stage linked by two transition periods. Trainees may progress forward or regress to earlier, “safer” stages to permit emotional “refueling” before moving on. Competence is forged by a trainee’s dialectically opposed, dependency strivings (needs for connectedness, trust, and identification with the supervisor) and differentiation urges (separation, individuation and establishing a distinct professional identity). In the first phase, called “differentiation,” the task is to distinguish a professional identity from the roles which trainees played out in their families of origin. Families of therapists are assumed to have fostered in them intrinsic needs to nurture and control others, often through triangulated and parentified roles. Supervisors at this stage must help them identify and transcend these needs, allowing trainees then to identify a more appropriate professional self. Success at this task precipitates the first transition period, characterized by increased vulnerability for trainees and disorganization of their sense of identity. This clears the way for them to identify with their supervisors in the next phase. However, this transition may be marked by increased reactivity, unstable or regressive behavior and an ambivalent struggle about giving up some control in order to deepen the learning alliance with the supervisor. Ambivalent supervisees may regressively distance from supervisors or manipulate them in an attempt to control the supervision. In the middle stage, called “functional dependency,” supervisory relationships are relatively open and conflict-free. Supervisees are much more transparent and are inclined to idealize, imitate and seek approval from their supervisors. Supervisory relationships may flounder at this stage either from an idealizing fusion or from reactive distancing and passive resistance on the part of the supervisees. The second transition period involves much less upheaval than the first, as supervisees begin to separate and individuate from the supervision structure to claim their own autonomous identities. Separation anxiety, moodiness and self-doubt proceed and accompany the testing of this autonomy. Anxiety and frustration may be displaced onto the supervisor. The supervisor, like the parent of an adolescent, must support the separation and spurts of autonomous functioning while continuing to offer an appropriate level of security. During the third and final phase, “individuation,” supervisees experience self-confidence in their professional identities, assume fuller responsibilities for their cases and establish a more collegial, consultative relationship with supervisors. Though increasingly complex, Everett’s schema parallels those discussed so far, including that of Ekstein and Wallerstein. In their beginning phase they described distortions in therapeutic and supervisory processes created as supervisees attempted to form relationships with clients and supervisors similar to previous familiar relationships. In fact, neophytes at any level in training systems (administrators, supervisors’ supervisees, or clients) attempt to relate to others from roles at which they are already expert. The middle phase of development for all of PRACTICAL APPLICATIONS IN SUPERVISION

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them involves relinquishing the security of old relating styles in order to add new interpersonal competencies. Widick, Knefelkamp and Parker (1975) offer a three-stage developmental model, applied here to MFCC trainees, in which adult learners develop by resolving a dichotomy between knowledge of reality that comes from personal experience and that which is understood via the intellect. During the stage of dualism, supervisees regard themselves as receptacles ready to receive some unitary “truth.” Consequently, they have difficulty with learning tasks which require differing points of view. Members of their client families and expert therapists, of course, hold differing views on almost any situation that can present itself clinically and trainees are asked to consider them. They take this diversity and uncertainty to mean that “the authorities” have not yet found “the answer,” because beginning trainees cannot yet acknowledge a reality in which differing viewpoints are acceptable. When they enter the stage of relativism, some of the old cognitive signposts disappear, leaving supervisees feeling lost and alone in a chaotic world. Gradual realization dawns that “truths” emerge from integrating their own experience and judgment with factors external to self. Toward the end of this stage, they recognize the need to make some form of personal commitment so they can orient themselves in a relativistic world. During the third stage, “commitment in relativism,” they establish a personal identity by their willingness to make commitments. External commitments (to a career path) as well as internal commitments (finding a point of equilibrium among one’s many paradoxical personal themes) are made. When this is accomplished, they integrate an approach to therapy, based on a personally regulated balance between activism and contemplation. Lastly, they experience an affirmation of their professional identity among multiple unfolding activities, which have been delineated in an extremely useful way in the comprehensive model described next. Our most comprehensive developmental stage model for supervision appeared as the major contribution (Loganbill, Hardy & Delworth, 1982) to a special supervision issue of The Counseling Psychologist. These authors recognize eight critical issues with which supervisees must struggle as they move through three developmental stages and two transition points, similar to Everett’s. Throughout their development, supervisors must perform the four functions of (1) monitoring client welfare, (2) enhancing growth within stages, (3) promoting transition from one stage to the next, and (4) evaluating supervisees. The goal of this complex process is for supervisees to consolidate a professional identity that is cognitively and emotionally well integrated. The eight critical issues to this integration are: (1) issues of competence (skill, technique), (2) issues of emotional awareness (knowing oneself, awareness of feelings), (3) issues of autonomy (self-directedness), PRACTICAL APPLICATIONS IN SUPERVISION

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(4) issues of identity (theoretical consistency, conceptual integration), (5) issues of respect for individual differences (tolerant, nonjudgmental acceptance of others), (6) issues of purpose and direction (structuring a therapeutic direction, setting appropriate goals), (7) issues of personal motivation (awareness of the satisfactions and personal meanings inherent in practicing therapy), and (8) issues of professional ethics (values). Therapist development is assumed to be continuous throughout professional life, and therapists may cycle and recycle through any or all stages along any or all critical issues at increasingly deeper levels. The authors used the metaphor of changing a tire with eight bolts to represent the issues. One tightens the bolts one after another, just enough so that the wheel is attached. Then the process is repeated. Each bolt is tightened and retightened in turn until the wheel is entirely secure. The three stages, analogous to one rotation of the bolts, may be summarized as follows. “Stagnation,” the first stage, refers to trainees’ naive lack of awareness of any difficulty or deficiency with regard to any of the issues. This blissful ignorance eventually produces a noticeable “stuckness” or “stagnation” with regard to clinical effectiveness and professional development. Patterns of avoidance and emotional blocking indicate that the supervisee is “frozen” into old and inappropriate patterns of thought and behavior. Supervisors must be wary of idealizing transferences their supervisees are likely to develop toward them. As these cognitive and affective structures begin to “unfreeze,” the resulting cognitive and behavioral disorganization signal entrance into the second stage, “confusion.” This is a turbulent and chaotic stage, marked by subjective anxiety and interpersonal conflict with the supervisor. Remaining heavily dependent on the supervisor, supervisees can become disappointed and angry that “the golden answers” to clinical problems do not seem to flow from the supervisor to the ready and waiting new therapist. Supervisors are alternately idealized as magical and all-knowing, much as they were in the previous stage, and devalued as either withholding knowledge or inadequate to come through when they are so badly needed. It can be a very frightening phase; and supervisors do well to anticipate and understand the developmental nature of this stage rather than taking personally the attitudes which supervisees may have at some points. The confusion and conflict of this middle stage serves to clear the way of old, inappropriate structures allowing cognitive integration of new ones, which is the task during the last stage. In this stage of “integration,” the intense emotional factors that emerged previously become assimilated and, finally, integrated with cognitive, conceptual understandings which come about during the transition. Supervisees at this stage have acquired nothing less than a new, more complex world view and with it, a professional identity. A resolution of conflicting opposites has occurred, permitting, for example, a sense of “personal security based on awareness of insecurity” (Loganbill, et al 1982, p. 19). Evaluation Supervisee Development Diagnosis and Treatment of Developmental Impasse PRACTICAL APPLICATIONS IN SUPERVISION

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This model permits an in-depth and broad-based evaluation of supervisee development. Supervisors and supervisees alike will find the authors’ complete descriptions of supervisee behavior at each of the three stages for each of the eight critical issues useful in informing themselves about adequate training progress. This author has used these descriptive categories in diagnosing and planning interventions with several trainees who did not seem to be increasing in competence despite a year or more of clinical experience with weekly supervision, two hours in group and one hour of individual face to face supervision. Their supervisors reported that they felt as though they were starting with a brand new supervisee every time these trainees would present a case. Despite giving this feedback to the supervisees, the supervisees maintained an optimistic confidence in their clinical abilities and progress. First, these trainees were asked to read the Loganbill, et al, article and assess themselves as to which stage they believed they had achieved in each of the eight critical issues. In a meeting of the supervision team, a written description was prepared of supervisee performance in the eight categories, accompanied by the team’s consensus as to which stage the descriptions suggested the trainee had achieved. In one case, the descriptions showed a trainee to be functioning at stage one in seven of the eight categories, and they pointed to emotional “frozenness” as the probable cause. This trainee had difficulty accepting the supervisors’ evaluation, having rated himself at stage two in three categories and in transition to stage three on the others, so a probationary period involving the following four-step intervention was instituted. First, because the trainee had been in therapy for some time, the decision was made with the supervisee’s consent, to share the evaluation with the therapist. The difficulty seemed to be one that could be best diagnosed in supervision and worked through in psychotherapy. Second, his caseload was reduced, allowing intensive supervisory attention to be paid to the ongoing process in each case. Third, videotapes of each session were reviewed for the purpose of teaching this trainee to point out to the therapist where he was having difficulty or believed he had responded suboptimally to his clients. He was told that little or no supervisory attention would be paid to what he was doing well, the rationale being that only by requiring him to recognize and attend to his deficits, could the necessary “unfreezing” occur, enabling him to enter stage two. Fourth, he was told that the supervisors would conduct another evaluation in three months. If, by that time, he was recognizing and pointing out his clinical weaknesses to supervisors on a regular basis, he would undoubtedly show developmental progress according to this model and supervisors would consider lifting the probation. If he remained unchanged, supervisors would recommend he take a leave of absence while continuing in therapy, returning at a later time when he would be able to benefit more from the supervisory experience. If he had shown some progress, but not enough to lift the probation, it could be extended. This effort required considerably more time and energy on the part of supervisors than is usually required and which is a primary drawback. However, it was quite successful. A breakthrough in this trainee’s personal therapy occurred just before the probationary period ended and he began to experience intense anxiety reporting cases. He congruently, earnestly and accurately identified moments in his taped sessions when he felt uncertain and confused as to how to respond. As this clearly signaled entrance into stage two in the category of emotional PRACTICAL APPLICATIONS IN SUPERVISION

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awareness, which supervisors felt to be the key to unfreezing development in other categories, they decided to extend probation another three months and evaluate him in all categories at that time. The trainee made rapid progress and had achieved level two in all categories. Supervisors pointed out to him that he had not caught up to where most others would be after 1,000 direct hours and he should not “short change” his training by rapidly accruing hours and becoming licensed. They continued to limit his caseload somewhat out of respect for his slower developmental pace. In another instance, supervisors shared their eight area descriptive evaluation with the trainee in question, who refused to accept it as valid or to follow their recommendations. As a result, when it was decided that a training impasse had been reached, the trainee decided to leave the training program. Although this was perhaps a less desirable outcome than the first, the use of the Loganbill, et al, model clarified the problem just as clearly and facilitated its resolution. The Loganbill, et al, article also contains five types of useful supervisory interventions and useful assessment criteria for evaluating supervisors. The criteria are especially useful for self-evaluation by novice supervisors or for feedback by supervisors of supervisors. In addition, they present criteria for evaluating effective supervisory relationships and contextual factors, such as timing, administrative factors, client population, facilities and environmental stressors. A Synthesis of Developmental Trajectories These models have been summarized because the author found them clinically useful and valid in supervising MFCC trainees and interns in both group and individual settings. A synthesis of the models, integrated with the author’s clinical experience follows. Supervisees seem to evolve through the following eight sequences during their training, largely irrespective of clinical discipline or methodological approach. First, they become dependent on supervision, then they react to ego dystonic regressive feelings and attempt to be independent before finally settling into an ego syntonic interdependency and collegiality with supervisors. Second, they evolve from uninsightful confidence toward anxiety and ultimately, toward confidence based on self-awareness and security based on awareness of insecurity. Third, trainees shift out of an undifferentiated awareness to cognitive and emotional disorganization and then to increasing levels of differentiation and integration. The emotional integration seems to precede the cognitive integration in this author’s experience. Trainees who do not have an integrated emotional “self” available to them, are not able to select or integrate a psychotherapeutic world view and consistent clinical approach that fits with that “self.” In the middle phases of training the trainees, emotional self becomes an important focus for supervision, while in the later phases, the way that self conceptualizes and articulates, the therapeutic enterprise becomes a central concern. Fourth, trainees change from an initial technique-oriented, method-bound clinical approach toward one that is oriented to the proclivities of client-therapist interactions and finally, to a professional identity in which the clinician uses self as a flexible, diagnostic and change agent. Fifth, they seem to begin with a conflict-free, uninsightful defensiveness that gives way in mid-training to conflicted defensiveness and finally resolves into nondefensiveness toward the supervision process. Sixth, as trainees struggle with these tasks, they gradually shift from an PRACTICAL APPLICATIONS IN SUPERVISION

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extroverted learning mode to one with more introspection. Seventh, trainees start out learning via unquestioning receptivity and imitation, using the external world as a source of knowledge. Next, they shift toward learning via active commitment and choice, which permits them to continually challenge those chosen commitments. To do so they must also use inner processes as sources of wisdom. Lastly, they move from stable simplicity in their conceptualization of themselves and the therapeutic task, through chaotic instability with increased complexity, and then into stabilization of the increased complexity. Summary and Conclusion As in therapy with individuals and families, a knowledge of normal development and the tasks that must be mastered at each phase is useful in diagnosing the needs of LMFT supervisees and offering appropriate supervisory interventions. This article has reviewed those developmental models found by the author to be most valid and useful in her practice as a clinical supervisor. Examples were given of the application of one of these models to the evaluation of two training impasses and their resolutions. It concluded with the author’s synthesis of the various models. Beginning supervisors are encouraged to read the original publications, as well as the cited publications by Mueller and Kel (1972), Rioch et al (1976) and Doehrman (1976) for more in-depth treatment of how supervisors can best facilitate optimal professional development in their supervisees. In conclusion, it must not be forgotten that supervisors and administrators are involved in their own professional developmental trajectories, complicated by complex tasks that have both emotional and cognitive components. Anxiety is a by-product of ego development, whether it be that of clients, supervisees, supervisors or administrators. Anxiety will be continually present in training environments, exerting a regressive influence on all concerned. When anxious individuals get into relationships with others who can remain nonanxiously present to them while they freely discuss their anxiety arousing situations, personal and professional maturation throughout the system is enhanced.

References Archer, R.P. & Peake, T.H. (1984). Learning and teaching in psychotherapy: Signposts and growth stages. The Clinical Supervisor, 2(4), 61-74. Ard, B.N. (1973). Providing clinical supervision for marriage counselors: A model for supervisor and supervisee. The Family Coordinator, 22, 91-97. Bernard, J.M. (1979). Supervision training: A discrimination model. Counselor Education and Supervision, 19(1), 60-68. Blocher, D.H. (1968). Counselor education: Facilitating the development of a helping person. In C.A. Parker (Ed.) Counseling theories and counselor education. Boston: Houghton Miflin. Bowen, M. (1978). Family therapy in clinical practice. New York: Jason Aronson. Byng-Hall, J. (1982). Symptom bearer as marital distance regulator: Clinical implications. Family Process, 19(4), 355-365. Cohen, M., Gross, S., & Turner, M. (1976). A note on a developmental model for training family therapists through group supervision. Journal of Marriage and Family Counseling, 2, PRACTICAL APPLICATIONS IN SUPERVISION

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48-56. Doehrman, M.J.G. (1976). Parallel process in supervision and psychotherapy. Bulletin of the Menninger Clinic, 40(1), 3-104. Ekstein, R., & Wallerstein, R.S. (1972). The teaching and learning of psychotherapy. New York: Basic Books. Everett, C.A. (1981). Developmental stages and transitional crises in the supervision of family therapy students. A paper presented at the annual meeting of the American Association for Marriage and Family Therapy, San Diego, CA. Everett, C.A. (1981). Supervision of marriage and family therapy. In A. Hess (Ed.), Psychotherapy supervision: Theory, research and practice. New York: John Wiley. Flapan, D. (1984). The emerging self of the therapist. Issues in Ego Psychology. 7(1-2), 18-22. Freidlander, S.R., Dye, N.W., Costello, R.M., & Kobos, J.C. (1984). A developmental model for teaching and learning in psychotherapy supervision. Psychotherapy, 21(2), 189-196. Fulmer, R.H. (1983). A structural approach to unresolved mourning in single parent family systems. Journal of Marital and Family Therapy, 9(3), 259-270. Goodyear, R.K., & Bradley, F.O. (1983). Theories of counselor supervision: Points of convergence and divergence. The Counseling Psychologist. 11(1), 59-67. Grater, H.A. (1985). Stages in psychotherapy supervision: From therapy skills to skilled therapist. Professional Psychology: Research and Practice, 16(5), 605-610. Haley, J. (1976). Problem solving therapy. San Francisco: Jossey-Bass. Hart, G.M. (1982). The process of clinical supervision. Baltimore: University Press. Heppner, P.P., & Handley, P.G. (1981). A study of the interpersonal influence process in supervision. Journal of Counseling Psychology, 28, 437-444. Heppner, P.P., & Roehlke, H.J. (1984). Differences among supervisees at different levels of training: Implications for a developmental model of supervision. Journal of Counseling Psychology, 31, 76-90. Hess, A. K. (Ed.). (1980). Psychotherapy supervision: Theory, research and practice. New York: Wiley. Hill, C.E., Charles, D., & Read, K.G. (1984). A longitudinal analysis of changes in counseling skills during doctoral training in counseling psychology. Journal of Counseling Psychology, 28, 428-436. Hoffman, L. (1981). Foundations of family therapy. New York: Basic Books. Hogan, R.A. (1964). Issues and approaches in supervision. Psychotherapy Theory: Research and Practice, 1(3), 139-14 1. Johnson, D. (1961). Marriage counseling: Theory and practice. Englewood Cliffs, NJ: Prentice-Hall. Kohlberg, L. (1975). Counseling and counselor education: A developmental approach. Counselor Education and Supervision, 14(4), 250-257. Littrell, J.M., Lee-Borden, N., & Lorenz, J.R. (1979). A developmental framework for counseling supervision. Counselor Education and Supervision, 19, 129-136. Loganbill, C., Hardy, E., & Delworth, U. (1982). Supervision: A conceptual model. The Counseling Psychologist, 10(1), 3-42. Madanes, C. (1981). Strategic family therapy. Washington: Jossey-Bass. Miars, R.D., Tracey, T.J., Ray, P.B., Cornfeld, J.L., O’Farrell, M., & Gelso, C. J. (1983). Variation in supervision process across trainee experience levels. Journal of Counseling Psychology, 30, 403-412. PRACTICAL APPLICATIONS IN SUPERVISION

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Minuchin, S. (1981). Family therapy techniques. Cambridge, MA: Harvard University Press. Mueller, J.W., & Kell, B.L. (1972). Coping with conflict: Supervising counselors and psychotherapists. Englewood, NJ: Prentice-Hall. Munson, C.E. (1976). Professional autonomy and social work supervision. Journal of Education for Social Work, 12(3), 95-102. Napier, A., & Whitaker, C. (1980). The family crucible. New York: Harper & Row. Paul, N.L. (1967). The role of mourning and empathy in conjoint marital therapy. In G.H. Zuk & I. Borszormenyi-Nagy (Eds.) Family therapy and disturbed families. Palo Alto, CA: Science and Behavior Books. Ralph, H.B. (1980). Learning psychotherapy: A developmental perspective. Psychiatry, 43, 243-250. Raphael, R.D. (1982, August). Supervisee experience: The Effect on supervisor verbal response. Paper presented at the meeting of the American Psychological Association, Washington D.C., Reising, G.N., & Daniels, M.H. (1983). A study of Hogan’s model of counselor development and supervision. Journal of Counseling Psychology, 30, 235-244. Rioch, M., Coulter, W., & Weinberger, D. (1976). Dialogues for therapists. San Francisco: Jossey-Bass. Robinson, V. (1978). The development of a professional self. New York: AMS Press. Stansbury, D.L. (1982). Developmental supervision from a skills perspective. The Counseling Psychologist, 10(1), 53-57. Stoltenberg, C. (1981). Approaching supervision from a developmental perspective: The counselor complexity model. Journal of Counseling Psychology, 28, 59-65. Westheafer, C. (1984). An aspect of live supervision: The pathological triangle. Australian Journal of Family Therapy, 5(3), 169-175. Widick, C., Knefelkamp, L.L., & Parker, C.A. (1975). The counselor as a developmental instructor. Counselor Education and Supervision, 15, 286-296. Wiley, M.O. (1982, August). Developmental counseling supervision. Person-environment congruency, satisfaction, and learning. Paper presented at the meeting of the American Psychological Association, Washington, D.C. Williamson, D.S. (1982). Personal authority in the family experience via termination of the intergenerational hierarchical boundary: Part III: Personal power defined and the power of play in the change process. Journal of Marital and Family Therapy, 8(3), 309-325. Worthington, E.L., Jr. (1984). Empirical investigation of supervision of counselors as they gain experience. Journal of Counseling Psychology, 31(1), 63-75. Worthington, E.L., Jr. & Roehlke, H.J. (1979). Effective supervision as perceived by beginning counselors in training. Journal of Counseling Psychology, 26, 64-73. Yogev, S. (1982). An eclectic model of supervision: A developmental sequence for beginning psychotherapy students. Professional Psychology, 13, 236-243.

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DIFFERENT TYPES OF COUNTERTRANSFERENCE AND THE IMPORTANCE OF ADDRESSING THEM IN SUPERVISION SARAH GILLEN, M.A.

The majority of people who enter the profession of psychotherapy do so in response to experiences in their own lives. They have a strong desire to help others, as well as a need to be helped with their own pain. It is how this “helping” is translated by interns that leads to intrusive manifestations of countertransference. Countertransference, like transference, is a natural phenomenon and may even be considered an ego function (Bird, 1972). As such, the practitioner’s reactions are essential to the therapeutic process if they are recognized and worked with responsibly. Countertransference may be defined as any reactions the clinician has to the client in the course of the work. Unaddressed countertransference greatly interferes with the intern’s ability to see and hear the client’s process, structure, or developmental task in therapy. On the other hand, being comfortable enough with one’s own material to use it in the best interest of the client adds immeasurably to the clinician’s effectiveness. A distinction needs to be made between different types of reactions and how they must be used. For the sake of clarification, I have developed terms to distinguish two types of countertransference — historical and diagnostic. Historical countertransference includes all reactions the intern has to the client, the client’s material or the therapeutic setting, arising from the intern’s past experiences. It is all too clear that virtually every intern, at least in the beginning, carries some form of belief that by helping others to feel better, the intern’s own pain will be resolved or managed enough so that it seems to have disappeared. Interns show this constantly. They so often have to feel effective and helpful in order to assuage their own historical dilemmas. They have such an urgent need to rescue the client — to fix problems — that interns get lost in the content, and often in the client’s defense against his/her own pain, and miss the client’s process and skill at self-healing. Interns need first to learn to listen — to be quiet enough to hear the client. They need to get out of the way. In order to allow the client’s process, the interns need to be able to be present with themselves and to tolerate and feel comfortable with their own historical material. Their attempts to fix the client are actually efforts to avoid or manage their own pain and therefore of no use to the client. Many clients love this interaction, for the intern has projected his/her own hurt self onto the client and is then treating that self as he/she always wanted to be treated. The actual client doesn’t have to do any work! (Masterson, 1989). There are several areas of historical countertransference in which interns most frequently get lost. One is parallel process. The intern has similar events in their past as those described by the client — abusive parenting, eating disorders, etc. The interns’ projection is likely to be very strong under such circumstances. Because interns are then so wrapped up in providing answers and “help” to their own wounded selves through the client, they may not be able to see that the client is a separate person with different therapeutic needs. PRACTICAL APPLICATIONS IN SUPERVISION

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Another area of historical countertransference is that which is not directly triggered by the client but has more to do with the process of therapy in general. No matter who the client is the intern may be caught in this type of material. The most prevalent examples seem to be the need to do a good job as therapists in order to win their introjected mothers’ love and approval, or their need to prove to their introjected fathers that they are competent. This layer of countertransference blinds interns to that which is appropriate in the actual session. It may be that they should seem stupid, without answers, let the client flounder, or not be liked by the client in the process of providing therapeutic neutrality and frame. If getting another’s approval is material that has not been addressed, interns will not be able to do the basic task of maintaining a therapeutic stance. Another difficulty that occurs when interns are not familiar with their own issues is that they are unable to use their reactions to the client as diagnostic material. Diagnostic countertransference refers to any emotions or responses that the clinician experiences which are indicators of the client’s subjective experience, object relations, defense structure, or pathology. These diagnostic reactions clearly are valuable in the therapeutic process to gain a sense of the client’s function in relation to others in the world. For example, the intern may feel depressed and hopeless in response to a severely depressed client. Or, in responding to a client’s projective identification, clinicians often feel attacked and undermined, trapped and angry, as if nothing they do is right. The client has projected his self-representation on the intern and is acting as the negative, but powerful, object toward the projected self, i.e., the parent attacking the unpleasing, helpless child (Scharff & Scharff, 1987, Fritts, 1989). When practitioners become aware of this kind of reaction in themselves, they can see the client’s contribution to their feeling-states rather than reacting blindly to it, and therefore have more insight into the client’s pattern. It is then possible to assess more accurately what intervention would be effective. In order to use diagnostic countertransference, interns need to be able to differentiate between feelings that come from their own past and those that are generated by others. The interns have to have enough observing ego to be able to make this distinction. The only way it is possible for interns to have clear, observing egos is to have worked through their own historical material. If they have sufficiently worked through these effects, they can stay in contact, both with their own material and with their clients. This requires a softness and compassion in themselves in regard to these painful feelings, even in the middle of a session. It also requires a dedication to the client’s work. It is necessary for the interns to keep their material separate in order to be emotionally available for the client. Emotional availability is only possible if interns are not resisting their own material and therefore not distracted by it. An example of a mix of two types of countertransference would be an intern wanting to reparent a borderline client who was pulling for rescue by acting helpless and overwhelmed by emotional material. The intern would need to identify her desire to mother the client or to be perceived as warm and caring in contrast to the harsh experiences the client may be reporting. The intern would need to work through the historical countertransference involving those issues in order to see what was actually appropriate with the client. The intern could then learn to use PRACTICAL APPLICATIONS IN SUPERVISION

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the occurrence of those urges in sessions as diagnostic countertransference to become aware of how and when the client is pulling for that reaction, and what it must mean about the client’s developmental structure that the behavior is occurring (Masterson, 1976, 1981, 1983; Masterson & Klein, 1989). In my experience, most of the difficulties interns have in their work is because of their failure to address their historical countertransference. It is imperative that the supervisor probe for the interns’ countertransference. The material becomes apparent in a number of ways. The most obvious is in the interns’ responses to clients or difficulty in treating clients. It also occurs in the process of supervision, either in relation to the supervisor or in group interaction. Any emotional material that seems noteworthy, or which consistently recurs in supervision, should become a topic of investigation. It is in the interns’ process of managing the reaction to the client, as well as the supervisory relationship, wherein lies the key to their historical material. It is the supervisor’s job to uncover the intern’s countertransference and to point out ways in which his/her work is affected. Working through the material that is uncovered needs to be handled in the intern’s therapy and NOT in supervision. The supervisor needs to direct the intern to work through the material on the grounds that the work will not improve without these issues being addressed. As such, it is the supervisor’s responsibility to assess that the intern’s treatments are occurring and that the intern is grappling with the countertransferential issues. Clearly, we are all in process and hopefully always will be growing. It is not necessary to have “completed” work on an issue to be effective as a therapist. (Many interns do have that unrealistic goal for themselves and view therapists as “finished” and problem-free.) However, there does seem to be a baseline in order to have potential as a clinician. This baseline includes awareness of and tolerance for one’s material, having sufficiently attenuated its emotional impact, and having adequate real internal structure. The baseline is demonstrated by commitment to the therapeutic process from both sides — the intern’s personal growth as well as the commitment to do whatever is necessary to become better as a therapist. The supervisor must assess, through the intern’s work with clients, his/her process in supervision, and his/her ability and willingness to confront his/her issues, including whether the intern has adequate internal strengths to be useful in the field of psychotherapy. References Bird, B. (1972). Note on transference: Universal phenomenon and hardest part of analysis. Journal of the American Psychoanalytic Association, 20(2), 267-301. Fritts, K.D. (1989). Personal conversation. Masterson, J.F. (1976). Psychotherapy of the borderline adult: A developmental approach. New York: Brunner/Mazel. Masterson, J.F. (1981). The narcissistic and borderline disorders: An integrated developmental approach. New York: Brunner/Mazel Masterson, J.F. (1983). Countertransference and psychotherapeutic technique: Teaching seminars on psychotherapy of the borderline adult. New York: Brunner/Mazel. Masterson, J.F. (1989). Psychotherapy of the personality disorders: The self and intimacy. San Francisco Conference. PRACTICAL APPLICATIONS IN SUPERVISION

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Masterson, J.F., & Klein, R. (Eds.). (1989) Psychotherapy of the disorders of the self: The Masterson approach. New York: Brunner/Mazel. Scharff, D.E., & Scharff, J.S. (1987). Object relations family therapy. Northvale: Jason Aronson.

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SUPERVISION OF INTERNS: BALANCING ALL THE HATS LYNDA HARBERT, M.S.

For most interns, licensure is seen as a road filled with major obstacles. One of the first hurdles is securing a supervisor for supervised experience. Securing supervision for the practicum or fieldwork is an expected component of most graduate programs, while securing post-degree supervision can create anxiety since it is of such importance to one’s future. Supervision is a process that should continue throughout a person’s professional career. However, supervision for the intern is quantitatively different depending upon the level of experience and knowledge the intern brings into the therapeutic process. For the most part, the focus for MFCC interns is concentrated on the 3,000 hours required for licensure. Both supervisor and intern aim for that goal in varying degrees. However, this narrow focus often negates the process that needs to occur along the path to licensure. It also ignores the roles that are required of a supervisor. A review of the supervisor’s role may emphasize the importance of the supervisory task. It may also aid in the reduction of unrealistic expectations, confusion and frustration that is often experienced in this influential relationship. Supervision as Training Traditionally, supervision is to provide a teaming experience for the intern. In Dr. Ernst G. Beier’s book, The Silent Language of Psychotherapy, the purpose of supervision for the intern is clearly outlined: The purpose of the supervisory session and later of the “control” session is to create in the inexperienced therapist a sense of awareness of his own participation in the demands of the patient; and to sensitize him to “read himself” and learn about the patient from his own involvement. In the early 70s and continuing into the 80s, the American Association for Marriage and Family Therapy (AAMFT) established detailed guidelines on the role of the supervisor in the supervision session. Outlined responsibilities and guidelines for AAMFT-Approved supervisors not only includes the evaluation of the intern’s theoretical knowledge on many levels, but also screens the candidate; establishes clear supervisory goals; develops a contract; delineates fees, hours, times and places of meetings; differentiates case management; and administrative supervision from periodic, clinical evaluations which may include written reports. Existentially, the role of the supervisor in the supervision session has also been outlined in Drs. Bill L. Kell and William J. Mueller’s book, Impact and Change: A Study of Counseling Relationships. They describe the role of the supervisor as follows: The supervisor ... is a person who through his interaction with the counselor, attempts to assist him to develop, to restore if necessary, and to bring his relationship with his clients PRACTICAL APPLICATIONS IN SUPERVISION

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to a satisfying close. While the above references approach the therapeutic process of supervision differently, there is the underlying theme that the supervisor is an active participant and the supervision session is a training experience. This concept suggests that the supervisor set limits and guidelines, directs the process when necessary, observes the process and explores with the intern his clinical knowledge and self-motivation. This is in contrast to a now widely held perception of the supervisor as passive, non-directive and non-confrontive; and simply a means to an end for the signing of hours. This misperceived view often includes the intern as a colleague in a professional relationship which, by its structure, cannot imply equal status. While the inequity of the relationship is viewed by some as arbitrary, it is not. The intern, while theoretically knowledgeable, is limited in terms of the application of this knowledge at various levels of the therapeutic process. The intern is often still in the process of discovering aspects and motivations for his/her own behavior and at the same time attempting to assimilate theoretical information within the context of a dynamic, therapeutic relationship. Since the client is the primary focus in the therapeutic relationship, a supervisor acts as a mediator to insure that the integrity of the client and the therapeutic process is maintained. As the intern progresses through the professional process, the degree and intensity of therapeutic interventions by a supervisor should change. Through active supervision, a supervisor can observe the intern’s professional growth and make the necessary adjustments enhancing the quality of supervision. The above description of an active supervisor does not require that the supervisor be dictatorial. Supervision is not a process where the supervisor creates the intern into one’s own image; nor is it a collusive relationship between a supervisor and intern limiting the latter’s skills and abilities. Supervision, at its most fundamental level, is a teaching relationship that assists the intern in developing his/her professional ability and blending his/her theoretical and introspective knowledge. Supervision at this level is not a passive exercise by a supervisor. Like the therapeutic process, it is a relationship that encourages exploration, introspection and assimilation. Supervisor as Employer/Manager While supervision in larger non-profit and for-profit organizations is predominantly managerial, supervisors in private practice often diminish this role. The increase in interns seeking hours toward licensure has increased the number of interns in private practice settings and has helped to create managers from supervisor/therapists. Supervisors and interns are thus plunged into the unfamiliar world of business. Typically, supervisors are managers. The direction and observation of case progress, assignment and acceptance of clients, establishment of procedures for intake and assessment, payment agreements, scheduling, establishment of office guidelines, etc. are managerial functions. What creates stress for the private practice supervisor is the combination of these tasks, with the added functions of salary negotiations, payroll deductions, professional liability coverage, as well as clinical supervision. PRACTICAL APPLICATIONS IN SUPERVISION

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The private practice supervisor is faced with legal, ethical and professional considerations when employing interns. This role includes not only the scheduling of office hours and supervisory sessions but also employment, termination and compensation criteria. As with most employment situations, supervisor and subordinate negotiate with different views on the execution of duties and salary. However, at this juncture, the “business” of psychotherapy turns into the “business of doing business.” For the supervisor, focus includes profit margin, liability, new account development, record keeping, possible misrepresentation of services and overhead costs. For the intern, the focus includes income and accrual of hours toward licensure. The goal is to develop a compromise that does not endanger the integrity of either individual emotionally or financially, while maintaining quality client service. The supervisor, not the intern, sets the boundaries. The supervisor and not the intern, must enter negotiations knowing the expectations and limitations, and must clearly set boundaries early in negotiations. Supervisor as Facilitator Of all of the various roles of a supervisor, none is more delicate than the role of facilitator. The facilitator role not only applies to the evaluation of the intern’s therapeutic skills, but also the recognition of countertransference issues that interfere with the intern’s therapeutic performance. The latter requires a supervisor to do a balancing act to identify and facilitate blocks in the therapeutic process that result from the intern’s inexperience or client resistance as compared to addressing the intern’s unresolved issues. According to Kell and Mueller, the balancing act is required due to the instructional as well as mediator function of the supervisor relationship. ... supervisors enable counselors to counsel by helping them to differentiate their feelings and conflicts from those of their clients... As noted, supervision is a training experience and as such requires a supervisor to make the intern aware of his/her impact in the therapeutic process and to assist in developing his/her therapeutic style and skills. A supervisor’s facilitation of therapeutic movement, while direct and clear, must also respect and maintain the dignity of the intern. Intervention should be clearly focused and directed toward clinical issues and not a supervisor’s/supervisee’s personal needs or conflicts. Kell and Mueller continue: In the supervisory relationship, the counselor is as vulnerable to hurt and can experience the damaging consequences of a significant failure in the same way that a client often does. Likewise, when it becomes evident that the integrity of the client is being compromised, or the intern, due to unresolved issues, cannot benefit from supervision, a supervisor must identify these conflicts, the clinical implications for the client and direct the intern to appropriate assistance. While a supervisor wears many hats, the role of therapist is not one such role. The supervisor relationship is useful to the counselor if it enables him to view all of himself — needs, conflicts, life experience — as potentially helpful to clients. Supervision is not, PRACTICAL APPLICATIONS IN SUPERVISION

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therefore, a process of unraveling and resolving the counselor’s conflicts, but rather it is a process of mobilizing his adequacy (Kell & Mueller). The inclusion or attempt to act as therapist to an intern places the supervisor in a dual relationship that weakens and clouds the supervisory interaction. The phrase “dual relationship” is well-known to the therapeutic community. However, the ease with which one can cross the boundary in supervision is less widely recognized. The appearance of personal conflict by the intern and confrontation of that issue by a supervisor, in and of itself, does not constitute therapy. Reoccurring conflicts or therapeutic blocks along the same theme requiring supervisory intervention and confrontation does constitute therapy. Once a supervisor’s primary focus shifts from the client’s conflicts to the intern’s conflicts and requires time during the supervisory session or even additional sessions to deal with resolution of the intern’s conflicts, a supervisor has moved into the role of therapist. The key to this delicate balancing act is the identification of boundaries which focus on maintaining the integrity of the therapeutic process and not on the integrity of the supervisor or intern. Likewise, lack of intervention, when one observes intrapsychic conflicts for the intern that hinder the therapeutic progress, moves a supervisor into the role of enabler which is neither beneficial for the client nor the intern. We suggest that a counselor may often attempt to make a relationship with his supervisor which is similar in some dimensions to the relationship he has with his clients. The supervisory relationship then may serve as a defensive screen which enables the counselor to continue, and even justify, the unchanging, probably ineffective ways he is treating his clients (Kell and Mueller). The supervisor as facilitator maintains a delicate balance between assisting in the development of the intern’s therapeutic intervention skills as well as the development of the intern’s self-awareness. Although the role may necessitate intervention on the part of a supervisor, the role is not therapeutic. It requires a supervisor to recognize the need for therapeutic intervention and guide the intern in obtaining the appropriate assistance. In addition, supervisors wary of crossing dangerous boundaries in the course of supervision will not invite, in fact, will not even discuss, the intern’s personal life or personal issues. Supervisors, likewise, will be cognizant of their influential role and will avoid any dual relationships which could impair professional judgment and/or reduce the effectiveness of the supervision process. Activities which supervisors should avoid include: remarks about the physical appearance of the intern, unless, of course, such remarks are necessary to improve the professional appearance of the intern; hugs at the end of supervision; neck rubs or other kinds of physical contact or touching; invitations to meet for lunch, dinner, social events, parties, or in the supervisor’s home to do supervision. Even though the intent in each situation may be harmless, the supervisor has to recognize and avoid potential dangerous situations. Section 4.1 of Part I of CAMFT’s Ethical Standards (2008) state: "Marriage and family therapists are aware of their influential position with respect to students and supervisees, and they avoid exploiting the trust and dependency of such persons. PRACTICAL APPLICATIONS IN SUPERVISION

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Marriage and family therapists therefore avoid dual relationships that are reasonably likely to impair professional judgment or lead to exploitation. Provision of therapy to students or supervisees is unethical. Provision of marriage and family therapy supervision to clients is unethical. Sexual intercourse, sexual contact or sexual intimacy and/or harassment of any kind with students or supervisees is unethical. Other acts which could result in unethical dual relationships include, but are not limited to, borrowing money from a supervisee, engaging in a business venture with a supervisee, or engaging in a close personal relationship with a supervisee. Such acts with a supervisee's spouse, partner or family member may also be considered unethical dual relationships." Supervisors who develop feelings of sexual attraction or arousal toward supervisees should see this as a warning signal. Steps should be taken to terminate the supervisorial relationship as the effectiveness of the supervision will be undermined. Besides, Section 1833 (b)(3) of the California Code of Regulations states: ". . . any experience obtained under the supervision of a spouse, relative or domestic partner shall not be credited toward the required hours of supervised experience. Any experience obtained under the supervision of a supervisor with whom the applicant has had or currently has a personal or business relationship which undermines the authority or effectiveness of the supervisor shall not be credited toward the required hours of supervised experience." The intent of this regulation is clear. Even though the hours are what are at stake should the regulation be violated, the message is that “personal or other business relationships” between supervisor and supervisee affect the quality of supervision and should be avoided. Supervisor as Colleague “Colleague: n. a fellow member of a profession, staff or academic faculty; associate.” The intern’s focus on the road to licensure is upon the eventual designation as a licensed clinical therapist, an independent practitioner, a colleague. While some may argue “colleague” status has been obtained once one has gained the required hours or completed the necessary course work, such a narrow view negates the depth of expertise required for the independent practice of psychotherapy. Whether the conceptual style is cognitive, systems, psychodynamic or existential is irrelevant to the inherent intent of the process. In general, psychotherapy can be defined as the treatment of mental, emotional and nervous disorders. Clinically, this process analyzes behavior in terms of motives, drives or associations and assists the individual in bringing unconscious styles of relating to a conscious level of awareness in order to facilitate emotional growth and the reduction of emotional distress. The therapist observes and utilizes the covert and overt information provided by an individual’s behavior to draw inferences regarding the level and nature of the unconscious distress and guide the individual to a healthy level of functioning. However, it is the ability to conceptualize behavior, analyze covert information and to interact with an individual with the intent of bringing unconscious behavior to conscious PRACTICAL APPLICATIONS IN SUPERVISION

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awareness for examination, that differentiates the therapeutic process from other social interactions. The practice of psychotherapy then, requires the therapist to analyze behavior beyond the surface presentation, take into account the many levels of why individuals behave in certain ways, examine the purpose for current behavior, and look at the emotional depth the individual can explore in the therapeutic process. The therapist identifies overt as well as covert dangers for the client. In this process, the therapist may need to assume an active protective stance, as in the case of suicide or abuse, not only for the benefit of the client but also for others. The demonstration of this depth of understanding and functioning in the therapeutic process moves an individual quantitatively from the stance of intern to colleague and changes the dynamics of the supervisory relationship. Once a supervisor identifies this level of functioning in the intern, clinical supervision should be directed to test this hypothesis. The intent is not to “trick” the intern in demonstrating incompetence but to carefully observe and analyze the intern’s level of skill and functioning. The method for this evaluation may take many forms, such as correlation of case notes with therapeutic intervention and case discussion; supervision of the intern’s duties to obtain a broader picture of independent functioning and skill; or broadening of the intern’s client population to determine consistency of depth in assessment across a broad client spectrum. Evaluation and outcome are the important elements, not the method of evaluation used to test this hypothesis. In the Handbook of Counseling Supervision (Borders & Leddick, 1987), guidelines are presented to assess the intern’s developmental level. Borders and Leddick’s review of the research on this topic also indicates that experience level and developmental level are not equivalent. Since one may enter into the supervisory process at any given point of the pre-licensure continuum, supervisors must have clear assessment guidelines to identify each intern’s developmental stage. Without this assessment, supervisors can attribute competency to interns well beyond clinical skills and thus deny opportunities for growth. Likewise, underestimation of intern skills can add frustration to supervisory interaction and possibly curtail development of depth and sophistication of clinical skills. Summary The role of supervisor requires the wearing of many hats. The role, while primarily focused on clinical ability as executed by the intern, includes managerial and mediation functions and may involve work beyond the supervision hour. While interns may enter into the process with a narrow focus on getting licensed, supervisors must enter into each relationship with clearly defined guidelines and expectations. Attention to detail is a critical element of this role. The relationship is beneficial if it provides the intern with constructive feedback about his/her intervention process while it provides an opportunity for clinical growth and development. References Beier, E.G. (1973).The silent language of psychotherapy: Social PRACTICAL APPLICATIONS IN SUPERVISION

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reinforcement of unconscious processes. Chicago: Aldine Publishing Company. Borders, L.D., & Leddick, G.R. (1987). Handbook of counseling supervision. Alexandria, VA: Association for Counselor Education and Supervision. Division of American Association for Counseling and Development. Commission on Supervision. (1989). Marriage and family supervision course guidelines. Washington, D.C.: American Association for Marriage and Family Therapy. Federal Tax Guide Reports.(1987). Commerce Clearing House, Inc. Kell, B.L., & Mueller, W.J. (1966). Impact and change: A study of counseling relationships. Princeton, New Jersey: Prentice-Hall, Inc. Title 16, Behavioral Science Examiners Chapter 18. Sacramento, CA: Board of Behavioral Science Examiners.

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THE SUPERVISORY EXPERIENCE: AN OBJECT RELATIONS PERSPECTIVE HAROLD JARMON HARVARD MEDICAL SCHOOL PRINTED WITH PERMISSION FROM PSYCHOTHERAPY, VOL. 27, SUMMER 1990, NO. 2.

This article presents a theoretical framework for understanding important aspects of the supervisory process, one that seems especially applicable to supervisees in their early years of training as psychodynamic therapists. It employs several concepts drawn from Winnicott’s view of the psychotherapeutic relationship, based on the metaphor of the caregiving relationship between mother and infant. The purpose of this article is to provide a theoretical framework based on Winnicott (1965, 1971) theory of object relations for understanding an important aspect of the supervisory relationship. An important contribution of Winnicott’s theory is his use of the early caregiving relationship as a metaphor in delineating important aspects of the therapeutic experience. In the present article this metaphor is applied to supervision, where it can guide the supervisor in addressing the emotional vulnerability that therapists in training experience in their early encounters with patients. Such guidance can enable therapists-in-training to move toward, and remain open to, interactions that increase their—as well as their patients—anxieties. The supervisor can play a central role in enabling therapists-in-training to change, in this fundamental respect, their capacity to develop and participate in a therapeutic relationship. The applicability of the caregiving metaphor to both psychotherapeutic and supervisory experiences helps us to understand why each elicits parallels in the other. Concepts drawn from this perspective may assist supervisors in establishing guidelines for their interventions and in clarifying important objectives. Supervision and Psychotherapy: A Comparison of Contexts The psychoanalytic literature on the previously unexamined topic of supervision has increased significantly in the past thirty years. However, there are only a few major works that treat supervision as an important and complex phenomenon that needs to be considered from many perspectives (Caligor, Bromberg, and Meltzer, 1984; Eckstein and Wallerstein, 1958; Fleming and Benedek, 1966). Generally the literature deals with specific issues such as whether supervision should emphasize educative vs. therapeutic approaches, whether and how to deal with the supervisee’s countertransference problems, and how much the focus of change should be on a patient vis a vis the supervisee. Several writers (Gediman and Wolkenfeld, 1990; Grey and Fiscalini, 1987; Sachs and Shapiro, 1976) draw attention to the structural similarities between psychotherapy and supervision. Pedder (1986) outlines their structural differences as well as their similarities. The following is an elaboration of his discussion. Psychotherapy and supervision typically involve two people sitting across from one another in a relationship of authority: one is assumed to know more, and the other less, about PRACTICAL APPLICATIONS IN SUPERVISION

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human behavior and experience, one is assumed to have a problem or problems and the other the capacity to help solve the problem(s). One is to speak more than the other. The narrative focus includes feelings expressed or hidden experiences and other internal and interpersonal matters. The interactions between the two are limited almost entirely to words, although nonverbal communication is extremely important. The meetings have a regular length and weekly rhythm. Finally, there is considerable agreement that supervision, like psychotherapy, has as one of its objectives the growth and change of at least one of the two participants in the encounter. As a supervisory objective, this orientation may originate in Freud’s (1910) early recognition that therapists cannot take a treatment situation beyond the level at which they have developed some understanding of their own inner conflicts and issues. There are also several differences between psychotherapy and supervision. Some are an outgrowth of the fact that for a therapist-in-training, supervision is required, whereas therapy is rarely coercive for the prospective patient. Also, there is often an explicit evaluative element to supervision. However, for the purpose of the present discussion, the most important difference is that the focus of supervision is likely to be more or less limited to the recipient’s (therapist’s) relationship with one person, the patient. In therapy the dialogue is less restricted, most typically the recipient is encouraged to talk freely about his relationships with any person he chooses, including feelings and thoughts about the provider, and the emphasis tends to be on the recipient. One could say that the primary object of change, the patient, seems more remote in supervision because he is not present in the room. This difference gives the therapeutic relationship more of a two-person, and supervision more of a three-person character. Parallel Processes It is useful to consider the supervisory situation from two process perspectives. The first has to do with parallel processes, the most distinct and important phenomena identified in studies of the supervisory relationship and the subject of most discussion. This phenomenon was first noted by Searles (1955) in an article entitled. “The informational value of the supervisor’s emotional experience.” His emphasis was on the extent to which a patient’s relational difficulties could be unconsciously transmitted to (i.e., enacted toward) the supervisor by the therapist. If the supervisor is attuned to these transmissions, they register in the supervisor’s conscious rather than unconscious experience. This enables the latter to observe potentially important but not directly reported aspects of the patient’s personality and the psychotherapeutic relationship. Since 1955 there have been a number of work’s (e.g., Bromberg, 1982; Caligor, 1981; Doehrman, 1976; Gediman & Wolkenfeld, 1980; Grey & Fiscalini, 1987; Hora, 1957; Mattinson, 1975; Sachs & Shapiro, 1976) identifying, describing, elaborating on, and attempting to explain the phenomenon. It has come to refer, most broadly, to the transposition through unconscious re-enactment, of important subjective aspects of the relationships between either of the two operational pairs of the supervisory triad (patient-therapist-supervisor). Re-enacted experiences reflect core unconscious, anxiety-laden aspects of significant relationships for one or more of the participants. They are more prominent when there are overlapping unconscious issues for two or more members of the triadic supervisory system. Isacharoff (1984) points to the similarities between the concept of parallel process and countertransference. He proposes that, during therapy sessions, therapists-in-training must learn to shift from transient empathic identifications to self observation. When they have been unable PRACTICAL APPLICATIONS IN SUPERVISION

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to do so there is a discrepancy between what they report and the affective tones they transmit in their supervisory sessions. This discrepancy reflects a regressive shift in the therapist. He discusses the implications of this explanation for the supervisor’s interventions, emphasizing the interpretation of the therapist’s countertransference. A recent examination of the concept of parallel process by Grey and Fiscalini (1987) differentiates explanations based on identificatory processes and others based on the structural similarities of the supervisory and psychotherapy contexts and the characterological similarities among the participants. They pose them as either/or propositions, but some combination of the two may provide the most useful basis for understanding. Useful as Isacharoff’s and Grey and Fiscalini’s explanations may be, our current understanding of the phenomena remains limited. Yet there is a growing recognition that parallel processes are omnipresent in supervision and that they may be the supervisor’s primary source of data about patients’ and therapists’ unconscious processes and the ongoing relationship between the two. Caregiving Applying the caregiving metaphor to the supervisory situation provides a basis for integrating explanations of parallel process based on identification and those that emphasize similarities of context. Three aspects of the caregiving relationship that Winnicott (1965, 1971) has taken from mother-infant observation and applied to the therapist-patient relationship are most relevant. They are the concepts of regression, the holding environment, and identification. The supervisory relationship, as does the psychotherapeutic, evokes feelings about one’s dependency on and responsibility toward others. The affective interchange among the three participants is a fundamental focus and consideration must be given to non-verbal communication to make sense of this realm. In the verbal domain, an emphasis is placed on subjective experience and free-associative activity. In supervision, the range of verbalizations and free associations is more or less bounded by its focus on the patient and the therapeutic relationship. It shares with psychotherapy the objective of enabling its recipient to develop a freely roused emotional sensibility that can be subordinated to contemplation rather than action (Heimann, 1950). Consequently, no matter how much structure supervisors introduce to mitigate the effect, the supervisory context fosters regression in the sense that it is evocative of early emotionally-laden relationships. Regression in this sense need not be a pathological phenomena, but one that can be used in the service of the therapist’s ego (Hartmann, Kris & Lowenstein, 1946). The setup tends to exert pressure on the boundary between the professional and personal identities of the participants, i.e., transference and countertransference phenomena are promoted. This is true for the caregiver as well as the care receiver. Both roles are among those we experience from the earliest years of our lives. Our subsequent significant relationships are all influenced by the balance achieved between these roles, which constitute the relational nexus of early mother-infant experience. It is no wonder, then, that in our professional roles as supervisors—as well as psychotherapists—we must struggle with deeply felt needs to be a good and effective provider, our fears of helplessness and our limitations in relation to a significant other. In these respects our self concept and self esteem are continually on the line.

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If the supervisory relationship promotes regression, then the value of considering it from the standpoint of a holding environment becomes clear. “Holding,” in the Winnicottian sense, refers to the environmental provisions that are essential in the earliest phases of human development. Winnicott (1965) meant holding in the physical sense but also with respect to those empathically-based activities that (1) permit the infant the normal expression of those physical needs that have psychological implications, and (2) prevent impingements that would threaten the infant’s existence. In the context of a safe holding environment the infant can begin to differentiate between self and other, i.e., to develop its own identity. At the outset these environmental provisions come mostly in the form of appropriate spatial arrangements, but the time dimension gradually becomes an essential consideration. The continuity and reliability of events, as well as their responsivity to signs of infant growth, build a foundation for psychological development. Holding is a primary function of what Winnicott called “good-enough mothering” and if it is insufficiently provided it can have the consequences of the infant’s developing a premature self, a false self, for whom self-holding is viewed as essential to survival. In supervision, as in psychotherapy, creation of a holding environment begins with appropriate spatial and time arrangements. Supervision must have a regular time and place with serious consideration given to interruptions in routine by either participant. The set-up must come to feel secure from outside intrusions so that the participants can develop a sense of safety with each other. What the supervisor offers the supervisee in the way of help must always consider and encourage the supervisee’s emotional development as a therapist. For the beginning therapist, an important aspect of the holding environment often involves the supervisor’s effort to provide a sense of the continuity of relational themes from session to session and a perspective on what constitutes a reasonable tempo of change for oneself and the patient. It seems especially useful to consider the supervisory relationship from the standpoint of the identificatory processes it engenders. Structurally, supervision involves the formation of a three-person relationship (i.e., patient-therapist-supervisor) from a dyad (i.e., therapist and patient). One of the supervisor’s most important functions in this arrangement is to enhance the supervisee’s ability to hold the whole field in awareness and to shift awareness from one’s own experience of the encounter to the patient’s, to make sense of the patient’s internal experience in light of one’s own and, most importantly, how the two form a whole field. (i.e., construct a relationship). The supervisor’s role, then, is to strengthen the supervisee’s capacity to scan and divide the therapeutic field through their mutual examination of the therapeutic process. This process is enhanced by the reciprocal interplay of identifications between the supervisor and supervisee. Padel’s (1985) discussion of identification is useful in understanding how the caregiving metaphor can be utilized to elucidate this aspect of the supervisory process. In his view, “identification occurs in all human relationships and is (as) profound and lasting . . . as the relationship is . . . (p. 162). Identification is a primary ego function at the very root of living and growing. The individual’s self develops in part as a function of its identification with others. Drawing on Winnicott’s and Fairbairn’s ideas, Padel examines the origins of the identificatory process in the relationship between the infant and mother in the feeding situation. Freud (1914) had theorized that the infant can identify in this context with mother, the caregiving position, or PRACTICAL APPLICATIONS IN SUPERVISION

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with the receiving, taking, self. Padel points out that, “the very fact of being able to choose to identify with one or the other means that he has adopted a third position from which he could observe self-and-mother as a couple and be for a while identified with neither. The detached and observing self forms a third term and has created a three-term relationship out of a two-term one.” The ability to choose the third position complicates and enriches the identificatory process. Identification with this third-term position precedes the presence of the father but is strengthened by it. This view of parent-infant relations allows us to see two functions that make identification possible. These are the abilities to divide and scan the field consisting of mother and child. Dividing a field allows us to identify with one part of it and from that position relate to the other. But to avoid narrowly limiting the development of identity, we must be able to scan a field, observe the related positions, and choose a position with which we identify. Development of this scanning function requires the capacity to identify with a third-term position from which we can observe and hold in awareness the field as a whole as well as each of the two persons in it. This conception of the identification process seems especially applicable to understanding an important aspect of what takes place in supervision. Case Illustration The Patient—Don is a single white male in his early thirties who was referred to the clinic two years prior to the episode I will focus on, following a psychiatric hospitalization for non-psychotic depression. He has a history of non-psychotic illness that includes other hospitalizations for depression with suicidal tendencies and frequent contacts with a number of outpatient mental health facilities, usually when in a state of crisis. Several of these facilities have come to view Don as a persona-non-grata because of the persistence and intensity of the demands he makes on them, which were exacerbated three years prior to the referral when he was violently raped. The recent hospitalization seems to have been precipitated by the intensification of terrifying hallucinatory-like flashback experiences as the anniversary of the trauma approached. Despite his long-term, non-psychotic difficulties, Don had never been offered psychotherapy. He was repeatedly treated with crisis intervention, medication, and hospitalizations. One of the reasons was evident from his first phone contact with the clinic. His speech seemed clearly unintelligible, agonizingly slow, and poorly articulated; his voice had a forced, whiny ring to it. Upon meeting Don, one learns that he walks precariously with the aid of a crutch and generally displays the motoric disabilities of moderately severe athetoid cerebral palsy. Yet, despite this he is self-supporting, lives alone, works consistently at a clerical job, drives a specially equipped car, and takes care of his appearance. Don was first seen in psychotherapy by a third-year female clinical student supervised by myself. It became clear, fairly soon after the work was begun, that he was an extremely motivated psychotherapy candidate and that his therapist was an excellent match for him. They rapidly developed a strong working alliance, although his suicidality was among the major obstacles to be overcome. I was the supervisor that year and, when I went on leave at the end of the year, the supervision was taken over by a colleague of similar theoretical persuasion. At the end of Don’s second year of therapy, his therapist left and he was transferred to a fourth-year trainee, “Ann.” Shortly thereafter, I resumed the supervision. I was impressed with how much progress Don had made (e.g., he no longer was suicidal), how well the transfer of therapists had PRACTICAL APPLICATIONS IN SUPERVISION

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been handled, and how quickly a new therapeutic alliance had been formed. Ann and I rapidly developed a working alliance and, in a very short time, there was a sense of strong, effective working alliances in both the psychotherapeutic and supervisory contexts. The episode I want to focus on began about a month after I had entered the picture, after the summer break. The anniversary of the rape experience was approaching as was Don’s planned two-week vacation from work. In his regular Wednesday session he mentioned with some anxiety, that he had received some prank phone calls. Then, on Friday, he called Ann in a panic. He reported that the night before he had received a series of prank phone calls like those that occurred prior to the rape, including one in which his life was threatened. Although he did not ask directly, he seemed to want Ann to find some way to protect him. She had felt “pulled in” and responsible and struggled to contain his, and now her, panic. She ended the conversation after offering to make some inquiries about help and call him back. Afterward, she called me and, with evident concern in her voice, described the phone conversation and what she had learned about the kind of help the authorities could offer. I felt that it was appropriate for her to give Don this information and emphasized that she could offer to see him for an extra session if he wished. She already had this in mind. I added that I would be available if she felt she needed to contact me. By the end of our talk, Ann seemed in control of herself and the situation. I subsequently found myself experiencing some of Ann’s concern about Don and what I understood to be some of Don’s panic about the threat. I did not hear from Ann again until our regular supervisory session on Tuesday. I learned then that Don had accepted the extra session but felt that he could wait until Monday. He had used the session to tell Ann about the rape experience in detail, something he had never done before with anyone. Ann found it to be the most overwhelmingly painful experience she had ever had in the clinical setting. After years of referring to the rape in a highly defended way, Don had been able to express the previously unmitigated anguish, rage, and humiliation he had experienced. I could see that Ann was still containing much of the emotional charge of the previous day’s session when she said she wanted to talk about several other cases first. I agreed she could determine the order of the supervisory session’s content, sensing that it would be useful for her to have that control and having faith, based on what I had learned about her and her work with Don, that we would get to this most urgent matter in time. With a half-hour left, Ann began telling about her session with Don from process notes. She repeated what she had said at the beginning of our session about the emotional intensity of being with him. He had begun his extra session by telling her how frightened he was, thinking that the punk phone caller might be the same man who had raped him five years earlier. He had another bad flashback after a number of such calls the night before he had phoned Ann. Don then began to talk about his concerns about Ann’s availability and his fears about whether she would believe him. He wished the rapist had cut him with his knife so that he would have proof that it had happened. Ann, sensitively but firmly, made clear the reality of her availability and interpreted Don’s effort to defend against the terrible feelings that were associated with his rape. Finally, with Ann’s steady assistance and empathic interpretations, Don had arrived at the point where he could safely tell her what had happened. I found myself on edge in supervision. I wanted to know but was anxious about hearing what Don had said about the details of the PRACTICAL APPLICATIONS IN SUPERVISION

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experience, with all his attendant feelings. But Ann was evidently reluctant to report them to me. Instead, she told me more about what it had been like for her to hear Don describe them, and how she had been kept awake that night by the impressions left from his story. She began to go on to talk about the implications of what she had heard and I said that I felt it would be important for her to tell me the details of just how Don had described the experience. She hesitated but then proceeded in tones that conveyed the powerful feelings of shame, disgust, confusion, and helpless rage that Don had felt. The intensity of these feelings nearly obscured Ann’s frustrated desire to ease Don’s pain, to repair the damage, to care for him as she listened and responded with all that she could offer—her presence and understanding. The feelings were all evident in the here-and-now of Ann’s report to me. Perhaps because they were somewhat less immediately intense for me, I could hear Ann’s report in terms of the profound emotional exchange between herself and Don. From my third position, as supervisor, I am less overwhelmed and better able to distinguish the feelings of the two participants in the interaction, and to observe the relationship as a whole. Although Ann had been powerfully identified with Don during the session, I could identify more readily with her position as therapist and so I commented on how difficult it must have been for her to hear Don’s pain and how much she must have felt the desire to do something to ease it for him. She acknowledged these feelings and then said how she had expected it to be more difficult to report the session’s details to me and that, in the retelling, it seemed a shorter episode than she remembered when she was in the session listening to Don. Ann clearly seemed to have been relieved by telling me what had transpired. It was as if she had used the telling to me, her supervisor, to reaffirm her identity as therapist in relation to Don. My intervention had been to gently but firmly encourage her to repeat for me the details of Don’s story. It was not that I was interested in the facts per se but that in her retelling I could absorb some of the painful feelings with which she had been left. I would provide her with the “holding” she needed and with which she could identify. This would re-establish her sense of self as therapist and enable her to return less anxiously to explore further Don’s experience of the rape. We agreed that Don would have more to say about it and that it made sense to allow him to set the tempo for further exploration. Then, feeling it to be important, I decided to discuss some of what I anticipated might be useful to examine about the rape when Don returned to it. Although it had been a violent attack and had been so experienced, it was the closest Don had been to an adult sexual experience and might have had its exciting aspects as well. Exploration of the experience in this light might have a bearing on the sexual aspects of Don’s transference to Ann, which had not been observable previously in his therapy. Discussion If we examine the above vignette in light of the theoretical considerations regarding the parallel, caregiving processes previously outlined, the data help to clarify a number of points. The supervisee brings the patient to supervision in the form of an internalized relationship, as well as in the verbal report of the treatment process. In the above episode, especially following Ann’s contacts with Don, the part of the internalized relationship that seemed most salient in her enactments and verbalizations with her supervisor was her identification with Don. By providing her with a safe holding environment, the supervisor enabled her to regress sufficiently to convey to him unconsciously, as well as consciously, the intense affects that she had experienced with Don. Based on her unconscious communications about the experience as well as verbal description, her supervisor focused his inquiry on the less distinct part of those interactions-—her PRACTICAL APPLICATIONS IN SUPERVISION

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own experience as therapist. Finally, by offering to her his observations about what had been transpiring in the relationship between her and Don, her supervisor could strengthen, through her identifications with him, her ability to take the third position of observer of the therapeutic relationship. For her supervisor, the task was, through his whole way of relating to her as well as verbal feedback, to enhance her self-awareness and thereby help her to see the whole relationship she had taken in and to differentiate her experience from Don’s. The supervisor’s task was not to provide Ann with “clever and apt interpretations” which is precisely what Winnicott (1971) says psychotherapy is not about. To offer definitive interpretations or neatly-wrapped formulations about the patient for the supervisee to take in whole is no more an effective way of encouraging a supervisee’s learning than it is for therapists to support their patient’s growth. The above case illustration demonstrates more dramatically than most the role of enactments of internalized relationships and the value of the holding function in the supervisory process. Frequently the nature of the internalized therapy relationship is much more obscure, the working alliances in therapy and supervision are less secure, and the observing capacities of the therapist are less in evidence. In this case, the therapist became over-identified with the patient’s painful experience of being raped. She was left with the anxiety and flashbacks of the experience. Frequently a therapist may become over-identified with one or more of the patient’s significant objects. In this case this would have meant that, following the therapy session, Ann would continue to experience the destructive feelings of the rapist which might have interfered with her ability to further explore her patient’s experience. Often impasses in therapeutic work occur when the therapist over-identifies with the patient’s self or object(s). Supervisors collude in such an impasse if they are unable to see the therapeutic relationship as a differentiated whole and are inflexible about their own identifications with each of the three positions. The identifications discussed above are not as fleeting as Isacharoff (1984) implies when he uses Arlow’s (1963) concept of “transient identifications” to explain countertransferencc phenomena. They are a problem precisely because they are not transient. They take hold of the therapist and impede the capacity to both retain a sense of therapeutic self and to respond empathically to the patient. The more important the patient and treatment is to the therapist, the stronger and more lasting these undermining identifications may become. Making them conscious for the therapist and thus making it possible to move freely among each of the positions in the whole relationship are essential aspects of the supervisor’s interventions. This view has implications for the question of whether and how supervisors should take up their supervisee’s countertransferences. By providing a safe environment for the controlled regression of the supervisee and making clear that the supervisee’s innermost responses to the patient are essential data, the supervisor enables the supervisee to take the initiative in introducing the countertransference reactions within the supervisory context and examining their meaning in relationship with the patient. The above considerations suggest that supervisors must make allowances for regression of the sort that enhances interpersonal communication at nonverbal and metaphoric (i.e., affective) levels. Such regression facilitates our ability to play in our minds with the identifications that are available in our experiences of ourselves and others. This kind of playing requires a sense of safety derived from a “good-enough” holding environment. Finally, PRACTICAL APPLICATIONS IN SUPERVISION

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supervisors must always be aware of the identificatory implications of their interventions with supervisees. What we do as supervisors will have more impact on our supervisees than what we say about what should be done. To quote Searles (1977), “The analyst must both require and primarily by collaborative personal example, help (the analysand) to internalize the participantobserver activity as an ego function, which he can carry away from the analysis as part, now, of himself” (p. 581). I believe the same can be said of the supervisor in relation to the supervisee. Conclusion Changes that involve the therapist’s internalizations of and identifications with the patient and supervisors have been highlighted. If supervisors are receptive to and respectful of supervisee’s struggle to be with and be used by patients, we open an important channel to our own continuing development as therapists and supervisors. The view of psychoanalysis implicit throughout this article is derived from the idea that truth is something arrived at in the dialogue between oneself and others (Symington, 1986). The same holds for change. Change can be brought about in other ways—through one person’s influence or control over another, for example—but it can occur noninstrumentally, when each of the two participants in a dialogue is prepared to discover some new truth about himself and the other. The potential for such change is furthered if they are each able to take a third position perspective on what is happening between them. This holds true for supervision, psychotherapy and other significant relationships in one’s life. References Arlow, J. A. (1963). The supervisory situation. Journal American Psychoanalytic Association, 11, 576-594. Caligor, H. (1981). Parallel and reciprocal processes in psychoanalytic supervision. Contemporary Psychoanalysis, 17, 1-27 Caligor, L., Bromberg, P. M., & Meltzer, J.D. (1984). Clinical Perspectives in the Supervision of Psychoanalysis and Psychotherapy. New York: Plenum. Doehrman. J. G. (1976). Parallel processes in supervision and psychotherapy. Bulletin of the Menninger Clinic, 40, 3-104 Eckstein, R. & Wallerstein, R. (1958). The Teaching and Learning of Psychotherapy. New York: International Universities Press. Fleming, J. & B Benedek, T. (1966). Psychoanalytic Supervision. New York: Grune and Stratton. Freud, S. (1910). The future prospects of psychoanalytic therapy. In J. Strachey (Ed.). The Standard Edition of the Complete Psychological World of Sigmund Freud, Vol. II. London: Hogarth Press. Freud, S. On narcissism: An Introduction. The Standard Edition of the Complete Psychological Works of Sigmund Freud. Vol 14. London: Hogarth Press. Gediman, H. & Wolkenfeld, F. (1980). The parallelism phenomenon in psychoanalysis and supervision: Its reconsideration as a triadic system. Psychoanalytic Quarterly, 49. 234-255. Grey, A & Fiscalini. J. (1987). Parallel process as transference- countertransference interaction. Psychoanalytic Psychology. 4, 131-144. Heimann, P. (1950). On countertransference. International Journal of Psychoanalysis, 31, 81-94. PRACTICAL APPLICATIONS IN SUPERVISION

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Hora, T. (1957). Contributions to the phenomenology of the supervisory process. American Journal of Psychotherapy, 11, 769-773. Issacharoff, A. (1994). Countertransference in supervision: therapeutic consequences for the supervisee. In L. Caligor, P. M. Bromberg, and J. D. Meltzer (Eds.), Clinical Perspectives on the Supervision of Psychoanalysis and Psychotherapy (pp. 89-105). New York: Plenum. Mattinson, J. (1975). The reflection process in casework supervision. London: Institute of Marital Studies, the Tavistock Centre. Padel, J. (1985). Ego in current thinking. International Review of Psychoanalysis, 12, 273-283. Pedder, J. (1986). Reflections on the theory and practice of supervision. Psychoanalytic Psychotherapy, 2, 1-12. Sachs, D. M. & Shapiro, S. H. (1976). On parallel processes in therapy and teaching. Psychoanalytic Quarterly, 45, 394-415. Searles, H. F. (1955). The informational value of the supervisor’s emotional experiences. Psychiatry, 18, 135-146. Searles, H. F. (1977). The analyst’s participants observation as influenced by the patient’s transference. Contemporary Psychoanalysis, 13, 347-386. Symington, N. (1986). The Analytic Experience. London: Free Association Books. Winnicott, D W. (1965). The Maturational Processes and the Facilitating Environment. London: Hogarth Press. Winnicott, D. W. (1971). Playing and Reality. London: Tavistock.

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PRACTICAL AND CULTURAL ASPECTS OF SUPERVISION DOLORES S. JENERSON, PH.D.

Introduction As an LMFT supervisor, the writer has supervised trainees in practicums for graduate level counselor training courses, interns in private practice and acted as a consultant to supervised trainees for a non-profit Christian center which specializes in treating child abuse victims. Although the settings and level of experiences of the various supervisees were different, the general model of supervision is the same. Obviously, modifications are made for individual differences and the levels and needs of each supervisee. The writer is a black, female therapist which adds another dimension to the supervisory relationship, especially when the majority of persons being supervised are of the dominant culture. In addition, there is an added dimension due to the cultural backgrounds of the clients to which the supervisees are exposed. This chapter will focus on a particular model utilized in the supervision of interns and trainees. This model utilizes methods to sensitize supervisees to cultural issues pertinent to their cases. The Supervisory Relationship In practical terms, the most important aspect of the supervisor is that both parties understand the parameters of the supervisory relationship. Historically, starting around 1950, the early literature on supervision centered on the relationship from a psychodynamic orientation and tended to suggest that the supervisory experience was parallel to that of the client therapist relationship. More contemporary literature focuses on different models of supervision and the fine line between teaching and therapy, as well as the many new observational techniques. In addition, the population characteristics of the United States are undergoing rapid change in terms of the variety and numbers of cultures represented in the mainstream of American society. As a result, more attention is now devoted to cultural issues. In the model being presented, the role of culture in both the supervisory relationship and the therapeutic relationship will be discussed. At the beginning, it is important to clarify with the supervisee exactly what one’s orientation to supervision and the expectations one has for the supervisee. An example will illustrate why this is so important. A supervisee had three supervisors, each of whom was responsible for the supervision of approximately 10 cases. The supervisee was to meet with each supervisor weekly, and each had a very different manner of conducting the supervision. You can imagine how this added to the level of normal anxiety of the beginning therapist. The beginner not only has to explore how effective or ineffective textbook-learned interventions are in real life with real clients, but also has to present the material to three different supervisors to learn from the process. On the first day of supervision one of the supervisors, following introductions, said “Please make a case presentation.” The supervisee proceeded following the technique learned in graduate school. The supervisee was amazed, horrified and embarrassed to be immediately “torn to pieces” by the supervisor. Granted, the supervisor did not hear the material in the manner he expected, but he had not informed the supervisee of the particular format he had in mind. Momentarily, the supervisee felt as if she had chosen the wrong field. She felt, after all those years of training, she couldn’t even make an adequate case presentation. The reality was that she could make an adequate case presentation, but the supervisor failed to indicate his specific PRACTICAL APPLICATIONS IN SUPERVISION

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requirements for such presentations, and they were not overtly obvious to the supervisee. You can be sure that upon learning what the supervisor wanted, and the format in which he wanted it presented, the supervisee was prepared and practiced before conveying the required information. The heightened level of anxiety which was created was unnecessary and could have been avoided had the parameters of the supervision been clearly discussed during that first session. What are the parameters that should be discussed? First, it is important to explore the personal and professional goals of the supervisee. This information helps the supervisor understand the ultimate goal and what skills will need to be refined in order to meet those goals. In this process, it is often helpful to ask the supervisee why he/she chose to become a therapist, and what relationships, experiences, feelings, etc. influenced the decision. It might seem unusual, but it is good to ask what the supervisee will do if for some reason he/she is unable to become a licensed therapist. The response shows whether the supervisee has considered other alternatives. Second, it is important to find out what the supervisee expects from supervision. This ranges from dependence upon the supervisor to tell the supervisee exactly what to say to a client, to wanting no interference from the supervisor. Depending upon the level of experience of the supervisee, a supervisor should be able to change the intensity and interaction with the supervisee. Supervision changes throughout the supervisory process as the supervisee gains more self-confidence, grows in ability to apply techniques and becomes more sensitive to the nuances of the therapeutic relationship. This is information that should be considered as part of a supervisory assessment. The supervisor still has the responsibility to decide exactly how he or she will work with the supervisee in order to meet the desired goals. Third, the supervisor has a responsibility to share his/her particular orientation to therapy and to supervision. It is also helpful for the supervisor to share why he/she chose to become a therapist. This information not only establishes rapport between the supervisor and the supervisee but also helps the supervisee place the supervisor in perspective. Often supervisees unrealistically see their supervisors as superhumans. This sharing helps to show that supervisors have undergone similar experiences as supervisees. Unfortunately, all to often, supervisees take whomever they can get for supervisors. In so doing, they may be short-changing their training goals. The supervisor may have a therapeutic orientation that is totally antithetical to the supervisee’s therapeutic orientation. The supervisor may not have any interest in helping the supervisee explore various theoretical orientations that are not within his or her particular scope of interest. Or, the supervisor may want to expose the supervisee to techniques that would not be appropriate for the limited scope of practice or competence of the supervisee. The public has been trained to become more aware of and informed as consumers of mental health care. Should supervisees ask less than clients? Fourth, the supervisor should discuss what she or he can offer in supervision. Ideally, the positive aspects of supervision would include: (a) (b) (c)

gaining valuable experience in a realistic setting with professional feedback, growing from the student sense of self into the professional sense of self, having an opportunity to observe other professionals at work and to evaluate their roles in order to explore how the supervisee might fit into the mental health care system,

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(d) (e) (f)

broadening one’s experiences and theoretical orientations, learning new skills and improving other skills, and making more definitive decisions regarding one’s occupational goals.

As the supervisor works with the supervisee, each should be helped to grow in the choice of therapeutic modality that best fits his/her personality and training. The supervisor’s goal should not be to make carbon copies of himself/herself. The ultimate goal is to aid supervisees to blossom into full-fledged professionals who are confident about their clinical skills and who will be ethical in their relationships with the public. These four issues, in establishing the supervisory relationship could conceivably take more than the time-honored 50-minute session. Supervisors and supervisees need quality time for these issues, not only in the beginning, but also throughout the supervisory relationship. Doing so starts the process in a very healthy mode. Once the parameters have been clarified, the actual work begins. Supervision is not therapy, but for it to be effective it does include many elements that are present in therapy, such as: unconditional positive regard for the supervisee, respect for her or him as a person, active listening, modeling, feedback, confrontation, support, affirmation, and a willingness to have a “close encounter of the supervisory kind.” In addition to their clinical work with clients, supervisees need to be actively reading current material in the counseling field. To assist them in this effort, it is good to provide them with a bibliography. This bibliography should include topics related to the clients of supervisees as well as topics to expand knowledge in areas to which they have not yet been exposed. One very useful text for beginning supervisees is, A Guide for Beginning Psychotherapists, by Joan Zaro, Roland Barach, Deborah Nedelman and Irwin Dreiblatt (1977). Although there are several guides for beginning therapists, this one is written in a very clear and practical manner. Supervisees are able to personally relate because it focuses on expectations and fears they may be experiencing. The text is useful to introduce many topics and as a point of reference for discussion. The book contains four key sections: Approaching the Task; First Client Contact and Assessment; The Psychotherapy Process; and Adapting to Other Treatment Contexts. Within each of these areas there is a multitude of subheadings that focus on the specifics of what to do and why to take certain actions. To illustrate, some of the subheadings include topics on: presenting yourself as a professional; ending the initial interview; common mistakes; how to approach a consultant; handling differences of opinion; refusing to treat the client; levels of psychotherapeutic interaction; a general strategy for handling emergencies; how to terminate a client; transferring a client to another therapist; and types of record keeping. Cultural Aspects Relevant to Supervision I have found that it has not been very helpful to attempt to hold a “color blind” orientation to ethnic, religious and cultural differences in either the relationship between the client and the therapist, or the relationship between the supervisor and the supervisee. In referring to being “color blind,” I am referring to the concept of ignoring relevant differences and treating all individuals as the same. Thomas and Sillen (1972) suggest that “color blindness” is not virtuous when the use of it means denial of differences of experience, culture and psychology of people of PRACTICAL APPLICATIONS IN SUPERVISION

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color in the United States. The reality is that all individuals are not the same, therefore we must modify our treatment orientations to fit the needs of the client. This is not meant to imply that each individual should not be valued and given the best quality treatment that one is able to provide, but it does mean that one must also acknowledge that sensitivity to cultural differences can be beneficial to the therapeutic process, and in fact, is necessary. “The white psychiatrist who likes to think he is color blind may be as far off the mark as the psychiatrist who is blinded by color.” (Thomas and Sillen, 1972, p. 66). Describing an example of a supervisee can best illustrate this point. A supervisee working at a child guidance clinic was assigned a Mormon family. Even though the supervisee noted the religious orientation on intake, no attention was paid to the fact that they were Mormons and even less was paid to the fact that the supervisee was a Black American. In addition, it was the mid-seventies when some segments of the Mormon religion were very vocal and negative regarding Blacks. The ramifications of color-blindness toward the family’s religion as well as their possible racially-biased attitudes affected the therapeutic process. The family terminated prematurely, loudly protesting their assignment to a Black therapist. In order to facilitate cultural sensitivity, it is important for the supervisor to explore with the supervisee each of their particular ways of viewing the world, their ethnic identifications, their values and their cultures. Not being aware leaves one open, placing one’s personal values upon the client or supervisee. This exploration can be done in a very positive and sharing manner as an educational aspect of the supervision. This topic sometimes is viewed by the supervisee as embarrassing or a topic to be avoided. Supervisees’ culturally-sensitive concerns, stereotypes and fears should be openly addressed so that their knowledge about cultural issues can be broadened. Sometimes what surfaces are concerns about qualifications. Supervisees from the dominant culture may be concerned about having an opportunity to counsel people from the dominant culture if the supervisor is from another ethnic group. Or, questions regarding gender issues may surface. The supervisee may expect a Black supervisor to know all there is to know about doing therapy with Black people but expect that she or he would be inexperienced in doing therapy with the dominant culture or other people of color. This experience cuts across all permutations of race, sex, religious orientation and social class. Having the supervisee share his/her cultural background and the positive and negative personal reactions, helps the supervisee to see that other people may have similar feelings with respect to their cultural backgrounds. Examining what role his/her ethnic origin played in the development of who they presently are as a person can be a sensitizing experience. Exploring how the supervisee’s cultural background may affect the counseling situation before he/she is confronted with clients from various ethnic backgrounds can help him/her to become more comfortable interacting in that situation. Every supervisee has both positive and negative aspects. When the supervisee is aware of these, he/she can be a benefit rather than a detriment. Another helpful tool is to have the supervisee become familiar with a process by which people of color come to identify with their ethnic identity. Atkinson, Morten and Sue (1989) have suggested a Minority Identity Development Model that is only one of several schemes proposed to explain this process. Basically, it focuses on helping the therapist understand the client’s attitude toward self, towards others of the same minority, towards others of a different minority, and towards the dominant group. Knowledge regarding these attitudes of the client can PRACTICAL APPLICATIONS IN SUPERVISION

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be very helpful in suggesting to the supervisee the perspective of the client, which in turn should suggest some issues upon which to be sensitive in the counseling process. Without this sensitization process, which should be discussed as part of the regular supervisory relationship, many avoidable problems could emerge. Misdiagnosis of the problem has been documented when some cultural issues are ignored. Misreading of non-verbal language and body cues can lead to misinterpretation of the interactions. Not being aware of one’s own values, and at the same time not being able to positively regard the values of others, may present a subtle, negative attitude which becomes apparent to the client. Although more attention is focused on cultural issues in academic work, putting that knowledge into practice is difficult. The optimal time to help the student implement the previously learned textbook information regarding people from other cultures is when the student is receiving professional supervision. This requires the supervisor to have general knowledge about the racial/ethnic identity process, have some knowledge about cultural norms, and be ready to address such topics with supervisees. Unfortunately, many supervisors have not had even minimal training on culturally-sensitive therapeutic issues that their supervisees are now being taught in their academic programs. Two informative textbooks are, Counseling American Minorities: A CrossCultural Perspective by Donald Atkinson, George Morten and Derald Sue and Ethnicity and Family Therapy by Monica McGoldrick, John Pearce and Joseph Giordano. Additionally, supervisors should take coursework in cross-cultural counseling. Utilizing multicultural specialists as consultants is also helpful for supervisors to remedy their lack of knowledge. Finally, non-informed supervisors may learn from supervisees about cross cultural counseling. Supervision is a two-way process. In addition, cultural issues are just as important when both supervisor and supervisee are members of the dominant culture. There may be more similarities, but it is also possible that there may be just as many differences. The dominant group in this country is just as heterogeneous as the groups that constitute the people of color. In particular circumstances, it is just as easy to ignore subtle, as well as blatant, cultural issues. Some of the obvious therapeutic issues are: language use and communication skills; immigration issues; and possibly a different orientation to what therapy is and who uses therapy. If the supervisee has a supervisor who is not sensitive to these cultural issues, then the supervisee is likely to miss relevant cues that could benefit the therapeutic process. What about the situation when the supervisee is a member of a people of color and the supervisor is a member of the dominant culture? Many might take the “color blind” approach and treat the situation the same as if both were from the same dominant group without being sensitive to cultural issues. This would be a grave error. This reversed situation represents a unique opportunity for the supervisor to learn in a close, intimate setting, more about a person of another culture. Finally, there is the situation where both the supervisor and supervisee are people of color either from the same ethnic background or interethnic backgrounds. In the intraethnic supervisor-supervisee relationship, there is an additional issue of the supervisor failing to explore cultural issues on the assumption that since the supervisee already is a person of color, that he or PRACTICAL APPLICATIONS IN SUPERVISION

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she automatically understands and is sensitive to these issues. The reality is that both the supervisor and supervisee have gone through a process of ethnic identification and may still be evolving through various stages of their individual identifications. This can become a complicating factor in the supervisee’s attempt to do therapy with other people of color. He or she may over-identify with such a client, play the role of a “rescuer,” experience personal guilt for having made it in mainstream society and possibly overindulge the client’s emotional wallowing against the system, or become a “moralizer” and use his/her own success as an example of how the client can “pull himself/herself up by his/her bootstraps.” For these and other reasons, it is still very important for cultural issues and sensitivities to be discussed in the intraethnic supervisor-supervisee relationship. It is helpful for the supervisor to be aware of possible specific cross-cultural issues which they may need to bring to the attention of supervisees. One attitude is the “Great White Father Syndrome,” where the supervisee acts as if he/she knows what is best for culturally different clients. The supervisee would presume that clients should simply accept and do what the supervisor directs him/her to do. A second attitude would be that of the “Missionary Syndrome,” which suggests that the supervisee is out to “save” culturally different clients from “the system.” A third possibility is that the supervisee experiences “cultural confusion” by denying the existence of, or not being aware of his/her own cultural perspective. This would suggest that the supervisee may be experiencing ambiguity towards his or her own identity which could spill over into the therapeutic session. Summary and Conclusion This article has highlighted some of the practical and cultural issues that are relevant to the supervision process and suggests possible resources. Adequate supervision is one of the most important aspects in the training of a competently skilled and culturally sensitive therapist. The supervision cannot be adequate without proper attention to the supervisory relationship and appropriate attention devoted to culturally sensitive issues. The parameters of the supervisory relationship must be clear and openly discussed so that both the supervisor and supervisee understand the expectations and responsibilities of both parties. This does not mean that the supervisor abdicates his/her role as teacher, modifier of behavior, or introducer of new ideas and concepts, all of which may lead the supervisee to experience some anxiety. It does mean that through this process, both the supervisor and supervisee have the same ultimate goal, that of professional competence, cultural sensitivity, and ethical conduct of the supervisee. Since many supervisors have not had the opportunity to adequately explore cultural issues, it is important for them to take steps to rectify this oversight and gain training in this area. Doing so will enable the supervisor to be much more proficient. It will ultimately strengthen the field as more therapists are able to deal with the intricacies of treating a culturally diverse population. References Atkinson, D.R., Morten, G., & Sue, D.W. (Eds.) (1989). Counseling American minorities: A cross-cultural perspective. (3rd ed.) Dubuque, IA: Wm. C. Brown. McGoldrick, M., Pearce, J.K., & Giordano, J. (Eds.). (1982). Ethnicity and family therapy. New York: The Guilford Press. PRACTICAL APPLICATIONS IN SUPERVISION

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Thomas, A., & Sillen, S. (1972). Racism and psychiatry. Secaucus, NJ: The Citadel Press. Zaro, J., Barach, R., Nedelman, D.J. & Dreiblatt, I.S. (1977). A guide for beginning psychotherapists. New York: Cambridge University Press.

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SUPERVISION: AN HONOR AND A GIFT OF BOTH GIVING AND RECEIVING FOR BOTH SUPERVISORS AND SUPERVISEES STUART KAPLOWITZ, MS, MFT THE THERAPIST JULY/AUGUST 2008

To my fellow supervisors, I want to share my passion in supporting and guiding the minds and hearts of newer clinicians. Every clinician I have ever worked with has offered me something as well. To the dedicated students, trainees, and interns (and I graciously ask you for some latitude here as I will use these titles, including supervisee and clinician, interchangeably), I hope you are enjoying your journey thus far. There is a lot to learn, and I suggest you “get” all you can. Often, I have been asked what is the best practicum or internship? It is hard for me to imagine any “bad” internship; each has something to offer and, even in more challenging situations, it can be what you make of it. When I first started in the field, private practice was pretty much my only thought. I had no idea there were so many different options with my degree and license. While it may be easier and more comfortable to find that first one or two sites and complete all of your hours there, look at this as an incredible opportunity to explore the field of counseling/therapy. In his March/April 2008 The Therapist article entitled Intern Anxiety, Joel McLafferty points out, “I encourage you to have several internships and at least one in a clinic.” To this I say “yes!” Remember you are not locking into a career just yet, but rather gaining experience and learning more about what is available, what else you might like to do. I believe your training will be enhanced in the long run by experiencing the variety that a community clinic can offer. The Need for You is Great In working in a clinic, with perhaps the more financially downtrodden, you will learn more about community resources (housing, clothing, and utility assistance, etc.). Hopefully, you will link with these agencies in benefiting the client and also yourself as you develop a personal community resource directory (and even start to get your name recognized, which will come in handy as you later look to build your own practice or explore other job possibilities). Never have I been more humbled than when working with those struggling with so many basic life needs. A community clinic may also offer more of a smorgasbord of serious clinical issues (various forms of psychoses, Borderline Personality Disorder, the gamut of substance abuse struggles, etc.). As well, these clients with limited resources often fall through the cracks. Many such clients depend on the viability of low cost clinics, since perhaps they are not able to hold jobs or maybe they have a job that does not offer insurance or mental health benefits via the insurance, leaving them to be sent your way. Like anyone else you see, these clients will depend on you – and maybe even more.

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May the Force (of Patience and Tenderness) Be with You As even a new clinician, you are thrust into a position of power and authority – Are you doubting me? You may be, for example, a client’s last defense against self-harm, and it will be your job to help ensure his/her safety. You (and hopefully your supervisor) will be on the phone with an emergency response team, police, or hospital staff to have the client evaluated for a possible hold. In activating the client’s support system and whatever resources he/she may need, you have the ability to both save and enhance someone’s life – that’s power! These situations also become yet another opportunity to link with those needed community resources, which can offer other insights as well. For example, making a contact or two at the local police department1 may help you connect a client who may be fearing a domestic violence situation. If (assuming this is a female client) she is scared to go to the police or to learn about a restraining order, you can link her with Officer Jones who may have been involved in supporting your suicidal client. You may even help her call and ask Officer Jones what specific steps to take to make this as easy for your client as possible. Again, do not doubt that power that influence, as the client will look to you and your knowledge during her time of need. Utilizing these resources offers more opportunities for growth. For example, with the hospital resource, you will not only learn about their evaluation process for a 5150 hold, but also learn of their other treatment programs. These may include substance abuse treatment, inpatient and/or outpatient models, and any groups they may be offering. Mental health hospitals tend to offer low-cost and even free groups in a number of areas you or your facility/clinic may not. In helping with the potential domestic violence scenario, you can learn more about local shelters, crisis hotlines, etc. These can be fantastic adjunctive supports to the individual and/or family work you may be providing clients. How I Fit I see my primary role in supervision as guiding and supporting. Much like I believe my success with clients comes from a position of encourager, I see this same facet as the key to quality supervision. Being a trainee/intern can indeed be a harrowing experience. The expectations from both supervisors and agency can be Herculean—I know. I have guided many a clinician through it while teaching Department of Mental Health/Medi-Cal paperwork. Learning this type of documentation alone can take MANY months of practice. I do want to point out that once you have learned how to do this paperwork, any documentation you do in future positions should seem fairly simple. I do everything I can to help clinicians understand what is required. Along with helping with that paperwork, what I do in supervision is work with and punctuate supervisees’ strengths. I care about them, and am invested, so I find this easy to do. I want to know what motivates the student. I want to know what clinical passions we share. I want to know what fears may be coming up for them that may clue me in on the best ways to support them. I’m here for them and want them to succeed. My “fear” is that much like we worry about the licensure process, I have heard far too many interns express doubt and serious discomfort in sharing all of their clinical questions and issues in supervision. Think about this for a moment…have you ever had a client bring up impactful issues midway through (or even near the PRACTICAL APPLICATIONS IN SUPERVISION

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end of) treatment and you think “why didn’t they tell me sooner?” Peers share this feeling with me all the time and I have experienced it as well. Personally, I see this situation as a failure on my part. Likening this situation to supervision, if a student cannot feel comfortable putting all of his/her needs out there then, similarly, I see it as needed growth for me. If we do not create that holding environment of sorts, I believe we are limiting that clinician’s experience as well as our own. My Fellow Supervisors—What is Your Role? Fellow supervisors, how are we nurturing the minds and personhoods of our clinicians? You may not agree with me but, along with enhancing student’s tools and techniques, theory, diagnostic skills, treatment planning, etc., I want to emphasize their relational skills. I know how important my personhood is in my own success with clients, so I expect it can (and will) be so with my supervisees. Now don’t get me wrong, I love to discuss tools and then hear how students will use them in a session or even redevelop the idea into something of their own—these are truly noteworthy moments that excite me. When it comes to the relational skills though, this aspect cannot be overlooked. How are our supervisees relating to clients? I hope we are not undervaluing genuinely connecting with clients through tools like reflecting, validating, clarifying and normalizing. Similarly, while I know there is so much I want to share with supervisees, I don’t want to command what they do through their supervision – at least I try not to (smile). When I am truly listening and present-centered, supporting their efforts, I believe the clinicians I am working with feel valued. In turn, they are hopefully less inhibited to express their needs and worries, and therefore go deeper and get more from the supervision. Clinicians, take heed in attempting to meet all of the clients’ needs. If one comes into each session with more to do agenda-wise than they do, we have a problem. Our good hearts lead us down this path and I still have to remind myself of this desire now and then. Also, remember, you are not going to know it all. This can be important for clients to learn; “I don’t have to have all of the answers.” However, I will address what I can myself and reach out for support when needed, modeling for the client how this is okay and beneficial. Hands-on Supervision Watching and listening to some of our clinical forefathers provide supervision sessions at the Evolution of Psychotherapy Conferences, and seeing supervision from methods like being behind the one-way mirror, or via a “bug in the ear” (where the supervisee wears an earpiece so he/she can receive feedback from the supervisor observing outside the session), I have known the value of hands-on (i.e., inclusive) supervision. When supervisees are only able to talk about cases in weekly supervision, we miss a lot as supervisors. I cannot picture what the client is experiencing in the sessions, or see how he/she holds him/herself, and I am missing all the wonderful non-verbals, which would guide me in my work with clients. Having the opportunity to observe supervisees and clients behind the mirror offers us some of this experience. What I have found to be of even greater value (and most enjoyable) is to do cotherapy with supervisees. PRACTICAL APPLICATIONS IN SUPERVISION

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Working with clinicians at a number of schools over the years made this a neat way of being able to tag-team with clinicians in numerous school-based sessions. But, of course, you can do cotherapy in any forum. When I sit in, I am joining not only the client’s experience but also experiencing my clinician in action. Even being involved in a session or two offers more of a window into the client’s world. I am then better able to understand the client’s dynamics as well as those of the clinician. It is one thing to hear how your supervisee believes he or she is responding to a client’s needs and yet another to see that same clinician feel their way through a session. Now I am sure my presence in that session impacts the clinician, as he/she may feel some angst. However, much like we know a client being taped will soon settle into the session and forget the tape is going, the clinician with whom I do co-therapy will be able to focus on the client and be available to them. When I am modeling teamwork and support with the goal of enhancing the skills and experience of the clinician, he/she can feel this support and indeed go deeper with that client. The clinician also gains firsthand knowledge watching me perhaps introduce an idea with the client or even in my examining a tiny facet of the client’s life, while I see how the clinician may practice a tool or just be with the client through a challenging moment. Supervision can and should be a meaningful experience. Give all you can and watch how much you get in return.

Stuart Kaplowitz, MA, MFT, has previously managed and directed programs over the years but, along the way, missed the hands-on work with clients. Stuart has offices in Pomona (Los Angeles County) and Chino (San Bernardino County) and works extensively with children/teens (and their families) struggling with the more severe levels of pain. Stuart also continues as a school district consultant, each week addressing crises within the schools, as well as supervising interns. Stuart can be reached at [email protected] References 1

1If you want to make a connection with the local police department or treatment facility, I would encourage you to go there and introduce yourself. Find out about their programs, grab any flyers on activities or upcoming groups or classes and meet with their resource officer. Find out which department your potential clients would be talking to (if for a domestic violence related issue this would be the DV Investigations Unit or Family Protection Unit) and say hello to a few of the staff. Following-up with a phone call in the next week or so could help grow your rapport with such facilities, which your clients will benefit from.

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SCHOOL OR APPROACH SPECIFIC MODELS OF TRAINING AND SUPERVISION HOWARD LIDDLE, PH.D.

One of the major developments of family therapy’s early phases was its differentiation into particular schools of thought. This development had its positive and deleterious concomitants. On the advantageous side, this development has advanced the specification of family therapy training approaches, since it assumes that training in a generic, all-inclusive therapy model is unrealistic (or undesirable). To be specific about training necessitates that the trainer is clear about the content and methods of a particular therapy model. In this regard, particular training models therefore signify the existence of well-developed therapy approaches. The disadvantage of this is that such separation of therapy and training models into schools perpetuates rigid boundaries between approaches that, in practice, may not be so perfectly distinguished. In family therapy at least, the distinction drawn between the many “schools” of family therapy remains a matter of opinion and in a formal sense, is an empirical question. Despite the popularity of the integration movement in psychotherapy and family therapy, it is likely that “schools of thought,” in one form or another, will be with us for a while. This section highlights papers that describe training methods and procedures along the lines of particular models. A comprehensive comparative analysis of the all family therapy training models has not yet been written. A beginning step has been to compare the major models on the dimension of live supervision, and secondarily on the matter of hierarchy in the trainer-trainee relationship (Liddle, et al., 1988b). The present section offers a highlighting of the key characteristics of primary family therapy training perspectives. The Brief Therapy training philosophy offers what might be termed a no-nonsense, minimalist approach to training. Training is done in a small group setting with an emphasis on supervision rather than on didactics. Learning the Brief Therapy model is assumed to occur best, conceptually and technically, by doing treatment under guidance with ongoing cases. “While there is some initial didactic explanation of rationale and technique, the greatest bulk of the training involves direct supervision of treatment” (Fisch, 1988, p. 81). The process of learning this approach relies upon two key processes: unlearning one’s previous model, and learning the new, and in most cases radically different principles. One of the more difficult premises for Brief Therapy trainees to accept is the model’s “non-normative aspect.” According to Fisch (1988, p. 79), “we use no criteria to judge the health or normality of an individual or family.” This approach minimizes any claims of technical wizardry, preferring to frame its therapy and training in technical rather than artistic terms. In the Brief Therapy approach: “The therapist’s personality and psychological health play a relatively small role ... except inasmuch as they may interfere with the disciplined focus required” (Bodin, 1981, p. 303). Training should dispel any belief that “it takes a certain kind of character or ‘artistry.’” A one-down stance is as applicable in training as it is in therapy. Selection of trainees is handled in a unique and characteristically lean (or what Hoffman, 1981, termed parsimonious) manner: We do not lay significant emphasis on selection interviewing of trainees ... Our criteria for selection are not complicated and we are principally interested in the above cited PRACTICAL APPLICATIONS IN SUPERVISION

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factors, the trainee’s facility with English, their expectations regarding the training, and how they plan to use it (Fisch, 1988, p. 86). Evaluation is accomplished by the trainer’s judgment of the trainee’s incorporation of key model elements in subsequent sessions, as well as in case discussions about cases seen outside of the primary training setting. This is intended to assess the generalizability of training to the trainee’s work environment. The Milan Systemic (MS) training program places a great deal of emphasis on trainees’ theoretical development and epistemological shift. Theory is a critical aspect of the training program and conceptualization along systemic lines is acquired via observation and participation on a therapy team. Trainees are not only taught to use systemic thinking on their clinical families but also in the agency structures in which the treatment exists. Theory acquisition is facilitated by observation, role playing and eventually, in the later stages of training, by seeing families. It is the collective team that is emphasized rather than individuals (Pirrotta & Cecchin, 1988). Little regard is given for the acquisition of specific therapeutic skills, and the idiosyncrasies of therapist style are immaterial. Trainees see few families as part of their training, which is consistent with the point of view that it is the therapist’s thinking and his or her membership as a team member that should be accentuated. The MS trainers attend to macro rather than micro levels of in-session interaction. This level of attention also applies in their training approach, which is seen as isomorphic with therapy. For Cecchin, one of the original four members of the Milan team: We have become less interested in the small details. If we see that the therapist is missing some very important opening, something very obvious, we call the therapist out. But you can get obsessive, phoning in questions, “Why don’t you ask this ... If I were there, I would have asked...” and so on. We don’t do that so much anymore (Cecchin, G., 1987, p. 119). The trainee’s task, according to this model, is to learn effectiveness in the admittedly difficult position between team and family. It is the therapist’s responsibility to “...learn how to be connected” (Boscolo, 1987, p. 120) with both of these subsystems. Todd (cited in Stanton, 1981) has expressed concern about the difficulty and complexity of training Milan therapists, especially therapists at more beginning levels. Trainers in this model are concerned about training’s generalizability. Although MS trainees evaluated their training poorly in this regard (Pirrotta & Cecchin, 1988, p. 59), trainers provide activities designed to facilitate such generalizability of their thinking across contents. Trainees are given the opportunity early in training to present cases seen in their primary work setting rather than merely focus on training setting cases. Role plays and videotapes also are part of the MS training program. A trainer attitude of respect for the students is emphasized. The selection process is an important step in defining this attitude that is modeled as something the trainers want their trainees to convey to each other. Ideas and the intellect, rather than the personal characteristics of PRACTICAL APPLICATIONS IN SUPERVISION

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the trainees are primary. The trainers’ nonjudgmental attitude toward their trainees, and their de-emphasis of the individual in favor of the team process, allows the students more quickly to transcend the relational level of their participation in the training, and to focus on learning instead. There is no processing of the training group’s interpersonal dynamics, as the group is seen as an epistemological tool rather than an end in itself. It is not considered important to examine how the individual fits into this particular group, or how the group process affects individuals (Pirotta & Cecchin, 1988, p. 59). The group becomes a thinking machine, a group mind, where matters of personality, personal style and the modification of that style for therapeutic purposes becomes secondary or nonexistent. Although “no formal follow-up study or survey has been conducted by the Milan group to quantify the effects of the training” (Pirrotta & Cecchin, 1988, p. 58), these authors offer some impressionistic findings. They are remarkably candid in their revelations. Trainee response to the program is considered a function of their stage of involvement with the training. Initial reactions of delight and infatuation with the training process and the therapy are typically followed by several reactions. These include some disaffection with the therapy model itself, its apparent lack of transferability to a wide range of clinical settings, the few actual number of families that get seen by the therapists, and the insufficient focus on skill development. In the words of Pirrotta and Cecchin (1988), “the emphasis on the collaborative group process left individuals to fend for themselves in their own learning process” (p. 59). Probably the most comprehensive statement about training of Strategic therapists remains the contribution made by Haley, in his classic chapter on “The Problems of Training Therapists” (1976). In dealing with the issue of selection, Haley advises that strategic therapists in training should be mature and possess life experiences, intelligent with good interpersonal skills and a wide range of potential behaviors. These statements are made despite Haley’s objection to a “personality supervision,” a form of training in which the person of the therapist receives what is, in Haley’s view, inordinate focus (Haley, 1988). Haley is concerned about competing contexts of influence in training. He advises that trainees be cut off from other supervisors and sources of therapeutic influence during training in strategic therapy. This serves to prevent the potential confusion of exposure and attempted adherence to contradictory approaches. Haley’s training philosophy contains several key ingredients. These include: 1.

Supervisor responsibility. It is the supervisor’s responsibility to protect clients from the inadequacies of beginning therapists, as well as to assist the trainee to develop the skills that will solve clients’ problems.

2.

Supervision methods. Live supervision and direct observation of a therapist’s work are essential and indispensable ingredients in training. Video supervision is also a key component. A supervisor must understand the starting ideology of the trainee. This is best accomplished by watching the trainee in action with a case, and not merely through discussions with the

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supervisor. 3.

Training philosophy. Learning by doing is paramount. Minor emphasis is placed on didactics and theoretical acquisition. Theory grows out of action and experience. It is also important to teach a wide variety of therapy techniques as well as ways of crafting them to each case that comes along. One primary goal of training is to expand the range of therapist skills and behavior available in clinical situations.

4.

Evaluation. Therapy outcome is the sine qua non of effective training. If the cases do not improve, training and supervision cannot be considered successful. Obviously, from a standpoint of values, trainees in this approach are taught to take the outcome of their cases very seriously.

Mazza (1988) provides a number of therapist typologies for the strategic supervisor interested in anticipating common trainee profiles or characteristics (e.g., the overly eager, anxious, totally passive therapist). Mazza (1988), a former student of Haley and Madanes, has emphasized the indirect techniques used in training strategic therapists, citing, as Haley has often done, the hypnosis tradition as a metaframework of strategic therapy and strategic therapy training. This training philosophy, another exemplification of the isomorphism principle in action, has also been advocated by Protinsky and Preli (1987) and Storm and Heath (1982). In discussing feedback received from strategic therapy trainees, Storm and Heath (1982) make what will be seen as a controversial recommendation; they warn that supervisors try to avoid getting caught using strategic techniques with their supervisees. One dividing line between strategic therapy trainers is the degree to which all epistemological shift is facilitated directly. That is, should the systems perspective be influenced through particular training exercises with videotapes for example, or through the process of seeing cases under close supervision. The former philosophy is embodied in the work of authors such as Keeney and Ross (1983) and Reamy-Stephenson (1983). These authors are directly concerned with having access to and modifying the conceptual maps of their trainees. They advocate specific exercises, sometimes involving videotape viewing and discussion to alter the conceptualization ability and targets of inquiry (e.g., question-asking strategies) of therapists in training. Strategic therapists such as Haley and Mazza, on the other hand, are less interested in the conceptual life of the therapist. They advise that interview skills are the essence of therapy and it is acquisition in this behavioral realm that changes a therapist’s conceptualization ability. Structural family therapy has a tradition of keen attention to training and supervision issues. It is a treatment model that has been taught extensively at pre-professional, allied, and continuing education levels (Aponte & Van Deusen, 1981). It was one of the only family therapy approaches to implement a program to teach minority, indigenous community residents, without formal professional backgrounds, the skills of family therapy. The video teaching tapes of the Philadelphia Child Guidance Clinic should be considered, along with the seminal method of live supervision, to be foundational contributions to the specialty of training and supervision.

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In the early days of their training, the structural trainers seemed to have a strong, perhaps an univariate emphasis on the technique of structural therapy. It was important, to use one of Minuchin’s phrases of the era, to teach the steps of the dance. To illustrate: The staff handout, “An Alphabet of Skills of Structural Family Therapy” (“A” stands for accommodation, for instance) was used widely in Minuchin’s years at the Philadelphia Child Guidance Clinic. Despite this early emphasis on technique per se, there has, more recently, been an incorporation of other factors in training. There has been a change, perhaps in response to trainee feedback, in the emphasis of structural training. This approach has been increasingly attentive to the dangers of overfocusing on technique. Minuchin and Fishman (1981) assert that technique training must be balanced and sequenced with an equal emphasis on the self of the therapist. This focus expands the therapist’s personal range of skill and performance technical mastery. Minuchin and Fishman discuss the inherently disruptive aspects of the transitional period of training in which new skills are practiced and the self of the therapist is emphasized. A good training relationship is vital, particularly during these times. These authors discuss other hallmarks of the structural approach: direct observation and live supervision as a must of training, an ongoing theory/didactic seminar to integrate theoretical ideas with practice, and the need to take the long view of training and therapist development. In this regard, their thoughts on advanced therapists and the road to becoming a seasoned therapist are worthy of emphasis: On the way to becoming wise, the therapist finds himself moving from observations of particular transactions to generalizations about structure. He develops ways of transforming his insights into operations that have the intensity necessary to reach the family members. In this process of achieving a wisdom beyond knowledge, the therapist discovers that he has a repertory of spontaneous operations. Now he can begin to learn for himself (Minuchin & Fishman, 1981, p. 10). A second generation of structural therapists has written extensively and with excellent detail about the further applications of this training approach. Aponte and Van Deusen (1981), Hodas (1985) and Colapinto (1983, 1988) have contributed to this body of work. These contributions have developed such needed topics in the training and supervision area as the interdependence of video and live supervision (Hodas, 1985), a previously ignored area in the literature, and an elaboration of the key components of a structural training approach (the process of learning, trainer-trainee relationship, the supervisor attitude, context factors in supervision and training, and the ingredients of trainee change, Colapinto, 1988). Several common distinguishing characteristics can be said to identify the transgenerational approaches to therapy and training, which include the contextual therapy of Boszormenyi-Nagy (1981), Bowen (1972) theory and therapy, and the couples group therapy and family of origin approach of Framo (1981). Contextual therapy trainees are required to have a basic knowledge and commitment to the basic mandate of multi-dimensional partiality, a central precept of contextual work. An awareness of intrapersonal events, in one’s own life and with one’s clients, is deemed important for the contextual therapy trainee. Personal therapy is important, as is the personal growth of the trainee. An integrative understanding of intrapersonal (psychodynamic), developmental, and systemic transactional knowledge bases is also seen as vital. Combined didactic and clinical training is preferred. Co-therapy is recommended as a learning context as is practiced in a variety of real life applied settings. In short, contextual PRACTICAL APPLICATIONS IN SUPERVISION

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therapy’s training is undergirded by its concepts of therapy. The principles that are filtered into and used in the therapy context (fairness, accountability) are also important to factor into training (Boszormenyi-Nagy & Ulrich, 1981). The Bowen approach to training revolves around the central concept of differentiation of self (Kerr, 1981; Papero, 1988). This directly parallels the therapy model. As an approach to training, it has many unique features that set it apart from most other training models. First, there is the lack of emphasis on the technique of the therapy to be learned; some might call it an anti-technique stance. Supervisors are less concerned with what a supervisee says in reviewing a tape than with his or her own activity or personal level of functioning as it might pertain to differentiation of self from one’s family of origin (Papero, 1988). Clinical ability comes directly from effort with one’s own family of origin. Bowen theory is important to learn and attempt to operationalize. As both Papero (1988) and Kerr (1981) explain, since it focuses so much on the therapist’s personal growth, training is long term (e.g., 3-4 years, Kerr, 1981), and in most cases, open ended. Differentiation of self is assessed in the trainees’ clinical work and is monitored during the supervision meetings. Much of training in the Bowen approach seems indistinguishable from personal therapy for the therapist, since there is so little emphasis placed on the skills or objectives of training and the methods used for teaching. Papero (1988) cites an “observation” made by Bowen many years ago relating to the harm therapists can do with their “interventions” (therapists are helped more by research interventions than by therapy interventions, Papero, 1988, p. 73). Consequently, he adopts a kind of naturalist’s stance and philosophy of therapy and training. One almost might consider it an anti-intervention approach. Hierarchy is scorned in this approach. Supervisors are seen as equally needing to work on their own level of differentiation in the supervision relationship. They are to be forever vigilant recording differentiation of self. This will model appropriate behavior for their trainees. Little role-playing and no live supervision is used in this approach. As Papero proudly notes, there are no observation rooms or observation mirrors in the Bowen family therapy training center. They are seen as distractions from the real work of personal growth and differentiation of the supervisors’ and therapists’ selves. Evaluation is wholly related to the therapist’s level of differentiation of self. As Papero tells it, this process takes a very long time, indeed it can be considered a lifelong quest. He realistically cautions that perhaps the most reasonable outcome of training as he and Kerr (1981) have described it, is the cognitive understanding of the concept of systems thinking. True differentiation of self, at least at the lofty but still under-operationalized ways they have discussed, is too ambitious a goal of training. A clear understanding of theory is more important in this training approach than is technique. Ultimately, trainees are led on a philosophical quest that links the families they see, families in general, to nature and the world of the natural sciences. Evolutionary biology, sociobiology, and genetics are examples of conferences held at the Georgetown center for family therapy trainees. These therapists would seem to comprise a select group, a group whose mission is agreed to be their own personal growth, a quest that Bowen has declared to be the royal road to therapeutic effectiveness, which is defined as synonymous with the therapist’s level of personal functioning. Framo’s intergenerationally oriented therapy, one of the first integrative models, works PRACTICAL APPLICATIONS IN SUPERVISION

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at the interface of psychodynamic and interpersonal functioning. He sees both areas as keys to the content and personal growth domain a therapist must master. Although a staunch proponent of such training activities as personal therapy (marital or family therapy rather than individual therapy), and the writing of a family autobiography, Framo believes that skills are also important, and it is here where he clearly diverges from the Bowen position, another intergenerational model. Framo believes that therapists are primarily “trained” by their families of origin. He also defines more difficult family problems as needing treatment from a “natural,” a person who has had good family of origin “training” as well as formal professional training in family therapy. Another approach in the integrative tradition of training has been developed by Nichols (1988) who defines his model as an integrative psychodynamic and systems approach. Nichols believes it is important to broaden the usual range within which training is defined. Training, for Nichols, should include the education and career development of the therapist, a task that includes professional socialization and preparation in the broadest sense. Nichols (1988) has described the principles of a flexible model that apply to masters, doctoral, postdoctoral and freestanding institute settings. He notes the importance of a family therapy educator to flexibly craft the principles of teaching and therapy to the particular level of trainee as well as to the context of training. In this approach, theoretical content comes first (indeed, sequencing is important as is thinking of trainees in terms of stages of personal development), and is followed by the core of the training—practical clinical experience—under supervision by an experienced supervisor. There should be a flexible use of learning objectives. The program’s philosophy should embody a “hard but fair” attitude that is complimented by a spirit of “let’s learn.” Faculty should be reasonably diverse. Nichols advises against a guru or mentor system, worrying that this approach produces automated, non-individualistic, technique-oriented clones. Content of training is important and trainers are advised to think seriously about the content core of their curriculum. In this regard, an integrated developmental component is seen as crucial. Nichols believes that age and personal maturity are factors in trainee selection and training. He questions whether anyone under 30 is mature enough to learn all the knowledge, and perhaps more difficult, handle the personal issues of becoming a family therapist. Nichols believes that the commonly accepted practice of live supervision is more for the benefit of the supervisor and family than the trainee. Regarding live observation and the supervisor’s interventions, Nichols offers the following: My experience was one could get quick change in the actions of trainees by modeling or intervening into the therapeutic work of the trainee. If, however, one looked carefully at the development of the student a year or so later, it generally turned out that the student had tended either to rebel against the stance taken by the supervisor or to slavishly follow the mentor’s actions. In either instance, the student had not progressed in his or her own growth in the way that it is possible when the supervisor/teacher is absent (Nichols, 1988, p. 122). Nichols pushes for variety in supervision in order to keep the trainee, and presumably the PRACTICAL APPLICATIONS IN SUPERVISION

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supervisor at peak performance. Personal therapy or family of origin therapy during training is highly desirable but it can be over-recommended. For Nichols, the focus of training is not the personal growth of the trainees. In the available time, training should help the trainee become as learned and skilled in the technique, content and professional demeanor that constitutes family therapy. Over time, the hierarchical training relationship equalizes and a more collaborative, less directive set unfolds. Finally, Nichols believes that training should influence clinicians to pursue a lifelong process of professional learning and improvement. This area, the supervisor’s role in instilling values about such things as continuing professional education, is chronically underdeveloped in training. Perhaps it is the developing literature on the mentoring process that can provide clues to how we can appropriately expand our definition of a trainer’s mission. A third example, after Framo and Nichols, of integrative training that blends psychodynamic concepts with family systems ideas would be the work of Stierlin, Wirsching and Weber (1982). Integration issues in training are also addressed by Todd and Greenberg (1987) in their co-trainer supervision that integrates structural-strategic and symbolic-experiential therapies. While some family systems approaches emphasize articulation of content and skills, the Symbolic-Experiential Family Therapy (SEFT) approach must be understood as a model that has de-emphasized behavioral skills and techniques of family therapy. Although the experiential therapy movement has been active since the 1950s (Whitaker & Malone, 1953), SEFT has had some degree of difficulty in becoming systematized and developed in a coherent way (Connell, 1984). This has been due, in part, to such factors as the model being so closely tied to the personhood of one individual, Carl Whitaker, as well as to the nature of this particular individual. Certainly, when Hoffman (1989) coined the phrase, “The Great Originals” to describe the senior generation of family therapy innovators and clinical wizards, she must have had Whitaker, among a few others, firmly in mind. While useful for creating enthusiasm for a new field, one that had to compete for its place in the mental health marketplace, the emphasis on the Great Originals has proved deleterious (or at least is now anachronistic) to the evolution of the family therapy field. This is particularly so as it pertains to the further specification of any approach beyond the idiosyncrasies and personal style of a model’s originator. Gradually, however, Whitaker’s students and followers have developed his ideas and approach, and their contributions of model refinement, extension, and articulation have been impressive (see for example, Neill & Kniskern, 1982; Sugarman, 1983; Napier & Whitaker, 1978; Garfield, Greenberg & Sugarman, 1989; Whitaker & Keith, 1981). Learning to be a Symbolic-Experiential family therapist occurs in three stages. The first, learning about family therapy, is best done in seminars and workshops. This is the time in which the new language required within the family systems orientation is learned. Learning to do family therapy, the second stage, requires direct clinical experience with cases. This is best accomplished in an outpatient setting. Several competencies are stressed. These include the ability to take a family history, understand basic systems thinking and its relationship to the mental health field in general, assess family structure and process, provide crisis intervention, do long term couple’s therapy, organize a family conference around a crisis, and utilize consultation appropriately. A final competency, stated as the therapist’s ability to “know the potential use of family therapy in general psychiatric practice, as, for example, in doing medication checks or in PRACTICAL APPLICATIONS IN SUPERVISION

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seeing patients with psychosomatic illnesses” (Whitaker & Keith, 1981, p. 222) deserves special note less because of its content and more because of what it reveals about the context of the SEFT approach. Like the Bowen model, Whitaker’s therapy and training contains many references to and ties with the psychiatric community and psychiatric training settings. Although not as discipline-bound as the Bowen approach, Whitaker’s writings about SEFT contains many allusions to what could be taken as a medical or psychiatric chauvinism. The final stage, being a family therapist, which involves “orienting one’s clinical work around families,” consists of “a reorientation in which the therapist comes to believe in families rather than individuals” (Whitaker & Keith, 1981, p. 221). Co-therapy is one of the most powerful and central methods and philosophical tenets of SEFT and has been discussed by many of Whitaker’s proponents. More than any other contemporary family therapy school, the Whitaker tradition has kept co-therapy alive for new generations of clinicians. Learning family therapy via co-therapy is seen as a valuable vehicle for the personal growth of the therapist as well as a powerful force for change with the family. Since the creativity and freedom of the therapist (in terms of personal and professional roles and interpersonal restraints) are primary in SEFT, co-therapy is seen as a vehicle for releasing the therapist’s full creative potential. Additionally, since the growth of the therapist is also crucially important in SEFT, co-therapy also permits the therapist the flexibility to learn all that is possible from each therapeutic encounter. SEFT therapists are taught that reliance on technique is harmful to one’s health and growth as a therapist. In this school of thought, there is much emphasis placed on the personal side and personal development of the therapist. Paraphrasing Whitaker to refer to training, Sugarman (1987) has referred to this with his statement: “Teaching SEFT resides in the personhood of the teacher” (Sugarman, 1987, p. 138). Whitaker has assumed an almost anti-technical stance since his earliest days in family therapy. In many ways, he seems to have actively resisted codifying his methodology, sometimes apparently out of the fear that therapists will use such specification as a way to hide behind method. For Whitaker, it is openness that is called for in the therapeutic encounter (Whitaker & Keith, 1981). I have been hard put to explain what seems to work or how I end up operating in my role as a teacher. It seems more and more clear that I don’t believe in supervision. Supervision is a process of looking over somebody’s shoulder and telling what to do or how to maneuver. It’s like teaching somebody to ride a bicycle. Advice may be useful, but also is constricting that its usefulness seems minimal (Whitaker in Whitaker & Garfield, 1987, p. 106). SEFT is quite concerned with what he believes to be the cloning process that comprises much of training. A mix of methods (live observation, co-therapy, group supervision, videotape, seminars, clinical experience with couples, couples groups, and families) makes sure that trainees do “not end up programmed to a set pattern” (Whitaker & Keith, 1981, p. 224). The role of the trainees own experiences is key. Trainee involvement is vital and must be initiated from the trainees (parallelwise: motivation must come from the family in Whitaker’s first stage of therapy, “The Battle for Structure"). Teaching involves a continuous dialogue, as does SEFT, in which the teacher and trainee discuss assumptions, beliefs, values, fantasies, and notions about PRACTICAL APPLICATIONS IN SUPERVISION

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what might be best to do in therapy. The teacher “can only share his belief system, he cannot replicate it for someone else. Trainees have to build their belief systems through their own experience” (Whitaker in Whitaker & Garfield, 1987, p. 107). Trainee anxiety should not be altered by the trainer, it is important to motivate the trainee to learn, grow and risk. The personal growth quest of the supervisor is connected to the goal of personal growth for the trainee. Co-therapy provides a context in which the supervisor models key traits such as imperfection, openness, caring and self-disclosure. It is a context for learning about and experiencing the very qualities one is trying to infuse into therapy. Therapist confusion is not something to be avoided but welcomed. It provides an opportunity for expansion, creativity, and growth. Trainees who are considered appropriate for this approach are mature, flexible and have a tolerance for ambiguity and organizational chaos (Whitaker & Keith, 1981). Responsibility is a key notion: each trainee is considered responsible for his or her own personal growth during training (and of course beyond). This instills a valuable belief that will be replicated in the therapy (patients are taught that they are responsible for themselves, and therefore, they must act). In sum, the SEFT approach represents another of the contemporary approaches that uses its therapeutic principles to guide its training principles. As has been observed, this isomorphism, however, can only be carried so far. Sugarman (1987) described his attempt to differentiate from the Whitaker charisma and still teach SEFT. Todd and Greenberg (1987) described their creative and personally growthful attempts at integration within the SEFT framework. Garfield (1987) too, has described his struggle to break the personal replication of his mentor Whitaker, and instead apply Whitaker’s principles such as personal growth and personal definition (also see Garfield, 1980, 1982). These are important ways in which the family therapy field has evolved, moving from the emulation of the Great Originals to more replicable, generalizable models. Along similar lines, Connell (1984), writing from the SEFT tradition, defines a supervisory approach based upon the ideas of Whitaker and his therapy. This paper represents the kind of next-generation thinking and model refinement that, although Whitaker may not approve because of its schematized nature, will be received warmly by many therapists who will never have the opportunity to be trained by Whitaker himself. It will also be seen as progress by those who have been skeptical about the repeatability of a Whitaker therapy approach. Let us close this section on SEFT, however, with a quote from Whitaker and Keith (1981)—illustrative of so much about this approach. Like becoming a parent in the nuclear family the qualitative effects of becoming a family therapist are often dramatic. Treating families is both painful and deeply moving. Doing psychotherapy is change-inducing in its symbolic effect on the therapist. The power of the family, like the power of the infant, is seductive and threatening. The therapist and the conceptual framework that emanates from his work live between the pressure for constructive narrowing toward more specific definition and allowing for more openness, vulnerability, which leads to growth and reparative experience. Next year we would not be able to write this chapter in quite the same way (Whitaker & Keith, 1981, p. 224).

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The unique contributions of SEFT to the training and therapy fields can be found in this passage. The vital focus on the therapist’s personal level of functioning and growth, the powerful effects of being and becoming, a family therapist, developmental (often parental) metaphors, symbolic representations in therapy, and the emphasis on the emotional side of a therapist’s functioning are all covered and worthy of note. Although it is not frequently referred to in the context of integrative approaches to family therapy, Functional Family Therapy (FFT) is a model that integrates principles of learning theory, systems theory, and cognitive theory. It is also an approach that illustrates many unique and exemplary characteristics of contemporary family therapy approaches. Originally tied closely to social learning theory and, of course, family systems thinking, FFT has changed over its two decades of existence. It has responded to feedback from the clinical and empirical arenas. Functional family therapy is, among modern day family therapy approaches, a fine example of an empirically-formulated approach. Its principles, clinical and training methods have been developed and refined in clinical research settings. This has allowed for a systematic examination and reevaluation of the approach as the studies have accumulated. FFT has also been quite explicit, detailed, and systematic regarding the key components in training clinicians who will have this orientation. In this approach, four elements of training are emphasized. The conceptual element is considered crucial. It provides the foundation of core concepts implemented in treatment. In true behavioral tradition, the techniques are explicit, but equally important are the principles upon which these methods are based. FFT has a clear phase in which these concepts are taught. Didactic and modeling are primary training methods at this juncture. This approach emphasizes the intellectual capacities of the therapist. Therapists are stretched to incorporate principles of social learning theory and behavior analysis. The emotional element of training refers to the trainee’s ability to work with families under real life conditions. This aspect of FFT training accepts the emotional stress brought on by doing family treatment. More specifically, FFT appreciates how such therapist distress can lead, not only to poor clinical performance, but also, potentially, to disastrous clinical outcomes. Therapists need to develop sufficient affective strength to cope with such clinical realities, and further, it is the supervisor’s responsibility to design the environment in which emotional resiliency can be acquired. This aspect of the training process should be highlighted since many misunderstand behavioral approaches to not include attention to such domains of the therapist’s (or the family’s) internal or affective life. The technical aspect of FFT concerns the skills necessary to conduct a thorough assessment, and to engage in two other key aspects of the model, therapy and education. This includes therapeutic skills in the relationship and structuring realm. These skill clusters have been empirically linked with positive outcome in the earliest work in FFT (Alexander & Parsons, 1973; Alexander, Barton, Schiavo, & Parsons, 1976). The final core element of FFT training is known as the relational realm. This refers to the trainees capacity to develop a relationship with the supervisor and use this relationship to learn the skills of the approach. This approach appreciates the various sets of skills in the complex art of family therapy. Experience is clearly not seen as sufficient to be successful with clinical PRACTICAL APPLICATIONS IN SUPERVISION

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families. Skill possession (and articulation) at various interconnected levels, including the affective and cognitive domains, are mandatory to success. At the level of attitudes, FFT is interested in sweeping away family therapy’s often unspecific, romantic notions about what produces good therapy. Its agenda is to make therapy skills definable and replicable, when possible, and leave the magical thinking accompanying guru worship to others (Warburton & Alexander, 1985). FFT believe in the importance of the supervisor’s role in helping therapists to motivate recalcitrant families to enter or remain in treatment. Motivation is a central concept within FFT, and it operates within the variety of interconnected systems of family, trainee, and trainer. Problems regarding motivation are defined as technical difficulties that require thought, analysis, and concrete solutions aimed at specific targets. Trainers are reminded of their responsibility to provide detailed feedback to their trainees so that trainee performance and skill level can be improved. A supervisor must assess the clinician’s ability to diagnose the interactional sequences and particular phases of therapy or intervention currently in operation. Again, we are reminded here of the necessity of conceptual ability on the therapist’s part, and further, ability to operationalize these conceptualizations that use behavioral principles. Also important is the trainer’s capacity to accurately assess this developing ability of the supervisee. The FFT approach has clearly articulated a theory of trainee learning and change, and further, related these processes to and distinguished them from a theory of change for families. Trainees change by observational learning (the staging or sequencing of training experiences is important), cognitive restructuring (supervisor feedback shapes trainees ideas), and evaluative feedback (in addition to its being an indispensable aspect of cognitive or conceptual change, constructive feedback is a powerful motivator for trainees to continue in their quest to improve). The first phase of training does not include direct clinical experience with families. Trainees, in this didactic phase, learn the theoretical content of FFT along with the concomitant skills of the approach. In the second phase, clinical work begins. It happens through a variety of supervisor formats, including live supervision, team supervision, videotape and individual supervision (which is actually done with pairs of trainees). The trainer-trainee relationship is hierarchical, especially at the early phases of training. It is characterized by an expert-novice description. This relationship changes in this structure over time and becomes more egalitarian. Trainers, from this perspective, need to have an understanding of the most common trainee problems. These occur in four areas. 1. Demand characteristics of setting: fear of evaluation, competition with peers, loss of status in attempting to learn a new approach, and unrealistic wishes about personal growth or problem solving as a result of participation in the training. 2. Aspects of trainee style: the emotional aspects of learning and conducting family therapy, and its impact on the developing clinician. 3. Features of the FFT model: difficulties with learning the logic or mechanics of reframing, for example. 4. Characteristics of trainer-trainee relationship: excessive dependence, or an inability to PRACTICAL APPLICATIONS IN SUPERVISION

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understand the supervisor (i.e., poor communication in the supervisory relationship). Just as the FFT clinician assesses problems of implementation in therapy (emerging from a conceptual model), the supervisor engages in the same behavior. Knowledge of these four classes of trainee difficulty sensitizes a supervisor to make early, preventive assessments of typical problem situations. Firmly rooted in the scientist-practitioner tradition of the applied areas of psychology, the FFT training approach represents a model that has family systems concepts at its foundation. Yet it is a model that has expanded and refined this emphasis, unlike some other approaches to family therapy. Its empirical values and clinical research tradition, attention to feedback at model development and clinical levels, articulation of skills clusters, and recent attention to specifying the process of family treatment, all stand as notable examples of why this model must be considered one of the premier approaches of contemporary family therapy. In concluding this section on school-specific approaches to training, it must be said that these training efforts are inextricably tied to the school-specific movement in the clinical realm of family therapy. Controversy exists about the future of such model-specific training and therapy. Clearly one of the Major issues and trends in family therapy, and psychotherapy at large, is the integrative movement. As new integrative models appear, concomitant integrative training and supervision approaches will also be developed. The particular problems of training integrative and eclectic therapists has only begun to be addressed in the psychotherapy field (Halgin, 1988; Norcross, 1986, 1988; Robertson, 1996) and has barely been brought up in family therapy. Bagarozzi (1980) offered an example of the kind of integrative work in family therapy supervision and training that will be likely in the era ahead. A major advantage of the school-specific models has been their degree of specificity and work toward more inclusive models of training and supervision. That is, although we need contributions on the particular methods of supervision, at least one study showed the need for comprehensive and true models of supervision and training (Saba & Liddle, 1983). The schoolspecific models have, in general, allowed for a close correlation between their theories and methods of therapy and theories and methods of training. As the family systems approaches become more complex (e.g., production of treatment manuals to deal with specific clinical problems and populations), the corresponding methods used to train the clinicians in these more sophisticated models will need to follow suit. References Alexander, (1973). Defensive and supportive communication in normal and deviant families. Journal of Consulting and Clinical Psychology, 40, 223-231. Aponte, H., & Van Deusen, J. (1981). Structural family therapy. In A. Gurman & D. Kniskern (Eds.), Handbook of Family Therapy. New York: Brunner/Mazel. Bargarozzi, D. (1980). Wholistic family therapy and clinical supervision: Systematic, behavioral and psychoanalytic perspectives. Family Therapy, 7, 153-165. Bodin, A. (1981). The interactional view: Family therapy approaches of the Mental Research Institute. In A. Gurman & D. Kniskern (Eds.), Handbook of family therapy. New York: Brunner/Mazel. PRACTICAL APPLICATIONS IN SUPERVISION

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Boscolo, L., Cecchin, G., Hoffman, L., & Penn, P. (1987). Milan systemic family therapy: Conversations in theory and practice. New York: Basic Books. Boszormenyi-Nagy, I., & Ulrich, D. (1981). Contextual family therapy. In A. Gurman & D. Kniskern (Eds.), Handbook of family therapy. New York: Brunner/Mazel. Bowen, M. (1972). On the differentiation of self in one’s own family. In J. Framo (Ed.), Family interaction: A dialogue between family researchers and family therapists. New York: Springer. (Also in M. Bowen [Ed.] [1978] Family therapy in clinical practice. New York: Jason Aronson.) Cohen, H., Sargent, M., & Sechrest, L. (1986). Use of psychotherapy research by professional psychologist. American Psychologist, 41, 198-206. Colapinto, J. (1988). Teaching the structural way. In H.A. Liddle, D.C. Breunlin, & R.C. Schwartz (Eds.). Handbook of family therapy and supervision. New York: Guilford Press. Connell, G. (1984). An approach to supervision of symbolic-experimental psychotherapy. Journal of Marriage and Family Therapy, 10, 273-280. Fisch, R. (1988). Training in the brief therapy approach of the MRI. In H.A. Liddle, D.C. Breunlin, & R.C. Schwartz (Eds.). Handbook of family therapy training and research. New York: Guilford Press. Framo, J. (1976). Chronicle of a struggle to establish a family unit within a community mental health center. In P. Geurin (Ed.), Family therapy: Theory and practice. New York: Gardner Press. Framo, J. (1981). The integration of martial therapy with sessions with family of origin. In A. Gurman and D. Kniskern (Eds.), Handbook of family therapy. New York: Brunner/Mazel. Garfield, R. (1980). Family therapy training at Hahnemann Medical College and Hospital. In M. Andolfi & I. Zwerling (Eds.). Dimensions of family therapy. New York: Guilford Press. Garfield, R., Greenberg, A., & Sugarman, S. (Eds.). (1987) Symbolic experiential journeys. A special issue of Contemporary Family Therapy, 9. Haley, J. (1975). Why a mental health clinic should avoid doing family therapy. Journal of Marriage and Family Counseling, 1, 3-12. Haley, J. (1976). Problems of training therapists. In J. Haley (Ed.) Problem-solving therapy. San Francisco: Jossey-Bass. Haley, J. (1988). Reflections on therapy supervision. In H.A. Liddle, D.C. Breunlin, & R.C. Schwartz (Eds.), Handbook of famil yand marital therapy. New York: Guilford Press. Hodas, G. (1985). A systems perspective in family therapy supervision. In R. L. Ziffer (Ed.), Adjunctive techniques in family therapy. Orlando, Fl: Grune & Stratton. Hoffman, L. (1981). Foundations of family therapy: A conceptual framework for systems change. New York: Basic Books. Keeney, B., & Ross, I. (1983). Learning to learn systemic therapist. Journal of Strategic and Systemic Therapies, 2, 22-30. Kerr, M. (1981). Family systems theory and therapy. In A. Gurman and D. Kniskern (Eds.), Handbook of family therapy. New York: Brunner/Mazel. Liddle, H. (1978). The emotional and political hazards of teaching and learning family therapy. Family Therapy, 5, 1-12. Liddle, H., Davidson, G., & Barrett, M. (1988). Outcomes of live supervision: Trainee perspectives. In H.A. Liddle, D.C. Breunlin, & R.C. Schwartz (Eds.). Handbook of family PRACTICAL APPLICATIONS IN SUPERVISION

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therapy training and research. New York: Guilford Press. Liddle, H., Davidson, G., & Barrett, M. (1988). Pragmatic implications of live supervision: Outcome research. In H.A. Liddle, D.C. Breunlin, & R.C. Schwartz (Eds.). Handbook of family therapy training and research. New York: Guilford Press. Liddle, H., & Saba, G. (1983). On context replication: The isomorphic relationship of training and therapy. Journal of Strategic and Systemic Therapies, 2, 3-11. Mazza, J. (1988). Training strategic therapists: The use of indirect techniques. In H.A. Liddle, D.C. Breunlin, & R.C. Schwartz (Eds.). Handbook of family therapy training and supervision. New York: Guilford Press. Meyerstein, K. (1977). Family therapy training for paraprofessionals in a community mental health center. Family Process, 16, 477-494. Minuchin, S., & Fishman, H. (1981). Family therapy techniques. Cambridge, MA, Harvard University Press. Napier, A., & Whitaker, C. (1973). Problems of the beginning family therapist. In D. Bloch (Ed.), Techniques of family psychotherapy: A primer (pp. 109-122). New York: Grune & Stratton. Nichols. W. (1988). Family therapy education/training: An integrative psychodynamic and systems approach. In H.A. Liddle, D.C. Breunlin, & R.C. Schwartz (Eds.). Handbook of family therapy training and supervision. New York: Guilford Press. Papero, D. (1988). Training in Bowen theory. In H.A. Liddle, D.C. Breunlin, & R.C. Schwartz (Eds.). Handbook of family therapy training and supervision. New York: Guilford Press. Pirrotta, S., & Cecchin, G. (1988). The Milan training program. In H.A. Liddle, D.C. Breunlin, & R.C. Schwartz (Eds.). Handbook of family therapy training and supervision. New York: Guilford Press. Protinsky, H., & Keller, J. (1984). Supervision of marriage and family therapy: A family of origin approach. The Clinical Supervisor, 2(2), 75-80. Reamy-Stephenson, M. (1983). The assumption of non-objective reality: A missing link in the training of strategic family therapists. Journal of Strategic and Systemic Therapists, 2, 51-67. Shapiro, R., (1975). Problems in teaching family therapy. Professional Psychology, 6, 41-44. Shapiro, R., (1975). Some implications of training psychiatric nurses in family therapy. Journal of Marriage and Family Counseling. 1(4), 323-330. Steirlin, H., Wirsching, M., & Weber, G. (1982). How to translate dynamic perspectives into illustrative and experimental learning process: Role play, genogram and live supervision. In R. Whitten & J. Byng-Hall (Eds.). Family Therapy Supervision: Recent developments in practice. New York: Grune & Stratton. Storm, C., & Heath, A. (July-August, 1982). Strategic supervision: The danger lies in the discovery. The Family Therapy Networker, 6(7). Sugarman, S. (1987). Teaching symbolic-experiential family therapy: The personhood of the teacher. Contemporary Family Therapy: An International Journal, 9, 1-2. Sugarman, S. (1987). Teaching symbolic-experiential family therapy: The personhood of the teacher. Contemporary Family Therapy: An International Journal, 9, 138-135. Todd, T., & Greenberg, A. (1987). No question has a single answer: Integrating discrepant models in family therapy training. Contemporary Family Therapy, 9, 116-137. Warburton, J., & Alexander, J. (1985). The family therapists: What does one do? In L. L’Abate (Ed.), The handbook of family psychology and therapy. Homewood, Il: The Dorsey Press. PRACTICAL APPLICATIONS IN SUPERVISION

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Whitaker, C., & Garfield, R. (1987). On teaching psychotherapy via consultation and co-therapy. Contemporary Family Therapy, 9, 106-115. Whitaker, C., & Keith D. (1981). Symbolic-experiential family therapy. In A. Gurman and D. Kniskern (Eds.). Handbook of family therapy. New York: Brunner/Mazel.

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MULTIPLE THEORETICAL APPROACHES TO SUPERVISION: CHOICES IN FAMILY THERAPY TRAINING SUSAN H. MCDANIEL, PH.D. TIMOTHY WEBER, PH.D. JAMES MCKEEVER, PH.D. REPRINTED WITH PERMISSION FROM VOL. 22, DECEMBER, 1983 FAMILY PROCESS, COPYRIGHT 1983, FAMILY PROCESS.

The supervision techniques used in structural, strategic, family-of-origin, and experiential family therapy training are discussed and compared, with emphasis on the isomorphism between supervision and therapy in each school. The usefulness of each supervisory model is related to supervisees’ needs at different levels of training. Recommendations are made about the sequence of family therapy training, including the utility of eclectic versus purist family therapy training programs for trainees at different levels of experience. Family Process 22:491-500, 1983 As the field of family therapy has grown, the focus of interest has widened from the process of therapy to include the process of supervision. In the literature recently, special attention has been given to the use of live supervision as a training format common to many schools of family therapy (1, 3, 5, 7, 10). While live supervision provides a common denominator in family therapy training, different theoretical orientations dictate different approaches to many other aspects of supervision, resulting in different experiences for the trainee. These various supervisory approaches can produce a confusing array of choices for the trainee who is seeking not only family therapy supervision but also a well-integrated sequence of family therapy training. A systematic consideration of different training approaches can provide a conceptual framework for the supervisor and the trainee that will allow these issues to be addressed. This paper chooses several family therapy orientations to illustrate how supervision is used to further the training of a family therapist in ways consistent with their respective theories of human behavior and change. The use of supervision in training structural, strategic, experiential, and family-of-origin therapists will be described, allowing an exploration of the similarities and differences in these particular training approaches. That section will be followed by a discussion of the relative merits of multiple versus single theoretical orientations in family therapy training programs. Recommendations will be offered with regard to training and supervision as it relates to the developmental level of the trainee. STRUCTURAL SUPERVISION Orientation The basic concepts laid out by Minuchin(6) as structural family therapy have become common language for most family therapists. The central premise of this approach is that families have an underlying transactional structure characterized by a hierarchy in which parents should have more power and responsibility than children. The goal of therapy is to create a structural context PRACTICAL APPLICATIONS IN SUPERVISION

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in which both individuation and family mutuality are strengthened. Familial subsystems (e.g., the marital subsystem, the parental subsystem, and the sibling subsystem), the boundaries between these subsystems, and the coalitions among family members constitute a structural mapping of the family. This orientation is defined by an acute sensitivity to issues of hierarchy and organization. For the trainee, the structural approach is a tight, understandable model of a family’s functioning that leads directly to clear, concrete goals for treatment, such as establishing the boundaries around the marital subsystem and reestablishing a parental-child hierarchy. Goal of Supervision The goal of supervision in structural family therapy is to teach trainees therapeutic techniques to bring about structural change in families and to help the trainees find their own ways to use these techniques (see Fig. 1). In the live supervision context, the structure that is addressed by the supervisor includes the family, the therapist/supervisee, and the supervisor. The essential work of the supervisor is to focus on and change dysfunctional interactions within the supervisory structure as they develop. The supervisor directs the therapist who directs the parents who direct the children. In effect, transactional problems will be “passed up” into the supervisor-supervisee subsystem for solutions, and if they are resolved on this level the solutions will be “passed back down” to the family. Supervisory Methods In live, structural therapy supervision, the supervisor directly intervenes with the supervisee, maintaining a clear boundary (the mirror) between the supervisor and the therapist-family subsystem. Live interventions by the supervisor consist of phone calls or direct intervention by the supervisor in the therapy room. These interventions forcefully establish the supervisor/supervisee hierarchy and underline the clear but permeable boundaries between supervisor and supervisee and between treatment team and family. The supervisory focus on techniques (“what you do”) mirrors the focus within the family’s treatment on behavioral transactions (“what they do.”) Like children in a family in which the parents are in charge, beginning supervisees usually find that live supervision increases their sense of security. They are helped to develop the family map and to plan goals and interventions, yet authoritative help and guidance is there. They in turn usually respond by feeling less helpless and more in charge. Inevitably, as they mature as therapists and are inducted into the family system, they will tend to challenge the supervisory hierarchy in various ways. Shifts resulting from the supervisee’s maturation and individuation are handled like the structural shifts in a well-functioning family with adolescents. The increased intellectual and emotional cooperation between supervisor and trainee acknowledges the trainee’s maturation while leaving intact the authority structure by which the supervisor is ultimately responsible for the conduct of the case. Specifically, this could be illustrated by the supervisor entering the treatment room, discussing the case with the trainee, listening carefully to the trainee’s experience and ideas, and utilizing these ideas to formulate the next interventions. Supervision Example An example of structural supervision occurred in a recent case involving a school phobic adolescent boy who had been hospitalized. Dysfunctional parental interactions and intrusions PRACTICAL APPLICATIONS IN SUPERVISION

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across boundaries abounded in this enmeshed family. The therapist’s goal had been to get the parents first to take charge by deciding on a discharge date and a plan. Although some success was realized, the parents persistently tried to turn to him for “expert” advice. The supervisee in turn would ask similar questions of the supervisor before and after sessions. As discharge approached, the patient proposed a delay in return to school following discharge, and the parents’ tenuous alliance began to crumble. Likewise, the therapist professed the same uncertainty about what to do. At this point the supervisor recognized the problem of successive levels in the hierarchy isomorphically abdicating responsibility. The supervisor intervened by directing the supervisee to make the parents follow through on the original plan. The parents carried out the plan and the patient returned to school without incident (all the time denying that he had any problem). Only later did the supervisor and supervisee discuss how supervision had gotten off track. To summarize, the structural supervisor helps the trainee to develop a structural map of the family and to formulate and apply directive interventions that modify the family’s organization. The supervisor also intervenes within the supervisory hierarchy when it is affected by the family’s pathology. STRATEGIC SUPERVISION Orientation Strategic family therapy views people’s symptoms as resulting from the application of maladaptive solution behaviors to recurrent problems. Therapy consists of planned, goal-directed interventions such as reframing, symptom prescription, and other strategies that interrupt these current, repetitive, nonproductive behavioral patterns (4, 9). With this orientation, treatment is viewed as problem-solving rather than growth, and insight is seen as a possible product of, rather than a necessary catalyst to, behavior change. Goal of Supervision In the supervisory context, the trainee is urged to identify and block maladaptive behavioral sequences related to the presenting problem in the family. The supervisor is termed the “consultant” on the case, emphasizing the supervisor’s greater expertise and the expectations that he or she will observe the treatment and intervene only at points where problems are occurring in the treatment, leaving the therapist to conduct the front-line therapy. This model is isomorphic to the role of the family therapist who intervenes only to block maladaptive solution behaviors, leaving the family to make major decisions and conduct their lives in general. Just as the theory states that people can get stuck in trying to solve their problems, so, too, therapists can become regulated or stuck in trying to intervene in a family system. The consultant, then, functions to deal with the stuck points or resistance between the therapist and the family so that the therapist is free to deal with the stuck points in the interactions among family members. Although hierarchy and authority are emphasized in structural training, strategic consultants emphasize respecting the system and its coherence by speaking the clients’ language, going with the resistance by never fighting the clients, and staying focused on the problem. Supervisory Methods Training is oriented to technique and theory, with no emphasis on the trainee’s person or internal PRACTICAL APPLICATIONS IN SUPERVISION

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experience (see Fig. 1). The consultant will use a one-way mirror and give directives or interventions by telephoning or entering the therapy room. A group of trainees or other professionals may also observe from behind the mirror and give their input to the consultant. The goal of the training is for the trainee to be an effective therapist who can successfully help clients to resolve their presenting complaints in relatively brief therapy. When the treatment becomes stuck, the consultant may intervene either with the therapist or with the family. The consultant may use the therapist’s “language” to reframe the therapist’s conceptualization of the problem and intervene in such a way as to move the treatment beyond the impasse. The consultant may also choose to enter the therapy room and intervene directly with the family to accomplish the same goal. This technique-oriented training is supplemented by seminars and reading so that the trainee can develop a theoretical foundation for this clinical practice. Training in strategic therapy may be appropriate for the therapist at any level of experience, from the beginning therapist to the seasoned therapist, because of its comprehensive theoretical and technical approach. Supervision Example As mentioned earlier, trainees in strategic live supervision may expect reframing, a symptom prescription, or some other intervention from the consultant when they begin to get stuck in helping a family. One example of this process occurred in a case in which a trainee was working with a difficult family with a mentally retarded member as the identified patient. The family came in struggling with each other over how much the retarded member was capable of doing. After initial progress, the therapist became covertly regulated by the mother who took the position that her retarded son must be babied and could not be expected to function well. In planning sessions, the therapist began talking pessimistically about the family, saying she felt they were moving slowly and were unlikely to make any more progress. The consultant agreed with her that the family seemed “retarded” and expressed his doubts that she could work with them. This articulation of the trainee’s position freed her to reassess the family’s strengths and help them to resolve their interpersonal struggles. Reframing may also be used in a more global way to increase a trainee’s motivation. For example, an advanced trainee had entered a period of self-confidence in her abilities as a family therapist, feeling she was effective and unafraid to approach most any family. In her evaluations with the training consultants the consultant accused her of “coasting” and not continuing to develop her abilities as a therapist. This intervention was an important and powerful motivator, a reminder of the complexity of human systems and the challenges put to therapists daily. To summarize, the consultant in strategic live supervision helps the trainee to begin treatment by clearly identifying the presenting problem, setting a goal, developing a therapeutic strategy to reach that goal, and intervening in the therapist’s maladaptive solution behaviors when the trainee begins to get stuck in treating the family. FAMILY OF ORIGIN SUPERVISION Orientation Family-of-origin therapy is based on a theory originated by Bowen (2) that views symptoms as resulting from unresolved conflicts transmitted through generations. The therapist functions as PRACTICAL APPLICATIONS IN SUPERVISION

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“coach,” helping the patient to identify and analyze multigenerational themes and specific problem areas and then devising a plan for the patient to interact actively with family members around toxic issues while controlling emotional reactivity. If the patient can consistently and effectively detriangulate, the avoided conflict around toxic family issues can begin to be resolved. Goal of Supervision Much like family-of-origin treatment, training in family-of-origin work emphasizes the personal growth of the therapist as well as a comprehensive understanding of the theory articulated by Bowen and his followers (see Fig. 1). Like patients, trainees are encouraged to focus on their own families of origin to understand the process of this work and to promote their own growth as people and as therapists. The supervisor models the coach role with the trainee so that the trainee may then coach a family or individual in their own family of-origin work. It is assumed that if the therapist can understand and be involved with the therapist’s own family while avoiding emotional reactivity, this may also happen in working with patient families. Supervisory Methods In each supervisory session, trainees make a choice about whether to present their own family or case material. When they choose to present their family of origin the coach works with them, directing the questioning and encouraging the investigation of multigenerational themes. The coach also models individuation by taking a position without becoming emotionally reactive in the face of highly charged issues. When the trainee chooses to present case material, the supervision may be live or use taped material. In live supervision, a one-way mirror may be used to allow the live supervisor to step out of the emotional field of the therapist and family. At other times, a trainee group may view the therapy process from behind the mirror while the supervisor consults in the therapy room with the therapist and the family, again modeling appropriate therapeutic interaction. The genogram is used as a tool to articulate multigenerational patterns in both the trainees’ own families and their families in treatment. Bowen (2) stated that the main emphasis of training is to promote personal growth and that techniques will follow. Because of the lack of emphasis on the techniques and structure of treatment, family-of-origin training may be particularly well suited for advanced level therapists, those already acquainted and comfortable with the therapy process. Supervision Example At times, family-of-origin training may focus on some unresolved issue in the trainee’s life that clearly affects that trainee’s role as therapist. For example, one 36-year old trainee consistently had difficulty asserting his authority as therapist with middle-aged couples. He reactively took a onedown, filial position and frequently lost these cases. Concurrent with working on these issues as a therapist, this trainee’s coach-supervisor began encouraging him to examine his relationship with his own parents and to explore the patterns of authority in his extended family. The culmination of this work was a session with the trainee’s family in which he renegotiated the intergenerational power structure (13, 14, 15); he declared his parents to be “former parents,” claiming his own personal authority in a more intimate, adult, person-to-person relationship with PRACTICAL APPLICATIONS IN SUPERVISION

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his parents. Successful renegotiation of this primary relationship then enabled this trainee to work more effectively and authoritatively with middle-aged couples. To summarize, the coach in family-of-origin supervision will primarily work with the trainee on his own family issues to promote his growth as a person and to provide a model for doing this work with patients. EXPERIENTIAL SUPERVISION Orientation The basic tenets and procedures of the experiential family therapy have been outlined in the writings of Carl Whitaker and his colleagues (8, 11, 12). The guiding assumption of this school is that health is a process of perpetual becoming, an unfolding of creativity within the person and within larger systems including the family. In this growth-oriented therapy, the presenting problem is regarded merely as the ticket of admission and not as the focus of treatment. The goals are more fluid and undefined than in problem-oriented therapy. The therapists’ responsibility is to challenge the family’s defensive and protective patterns through the sharing of their unconscious fantasies and personal stories. These interventions are intended to raise the family’s anxiety level, pushing them past their presenting impasse. Moreover, the success of therapy is believed to be in large part a function of the therapist’s own growth: “If the therapist does not get therapeutic input from his own work, chances are the patients will not get much from therapy” (12, P. 217). As the therapist grows, so grows the family. Goal of Supervision Consonant with this therapeutic orientation, the primary goal of supervision, in addition to what is considered the obvious goal of assisting the supervisee in professional case management, is to guide the supervisee in a journey of personal growth (see Fig. 1). The supervisee is invited to join the supervisor in a personal encounter and together they encounter the family. Rather than developing and sharpening particular skills or techniques, the supervisor forms an “apprentice” relationship with the supervisee. The supervisee learns not by watching or being watched but by being an integral, vital part of the therapeutic team. As with a family in therapy, goals of supervision are to help the supervisee to have increased access to the unconscious, an enlarged capacity to integrate the nonrational with the rational, and more flexibility in assuming a variety of roles in working with the family. Supervisory Methods Supervisor/supervisee cotherapy is the primary model of training. The difference between supervisor and supervisee is defined not in terms of power or authority but in terms of experience. The less experienced member of the cotherapy team usually follows the lead of the more experienced member. Except in rare instances when the supervisor deems it best to exercise unilateral authority in deciding how to manage a case, the supervisor does not direct the supervisee. As this pairing is nurtured, the cotherapists hope to develop a working synchrony and mutual trust that enable them to test out their respective growing edges with each other. In short, the supervisor is under no explicit or implied mandate to “do something” when working with the supervisor. Rather the trainee is invited to “be someone” with the supervisor/cotherapist. The learning of skills and techniques grows out of this encounter with the supervisor and the family.

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Given the paramount importance of the personal relationship between the supervisor and supervisee, encounters inside and outside the supervisory time are all part of the supervisor’s functioning as a more experienced guide in helping the supervisee to open up a greater range of experience and affect. The supervisor may prod, support, laugh, poke fun, argue and raise anxiety, leaving many of the supervisee’s questions unanswered. The intimate exchanges of supervision often seem like therapy. In such instances, where this fluid boundary between supervision and therapy becomes problematic, the supervisor may refer the supervisee for individual therapy. In fact, personal therapy for the experienced therapist is considered crucial, beginning with work on the supervisee’s own family, followed by intrapsychic therapy to increase access to his or her own creativity. Supervision Example A cotherapy pair of male supervisees was working with a blended family in which the male and female adults, who had not married, were having problems consolidating their own relationship as well as deciding how to manage difficulties with their children. Eager to organize their new family, the two adults had seized on compromises that were far less than satisfactory but at least appeared conflict-free. Their pseudomutual relationship was preventing any real growth in their defensive efforts to avoid the disasters of prior relationships. Isomorphic to this couple’s pseudomutuality, the supervisee cotherapists had been steadfastly avoiding any expression of conflict, even differences, between them. Their desire to be compatible was handicapping both their individuating from each other and their discovery of deeper, unconscious resources upon which they could draw as a team in working with the family. In supervision, the supervisor shifted the focus to the supervisees’ competitive feelings, feelings they had mentioned quickly in passing. The supervisor asked if they were always so unified in their opinions, and despite their protests, pushed them to examine their competitive feelings with each other. The supervisor then closed by suggesting, tongue in cheek, that they refrain from telling their wives of their closeness, for how could any marriage compete with such a tight relationship. Subsequent to this session, the supervisees first laughed at the supervisor who they thought was just trying to “stir up trouble.” Yet as the weeks passed, the supervisees gradually came to realize how they were in fact in a contest for top position in the internship, how the press to succeed had been a great burden on each of them for many years through school, how their position as first born in their families of origin had shaped this idea, and how indeed each had been resentful of the other when the latter made a creative intervention in the family. Their differences began to emerge with more color, and their competitive tugging with each other became more playful. To summarize, the experiential supervisor works with trainees in cotherapy and tries to catalyze their journey of personal growth so that they will have more of themselves to offer the family. The supervisees are expected to gain greater access to their unconscious, assume a variety of roles with more flexibility, and achieve a creative integration of these diverse parts of themselves. Implications for Training in Family Therapy PRACTICAL APPLICATIONS IN SUPERVISION

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These four supervisory models may be compared on a variety of dimensions including the degree to which each emphasizes the importance of theory techniques and internal experience in the training of family therapists (see Fig. 1). Whereas experiential supervision places a premium on developing the personal growth of the supervisee and minimizes the explicit teaching of technique, strategic supervision devalues attending to the supervisee’s personal experience and instead focuses on changing the supervisee’s technical work with the family. Family-of-origin supervision is founded on the teaching of a comprehensive theoretical model in which the supervisee is also encouraged to investigate his own family of origin. Like strategic supervision, structural supervision directs attention to the teaching of concrete techniques derived from a theoretical model of the family. These supervisory models also differ in their conceptualization of the relationship between supervisor and supervisee. In family-of-origin supervision, the supervisor functions as a coach, actively guiding the supervisee in linking theoretical principles with his or the family’s personal experiences. In strategic supervision, the supervisor serves as a consultant, limiting interventions with the supervisee to strategies that will help the supervisee get unstuck with the family. In experiential supervision, the supervisor is more of a partner, openly and dynamically sharing the experience of personal growth. In structural supervision, the supervisor operates as a director, systematically leading the supervisee in the planning and application of interventions that reestablish appropriate structure. A supervisee has much to gain by encountering the rich variations of these diverse models. Consideration should be given, however, to the developmental level of the trainee in determining what specific supervisory model would be of most benefit at any given time. Although this question is indeed a complicated one, we especially want to emphasize two guidelines in deciding what might be the best linkage between supervisory model and supervisee. Sequence of Supervisory Orientations First, at the beginning level of family therapy training, we recommend structural supervision with its straightforward approach to the teaching of a theory of family structure, the application of basic and concrete techniques, and a supervisory relationship in which the supervisor serves as a director in actively leading the supervisee. Strategic supervision is also useful at this stage, although it demands more from the supervisee in conceptualizing problems and engineering interventions to block maladaptive behaviors. Second, once a supervisee has been trained to apply theoretical principles by the use of a repertoire of techniques, it is important for that supervisee to work directly at integrating the “self” experience with these therapy techniques. The risk of being trained exclusively in structural-strategic therapy is that the therapist will become too mechanistic and rely too heavily on techniques. Both experiential and family-of-origin supervision, although not necessary for advanced training, are useful in helping a supervisee to expand a conceptual framework, gain a greater tolerance for the complexity of family life, and more fully integrate the self into the work of therapy. Purist vs. Multiple Model Programs PRACTICAL APPLICATIONS IN SUPERVISION

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In addition to the issue of the sequence of supervisory models, there is also the question of whether a supervisee should be trained in a purist program in which only one model is taught or whether a more eclectic, multimodel training program is more desirable. We believe the answer to this question depends upon the training experience of the supervisee. Prior to family therapy training, we believe the supervisee should be trained in a diversified curriculum of individual and group supervision with children and adults, using a variety of conceptual approaches, including an introduction to family therapy. Having a broad, heterogeneous training background militates against the danger that the supervisee might become overly zealous and jump on the family therapy bandwagon. Furthermore, at this stage it is important for the supervisee to be trained in models that allow him to go slower, to concentrate on listening, and to tolerate more ambiguity without wanting to mastermind quick solutions. These characteristics are a necessary balance to the more active, intervening behaviors often taught in family therapy training. Following this initial training, we would recommend an intensive purist family therapy training experience in one model (preferably either structural or strategic, as discussed above). A purist supervisor, in taking a strong, clear position, gives the supervisee an opportunity to learn an unambiguous model and concomitantly forces the supervisee to take a position (“What do I think?”) in response to the well-defined model. More eclectic supervisors are less likely to provide supervisees as this stage with this strong and stimulating experience. For the advanced supervisee, a more heterogeneous training curriculum is recommended in what we call “a consortium of purists.” Here the supervisee is trained concurrently by several theoretically “pure” supervisors who together may offer a curriculum including several different theoretical orientations. Training by a consortium of purists has several advantages. First, this framework helps to enrich the supervisee’s conceptual and technical skills beyond what can be provided by training in one model. Second, the framework also helps to sharpen, through contrast, the supervisee’s knowledge of each model rather than, as might be expected, increasing confusion. It is more possible for the supervisee to understand a model not only because he comes to know what it is, but also what it is not. Third, in a consortium there is less chance that the supervisee will become a “true believer” of any one model. What is more likely is that the supervisee will be pushed to individuate and integrate the models in such a manner that permits a unique style to emerge. There are risks in this consortium of purists. One danger is that the supervisee will get triangulated into differences or fights between supervisors of competing models. Another danger is the promotion of increased confusion in the supervisee who scurries from the supervisor of one model to the supervisor of another model without having opportunities to discuss the similarities and differences between models. In our experience, the risks of this format are minimized when (a) only one supervisor is responsible for supervising each case; (b) supervisors of differing models have a regular forum with supervisees during which their contrasting approaches as well as similarities are openly discussed; (c) supervisors acknowledge wanting to learn from each other; and (d) the supervisee is at a sufficiently advanced and mature level to deal with ambiguity and conflict and can take the primary initiative in this integrative process. Finally, the prime goal of the graduate of formal training in family therapy is to work on PRACTICAL APPLICATIONS IN SUPERVISION

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developing a model that further articulates family therapy theory and fits one’s personal style. The supervisee, at this point, becomes a "former supervisee." While continuing to learn from others, the supervisee makes a contribution by taking a creative, and perhaps unique, position, influenced by the best and most useful elements of what the supervisee has learned. In effect, the family therapist then creates a unique vantage point while recognizing the relativity of that position. References 1. Berger, M., and Dammann, C. (1982). Live Supervision as Context, Treatment, and Training, Family Process 21: 337-344. 2. Bowen, M. (1978). Family Therapy in Clinical Practice. New York. Aronson. 3. Gershenson, J., and Cohen, M. (1978). Through The Looking Glass: The Experience of Two Family Therapy Trainees with Live Supervision. Family Process 17:19-18. 4. Haley, J. (1977). Problem-Solving Therapy, San Francisco, Jossey-Bass. 5. Hoffman, L. (1981). Foundations of Family Therapy, New York. Basic Books. 6. Minuchin, S. (1974). Families and Family Therapy, Cambridge, Mass., Harvard University Press. 7. Montalvo, B. (1973). Aspects of Live Supervision, Family Process 12: 343-359. 8. Neill, J. R.,m and Kniskern. D. P. (1982). From Psyche To System: The Evolving Therapy of Carl Whitaker. New York. Guilford Press. 9. Watzlawick. P., Weakland, J., and Fisch. R. (1974) Change: Principles of Problem Formation and Problem Revolution. New York. Norton. 10. Whiffen, R., and Byng-Hall. J. (1982). Familv Therapy Supervision. London, Academic Press. 11. Whitaker, C., Greenberg, A., and Greenberg, M. (1981). Existential Marital Therapy, In G. P. Sholevar (Ed.). The Handbook of Marriage and Marital Therapy. New York, Spectrum. 12. Whitaker, C., and Keith. D. (1981). Symbolic-Experiential Family Therapy, In A. Gurman and D. Kniskern (Eds.), Handbook of Family Therapy. New York. Brunner-Mazel. 13. Williamson, D. (1981). Personal Authority Termination of The Intergenerational Hierarchical Boundary. Journal of Marriage and Family Therapy. 7:441-452. 14. (1982). Personal Authority Termination of The Intergenerational Hierarchical Boundary Part II. Journal of Marriage and Family Therapy. 8: 23-37. 15. ( 1982). Personal Authority Termination of The Intergenerational Hierarchical Boundary; Part III. Journal of Marriage and Family Therapy. 8: 309-323.

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IN TREATMENT JULIE OLSON, PHD., MFT THE THERAPIST MAY/JUNE 2008

In Treatment is an HBO series based on the show “Be Tipul” created by brilliant writers of therapeutic dialogue, Hagai Levi, Ori Sivan, and Nir Bergman. As a therapist, I find it interesting to watch how the media, in general, portrays therapists. And, they usually write so poorly. This time, HBO has portrayed fairly realistic sessions of four clients and the therapist/supervisor of one very overwrought therapist named, “Paul Weston, Ph.D.” As HBO describes it, “Paul is a therapist, and he has to help his patients with their problems and then deal with his own...in treatment.” I felt sad when the sessions had to take an unethical bent, but then I thought it wouldn’t be entertaining to the general public if it didn’t. Paul’s biggest problem is his lack of ethical boundaries with his favorite client, Laura. The boundaries get blurred when Laura tells Paul she is in love with him. I have found other TV and movie portrayals of therapy to be so misleading to the public. I was about to find this show very refreshing, until I saw how poorly he handled situation after situation with his clients. I have decided that since my supervisees are discussing the show, we could use it as part of our group supervision, on “what not to do.” We are all riveted by each session and how it will turn out. Five nights a week we see another side of Paul and his reactions to his clients. Time and time again, I point out the subtle grey line he crosses in therapy. There are times when his psychodynamic approach can be very insightful and you want to yell out, “Hooray!” Yet, we all agree, we more often want to stand up and yell, “No way, he did NOT say that!” One of my intern’s psychologically un-savvy husband watches the show with her and is concerned with her reaction to the show. She gets very upset when Paul will cross a blatant line. “Why? What’s so bad?” her husband asks. And, this makes her aware of how this show is being seen by many millions of people who do not know “the rules.” What are some of Paul’s ethical violations? He forgets that his client, who says she is in love with him, is not really in love with him, but with the fantasy of him she sees in her mind. So, a man who feels devoid of passion in his life, falls in love with his adoring client in return. He tries to tell her, “It can’t happen!,” but then when she asks, “You can’t deny that there is intimacy PRACTICAL APPLICATIONS IN SUPERVISION

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here. Paul! Is there intimacy here or not?!” He says, “Yes.” Her transference is a typical reaction. However, him not explaining how transference happens or why it may be happening to her, and using it to give her insight into herself, is harmful. Yet, because Paul is disturbed by this need to be loved by Laura, he goes to see his old supervisor for guidance. She immediately recommends he terminate the therapeutic relationship. At this suggestion, he immediately panics. This reaction should show him he has grown inappropriately attached to her, but instead he blames the supervisor for the poor way he attempts to end the sessions. Paul’s first real mistake was not taking full responsibility for his own life. He is putting too much energy into his clients and not enough into his family and marriage. Even having an office in his home seems to set him up to be too casual with his boundaries. Paul’s wife clearly states she is jealous of the time and attention away from her and in “that room,” but he doesn’t see that criticism as a request for making an accommodation for his wife and getting closer to her. He sees it as a threat. Paul seems to live vicariously through the more interesting lives of his clients. Americans throw themselves into their work when things aren’t so great at home. But, in treatment, our work is our client’s psyche—it is their lives. We must not think about them too much after they have gone. We must remember that they do not know much about us. So it would be natural for them to feel a sense of intimacy as they tell the most intimate details of their lives and we are non judgmental and accepting in return. Even Paul’s other clients have issues with how he treats them and asks, “what do you REALLY think about me?” … “Why do you care if I live or die?” Paul responds to this last question, with “Because I love you. I have to love each of my clients or else I can’t treat them.” Paul is personally confused about what love is and he is transferring this confusion onto his clients. There are times when Paul tries to play the analytical blank slate. There are other times when he lets his personal feelings leak out and reacts very inappropriately. One time, he attacked a client physically because he was countertransferentially provoked by the client’s transference anger. Another time, he tries to protect a girl so much that he won’t call the authorities when she says she has been sexually molested by her coach. Again, I find this HBO series very informative and useful as a way to do supervision. So often in school we watch documentary movies and they just do not have the same realism. With In Treatment, I ask my supervisees to look up at least one ethical violation a night and to say how they might deal with it better. I also point out the difficult decisions a therapist must make in a split second and how we react to our clients from our past experiences. It is so important to be aware of our unresolved issues and to recognize them when they pop up unexpectedly in a client’s story.

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I recommend that all of us seasoned therapists use this series as a “refresher course” to keep us on our toes. Paul’s been doing therapy for 20 years. Maybe he needs to retire. Or maybe he needs to go on a sabbatical or go into treatment. But, remember, this is only a show. Thank God.

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AN INTEGRATIVE APPROACH TO FAMILY THERAPY SUPERVISION WAYNE F. REGINA, PSY. D.

There are many factors that contribute to successful therapy and supervision. This paper presents a model for supervision that synthesizes the critical internal and external variables of therapy in a manner conducive to training interns. It is pragmatic by design, integrating theoretical, technical, collaborative and personal dimensions thereby maximizing therapeutic efficiency (Aponte & Winter, 1987). A family psychotherapeutic protocol is utilized as the cornerstone of this model. The protocol is designed to obtain the necessary information from a family in order to develop an effective treatment strategy for change. The outline (Table 1) is based upon an integrative approach to working with couples and families, one that combines elements of historical (intergenerational), structural and strategic therapy. Using this model as a guide, interns write a case presentation, the purpose of which is to assess, systemically diagnose and treat relationships combining theoretical, technical, collaborative and personal elements. This document forms the basis of supervision. At all times, the active involvement of the family system is sought in order to maximize the factors necessary for change to occur.

Table I Family Psychotherapeutic Protocol Issues of Danger Legal and Ethical Issues Assessment • The presenting problem • History of the presenting problem • Attempted solutions, previous therapy experience and the results • Three generational genogram, including full history of parents’ families of origin • History of current family: cultural, religious, social, ethnic and family life-cycle issues • Specific stressors on the system • Strengths in the system—actual and potential • Social/community supports • Addictive behaviors both historical and present Systemic Diagnosis • Structural diagram: three generations • Flexibility vs. rigidity of the system • Central hypothesis • Central reframe and dilemma of change Goals/Objectives, Therapeutic Strategies, Collaborative Systems • Goals and objectives: what needs changing and how the system will be changed (be specific) • Strategies for change: compliance or defiance-based techniques and why • Who will attend and why • Collaborative systems: resources and referrals • Concentric circles PRACTICAL APPLICATIONS IN SUPERVISION

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Counter-transference/Personal Concerns • Discuss countertransference issues, actual and potential • Interns personal reactions to the case • Has intern been “caught” by the family • Intern’s fantasy about the best possible outcome and the intern’s role in that outcome Specific Assistance Requested • What does the intern want from the supervisor • Why present the case at this time

THE FAMILY PSYCHOTHERAPEUTIC PROTOCOL Seven central areas are highlighted: Issues of Danger Before therapy can commence, interns are required to assess crisis concerns. Danger issues must be addressed with crisis management taking precedence over psychotherapeutic matters. Suicide assessment; child, elder and dependent abuse; danger to self (i.e., competency matters); and danger to others must be evaluated. If life-threatening problems are presented, they are addressed immediately and reported in this section of the supervision document. Without a context of safety, therapy cannot begin. Legal and Ethical Issues Related to danger issues are the legal and ethical considerations that follow (Conidaris, Ely & Erikson, 1989). Again, interns are asked to detail the appropriate action that they have undertaken with regard to reporting issues. Further, areas of ethical consideration, such as confidentiality, are also listed when working with various subsystems, privileged communication, therapy with minors and so forth. This section is utilized to highlight the legal and ethical concerns regarding therapy and to sensitize interns to these matters. Assessment After detailing the crisis management issues listed above, interns are asked to compile a systematic assessment. This is the information gathering component of the family protocol. It is here where data is conceptualized into a workable framework. Interns are requested to systematically gather the necessary material in order to evaluate and treat the relationship system. Included in the assessment is data regarding the presenting problem. Next, a history of the presenting problem is obtained along with facts regarding attempted solutions, previous therapy experiences and the results. To complete the assessment, a full description of the family is obtained including: • Genogram of the family encompassing three generations and including a detailed history of the parents’ families of origin. As an assessment technique, genograms are powerful tools which can unlock multi-generational themes, patterns and emotional/transactional/behavioral inheritances in a family (McGoldrick & Gerson, 1985). • History of the current family including relevant cultural, social, religious, ethnic and family life-cycle issues. This information helps to highlight both the family’s idiosyncratic as well as nomothetic experiences in relation to other families (Carter & PRACTICAL APPLICATIONS IN SUPERVISION

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• •

• •

McGoldrick, 1980). Also included in this area is information on child abuse (historical as well as present). Specific stressors on the system. This data permits the therapist to target precise areas to impact during treatment. Strengths in the system, actual as well as potential. A focus upon health and adaptability fosters a perspective of respect for the family’s inherent capacity to change by activating latent or underutilized resources. Social/community supports. This information helps establish the family’s degree of isolation versus connection with larger systems. Addictive behaviors both historical and present. Due to the increasing frequency of addictive disorders, it is useful to have interns ask about problems in this area.

Systemic Diagnosis Following the assessment, a systemic diagnosis is written. It, too, consists of several elements: • Structural diagram This diagnostic tool presents a map of the current family system while simultaneously providing a model of “normal” family functioning. Here, boundary make-up is examined along with the interactional style of the family (Minuchin, 1974). •

Central hypothesis A central hypothesis is formulated and the degree of flexibility versus rigidity in the system is speculated. A written reframe and dilemma of change is then produced (Papp, 1983). Reframing shifts the focus of the therapy by uncovering the function of the symptom for the family. That is, the purpose and adaptive nature of the symptom is detailed along with how the system supports the symptom. This reframing shifts the therapeutic focus from how to eliminate the symptom to the consequences to the family for either eliminating the symptom or remaining the same (Papp, 1983). At this time, a written report is compiled by the intern and read to the family which synthesizes the assessment data. Usually, the focus of the presented report centers on the reframing and the dilemma of change. All of the assessment material supports this report. As a supervision tool, this technique accomplishes two purposes. For the intern, it is a training exercise designed to clarify the systemic elements of the case and to conceptualize how this family organizes around the symptom. For the family, it accomplishes the same task and helps shift their usually linear perspective regarding the symptom to incorporate a circular, systemic viewpoint. In addition, however, this approach confronts the family with making a choice: to risk change and its consequences or to remain the same and confront the dangers which “no change” entails. The crucial element here is to obtain a mandate for change from the family. Without a mandate, attempts to change the family are disrespectful (Regina, 1988). With defiance-based families in particular, lacking a mandate for change, the therapist often faces a fearful family where homeostatic protective mechanisms activate and the family rigidifies, thus sabotaging well-intentioned efforts to help.

Further, obtaining a mandate for change is not only respectful of the family, it also outlines the areas in need of change and articulates a treatment plan in which everyone can be involved. Finally, the strategy of acquiring a mandate empowers the therapist as “expert” while PRACTICAL APPLICATIONS IN SUPERVISION

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simultaneously empowering the family as active and committed co-partners in the change process (Regina, 1988). Goals/Objectives, Therapeutic Strategies, Collaborative Systems Goals (what needs changing) and objectives (how will these changes occur) are written. Here, interns are required to target the areas and subsystems needing change and to stipulate the specific changes needed. Therapeutic strategies are then outlined. That is, strategies for change (i.e., compliance-based vs. defiance-based procedures) are highlighted and the provision of who will attend therapy and why is discussed. Issues of compliance-based vs. defiance-based therapy are addressed. With rigid families, defiance-based techniques such as those outlined in strategic therapy are often more appropriate, especially within the time-limited settings in which most interns find themselves (Haley, 1976; Papp, 1983). With flexible family systems, more compliant-based strategies often prove more effective. These families frequently have greater resources and their prognosis is usually better. Specificity is urged. Often in therapy, goals and objectives are vague and as a result difficulties arise when attempting to evaluate therapeutic effectiveness. With greater clarity comes a greater ability to monitor success and identify problem areas as therapy proceeds. Theoretical and technical consistency between assessment, diagnosis and treatment is stressed. Interns are asked to translate theory into practice vis a vis effective counseling methods. Further, they are requested to be cognizant of the family in the development of treatment goals. Family involvement raises self-esteem and family-esteem, important prerequisites for change (Satir, 1967). Collaborative systems are identified. Referrals and resources are addressed. Interns are asked to conceptualize this in terms of “Concentric Circles.” That is, resource activation begins from mobilizing the biological parents and current family, then moving outward to include the extended families, church and community organizations and, finally, social service systems. Adjunctive services and referrals are similarly identified. Appropriate referrals are made. Counter-Transference/Personal Concerns In this section, the personal dimension is investigated. Although counter-transference is technically viewed as an unconscious process, interns address it here in a conscious manner in order to help them articulate their personal reactions to their clinical families. Oftentimes, these reactions are powerful and can affect the course of therapy (Framo, 1968). Included in this section, as appropriate, are the therapist’s reactions to the case, how the intern has been “caught” by the family, and the fantasy as to the best possible outcome and the therapist’s role in that outcome. These areas pinpoint potential problems for the therapist in working with the family. Through addressing personal concerns, the intern learns to be with a family in a non-anxious manner. This, in turn, assists the intern to mobilize internal resources so that more effective therapy can occur. The goal, at all times, is to develop within the intern the capacity to be intimately involved with the family without becoming invested in the outcome. Non-attachment results in more healing therapy and a non-anxious presence is the best way to ensure this process (Friedman, 1987). Finally, it is here that supervision addresses areas where the intern’s own family, family PRACTICAL APPLICATIONS IN SUPERVISION

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of origin or other personal issues, affect the change process. The supervisor assists the intern to remain focused on the family’s agenda not the therapist’s. Specific Assistance Requested Lastly, the intern discusses what specifically is requested from the supervisor. Also discussed is why this case is being represented as opposed to another. The format of this case presentation protocol is a typed, double-spaced, five page document. For individual supervision, a copy is presented to the supervisor and a copy is retained by the intern. In a group supervision format, each group member receives a copy. Discussion This supervision model provides an opportunity to conceptualize, integrate and apply a four-part process for training therapists through synthesizing theoretical, technical, collaborative and personal elements. Further, the particulars of the family psychotherapeutic protocol create a foundation for therapeutic work which grounds the intern in a systemic as well as systematic conceptualization of the family. This base is utilized as a frame of reference which, while providing structure, allows interns to then engage with a family in the challenging task of change. In addition, as an integrative model, it is based philosophically on a humanistic growth perspective that respects both the family’s capacity to make choices for themselves as well as their inherent ability to mobilize family and self-esteem for morphogenic purposes. This model is also rooted in an appreciation of hierarchy and context, both diagnostically and with regard to treatment. Finally, this approach is based upon mutuality of accountability. The family is made accountable for their experience in therapy while the therapist is accountable for providing limits (including safety limits in abusive families), developing a treatment plan and remaining involved in the process without becoming invested or attached to the outcome. With regard to clinical application, this approach has been enthusiastically embraced by many interns. It works well in individual supervision and it is especially well suited for group supervision where training and teaching are so much a part of the supervision process. Interns have expressed appreciation for the freedom which this structure grants them. They are allowed to soar with the security that they have filed a working flight plan. They can enter the realities of their families and utilize an eclectic array of therapeutic techniques in their search for what works with which family. With a treatment protocol in hand, the supervisor can effectively follow the course of treatment with a family, modifying goals and giving further input as needed. Video and audio-taped sessions as well as live consultations can be utilized to supplement the written report. In this manner, all aspects of treatment and supervision are covered. Finally, interns can explore their own growth issues in the safe arena of the supervision environment as they struggle with the unique challenges that each family presents to them. And as a result, they learn to appreciate both the gifts that they bestow upon their treatment families as well as the gifts granted to them from these families. References Aponte, H., & Winter, J. (1987). The person and practice of the therapist: treatment and training. PRACTICAL APPLICATIONS IN SUPERVISION

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In M. Baldwin & V. Satir, The use of self in therapy. New York: Haworth Press. Carter, E., & McGoldrick, M. (1980). The family life-cycle and family therapy: an overview. In E. Carter & M. McGoldrick, The family life-cycle: a framework for family therapy. New York: Gardner Press, Inc. Conidaris, M., Ely, D., & Erickson, J. (1989 ed.). California laws for psychotherapists. Gardena, CA: Harcourt Brace Jovanovich, Publishers. Freidman, E. (1987). How to succeed in therapy without really trying. The Family Therapy Networker. 11, (3), 26-31. Framo, J. (1968). My families, my family. In J. Framo (1982), Explorations in marital and family therapy. New York: Springer Publication Company, Inc. Haley, J. (1976). Problem-solving therapy. San Francisco: Jossey-Bass. McGoldrick, M., & Gerson, R. (1985). Genograms in family assessment. New York: W.W. Norton & Company. Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press. Papp, P. (1983). The process of change. New York: Guilford Press. Regina, W. (1988). A systematic approach to assessment in couples therapy. Unpublished manuscript. Satir, V. (1967). Conjoint family therapy (Rev. ed.). Palo Alto, CA: Science and Behavior Books.

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GENDER IN SUPERVISION/TRAINING IN MARRIAGE AND FAMILY THERAPY ELIZABETH (LIBBY) J. REGISTER

This paper encourages the supervisor to confront her/his value system in regard to gender and stereotypical behavioral expectations for female and male family members. In turn, this experience allows the supervisor to encourage her/his supervisees to confront their value systems and determine how this can impact therapeutic interventions with families. Some practical applications of gender awareness and interventions in the supervisory process are presented. Retrospection or History When the Commission on Accreditation for Marriage Family Therapy Education revised its Accreditation Manual to require all AAMFT approved programs to offer course work in gender issues there was a major shift from thinking of gender as unimportant to including gender and sexism in clinical training. The guidelines presented in the Manual on Accreditation (1991) however, do not spell out how gender socialization should be taught. Three content areas in gender training were specified to be addressed: sexuality, sexual functioning and sexual identity. These are to be addressed “within a theoretical-clinical context” (p. 15). These guidelines are of little value in assisting faculty in developing courses which can convey an appreciation of how influential gender is in the formation of all areas of people’s lives. Since there is extensive literature documenting how gender organizes all aspects of life for women and men—from communication patterns, to division of labor, to use of leisure time, to physical safety—it is striking that sexuality would be so prominently emphasized as a major focus of gender training. Gender encompasses all aspects of life, not just one’s sexuality. Jacobson (1983) points out that gender biases are largely unconscious and accepted as “reality.” Without stating what is to be taught, it is possible that coursework on gender may simply reinforce the teaching of stereotypes of “how men are” and “how women are” which would do little to change what is taught in clinical training (Leslie, 1996). Leslie and Clossick, (1996) conducted an investigative study to determine the impact on clinical decision-making of those therapists having gender training—either through a separate course or by having gender issues integrated throughout the curriculum. They found that training in gender issues alone did not significantly influence the level of feminism and sexism in clinical decision making, however, those receiving gender training from a feminist perspective—whether it was taught in a separate course or integrated throughout the curriculum—were more likely to make feminist assumptions. Although gender training from a feminist perspective did not affect their likelihood of using feminist interventions. Courses taught from a feminist perspective addressed social construction of gender and the interplay of gender and power in families which tends to reduce sexism. Those taught from this perspective were significantly less likely to use sexist interventions. It seems to be easier for therapists to learn what “not to do” than what “to do” as they are sensitized to gender issues from a feminist perspective.

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Gender awareness does not come easily. It is a process that builds over time and occurs at the affective and cognitive level. Hence, time for integration is essential. Usually considerable time passes between cognitive awareness and emotional integration. Quoting Monica McGoldrick (1989), “There is no formula for gender-sensitive family therapy. We are not going to be able to come up with quick ‘technical’ or ‘strategic’ solutions, cookbook fashion, which will make this problem evaporate. This is going to take us all working together for many years, or probably more accurately, many generations” (p. 12). It requires a conscious decision and effort to learn to include this perspective in the therapeutic flow since our gender and cultural socialization is unconscious. James Framo (1996) wrote “. . . when feminists began talking about how women are oppressed, I had no idea, at first, what they were talking about. It took a while for me to make the distinction between the power politics in the family and the power politics outside the home in society (the personal is political). Feminist family therapists documented the second-class status of women in the treatment situation, showing how women were often discounted, discriminated against, and pressured toward traditional female roles, and how therapists reinforced the male privilege that existed in the wider culture, When feminists first brought to our attention the inequities in the power relations of men and women, centuries of conditioning made it difficult for men and even for some women to see. Basic assumptions of the field have been recast. Gender has been introduced as a major reformulation of family dynamics since it questioned the basic concept of systems theory and its potential disadvantage to women” (p.305). Thinking gender in terms of marriage may be the most difficult change to imagine, since marriage is the least examined and most honored linchpin in the entire structure of patriarchy (Goodrich, 1991). For family therapists to challenge our clients and ourselves with critical examination of marriage and the formulation of new models requires a major shift in our thinking. According to Goodrich, any formulation of change in marriage requires that we move from the realm of power into the realm of pleasure, where mutuality and reciprocity replace hierarchy and control. Such a change is inhibited by the unequal power in the world for men and women. Perhaps the model of female friendships might serve as a reference point, since, there are no such rules as “might makes right” or “money talks.” Mutuality from the standpoint of labor division might be an interesting starting point. In studies comparing different types of households—men alone, women alone, men living with their children, women living with their children, husbands and wives living together with and without children—the person who does the most housework is the woman in a household with a husband present. The presence of a husband creates more housework for a woman than the presence of a child under ten, even in cases where he reports himself an equal partner in the chores. The reason—husbands expect more of their wives, and wives expect more of themselves, in the presence of a husband (Hartmann, 1980). There are structures—economic, social, political, religious and psychological—that serve to maintain power imbalance within the institution of marriage (Goodrich, 1991). According to Judith Myers-Avis, women (the problem) are held responsible for change in marital and family therapy. For years, family therapists expected women to change, while just “being available or present” was enough to ask of men. A friend who is divorced said to me, “My adult children say to me, ‘get it together’ and don’t ask anything of their father, they just PRACTICAL APPLICATIONS IN SUPERVISION

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want a relationship with him and are willing to settle, without making any such demands.” Continuing to work from this widely held assumption—that if the women in families would work out their conflicts and contradictions, individually and within the family—reproduces transactions that both conform to and confirm this assumption. Myers-Avis states that this belief—that the more direct, less emotionally laden dealings of men are often impeded by the indirect, emotional, even mysterious dealings of the womenfolk—is so generalized in our culture that we hardly notice it, and are frequently moved to sort things out between the women while the men await a “higher” ground on which to enter the fray. At the same time, family therapy tends to exonerate and overlook men and their responsibility, perhaps, from societal male/female role expectations and unconscious conditioning. Betty Carter (1995) gives a personal example of this: “To Sharon’s grievance that he was never around, Gary admitted that he ‘sometimes’ worked late, that he traveled ‘occasionally,’ and brought work home ‘sometimes.’ In the old days, before my evolution toward a therapy of multiple perspectives (wide-angle lens), I would not have questioned his busy schedule (not unlike my own, after all), assuming the complete reasonableness of extended work hours for an up-and-coming professional on the fast track, and would have tried to help Sharon change her life—get additional childcare help, join some adult-oriented activities, learn to accept the inevitability of his unavailability. But now I shifted my lens beyond the close-up focus on Sharon’s (problem) to the concrete details of the couple’s timeline and began putting some pressure on Gary. How many hours a week, exactly, did he work? What time did he get home each night, and how much time, precisely, did he spend with his children, his wife? How much money did he earn? Both were a little surprised by the first questions and downright startled by the last. Ironically, many middle-class clients today are as uncomfortable talking about their prioritizing of money, work and time as they once might have been describing their sex lives. I told him there was no way that he could both work 65 hours a week and have any kind of marriage or family life. Until he changed that, there was nothing I could do to help him” (The Family Therapy Networker, 1995, pg. 32). The supervisor who brings such concerns to the attention of the supervisee, for the first time, may cause him or her to think “gender” and how gender and time influences family dynamics and satisfaction. If the supervisor is not aware of gender, or of gender-derived power or powerlessness, then opportunities for learning and presenting choices are lost. Virginia Goldner (1985) said that we, in family therapy and in supervision of family therapists, have learned to think generationally. Now, it is imperative that we include gender thinking as an organizing principle of society as a whole (just like race or class). As supervisors become aware of gender as an organizing principle in human relations, including the supervisor/supervisee relationship, one’s concept of relationships changes, comparable to moving from linear thinking to systemic thinking. With this perspective added to our consciousness, we can no longer think one’s gender is inconsequential. Harriet Lerner encourages supervisors to have trainees and supervisees look at multigenerational work patterns of women and the effect of marriage on one’s career whether working outside the home or inside the home or both. It is important to look at family messages regarding women and the work they do. It is essential for supervisors to keep in mind the division of labor in a family and pay attention to the one who carries a burdensome load and how that influences available energy for sexual activity and other activities that enrich a relationship and family life. Also, how does economic dependency determine a woman’s or man’s interaction PRACTICAL APPLICATIONS IN SUPERVISION

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and behavior within a relationship and how is the balance of power influenced when one is economically dependent? As Haley might ask, “How does economic dependency influence who sets the family rules and who follows the rules?” Lerner (1988) challenges therapists and supervisors to re-examine “circularity.” She contends that family systems theory is not circular enough in that it tends to treat the family as if it exists as a separate entity from the social, economic, and political system. Supervision and Clinical Application According to Turner and Fine, (1997), almost without exception, female supervisors have been the authors of what has been written in the marriage and family therapy (MFT) field about gender and supervision, following the lead of mainstream feminist authors (e.g., Hare-Mustin, 1978). Since that time, family therapy authors have pointed out the pitfalls of men supervising women, the likelihood that the contribution of women will be devalued whether they are supervisors or supervisees, and the difficulties male supervisors face in attempting to work effectively with female supervisees given the legacy of patriarchy ( Doherty 1991), (Turner & Fine 1997). The feminist model of supervision includes teaching an understanding of power and gender roles by example as well as theory. The supervisor and supervisee are continually in the process of cultural analysis to make unconscious sexism conscious. Wheeler, et all (1985/86) developed a “Family Therapy Education and Supervision: A Feminist Model” to assist supervisees and supervisors in their learning process; republished in “Women in Families: A Framework For Family Therapy” (1989). They have outlined their model in terms of specific perceptual/conceptual and executive skills which the therapist may employ during three phases of therapy. These are: (a) developing and maintaining a working alliance between family and therapist, (b) defining the problem, and (c) facilitating change (see pages 143-145 in “Women in Families”). The supervisor/supervisee relationship is a crucial element in the education and supervision process and hopefully embodies the values and behaviors which the supervisee is learning. The major characteristics of the relationship are the minimization of hierarchy and the use of social analysis—clarification of sex-role learning that impedes professional competency. Supervisors have greater responsibility than supervisees for opening up a dialogue about power, more generally, and gender inequality, more specifically (Fine & Turner, 1997). Minimizing hierarchy can be accomplished by establishing a contract between supervisee and supervisor for shared responsibility for change, and learning through evaluation feedback, using the goals and objectives outlined in the contract of shared responsibility as criteria by which progress can be measured. Individual strengths and competencies are valued and built upon. One responsibility of the supervisor is to challenge, respectfully, any stereotypical behaviors observed and bring them to the table for discussion and shared experience. Ridgley (1996) states that female supervisees need to develop increased comfort with assuming a position of influence and male supervisees need to develop increased comfort with relational aspects in therapy rather than relying on “doing” and “taking over.” The gender-bias aware supervisor is careful to avoid sexist language and encourages PRACTICAL APPLICATIONS IN SUPERVISION

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supervisees to develop language awareness and to be aware of its implicit power or disempowerment (Wheeler.) Using derogatory labels in regard to female clients, such as “castrating,” or “domineering,” or “she’s a bitch,” demeans and connotes a lack of respect for female clients and supervisees. When a supervisee uses such terms, the supervisor might ask, “If you could use another word other than, ‘domineering,’ what would it be?” This often brings a response like, “What do you mean?” which opens up the possibility of social analysis. An example of a sexist concept occurs in Napier’s book. The Fragile Bond (1988). He entitles one chapter “The Wife-Dominated Marriage.” There is no chapter entitled “The Husband-Dominated Marriage,” probably because “husband-dominated” marriage is the socially accepted and institution-supported marital organization. Social analysis by the supervisee and supervisor clarifies and politicizes a therapeutic issue (Wheeler, Goodrich, Rampage, Ellman & Halstead, 1988). To the female supervisee, the supervisor might say, “You are being too protective of this husband; his wife is already doing that. As females, we are socialized to be protective of males at our own expense. But this isn’t useful for female clients or therapists. Direct him to tell his wife how he feels.” This models an active, competent therapist. Or, the supervisor might say to a male therapist, “You’re being too competitive with this husband. As a male you are socialized to compete for power with other males. That isn’t useful for a male client or a therapist in establishing relationships. Find a way to cooperate with him,” Wheeler, et al’s training and supervision model is one of the most definitive and explanatory models available from a feminist family therapy perspective. A challenge for a female supervisor is to act with firm benevolence. Typically those supervisors who are primarily nurturing are devalued for not being clear thinkers; those who are primarily task-focused are perceived as dangerous (Ault Riche, 1987). At various times as a supervisor, I have experienced the second position as task-focused and agree with Benardez (1983)—it is best to detach, rely on a more neutral and objective stance, i.e., to contain without retaliation, helplessness, or expression of intense affect. Experience has contributed to my learning process. There are inherent complexities in the supervision process arising from two different axis of power: power related to role (supervisor and supervisee), and power related to gender (male and female). Since the power accorded to supervisors is legitimized by professional accrediting associations, it is more readily acknowledged, discussed, and negotiated by supervision parties (Fine & Turner, 1995). Power inequities related to gender lack social legitimacy in a social context where egalitarian values are now endorsed by many men and women. Just how to implement and to act on these values is still at issue. The lack of clarity and legitimacy impede open, overt dialogue about gender/power relations in supervision. Goode (1982) states that in relations of inequality, the more powerful actors risk being “blind” —unaware of the privileged position, especially if it has been inherited, rather than intentionally sought. In contrast, members of subordinate and marginalized groups are highly attuned to power dynamics, given that their lives are significantly affected by the actions of the more powerful. Fearing reprisal, members of the subordinate group are unlikely to openly voice their protest about injustices. Theorists of culture would suggest that women know more about men than men know about women. This idea comes from evidence that the subordinate culture knows more about the dominant culture. PRACTICAL APPLICATIONS IN SUPERVISION

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For the subordinate culture to survive, it has to “know” the ways of and adapt to the dominant culture. Based on this premise, the George Hull Centre Family Therapy Training Program in Toronto established a policy that the ideological preference for co-teaching is with a woman and a man and if this is not possible two women will teach together but not two men (Ridgely, 1996). According to Turner and Fine (1997), each gender configuration of supervisor/supervisee and client offers opportunities and constraints: Women Supervising Women: This configuration offers for a female supervisee a competent role model, an opportunity for engaging self-disclosure, and the possibility for a collaborative supervisory relationship. For the female supervisor, she may expect fewer challenges to her authority than from male supervisees and disclosure of personal experiences which enables a more trusting relationship. On the down side, there may be “power blindness.” The supervisor may underplay the power of the female supervisee, if she expects females to be less powerful participants in any interaction. Supervision can become a struggle when the supervisee meets up with her female supervisor’s expectations that she be independent and assertive with colleagues, clients and the supervisor herself, especially if the female therapist has grown accustomed to support and solidarity from women. Also, this configuration needs to be vigilant about gender experience gaps when their clients are males. Men supervising men: This configuration is the least written about in gender and supervision. It offers both supervisor and supervisee a mentoring model and a unique chance to work together in a domain that is not traditionally perceived as male-oriented—and that domain is of “caring,” and “helping” relationship-focused activities (Nelson, 1991). When the client is a female, male supervisees and supervisor are likely to be very conscious of the gaps in empathy and seek consultation. The aspects that are risky may be blindness to power relations and competition between males. The supervisor may be aware of his power position, but may be blind to the power the male therapist has in relation to his clients, especially if the client is a woman. Another pitfall relates to the traditional expectation that males should seek and receive support from females and display their independence in relation to male authority figures. If the client is male, the male therapist may find himself in competition for the authority position. Men supervising women: According to Turner & Fine, the advantages of male supervisor-female supervisee have been ignored and undocumented with the exception of Nelson’s short comment. Nelson commented that working with a male supervisor who had developed skills for observing relationships and the capacity to stay connected with clients when emotions ran high was a learning experience for female supervisees who had not been exposed to this ability in men. This experience enables females to value facets of their own gender identity that are contrary to traditional expectations. Also, if the male supervisor is able to stay with the female supervisee who is angry and in pain about her subordinate position, he can generate hope and trust. This configuration has been considered the most problematic given that male supervisors are accorded power greater than female supervisees on both supervision and gender axes of power. Because men have inherent power, when they may not desire it, they may have to remind PRACTICAL APPLICATIONS IN SUPERVISION

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themselves and be reminded that they have it (Nelson, 1991). Well intentioned, gender-sensitive male supervisors, out of subtle power blindness, tend to “correct” the gender inequities by insistently leading female supervisees and clients toward liberation, or protecting them without obtaining their permission (Turner, 1993). Out of zeal, he again, unwittingly exercises the kind of paternalistic privilege that robs women of voice and personal agency. Again, consultation is advisable in this configuration to increase accountability (Tomasese & Waldegrave, 1993). Women supervising men: This configuration provides opportunities for male supervisees to learn to respect female authority figures and gives the female supervisor a field from which to learn more about male experience from a position of strength. Little has been written on the constraints of the female supervisor/male supervisee. Since some female supervisors are oriented toward models of caring that emphasize empathy and empowerment, there may be a failure to recognize that male therapists may be just as empathetic as female therapists in different, but equally therapeutic, ways. Because of females’ experience with being the devalued, less powerful party in opposite-sex gender encounters. This can lead to an underestimation of their influence and control over male supervisees (Turner, 1993). This position can be even more consequential when females are supervising males who have themselves experienced oppression related to other aspects of their identity, (e.g., class, race, gender orientation, etc.). In mixed-sex group supervision where males are in a minority, female supervisors may need to guard against the inclination towards solidarity with the female supervisees in the group. Turner and Fine, in their review of the literature on supervision, found two areas that have not been addressed directly: (a) emotionally charged gender politics (b) sexuality, gender, and supervision. A few points for supervisors to be aware of when dealing with gender politics in a mixed-sex group are facilitation of open dialogue and providing ample time for open expression of feelings for both supervisor and supervisees. The opportunity to voice a range of emotions forestalls the development of direct outrage or indirect expressions of annoyance (e.g., sarcasm, innuendoes, etc.) and can prevent a buildup of closeted anger and bitterness towards the opposite sex that can occur in a same-sex grouping. Same-sex supervision groups may find it easy to converse and may need to set aside some discussion time to enable movement from venting about the opposite sex to reflection on alternative personal experiences and “realities” (Doherty, 1991). For open exchange to occur, females may need to feel safe from the negative influence of men’s power, and men may need to feet liberated from political correctness. Both sexes may need to accept that their feelings will sometimes offend the other person, who may experience their anger or hurt as a personal attack. Time for reflection on emotions is the most important factor because the links between feelings and ideas about them may be diffusable and changeable (Turner & Fine, 1997). When the focus of supervision is on the clients’ sexual problems, or sexual attraction between therapist and client, sex is likely to be discussed in the process of supervision; viewing a videotape can be helpful in sorting this out, but talking about sexual attraction or desire between PRACTICAL APPLICATIONS IN SUPERVISION

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supervisee/supervisor is more risky because the purpose is removed from client welfare and the misuse of power is at issue (Bird, 1993). More research needs to be done regarding the misuse of power. Raising power issues in supervision can be difficult. Strategizing with a supervisee as to how to get cross-gender couples to begin thinking about their dilemmas as having a basis in power differential without losing the couple can be challenging for the supervisor and the supervisee. Lynn Parker (1997) asked leading gender-sensitive supervisors and therapists to share how they broach the subject of power with couples. Parker found that they structure the session one of three ways: (1) Consciousness raising-education (2) Boldly naming the power or (3) Indirectly raise the power issues. Characteristics of each will be described. Betty Carter structures the sessions for consciousness raising by the questions she asks and then sequencing events so that a connection is made between partners’ concerns and the distribution of power in the relationship. The way the session is organized sets the course. So, the first session is structured by way of assessment questions that raise the power arenas for discussion and analysis. Examples of such questions are: how much money each earns (are both partners economically viable?), how resources get allocated, who makes decisions, who accommodates, and how labor and responsibility are distributed. This method gets the power issues on the table. Establishing the specifics of these arrangements helps partners begin to move beyond what is likely a denial of power disparities in the relationship. When there is a big difference in earnings, she asks “How does that effect your decision making process?” Most often, both people work and if they have children, she asks “Since you both work, how is the child care managed? When a child is sick, who stays home?” This form of information gathering introduces them to the notion that all of their domestic arrangements are important and reflect the power structure in the couple’s relationship (Parker, 1997). Virginia Goldner boldly names the power issues she directly identifies, and puts words to power issues she sees or experiences happening in the session; here issues are confronted as they arise. Attention is directed to the power maneuvers evidenced in behavior, expectations, and roles. She may question what it means to be powerful; she may reframe or redefine behavior or expectations as issues of power and she might even say, “This is wrong.” After identifying power issues, she then focuses on what she calls “power-over,” as maneuvers that protect partners from painful feelings. Goldner can be bold because she is careful to attend to establishing a sound therapeutic relationship. “Power-over” behaviors may be contrasted with what Surrey (1991) calls “power with” or mutual power behaviors in which all participants in the relationship interact in ways that build connection and enhance everyone’s personal power. Thelma Jean Goodrich indirectly raises the power issues by facilitating the clients to identify power issues in specific presenting problems they bring to therapy. She starts with the couple’s concerns, asking them to unfold the events. As the concern is described in detail, the therapist listens for how problems are related to power issues and may offer gentle probing questions that point in that direction. She then gives feedback and/or tasks that help partners make a connection between the problems that concern them and the underlying power issues. PRACTICAL APPLICATIONS IN SUPERVISION

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This structure asserts that it is better to get the client, not the therapist, to say, “This isn’t fair.” Goodrich calls this method “leading the witness” which creates less resistance. Peggy Papp also uses the indirect approach. When a couple who prides themselves on being sophisticated and intellectually up-to-date, present with a “division of labor” problem, Peggy assigns them to read the Second Shift by Arlie Hochschild, and decide if their marriage fits into the “traditional, the transitional or equalitarian” category. The wife classifies it as “traditional” while the husband classifies it as “transitional.” She asks each of them to observe and write down the choices they are making in their daily lives that they considered “traditional,” which they considered “transitional,” and which they consider “equalitarian.” She asks them not to discuss their list with each other but to wait and compare lists in the next session to see if they are each making the same or different choices. With this intervention, the couple is in charge of the kind of relationship they want. In changing beliefs, it is important to work on the action level as well as the conceptual level. Carmen Knudson-Martin (1997) offers these suggestions for making invisible social forces visible in the gendering of the supervision process. (1) Develop sensitivity to how gender shapes experience and infuses relationship structures. This requires learning how to stand back and look and then ask how gender is a part of what is happening. Failing to adopt this stance, previous gender patterns will remain unexamined and are likely to be reinforced. (2) Do not assume equality or no gender bias. Responding to people as if they are equal when they are not, puts the one who is unequal at a disadvantage. Systemically, this means recognizing that patterns may be reciprocal, and that does not mean that each person has equal power to shape the pattern or benefit by it. Also, when interventions focus on helping people separate or individuate, the positive aspects of affiliative, attentive behavior may be missed. (3) Do not confuse neutrality with no response. When one’s intention is “to not take sides,” since females are socialized towards a tendency to accommodate or be satisfied by understanding the other person’s side, deliberate action may be required, e.g., actively encouraging male accommodation as well. (4) Ask “gendercentric” questions. This is a form of circular questioning in which gender is central to the relationship processes. Ask questions such as, “Who attends to whom?”; “Who is the most stressed in the relationship?”; and “Which one benefits from a particular relationship pattern?” (5) Focus on process. When clients see their relationship patterns, it is possible to see other options and thus provides an opportunity for conscious decision-making. (6) Articulate the issues. Depending on how the therapist chooses to use himself or herself in the therapy, articulating the issues may involve an educational role, a leap into the expert role, or a collaborative role. But failure to articulate the gender and power issues embedded in the therapeutic conversation means both issues will probably go unnoticed and unaddressed maintaining the status quo. (7) Externalize. Framing issues in the context of gender and linking it to the larger culture helps clients see their problems as more than their own personal struggle—the struggle is universalized and helps them see they are not alone. Externalizing makes the social context visible and change less threatening.

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In response to Knudson-Martin’s article “The Politics of Gender in Family Therapy” Ronald Levant, (1997) states that it is very difficult to achieve gender equality in any context, therapeutic or otherwise. In his view, unexamined aspects of masculinity may account for much of the difficulty. He lifts up two themes to be examined: (1) the greater power and privilege accorded to men in a patriarchal society and (2) the vulnerabilities and severe limitations that accrue to most men by virtue of their gender role socialization under traditional masculinity ideology. Levant points to “a new psychology of men” for us to learn about the newer perspectives regarding men. We supervisors need to widen our perspective, according to Carter (1995), widen our lens to all the so-called “external” non-psychological dimensions of a client’s/supervisee’s reality and learn to pan forward and backward with an adjustable zoom lens to include the private and public, personal and political, mental and physical, emotional and spiritual. Marianne Walters says she thinks “gender” when supervising and looks for a parallel process between supervisee and client(s). “The issue for family therapists seeking a feminist perspective is to challenge our own assumptions and therapy traditions in order to probe the ways that sex roles and gender power systems structure family relationships and influence our own thinking about what is happening in the families we see. Within this framework, my supervision between therapy sessions is focused on analyzing and critiquing the concepts and assumptions underlying alternative interventions. We rightly assume that hierarchy, boundaries, authority, limits, and rules are necessary systemic regulators of healthy family functioning. Yet, seen in a larger social context, these properties, or areas of functioning, will be understood to have very different meaning and significance for men and women.” Marianne Walter’s suggested solution would be to support authority and challenge its “paternalistic” features. While working with boundaries and rules, pay careful attention to appropriate ways of empowering daughters. Olga Silverstein (1994) encourages supervisors and supervisees to challenge the prevailing cultural and psychotherapeutic messages that encourage mothers “to pull back” from their sons, and sons to distance themselves from their mothers. She says the traditional view that encourages a mother, especially if she is a single parent, to “turn her son over” to the father or another male figure or relinquish him to the peer group when he approaches adolescence is experienced as abandonment by the son. She finds herself expected to facilitate a pattern of emotional development in her son that stands in direct opposition to her own. In the traditional two parent home, the mother may hold back and expect the father to take over the parenting of the son. Silverstein contends that the social edict “no woman shall control a man, even her own son” may be responsible for this abandonment. Both mother and son lose. She believes that both sexes are capable of developing nurturant and task-oriented skills and she encourages supervisors to plan and strategize with this view point in mind. Group supervision is an excellent setting for exploring personal sex-role issues and their origins, perhaps through Bowenian, family-of-origin work. One technique would be to have the supervisee construct his/her own genogram and the client’s genogram and place them side by side and look for similar patterns, sex-role messages, male and female work patterns and power distribution, economic viability, caretaking and other gender issues. It is a non-threatening way PRACTICAL APPLICATIONS IN SUPERVISION

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to look at basic sex-role belief systems of supervisees and open a dialogue within the supervision process. An additional layer would be for the supervisor to construct her/his genogram and place it beside the supervisee’s and client’s looking for common gender threads. Monica McGoldrick (1991) includes in the genogram, above the name and birth date of each partner, their personal income and a notation of any inheritance they have or are likely to receive, She also includes the education and employment history of each spouse. This information helps her understand the stance each partner takes in the relationship. She believes it is dangerous to be economically inviable, and strives to get clients economically viable, especially female clients. McGoldrick suggests supervisees and supervisors be sensitive to the price males may have to pay in losing job advancement and, in addition, being discounted and invalidated by other men if they change their “male” success orientation to give higher priority to relationships, caretaking, and emotional expressiveness. She believes therapy with males is primarily about helping them learn to connect and overcome their typical dissociation of experiences and feelings. Conclusion Finally, Storm and Todd (1997) suggest that supervisors ask themselves the following questions: (1) How has the feminist critique of MFT changed your approach to supervision? (2)What gender issues should you be aware of as a supervisor? (3) In what ways might your gender and the gender of your supervisee affect the way you do supervision? (4) How do you as a supervisor deal with power differential in the supervisory relationship and in the families that your supervisees treat? There has been a long history of excluding the female perspective from supervision and training of marriage and family therapists. In the 1990s, power issues, economic viability and political advocacy for social change are being addressed in the field of marriage and family therapy. It is encouraging to see new inroads, from a gender perspective, into how to supervise and intervene with families. The integration of gender issues in training and supervision is an on-going journey. In my process of updating (more like rewriting) this paper on Gender and Supervision, I have contracted with myself, again, to focus attention on gender issues with the clients I see, the supervisees I supervise, and within myself and how I function within my primary relationships. It is so easy for me to be seduced into an unaware state. To use an expression often used during the consciousness-raising era of the women’s movement, I have had many new “click” experiences and insights while on this renewed journey into gender-aware supervision and family therapy. Hopefully, the references will provide a helpful guide for those interested in further exploration of the subject. References American Association for Marriage and Family Therapy Commission on Accreditation for Marriage and Family Therapy Education and Training. (1991). Manual on Accreditation. Washington, DC. Andronico, M. (Ed.) (1996). Men in Groups. Washington, D.C.: APA Books Ault-Riche, M. (1987) Teaching an integrated model of family therapy: Women as students, women as supervisors. Journal of Psychotherapy and the Family, 3 (4), 175-189. Avis, J.M. (1985). The politics of functional family therapy: A feminist critiques, Journal of Marital and Family Therapy, 11, 127-138. PRACTICAL APPLICATIONS IN SUPERVISION

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Bernardez, T. (1983). Women in authority: Psychodynamic and interactional aspects. Group Work with Men. Haworth Press: New York. Betcher, W., & Pollack, W.S. (1993). In a Time of Fallen Heroes: The Recreation of Masculinity. New York: Athaneum. Bird, J. (1993). Coming out of the closet: Illuminating the therapeutic relationship. Journal of Feminist Family Therapy, 5, 47-64. Brooks, G. (1995). The Centerfold Syndrome. San Francisco: Jossey-Bass. Carter, Betty. (1995) Focusing Your Wide-Angle Lens. The Family Therapy Networker. November/December pp. 31-3 5. Causts, B.L., Libow, J.A., & Raskin, P.A. (1981). Challenges and promises of training women as family systems therapists. Family Process, 20. 439-447. Doherty, W. (199 1). Can male therapists empower women in therapy. Journal of Feminist Family Therapy, 3,123-137. Eisler, R. (1995). Masculine gender role stress. In R.F. Levant & W.S. Pollack (Eds.), A New Psychology of Men. New York: Basic Books. Fine, M., & Turner, J. (1995). Collaborative Supervision: Minding the Power. Boston: Allyn and Bacon. Framo, J.L. (1996) A personal retrospective of the family therapy field: then and now. Journal of Marriage and Family Therapy, 22, (3) 289-316. Gilmore, David D. (1990) Manhood In The Making. New Haven: Yale Univ. Press. Goldner, V. (1985a). Feminism and family therapy. Family Process, 24 (1), 31-47. Goldner, V. (I 985b). Warning: family therapy may be dangerous to your health. The Family Therapy Networker, 19-23. Goodrich, T.J., Rampage, C., Barbara, E., & Halstead, K. (1988). Feminist Family Therapy: A Casebook. New York: Norton & Co. Goodrich, Thelma. (1991). (Ed). Women and Power: Perspective For Family Therapy, New York, New York: Norton & Co. Goode, W. (1992). Why men resist. In B. Thorne & M.Yalom (Eds.), Re-Thinking The Family: Some Feminist Questions (pp. 131-150). New York: Longman. Gurman, A.S., & Klein, H.H. (1984). The family: An unconscious male bias in behavioral treatment? E. Blechman (Ed.). Behavior Modification With Women. New York: Guilford Press. Haber, Russell & Ridgely, Elizabeth. (1996). Dimensions of Psychotherapy Supervision, Maps and Means. New York: W.W. Norton Haley, J. (1976). Problem-Solving Therapy: New Strategies For Effective Family Therapy. San Francisco: Jossey-Bass. Hare-Mustin, R. T., & Brodsky, A.M. (Eds.) (1980) Women and Psychotherapy: An Assessment of Research and Practice. New York: Guilford Press. Hare-Mustin, R.T. (1986). The problem of gender in family therapy theory. Family Process, 26, 15-21. Hartmann, H.I. (1980). The family as the focus of gender, class, and political struggle: the example of housework. Signs: Journal of Women in Culture and Society, 6 (3), 366-394. Jacobson, N. S. (1983). Beyond empiricism: The politics of marital therapy. American Journal of Family Therapy. 11-24. Knudson-Martin, Carmen. (1997). The Politics of Gender in Family Therapy, Journal of Marital Therapy. Vol. 23 (4) 421-437. PRACTICAL APPLICATIONS IN SUPERVISION

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Krugman, S. (1995). Male development and the transformation of shame. In R.F. Levant & W.S. Pollack (Eds.). A New Psychology of Men. New York: Basic Books. Lazur, R.F., & Majors, R. (1995). Men of color: Ethnocultural variations of male gender role strain. In R.F. Levant & W. S. Pollack (Eds.). A New Psychology of Men. New York: Basic Books. Lerner, H.G. (1988). Women In Therapy. New Jersey: Jason Aronson, Inc. Leslie, L.A., & Clossick, M.L. (1996). Sexism in Family Therapy: Does Training in Gender Make a Difference? Journal Of Marital And Family Therapy, Vol. 22, (2) 253-269. Levant, Ronald F. (1997) Gender Equality and the New Psychology of Men. Comment on “The Politics of Gender in Family Therapy.” Journal of Marital and Family Therapy, Vol. 23, (4) 439-444. Libow, J.A., Raskin, P.A., & Caust, B.L. (1982). Feminist and family systems therapy: Are they irreconcilable? The American Journal of Family Therapy, 10, 3-12. Liddle, H.A., Breunlin, D.C., & Schwartz, R.C. (Eds.). (1988). Handbook of Family Therapy Training And Supervision. New York: Guilford. McGoldrick, M., Anderson, C.M., & Walsh, F. (Eds.). (1989). Women In Families: A Framework For Family Therapy. New York; W.W. Nor-ton Morris, L. (1997). The Male Heterosexual. Newburry Park, CA: Sage. Myers-Avis, J. (1987). Deepening Awareness: A private study guide to feminism and family therapy. Journal Of Psychotherapy & The Family, 3(4). Napier, A.Y. (1984). The Fragile Bond. New York. Harper & Row. Nelson, T. (1991). Gender in family therapy supervision. Contemporary Family Therapy, 13, 357-369. Okun, B. F. (1983) Gender issues of family systems therapists. Issues In Training Marriage and Family Therapists. Ann Arbor: Ml: Eric/Caps. O’Neil, J.M., Good, G. L., & Holmes, S. (1995). Fifteen years of theory and research on men’s under role conflict: New paradigms for empirical research. In R. F. Levant & W.S. Pollack (Eds.). A New Psychology of Men. New York: Basic Books Parker, L. (1997). Unraveling Power Issues in Couples Therapy. Journal of Feminist Family Therapy, Vol. 9 (2). Pasick, R. (1992). Awakening From The Deep Sleep: A Powerful Guide For Courageous Men. San Francisco: Harper. Rice, D.G., & Rice, J.K. (1977) Non-sexist “marital” therapy. Journal of Marital Family Counseling. 3, 3-10. Silverstein, L. (1996). Fathering is a feminist issue. Psychology of Women Quarterly, 20, 3-37. Silverstein, 0., & Rashbaum, B. (1994). The Courage To Raise Good Men. New York: Viking. Stoltenberg, C.D., & Delworth, U. (1987). Supervising Counselors and Therapists: A Developmental Approach. San Francisco: Jossey-Bass Publishing Co. Storm, C.L. & Todd, T.C. (1997). The Reasonably Complete Systemic Supervisor Resource Guide. Boston., Allyn and Bacon. Surrey, J. (1991). Relationship and empowerment. In J. Jorndan, A. Kaplan, J. Miller, I. Stiver, & J. Surrey (Eds.). Women’s Growth In Connection: Writings From The Stone Center (pp. 162-180). New York: Guilford Press. Todd, T.C., Storm, C.L., (1997). The Complete Systemic Supervisor: Context, Philosophy, and Pragmatics. Boston: Allyn and Bacon. Tamasese, K., & Waldegrave, C. (1993). Cultural and gender accountability in the “just therapy” PRACTICAL APPLICATIONS IN SUPERVISION

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approach. Journal of Feminist Family Therapy, 5, 29-45. Turner, J. (1993). Males supervising females. The risk of gender-power blindness. Supervision Bulletin, 6 ,4,6. Turner, J. & Fine, M. (1997). Gender and Supervision in The Complete Systemic Supervisor. Boston: Allyn and Bacon. Walters, M. Carter, B., Papp, P., & Silverstein, O. (1988). The Invisible Web. New York: Guilford Press. Wheeler, D., Myers-Avis, J.M., Miller, L., & Chaney, S. (1985). Rethinking family education and supervision: A feminist model. Journal of Psychotherapy & The Family. 1, 53-71. Whipple, Vickie. (1996). Developing an identity as a Feminist Family Therapist: Implications for Training. Journal of Marital and Family Therapy. 22, (3) 381-396. Williams, E. (1976). Notes of a Feminist Therapist. New York: Praeger Publishers. Videotapes on Gender-sensitive Therapy Who’s In The Kitchen: Helping Men Move Toward The Center of Family Life. (1995). 29 minutes. Producer: Equal Partners Productions. Telephone (800) 944-7664. Therapist: Betty Carter. Addressing Economic Inequality In Marriage: A New Therapeutic Approach (1995) Producer: Equal Partners Productions. Telephone: (800) 944-7664. Therapist: Betty Carter. Mothers and Sons: The Crucial Connection (1996). 32 minutes. Therapist: Olga Silverstein. Guilford Publications, Inc, 72 Spring St., New York, N.Y. 100 12.

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OVERCOMING OBSTACLES TO LIVE SUPERVISION LYNNE SHOOK, PH.D.

The conjoint treatment of a couple or family presents special challenges to the beginning therapist. He/she must learn how to establish a therapeutic relationship with several individuals simultaneously, and be prepared to intervene directly and immediately in problems presented interactionally as well as verbally. The supervision of conjoint marital and family treatment is similarly demanding. The potential for supervisee distortion of the events of a session is greater than with individual treatment, and the need for practical suggestions is more pressing and immediate. Live supervision from behind a one-way mirror is the ideal method for coping with these demands. In the real world, however, there are significant obstacles to using this approach. This article will offer some practical suggestions about how to overcome those obstacles. The Benefits of Live Supervision Observation of a session in progress is the best way to correct for supervisee distortion of the events of a session. Supervisory intervention while a session is in progress allows therapeutic mistakes to be avoided or repaired quickly and effectively. The supervisor who intervenes in a session tends to have more of a stake in the case, something which supervisees’ experience as added support. Beginning therapists can learn quickly and directly with this supervisory method, and observing supervisees can be taught how to conceptualize and strategize as a session unfolds. Over the years family therapists have developed a variety of creative uses for the one-way mirror in supervision. In my own training at the Philadelphia Child Guidance Clinic, trainees were frequently sent into the ongoing sessions of fellow trainees to move the therapy along while experiencing the impact of the intervention for themselves. The Ackerman Institute in New York developed a technique for using those behind the mirror as a Greek chorus (Papp, 1980). A more recent development involves the use of a reflecting team. By turning on the lights in the observation room at mid-session, the therapist and family members observe first-hand the observations and impressions of those behind the mirror (Andersen, 1987). Most clinicians, however, don’t have access to the resources of training institutes like the Philadelphia Child Guidance Clinic, and the demands of agency and academic life are such that live supervision can seem to be more trouble that it is worth. Lack of Access to a One-Way Mirror The most common obstacle to live supervision is lack of access to a one-way mirror. One-way mirrors are surprisingly inexpensive to install. Sometimes it is possible to use or rent office space that already has a one-way mirror. By placing a video camera in one room, and a TV monitor in the other room, one can create the same effect as a one-way mirror with the added benefit of videotaping capability. Other ways of overcoming this obstacle involve elimination of the one-way mirror altogether. With this approach the supervisor sits in the session, observes, and participates PRACTICAL APPLICATIONS IN SUPERVISION

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directly when necessary. This method has been adapted for use with training groups who sit in the session as well (Olson & Pegg, 1979). Concern About Client Discomfort with the Process Supervisors and supervisees who are unfamiliar with live supervision are commonly concerned that their clients will find the process intrusive. Those who regularly use the approach rarely find this to be a problem, particularly if supervisor and therapist are open and matter-of-fact about the process. If a one-way mirror is used, family members should be offered the option of meeting those who are behind it. Since clients will already be aware of the fact that their therapist is a trainee, it can be explained that this form of supervision is more direct and potentially more beneficial to them. The presence of additional observers should be explained in an open and matter-of-fact manner as well. Options to the client for not being involved in a live supervision format would always be made clear. In one training institute where I worked, we reserved the right to “live supervise” any session conducted by our trainees. Those clients who didn’t want to be part of this supervisory process were referred to another department of the agency. (This happened rarely, if at all.) Supervisors will have different preferences with respect to this issue, but it should always be resolved before therapy is undertaken by the supervisee and family. Another concern is that interventions by the supervisor during the therapy process will be distracting to the family. There is some truth to this, particularly when supervisory interventions take place by phone call. On those occasions when a family member has become particularly annoyed by phone interruptions, I have asked to speak with that family member directly. Including them in the process of the phone intervention almost always diffuses the annoyance. There are a number of ways to make supervisory interventions besides the use of the telephone. If supervisor and therapist are in different rooms, they can make a prior agreement to meet at a certain point in the session. The supervisor can knock on the door of the therapy room whenever he or she feels the need for a supervisory conference, and the supervisee can excuse him/herself from the session for the same reason. If the supervisor is in the session itself, clear guidelines must be worked out between therapist and supervisor prior to the session about what form supervisory interventions will take. In most cases the supervisor will direct his/her interventions through the therapist, rather than speak to family members directly. The family should be informed prior to the session about the form of supervisory intervention that will be used. To further minimize client discomfort, interventions must be as concise and understandable as possible to the therapist. It has been my experience that adolescent clients are the most uncomfortable with live supervision conducted from behind a one-way mirror. I commonly handle this by bringing the adolescent behind the mirror with me for some part of the session and ask them to talk by phone with a parent about some issue while they are there. In every case, this procedure created an ally in the therapeutic process. Parents don’t object because the adolescent is participating in the process, and therapists don’t object because the adolescent is more cooperative once he/she returns to the other side of the mirror.

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Regardless of the content, supervisory interruptions are therapeutic interventions in and of themselves which circumvent endless rounds of blaming or complaining. A certain amount of client annoyance can be a sign that the therapy is challenging these patterns. What is ultimately important to family members is whether they feel that some kind of progress has been made once the session is over. Supervisor Discomfort with the Process Supervisors who conduct conjoint marital and family therapy sessions in their own practices are more likely to be comfortable with conjoint forms of supervision than those who do not. Since most experienced marital and family therapists use conjoint forms of treatment to some extent, supervisor reluctance to use live supervision for this reason is probably not that significant. Live supervision is most commonly used in those training institutes which teach structural, strategic, or systemic forms of family therapy. If a supervisor has not been trained by live supervision in one of these orientations, he or she will be less likely to use it as a training modality. This is unfortunate if the reluctance is based solely on a lack of familiarity with structural, strategic or systemic therapies. Live supervision was first used as a training device by those with no affiliation with family therapy whatsoever (Fleishman, 1955). It is an adaptable technique that can be used to train psychotherapists in a variety of theoretical persuasions (McDaniel, Weber, & McKeever, 1983). If a supervisor has never experienced live supervision, adaptation of one’s own therapeutic orientation to the technique can be difficult. The supervisor is also less likely to be empathetic to supervisees as they struggle with the process. By forming a live peer supervision group with like-minded colleagues, supervisors can experiment with the technique from both sides of the mirror before using it as a training device. Therapist Discomfort with the Process When supervision is helpful, supervisees are generally willing to overlook the discomfort of the supervisory process. This is especially true of therapists who have begun to see couples and families in conjoint sessions. Live supervision does, however, pose unique challenges to supervisors and supervisees. The presence of the supervisor in a session, behind the mirror or in the room, can be experienced as a threat to the authority of the beginning therapist (Gershenson & Cohen, 1978). One way to minimize this discomfort is to let the supervisee choose the form of supervisory intervention for each session. For example, the supervisee might decide that he or she would like no interruption for the first fifteen minutes, a face to face conference with the supervisor at this junction, and then no more than five phone calls for the rest of the session. As in any supervisory relationship, the supervisor must be clear with the supervisee where there is a choice and where there is not. Another source of therapist discomfort with live supervision is the fact that supervisees are often unable to conceptualize quickly enough in the course of a session to articulate their objections to supervisory interventions. If they follow through on the intervention anyway, they tend to become more disoriented and feel increasingly less in control of the therapy session. This PRACTICAL APPLICATIONS IN SUPERVISION

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is problematic for the therapist regardless of whether the session from a therapeutic standpoint has been successful or not. Supervisees need to be told that this is a natural stage of development in the process of live supervision, and that over time they will be better able to think quickly. Supervisors must remain sensitive to this issue, however, and not overload the beginning therapist with interventions that he or she will have difficulty understanding. As the supervisee becomes more articulate, supervisees must allow the design of interventions to become more collaborative. Another problem with live supervision for beginning therapists occurs when some supervisees in a group are observed from behind the mirror and others are not. This can be very divisive to a training group. If trainees are unable to bring in a family for live supervision, they can treat a role-played family made up of their fellow students. With this technique, trainee/family members have an opportunity to see therapy from the client’s point of view and can share their experience with the therapist. The Time Intensiveness of the Method Even though many supervisees can benefit from watching a live supervisory session, the fact remains that only one family can be seen for that period of time. This can pose a problem in agency or academic settings when many cases must be supervised in a fairly short amount of time. Once a supervisor has live-supervised a case, he/she tends to be able to cut to the core issues more quickly. By live-supervising every case at least once (preferably early on), but not every session, supervision may become more efficient than if live supervision has not been used. Conclusion Marriage, family and child counselors in the state of California can become licensed without ever having seen a couple or a family in conjoint treatment. This may reflect the reluctance of those in academic and training programs to provide supervision best suited for helping trainees. Obstacles to the use of live supervision can be overcome if supervisors are willing to improvise and are able to trust their supervisory skills. References Andersen, T. (1987). The reflecting team: Dialogue and meta-dialogue in clinical work. Family Process, 26, 415-428. Fleishman, 0. (1955). A method of teaching psychotherapy: One-wayvision-room technique. Bulletin of the Menninger Clinic, 19, 160-170. Gershenson, J. & Cohen, M. (1978). Through the looking glass: The experiences of two family therapy trainees with live supervision. Family Process, 17(2), 225-230. McDaniel, S., Weber, T., & McKeever, J. (1983). Multiple theoretical approaches to supervision: Choices in family therapy training. Family Process, 22, 491-500. Olson, U., & Pegg, P. (1979). Direct open supervision: A team approach. Family Process, 18, 463-470. Papp, P. (1980). The Greek chorus and other techniques of family therapy. Family Process, 19, 45-58.

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ENHANCING LIVE SUPERVISION WITH CREATIVE LEARNING ENVIRONMENTS IN AGENCY AND UNIVERSITY SETTINGS H. DAN SMITH, ED.D.

Background It would be difficult to find a counselor who cannot relate to the anxieties accompanying live supervision, which is defined as a type of supervision where one’s supervisor directly observes the counselor’s work and may be involved with the process as it happens (Borders & Leddick, 1987). Live supervision most typically occurs in university settings where facilities should be readily available for close monitoring of counselor development. Lately, however, an increasing number of counseling agencies are exploring the use of live supervision as a means of supporting their counselor training goals, to monitor the quality of counseling services provided to clients, and to assure that counselor trainees and interns are practicing and developing in a manner consistent with the ethical and professional standards held by the supervisor and the agency. Supervisee anxiety notwithstanding, live supervision techniques may be quite beneficial to counselor development. Live supervision improves the supervisor’s ability to assess the supervisee’s developmental level and thus tailor supervision strategies and learning environments which will promote greater counselor growth and satisfaction (Chagnon & Russell, 1995; Wiley & Ray, 1986). Further, a supervisor who observes a supervisee’s work is probably in a better position to give constructive feedback on the counseling process and technique than a supervisor who employs more passive supervisory practices. Typically, live supervision includes direct observation by means of a one-way window into the counseling room, supported by an audio- or videotape monitoring and recording system. Counseling agencies have discovered the relative ease of creating this type of learning environment by installing inexpensive silver reflective film designed for use as a sun shield on outside windows, purchased from their local home improvement center. Applying the film to an existing window between rooms takes only a few minutes and is relatively fool-proof. When completed, the window from a well-lighted counseling room appears to be a mirror, while the window is clear from the observation side when the lights are dimmed. Given the logistical constraints experienced in a particular agency setting, other models of live supervision may be utilized, including the counselor being observed via television hookup into another room, or even having the supervisor physically present in the room as counseling occurs. The historical literature on supervision lists a number of efforts to operationalize supervisor involvement beyond mere observation, including interrupting a session in progress to provide feedback and direction to the counselor (McClure & Vriend, 1976; Tentoni & Robb, 1977), communicating with the supervisee via an interoffice telephone system (Coppersmith, 1980), and even through an electronic receiving device worn in the supervisee’s ear, known as the “bug in the ear” (Baum & Lane, 1976; Boylston & Tuma, 1972). This literature typically notes that a significant attraction of live supervision is the availability of the supervisor to lend assistance with the session should the counseling process need to be directed toward other issues, which “eliminates a mutually frustrating situation when the supervisor sees a critical error made PRACTICAL APPLICATIONS IN SUPERVISION

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by the therapist in the session but must wait until later to tell the therapist—when it is too late to do anything about it!” (Bernard, 1981, pp. 744-745). Additionally, live supervision permits the supervisor to give feedback immediately following the session, thus aiding in the recall of feelings, perceptions and process interactions (Borders & Leddick, 1987). Many agencies supervise interns and trainees in a group format, and when several peers participate in live supervision activities, a team approach to counselor development and client treatment planning may naturally emerge. Live supervision approaches are not without their drawbacks, partly because they are the most labor-intensive supervisory associations possible. At the outset, they require that schedules be coordinated so that both supervisor and supervisee are available simultaneously. After a live supervision session, still more time is required to review the session, communicate the supervisor’s remarks, and engage in meaningful discussion. In this fast-paced and thinly financed managed care marketplace, finding the time to utilize live supervision may actually be more of an obstacle than the logistical matters of devising a usable observation setup with accompanying monitoring/recording equipment. Beyond the time constraints, counselors must also be certain to discuss the practice with their clients and “obtain written informed consent from patients before videotaping, audio recording, or permitting third party observation.” (CAMFT Ethical Standards, Part I, 2008, section 1.5.3). In spite of these difficulties, counselor trainees are reported to prefer supervision which has a “live” component. Worthington (1984) surveyed over 200 supervisees from 10 graduate counseling programs and found that supervisees gave higher satisfaction ratings to supervisors who consistently utilize live supervision techniques. In a study by Smith (1984), graduate student trainees were asked to evaluate several supervisory activities employed in their university counseling practicum and to rank-order them with respect to perceived effectiveness and time involvement with the activity. A strong preference was expressed for direct supervisor feedback associated with live supervision, yet this activity ranked fifth among seven on time involvement. In essence, the supervision activity that trainees most highly valued was among the least available. Time involvement rankings in the same study revealed that among seven supervisory activities, trainees eagerly devote the greatest amount of time to listening to audiotapes of their sessions when required by their supervisor, yet this activity ranked fifth on perceived effectiveness. In an effort to maximize trainee preference and time involvement rankings of these two activities, a means of combining feedback resulting from live supervision with listening to audiotapes of sessions was pursued. Method A technique first reported by Harmatz (1975), and later by Smith (1984), known as dual-channel feedback or stereophonic feedback, makes it possible to record supervisor comments on the actual audiotape used to record trainee counseling sessions. As a result, supervisees are provided with precisely timed supervisory comments on the moment-to-moment process of their counseling sessions. The procedure, while highly regarded as a desired supervisory method by trainees, requires no extended time commitment on the part of the supervisor beyond that already required for live supervision. PRACTICAL APPLICATIONS IN SUPERVISION

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The technical expertise required to implement dual-channel feedback is nominal. In addition to some type of live observation arrangement, all that is needed is a stereophonic cassette tape recorder (preferably of “higher” quality, with microphone inputs), two microphones, and a stereo headphone set (or as many headphone sets as may be needed for additional observers, thus necessitating an inexpensive multiple phone-jack box). The basic electronic components described herein may be purchased for $150 to $200 at a local discount electronics warehouse-type store. One microphone is placed on a table in the counseling room with the supervisee and client(s), and the wire is brought through the wall and plugged into the “left” microphone jack on the recorder. The other microphone remains in the observation area in the hands of the supervisor, and is plugged into the “right” microphone jack. Ideally, this microphone should have an on/off switch so it can be disabled during counseling sessions for unrecorded discussion among observers. The headphones must be plugged into the “monitor” or “phone” jack on the front panel of the recorder. Through the headphones, the supervisor (and other observers if more than one set of headphones is available) monitors the counseling session and the supervisor feedback that is being recorded simultaneously. Adjusting the controls on the recorder will yield a comfortable volume balance between the counseling session and the supervisor’s voice. Results From the supervisee’s standpoint, dual-channel feedback is an attractive medium for receiving supplemental supervisory input. When a counseling tape is played on a stereo cassette player, whether it be a home system, a car stereo, or a Walkman-type unit, the actual counseling session is heard from the left speaker or earphone. Supervisor comments, precisely timed with the counseling event, are emitted from the right speaker or earphone. On home and car stereo systems, rotating the stereo balance control completely to the left permits the supervisee to review the session without the benefit of supervisor feedback; at midpoint, both the session and feedback are replayed concurrently. Walkman-type units lose some flexibility since they typically do not have a balance control. A highly regarded feature of this procedure is that supervisees can review feedback on their own time schedule; some have been known to listen to dual-channel feedback several times between sessions. While it is gratifying to see such enthusiasm for the procedure, a busy supervisor will appreciate that it does not require a physical presence beyond the actual live supervision session where the dual-channel feedback was recorded. For the supervisor, utilization of this procedure is thoroughly enjoyable and may result in higher quality feedback. Since taking process notes for later reference is no longer necessary, the supervisor can devote full attention to the counseling session in progress. The resulting tape, with spontaneous commentary on counselor behavior, can be very reinforcing. A supervisor’s “very good,” recorded directly after a particularly effective counselor intervention, is extremely meaningful to a supervisee undertaking to develop a repertoire of appropriate counseling skills. Supervisors will require an initial adjustment period for the procedure to determine the type of comments that will be most useful to their supervisees; brief comments couched in behavioral PRACTICAL APPLICATIONS IN SUPERVISION

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terms tend to be most easily understood and assimilated. Matters of philosophical and theoretical relevance which require discussion and contemplation are best reserved for face-to-face supervisory interactions. Supervisors will also readily learn that once a comment is made on tape, it cannot be taken back; a more deliberate and articulate level of commentary generally ensues from the observation area when the procedure is employed. Although dual-channel feedback is not intended to replace face-to-face supervision, it will likely alter the format that such supervision takes. Using the procedure, supervisors no longer have to rely on memory or sketchy notes to recall and comment on specific counselor behaviors; these important comments have already been made and recorded on tape. Instead, supervision sessions will likely focus on deeper issues, including interpersonal matters that may affect counselor effectiveness. An additional feature of dual-channel feedback is the supervisor’s ability to recommend readings or to make other assignments while observing. For instance, a supervisee struggling with a particular client issue who could benefit from a selected reading can receive the reading assignment directly from the tape. Knowing that a supervisor frequently makes such assignments assures compliance among supervisees with their responsibilities to the supervision process. In summary, dual-channel feedback is a relatively straightforward technique that may assist supervisees to learn and integrate more effective counseling behaviors. In this supervisor’s experience, it is one of the most effective procedures yet employed for enhancing the live supervision experience. The goal is to convey meaningful process feedback between supervisor and supervisee on the counseling process.

References Bernard, J.M. (1981). Inservice training for clinical supervisors. Professional Psychology, 12, 740-748. Borders, L.D., & Leddick, G.R. (1987). Handbook of counseling supervision. Alexandra, VA: Association for Counseling and Development. Boylston, W., & Tuma, J. (1972). Training of mental health professionals through the use of the "bug in the ear." American Journal of Psychiatry, 129(1), 92-95. California Association of Marriage and Family Therapists (1997). Part I: Ethical Standards for Marriage and Family Therapists, Section 1.13. Chagnon, J., & Russell, R.K. (1995). Assessment of supervisee developmental level and supervision environment across supervisor experience. Journal of Counseling and Development, 73(5), 553-558. Coppersmith, E. (1980). Expanding uses of the telephone in family therapy. Family Process, 19, 411-417. Harmatz, M.G. (1975). Two-channel recording in the supervision of psychotherapy. Professional Psychology, 6(4), 478-480. McClure, W.J., & Vriend, J. (1976). Training counsellors using absentee-cueing system. Canadian Counsellor, 10, 120-126. Smith, H.D. (1984). Moment-to-moment counseling process feedback using a dual-channel recording. Counselor Education and Supervision, 23(1), 346-349. PRACTICAL APPLICATIONS IN SUPERVISION

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Tentoni, S.C., & Robb, G.P. (1977). Improving the counseling program through immediate radio feedback. College Student Journal, 12, 279-283. Wiley, M.L., & Ray, P.B. (1986). Counseling supervision by developmental level. Journal of Counseling Psychology, 33, 439-445. Worthington, E.L. (1984). Empirical investigation of supervision of counselors as they gain experience. Journal of Counseling Psychology, 31, 63-75.

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COLLABORATIVE TRAINING TOOLS FOR SUPERVISORS AND SUPERVISEES NANCY STEINEY, PH.D.

Currently in California, new therapists (supervisees, trainees, interns) must have 3,000 hours of supervised experience to obtain a license. The Board of Behavioral Sciences is vigilant about verifying these hours, however, until recently there has been little formal concern or dialogue about the qualifications of the supervisors. Since supervisors are the gatekeepers for those who are new to the profession, providing opportunities to further supervisor’s training skills is critical. Learning new and revived techniques for supervising interns can enrich even very seasoned counselors’ understanding about their own therapeutic process and practices. New models for the supervision of therapists-in-training have moved beyond the authoritarian, all-knowing supervisor who merely identifies what has been done wrong or right. Supervisors have become coaches and collaborators rather than master instructors. The seasoned therapists’ experience is invaluable to the newcomer, but in his/her role, as one of a new breed of supervisors, he/she will learn along with the intern, albeit at a more advanced level. The benefactors of this collaborative learning—where both green and seasoned therapists hone their techniques together—are the clients. Collaborative learning is a win for all parties. Perhaps the most difficult aspect of the collaborative model is the bravery required on all sides. Risk-taking has always been demanded of clients and therapists-in-training, but to expect the supervisor to also take such risks is quite different. Authoritarian supervisors were safe inside their infallibility. The intern verbally presented cases and the supervisor gave advice, “Why don’t you try. . . ” or “Why did you do that?” In effect, they behaved as therapists once-removed. Conventional group supervisions also often suffer from the same “once-removed” malady. Listening and giving advice requires much less creativity and curiosity than getting inside of the trainee’s role to work toward collaborative solutions. After all, much of therapy is modeling “getting unstuck.” When a combination of green and seasoned experience collaborate on a therapeutic problem, both the supervisor and intern are forced to think beyond themselves, outside of their respective boxes and comfort zones. Getting off to a Good Start Supervision that begins well is more likely to end well. Supervisees come to supervision at widely different points in their learning. Each one needs help from the supervisor to customize clear, attainable goals. The supervisory relationship is full of unavoidable complexities; being explicit about the expectations on both sides eliminates many avoidable pitfalls. Supervisors need to clearly state their expectations regarding attendance at meetings; the methods they will use to supervise, e.g., one-way mirrors; and so on. Supervisors also have the responsibility for helping interns, often through an interviewing process, to state clear goals. If the goals are vague, e.g., “To be a better therapist,” a supervisor might ask, “What will you be PRACTICAL APPLICATIONS IN SUPERVISION

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able to do with clients that is hard for you to do now?” Interns might answer that they want to “be more focused,’’ or “have less anxiety.” This clarifying process helps the supervisor understand how to best fulfill the intern’s specific needs. Simultaneously, the process helps interns take responsibility for their own learning, and for setting realistic, accomplishable goals. If the intern’s goals have identifiable benchmarks, both the supervisor and intern can, in their work together, experience concrete, measurable success. Taping, live supervision and reflecting teams all involve close collaboration between supervisors, supervisees, and clients. Clients must give written authorization for their involvement in any of the above techniques. And they should be thoroughly oriented to the technique in which they will be participating. For the technique to have maximum effect, the client must feel a sense of power over his/her decision to participate. Often, through role-play, supervisors can help interns discover effective ways to offer these opportunities to clients. These collaborative techniques are not appropriate for all clients. A client’s history is an essential prelude to determining the client’s appropriateness for any of these methods. What is best for the client remains primary. Four Collaborative Techniques New therapists — as well as clients — have very different learning styles. Thus, supervisors need to explore a variety of approaches with interns to broaden their range and repertoire. I will discuss the following techniques: role-play, videotape, live supervision and reflecting teams. I focus on these because I have found them to maximize supervisory creativity and collaboration. Each comes with its own unique advantages and disadvantages. Of course, supervisors should acquaint themselves with as many models of therapy skills and techniques as possible. The Four Collaborative Techniques #1 — Role- Playing Role-playing is by no means new, but the dimension it adds to therapist-in-training skills is often overlooked. An intern trying to describe a current client is often placed in a difficult position. While trying to present the case with clarity and honesty, the intern struggles with being objective. Life experiences and assumptions can’t help but sneak in and taint the purity of the case presentation. By using role-play, the new therapist takes on the client’s issues as his or her own, while “acting” in the role of the client. This “experience’’ is much more powerful and illuminating than a third-party report. In the context of supervision, role-playing permits the intern to behave as they experience the client in the therapy session. One method to begin the role-play is to have the supervisor interview the trainee acting in the role of the client. Warm-up questions, such as those that follow, will help the intern get into the client’s “skin.” • • •

What’s it like to be with this client? Does this client remind you of any one you know? If you believe that this client provokes you into having an agenda for them,

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how would you proceed? How does your agenda sometimes block your curiosity in discovering the client’s goals?

“Becoming” the client gives the intern experiential learning which is not bound by rational explanation. Through this experience, the new therapist gets a sense of what it’s like to be in this particular client’s life (2). Furthermore, role-playing gives the supervisor insight into both the trainee’s ability to have a sense of the client’s experience and into the trainee’s ability to understand the interrelational process that exists between therapist and the client.3 During the interview, with the intern as client, the supervisor models a therapeutic interviewing process which is designed to help the trainee work with this particular client. When the supervisor has asked enough questions to get a sense of the client/therapist relationship, the supervisor may debrief the trainee by stepping out of the interviewer’s role and by asking the trainee questions directly such as: • •

What was it like to be this client? How would you describe this client’s world?

If supervision is done in a group setting, the other trainees have a chance to observe the supervisor as a model. The observing trainees might also note that the intern’s case is similar to a case with which they’re struggling, so all participants benefit from the role-playing experience. As an example, Mary, an intern in supervision, who was recently divorced and raw from the experience, held strong convictions about women’s rights and rules that “should” govern marriage. She insisted that most women deny their real self in order to be in a marital relationship. Mary had trouble believing that her client, Irma, from El Salvador, was content and unquestioning about her relationship with her husband. Their relationship operated within a structure traditional to their culture. Irma’s presenting problem was that her daughter had become too Americanized. Irma was afraid her daughter would take on values not compatible with the South American culture. By role-playing Irma, Mary could see that her therapeutic work had drifted towards her own needs and values and away from the objectives of her clients. Role-playing gave her a prospective that helped her become curious about how her personal values might hinder her from being tolerant and objective. Role-play is equally effectively in individual and group supervision. When the supervisor takes on the role of the therapist-in-training, that new trainee learns by experiencing what kinds of questions are most helpful. Again, through experience, a trainee can sense what questions not only establish empathy and understanding, but also empower and expand the clients’ vision of themselves. Then, when the supervisor has become familiar with the client through role play, he or she may reverse roles and play the client, putting the trainee back into the role of therapist. In group supervision, when the members become more comfortable with each other, other trainees may offer to play the “therapist” while the case presenter plays his or her client. PRACTICAL APPLICATIONS IN SUPERVISION

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Obviously, the “therapist” and “client” are never played to perfection. However, the role-play exercise reveals much about the supervisee’s stage of development, natural talents, competency, and observational skills. As the client, the trainee is “trying it on” so he can see how certain actions might evoke certain types of thoughts, or how a client might think and feel in order to create certain actions. “Trying it on” helps diffuse the intern’s defensiveness and anxiety. The learning comes from literally being the client, for a moment, and not from a disembodied case description. When playing the role of therapist, the supervisor implicitly gives feedback to the intern in an atmosphere promoting cooperation rather than one that invites tiresome battles [overt or covert] with trainees. Role-playing helps supervisees to connect empathetically with their clients, and to learn the client’s response to the therapist’s style of questioning. Similarly, role-playing helps supervisors connect more empathically with their trainees. #2 — Videotaping Nearly since they came on the commercial market, videotapes have been popular among therapists. Videotaping enhances therapists’ effectiveness with clients. Therapists have considered the ability to tape and view their own clinical work as a contribution to their own professional development. But equally important and often overlooked, is the evolving use of videotaping in supervision — a feedback process which truly enriches the training (4). With videotaping, interns are no longer limited to their recollections of prior therapy sessions. While viewing a tape, the supervisor and intern have access to the nonverbal behaviors of therapist and client. Re-playing permits sessions to be studied in detail. Re-playing a tape is a form of self-confrontation (5). When more than one person views a tape, there can be multiple viewpoints. Often when the supervisor and trainee exchange views about the video, new approaches to the therapeutic process evolve, giving the therapist-in-training more options for interacting with the client. Videotaping is useful with any theoretical framework. Viewing a therapist’s work has the capacity to teach trainees both theory and technique and helps trainees to trust, monitor, and develop their own styles and abilities. Yes, obtaining video equipment involves an initial expense. But when used correctly, videotapes offer one of the richest learning experiences an intern (and a supervisor) can have. “If used correctly” is key, because complexities do arise when using video. First and foremost, trainees respond more positively when the supervisors are willing to be taped. preferably showing an early, unedited and imperfect segment. Interns tend to think of supervisors as “knowing it all,” so exposure to the supervisor’s fallibility and vulnerability will ease the intern’s tension and anxiety. Second, before viewing a trainee’s tape, ask the trainee to outline how he/she would like to receive feedback. The trainee’s sense of empowerment over his/her feedback will contribute toward easing anxiety. For example, a counselor was asked to describe desired feedback. He replied that all he wanted was to be told how wonderful he was because he’d had a bad day. After viewing his tape, he was given the “wonderful feedback.” He then went on to say, “I’m feeling better now and would like some helpful guidelines.” Interns who are in charge of their feedback are much more likely to be curious and less defensive. Third, an intern should preview the tape on his/her own. When an intern has seen his/her PRACTICAL APPLICATIONS IN SUPERVISION

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tape, he/she might pick, for example, two five-minute segments to show to the supervision group — one he/she really liked, and one where he/she is seeking assistance from the group. The explanations for picking each choice can be revealing. The trainee might begin to explore other therapeutic avenues or to ask questions about how the more difficult selection might have been improved. This previewing process helps the new therapist clarify and mentally organize what he or she might want from the supervision. Unless trainees take some responsibility for what is helpful for their learning and development, the supervisor’s efforts can easily backfire, producing defensiveness, anxiety and little learning. Fourth, after the intern has designed a format for feedback, viewed the tape, and selected the two segments, the supervisor might prepare for the more complete viewing by asking the intern a few clarifying questions. Some examples might be: • • • • • • •

What were some of your observations that you liked while you were viewing the tape? What will help you lessen your critical voice when we view this tape together? What is your inner experience of being with this particular client? How do you think your internal reactions to this client influenced the questions you asked? What was going on in you [therapist] that helped you design this particular question? What was the process you used to organize the client’s information that gave you a meaningful way to proceed? How did you use the client’s feedback process to continue in this session?

For videotaping to be effective as a learning tool, a supervisor must pay careful attention to establishing a positive atmosphere of learning. The time interns spend on designing their goals and preferred manner of feedback is an excellent investment. #3 — Live Supervision (Using a One-Way Mirror) For supervisors (and fellow interns) to observe a live, in-progress therapy session is immediate, effective and potent. At first, therapists such as Minuchin and Haley (among others) who were experimenting with a new concept of family therapy, used one-way mirrors to demonstrate their work to one another (5). From this beginning, live supervision eventually evolved as a training tool. One-way mirrors have been around since the early ‘50s, but these eminently useful tools are under-used. Of course, the initial expense of installing such a device stops many struggling agencies. A one-way mirror requires two rooms: one for observation, and one for the actual interaction with the client. Many anxious supervisors avoid the opportunity out of fear that it will become unmanageable and personally exposing. In the days of authoritarian supervision, the supervisor would often use the phone connection between the observation and the interviewing room to interrupt and give directions to the intern. These interruptions understandably produced anxiety. Sometimes supervisors would direct the therapist to leave the interviewing room for a consultation with the supervisor. Perhaps most invasive (7), the supervisor would enter the interviewing room after a designated period of time to participate in the session. At that time theory held that these practices helped avoid major PRACTICAL APPLICATIONS IN SUPERVISION

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therapeutic mistakes, especially preventing the therapist from becoming “enmeshed” in the client’s system. Therefore today, using one-way mirrors as a supervisory tool requires a careful approach. Supervisors must create an atmosphere where fear of evaluations quickly dissolves into an environment of collaborating with colleagues for the benefit of clients. Fortunately, the work of Anderson & Goolishian (1988), White & Epstein (1988), and Tom Anderson (1987) have moved beyond rigid and intrusive practices to develop highly effective, collaborative methods of training new therapists with live-viewing making the process of therapy more public and the therapist more accountable to the profession (9). Because mirror work is rarely used in private practice, the following discussion is primarily for the benefit of agency settings. As a mode of supervision, live observation is more intense and condensed than case reporting and discussion. Information is immediate and thus must be processed and used quickly (10). Live supervision is complex and has possibilities for both technical and interpersonal difficulties. Thus, several conditions must be met to create a safe learning atmosphere for interns. As with videotaping, the supervisor must be the first to be observed by the supervision group. A good start would be for the interns to observe their supervisor doing an initial agency intake. A veteran supervisor’s seasoned demonstration conveys much technical information and role modeling. To augment this learning opportunity, interns can write questions about areas of confusion or disagreement that might have come up while observing their supervisor. Thus, the supervisor is the first to be put into a position of modeling non-defensive responses to the suggestions and questions of others. Again, so that supervisors can intervene in a way that will benefit the clients’ therapy and promote the supervisees’ growth, it is extremely important that the intern therapist behind the mirror design his/her desired feedback. By empowering the therapist under observation, the supervision ambiance will change from one of “gotcha” judgment and criticism to one of “we are a team working together for the benefit of clients.” Interns’ apprehensions about power and control issues with supervisors dissipate considerably once supervisees feel respected and empowered by their supervisors. A supervisor can offer an intern a list of options in pre-session discussions. For example: • • • • •

What would be most helpful for you during the session? Would you want some phone calls, none, or only when you feel stuck? Would you like a reflecting team today? Are there any of your goals you would like us to pay special attention to today? What style of feedback during our time together has been most useful to you?

Each question can be designed to enhance the intern’s awareness of his/her own process and needs. In an atmosphere of empowerment and collaboration, live supervision can significantly accelerate a trainee’s growth as a therapist. Different styles PRACTICAL APPLICATIONS IN SUPERVISION

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and skills become immediately obvious by observing colleagues and supervisor. A trainee’s experience both in front of and behind the screen offers two very different, but valid views of the same coin. Interns explore different ways of receiving and asking for support. The experience offers such intensified learning for interns that their initial stage fright quickly changes to curiosity and a yearning to grow and be independent, See Todd and Storm(6) for a detailed discussion of the ways to promote a supervisee’s development and autonomy and ways that do not. When using one-way mirrors for the first time, supervisors usually experience a process similar to the interns — evolving from performance anxiety to a gradual feeling of being part of a team. Supervisors, like interns, quickly improve their ability to fulfill their responsibilities as trainers. As the supervisor notices and comments on the trainees’ strengths, trainees increasingly focus on empowering their clients. Anyone unfamiliar with using a one-way mirror may worry about its effect on clients. In a research study (Piercy, Sprenkle & Constantine, 1986), clients reported a positive reaction to live supervision, indicating that they felt two or more heads were better than one. Of course, not all clients are appropriate for participating in this technique. And, the client must voluntarily choose to participate. Usually when therapists become comfortable with the mirror, so do their clients. #4 — Reflecting Teams We have Tom Anderson (12) to thank for his concept and explanations of the use of reflecting teams. Anderson makes clear that reflecting teams are not so much a “method” as they are a way of thinking — a way of putting ideas into action. A reflecting team is usually made up of at least one supervisor and fellow interns, working together to provide feedback from various points of view. Teams might work with or without a one-way mirror. Clients are offered the opportunity to work with a team as an adjunct to their work with the therapist. A clear explanation of the team concept gives the client power over the decision as to whether he/she believes the process will be useful. Reflecting teams are inappropriate for some clients. For others, the introduction of reflecting teams needs to be timed sensitively. Some clients having experienced reflecting teams immediately request further sessions in this format. Many express their enthusiasm about having several therapists involved in their therapeutic progress. Clients should be offered the option to meet the team before the therapist begins the session. Permission to use a reflecting-team should be obtained from clients in writing. A typical reflecting-team session begins with the therapist and client(s) interacting in therapeutic conversation for perhaps a half an hour or until a break seems appropriate. At that time, either the therapist will ask the client(s), if it seems like the right time to hear from the team, or the team will announce its readiness to respond. If the therapist, the client(s) or the team chooses to decline an invitation for a reflection, it is, of course, respected.

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Some agencies have facilities capable of switching light and bringing sound into the consulting room. This mechanical method is expensive to install. Equally useful and more accessible is merely having the team switch rooms whereby the client(s) and the therapist move to the observational side. Before switching, the therapist might say to the client(s), “The team has some comments on what they have observed. Some of their thoughts may be useful and others may not.” When the client(s) and therapist have heard the team’s reflections, the participants switch back to their original rooms. At that point, the team now hears the client(s)’ comments. The therapist may start the conversation by asking the client, “What, if any, of the teams comments stood out for you or seemed helpful?” The objective of team reflection is to give the client(s) and therapist an opportunity to sit back and hear alternative meanings or issues raised during the clinical interview (13). Often the experience allows client(s) and therapist to see themselves, their actions, and their relationships in new ways. Reflecting often helps both client(s) and trainee loosen their tenacity to the one view they have found credible which broadens the behavioral and therapeutic options. Teams are coached to offer reflections that are liberating, not corrective or prescriptive. The method of working with reflecting teams tends to be very respectful of clients since they not only get to observe the team’s reflections, but also have the opportunity to comment on the team’s observations. This allows the clients to pick and choose as to which of the teams’ tentative wondering and ideas are most likely to be therapeutic and useful. Each team member codes and collects information differently, so clients have the option to view their relationships and problems from various perspectives. These new meanings and perspectives are also available to the therapist, supervisor and members of the team (interns). Team members are discouraged from talking to each other during the observation to avoid developing a sense that any one team member’s construction is “right.” As team members, trainees learn that their views are neither right nor wrong and that these differences promote creativity and self-confidence. By removing most of the hierarchical structure of supervision, collaborating on speculative reflections stirs the interns’ curiosity on many levels and expedites their growth as therapists. Both therapists and supervisors have expressed relief at working in a team format. No one person carries the load of working with difficult clients. Supervisees respond very positively to this collaborative model and find it useful in their own clinical growth. This more open way of working quickly exposes secret agendas that interns might unknowingly be imposing on clients. Reflecting teams push trainees to learn and have curiosity about the use of language when forming questions that influence the interaction between themselves and their clients. Becoming A Supervisor Guarantees A Quantum Leap In Professional Development Clearly, the transition from being a therapist to being a supervisor requires a significant leap in thinking, skills and professional identity (14). Merely taking charge over an intern’s training is hugely different than taking responsibility for it. Being a good supervisor requires more than good will. The field badly needs risk-takers willing to give up a comfortable authority to work shoulder to shoulder with interns. Only by challenging themselves and their own positions will supervisors create a professional culture dedicated to continuous growth among seasoned and novice therapists. The primary benefactor of this culture will be the client. PRACTICAL APPLICATIONS IN SUPERVISION

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References 1. Protinsky, H. (1997). Dismounting the Tiger: Using Tape in Supervision. The Complete Systemic Supervision, (pp. 298-307). Boston: Allyn & Bacon. 2. Gliekauf-Hughes, C., Campbell, L.R., Experiential Supervision; Applied Techniques for a Case Presentation Approach. Psychotherapy, Volume 28/Winter 1991/Number 4. 3. Bugental, J.F.T. (1981). The Search for Authenticity: An existential-analytic approach to psychotherapy (rev. ed.) New York: Irvington. 4. Breunlin D., Karrer, B., McGuire, D., & Cimmarusti, R. (1988). Cybernetics of Videotape Supervision. H. Liddle, D. Breunlin, and R. Schwartz (Eds.). Handbook of Family Therapy Training and Supervision (pp. 194-206) New York: Guilford Press. 5. Heilveil & Muehleman, J. (1981). Nonverbal clues to deception in psychotherapy analogue. Psychotherapy, Theory, Research and Practice. Volume 18 (pp. 329-335). 6. Storm, C.L. & Todd, T.C. (1997). Live Supervision Revolutionizes the Supervision Process. The Complete Systemic Supervision, (pp. 283-297) Boston: Allyn & Bacon. 7. Gershenson, J., Cohen, M.S. (1978). Through the Looking Glass: The Experience of Two Family Therapy Trainees with Live Supervision. Family Process, Volume 17, June 1978. 8. Anderson, H., Goolishian, H. (1988). Human Systems as Linguistic Systems: Preliminary and Evolving Ideas about the Implications for Clinical Theory. Family Process, Volume 27 (4) (pp. 371-394). White, M., Epston, D. (1989) Literate Means to Therapeutic Ends. Dulwich Centre Publications. Anderson, T., (1987). The Reflecting Team: Dialogue and Meta-dialogue in Clinical Work, Family Process Volume 26 (pp. 415-428). 9. Young, J., A Critical Look at the One-way Screen. Dulwich Centre Newsletter, Summer 1989/90. 10. Berger, M., Dummunn, C., (1982) Live Supervision as Context, Treatment and training. Family Process, Volume 21 (pp. 337-344). 11. Piercy, F., Sprenkle, D., & Constantine, J. (1986). Family Members’ Perceptions of Live Observation/Supervision. Contemporary Family Therapy.- An International Journal Volume 8 (pp. 171-187). 12. Anderson, T., (1990). The Reflecting Team Dialogues. Kent, U.K.: Borgmann Publishing Ltd. 13. Tomm, K. (1991). Orienting Notes for Members of a Reflecting Team. An unpublished manuscript. 14. Borders, D.L. (1992). Learning to Think Like a Supervisor. The Clinical Supervisor, Volume 10.

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THE USE OF ROLE-PLAYING IN PSYCHOTHERAPEUTIC TRAINING MOLLY MERRILL STERLING, PH.D.

Phenomenological research on the experience a therapist has when role-playing a client in supervision has demonstrated the intersubjective depth evoked in the meeting of client and therapist. When role-play is used as a portion of a supervisory hour, therapist and supervisor enter a version of the ways the therapist is caught in the unconscious therapeutic course. The interaction of the stages of role-playing and the signs of its development are described. Role-playing also teaches some valuable aspects of psychotherapeutic attention: subjective presence, empathy, bodily-felt sense, and intersubjectivity. “The patient needs an experience, not an explanation” — Frieda Fromm-Reichmann1 If the psychotherapeutic patient needs an experience within the psychotherapeutic session, the therapist needs to know how that can occur. And, if Fromm-Reichmann’s statement is fundamentally so, we might also say that therapists need experiences as well as explanations of their clients, of the process which psychotherapy is, and of their own functioning as therapists. Beginning therapists come to their profession with considerable didactic teaching; they also need experiential opportunities. Experiential learning is not bound by explanations. Rather, it is full of surprises and requires that teachers and therapists stand openly before the unexpected and the unique. Role-play adds an enactment of therapy to supervision and consultation. Role-play provokes the opportunity to reach and respect the client’s world view, or self-and-world construct (Bugental, 1981, pp. 97-100), the interaction of the client’s world with the therapist, as well as the experience of doing and receiving therapy as practiced by the supervisor. Role-play can be used in individual and group supervision. Yet, the literature rarely mentions role-play (Signell, 1974). To role-play the therapist/supervisee enacts a client who is in therapy. By drawing upon everything the therapist knows and senses about the client, the therapist “becomes” a particular client. Meanwhile, the supervisor acts as therapist to the enacted client. After the role-play, therapist and supervisor pool their respective experiences as they reflect together. I am interested in what happens experientially for the therapist as the client is experienced through role-play. Role-Playing Nora My client, Nora, is a woman in her mid-twenties, a highly successful professional—vivacious, extroverted, and very intelligent. In recent years she has suffered several losses by death. Her family masked chaos with respectability. Her relationships with men have been brief, shallow and dependent. At this point in her life and in her therapy, she has not lost a beat, missed a day at work, or failed to make an amusing retort. She always has an explanation for her behavior. She prides herself on “doing” her therapy alone in her car. Although she is appealing and engaging, I often feel that I am bumping into an invisible wall. If I prompt her to explore the impasse, she earnestly assures me that she will close down in the face of my “intrusion.” A sense of panic which is hard to label then arises in the room. PRACTICAL APPLICATIONS IN SUPERVISION

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In supervision, I role-played Nora while my supervisor acted as her therapist. What follows here is a phenomenological description of my experience. Note that the locus of “I” shifts between “I,” the observer of it all; “I” as a person who responds; and, “I” who is Nora with her own awareness. During the role-play, this shifting has its own qualities which eventually relate to the therapeutic field. During the descriptive retelling, shifting the locus of “I” tends to be effortless. The “as if” quality of enactment also shifts in intensity. And, much of this shifting awareness happens interiorly in the realm of the subjective. The behaviors which show externally are Nora’s words and gestures as best I can enact her. The goal of the role-play in supervision is to bring these two together and into greater focus. Thus, I present my account of role-playing Nora in supervision as it happened. If it seems amazing that so much can go on at once, no wonder. This is the most direct account I can give of the experience. I assumed Nora’s mannerisms, her vivaciousness and charm. Internally, I moved myself aside to become her as much as possible. In gently challenging me to engage, to become present to myself (as Nora), my supervisor encountered Nora’s lack of presence, her ways of telling about herself through her work. In my subjective awareness, I was making instantaneous distinctions. As myself, I heard my supervisor’s intentions in his interventions, and felt my own natural responses to his empathic contributions. Nearly simultaneously, I put myself aside to respond to the supervisor as Nora would respond. As my supervisor pursued Nora’s ways of avoiding, I became Nora. Increasingly, I could easily sense that I, as myself, would have stopped avoiding long before Nora did. Nora’s layers of defense conveyed by her excited talk, parried insistence that her life was hers to claim. Suddenly my supervisor said something which indicated that he completely misunderstood Nora. I, as Nora, felt lost, enormously let down, frightened, bewildered, and immensely disappointed. I stopped the role-play because I knew that I, as therapist, would have misunderstood her as well. There was confusion and distress—even fear—in my body which was not really conscious. What I could not yet discern was that I was simultaneously overtaken by bewilderment and disappointment. I knew that herein was my blind spot, the locus of my countertransference. Here was the entrance to the mine shaft of the supervisory work. Nora lived inside a double wall of her own making and when someone tried to reach her by understanding the outer wall, she felt grossly abandoned. She was not only protected by the double wall; she was trapped and beyond reach. I now had my own experience from the inside of her terror and loss and of her two-walled defense. The image of walls which I use here was felt by both Nora (verified in a later session) and me and was understood by my supervisor. The remainder of the supervisory hour used this immediacy in experiencing to explore my blocks in relation to this wall with this client. This is the core of existential work. In the moment in the role-play when Nora felt misunderstood and pulled in within her disappointment, I suddenly knew that I too as therapist gave up in the face of such formidable buttressing. I had never yet, as therapist in the room with her, so clearly felt or seen the quality of PRACTICAL APPLICATIONS IN SUPERVISION

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her fear. During the role-play my supervisor missed it, thus misunderstanding her. Role-playing Nora, I did feel her fear and I knew that my own reluctance to penetrate her walls was colluding with her hiding within. The possibility of anger, distance and pain, which the walls represented, daunted me during our sessions as well. Up to that point in the therapy, I had not yet discerned these distinctions, however obvious they might seem after the fact. Structure of Role-Play Through a phenomenological analysis (Giorgi, 1986) of the experience of therapists (Sterling, 1992; Sterling & Bugental, 1993), another layer of experience has been found to be intrinsic to the experience of the role-playing therapist. At the point of calling a halt to the role-play, I was in a state of bewilderment, an emotion specific to Nora. I was also confused, surprised to the point of shock, and in fear. Because I could not discern such nuances in the experience at the time, I did not disclose these feelings to my supervisor. I could not separate my own experience from Nora’s; I only knew distress—a sense of being suddenly lost. For the therapist, the subsequent portion of the supervisory session becomes a doubly-tracked experience. On the surface, therapist and supervisor work together under his or her direction to understand the experience and its importance for the therapist, the client and the alliance between them. Simultaneously, the therapist ventures into the hidden, subterranean, and idiosyncratic and without fully realizing, strains towards a moment of “Ah hah! This is what I could not see—yet now I know what I already knew but didn’t know I knew.” When this moment happens, resolution registers in the body as a relaxation of stress and fear. Simultaneously, the moment initiates the recovery of the therapist’s ability to distinguish between the client and the therapist’s sense of individual self. Meaning has come to consciousness as well as a discernment of how the meaning applies to both therapist and client. In summary, the phenomenologically lived experience of role-play in supervision has a structure which parallels the timing of the supervisory hour. What follows here is a summary of the structure of the experience of role-play. The therapist presents a client and states the therapist’s dilemma—perhaps reason for concern at this juncture in the therapy—and a description of how the client presents in the therapy hour. At some point the supervisor invites the therapist to “become” the client. In individual ways, the therapist, marked by the intention to authentically represent the client, invites into his or her own consciousness and body the ways, words, and content of the client. The therapist swings between awareness of self, which is carefully put aside, and discernment of the client’s way of being in the world, which is given full space within the therapist’s consciousness: it is a process of differentiation which supports immersion into the client’s way of being. At some point (and it can appear quickly), the therapist loses the ability to differentiate self from other and at the same instant experiences distress which may or may not be apparent to the supervisor. One therapist named this phenomenon: “I am in a meld with my client!” and thus I have named the loss of the ability to move between “Nora’s” consciousness and the therapist’s, the loss of the ability to distinguish self and other—experienced with distress to the point of fear—the Meld. At this point or later, either the supervisor or the therapist may call a halt to the role-play. Supervision then proceeds as therapist and supervisor attend to the experience of the therapist and its relevance to the client, the therapy and the alliance between therapist and client. PRACTICAL APPLICATIONS IN SUPERVISION

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At some point the therapist, usually during the supervisory session but sometimes later, arrives at a sudden sense of “Ah hah!” This is the bringing into consciousness what was unknown before and during the supervisory session, and is relevant to the work at that point, the Resolution. Later sessions with Nora In a subsequent session with Nora, I, as her therapist, waited until I suspected that the double wall was clear to her in our interaction. I said “Am I speaking to an outer wall which covers the next wall?” She said, “Oh yes, I have two walls, but I assume you can see through both” and was surprised to learn that I could not. Only then did she begin to see that her walls were successful. She was invisible to me. With touching seriousness, she knew herself to be caught within her own charade—unseen and misunderstood just when she was most anxious to be known. For a moment, as in the role-play itself, we were both open to her vulnerable inner world. For this moment, her core was not covered by its exact opposite: the controlling, competent behavior in the world which successfully kept everyone at bay. The felt sense of her world within is still hard to touch in our therapy sessions. But since, during the role-play in supervision I once experienced the tremendous lost confusion I sometimes see only flickering in her eyes, I am now able to remind myself to suspect her unseen fear and to address her need to be covered rather than succumb to my own fears that lead me to attend to her needs generated by the cover itself. In time we should be able to tolerate her experiences associated with the “second wall.” Value of Role-Play Three people are involved in supervision: the client, the supervisor, and the therapist. I will concentrate on what I think the therapist can learn about therapy. But before doing so I will briefly note that the client stands to gain from this exercise because the therapist puts aside theory and an external perspective in order to experience directly the client’s world from within. Therapists say after role-playing a client: “So that is what she or he feels like when all I can sense is her or his resistance.” Supervisors, recognizing that the role-played client is a version of the whole person, have a first-hand opportunity to “see” the supervisee’s client, interact with the role-played client, and gain an immediate experience of the client. This is then added to the rest of the supervisor’s agenda for supervision. New Content Often the therapist senses new content of experience from within the role-played client. Great caution must govern the therapist’s—and supervisor’s for that matter—assumptions about its actual validity. The supervisor must teach the beginning therapist to be patient about content, to wait for a possible demonstration within the therapeutic session of the educated guesses therapist and supervisor make based on the content evoked in the role-play. Meaning making itself resides ultimately in the client. Specifically, in the vignette cited herein, it is of primary use that the therapist felt PRACTICAL APPLICATIONS IN SUPERVISION

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misunderstood, felt the limits of the client’s world. The image of a double wall which arises for the therapist need not be interpreted. The felt sense is important for the therapist to experience; the meaning is left to the client to discover in subsequent sessions, should that become relevant. During the supervisory session, it is useful for the therapist to discover the client’s inner structure which shows how the supervisor came to misunderstand during the role-play. Role-play is not about the story a person tells nor about why a resistance developed. Role-play does reveal how a resistance process creates limits for the client’s inner world and interpersonal world. Supervisor’s mode of working The therapist learns new options from the supervisor’s modeling. From an inner perspective that is unavailable during a demonstration watched as audience, the therapist directly discovers what can be evoked by the supervisor’s working style and intention with this client. Since the therapist is busy responding as the enacted client to the supervisor, the observing remains peripheral but is recoverable during subsequent reflection on the role-play. Bodily Felt-sense In role-play I use whatever I can muster from my knowledge of the client and my work with my client to portray my client as an actor portrays a character. I may start by mimicking the mannerisms and content of the client. By so doing, I evoke my client. To actually “become” the client, I pass beyond mimicry experientially, thus entering another’s consciousness by allowing the client to inhabit my body. Most of the time I am aware of both of us. I move aside as much as I can to let this version of my client shine forth. If I begin to lose the sense of her or him, I do something characteristic such as break role, laugh, slow down, or breathe deeply, to regain the oscillating capacity to separate myself out to an observational consciousness while he or she occupies the “space” of my bodily enactment. This is the process of Immersion in the client. I am able to recover memory of all that happens to her or him during this time and to me through a body memory. The source of my “knowing” is my bodily felt-sense of “Oh, this is my client; but this is me.” What comes to consciousness, including the sense of the gestalt of the client, comes through my body. Thus, because of role-play, I become aware that I am relying on the similarities grounded in the commonalties of embodiment in order to know my client (Gendlin, 1974; Heidegger, 1962; Merleau-Ponty, 1968, 1983), a condition that also exists during the psychotherapeutic encounter. Body, psyche, and behavior not only are unified in the individual but, even more fundamentally, are the way we are accessible to one another. We are not monads but interconnected; we are co-creating existence; and it is happening pre-reflectively. Subjective Presence This realm of felt-sense, the realm of pre-reflective bodily knowing, is also the realm of subjective awareness and of presence. During training, the trainee continually wonders what the words taught in class stand for in the doing, what theory looks like in practice, and how a personality style feels in its living. Being open to a client’s world, while simultaneously being open to oneself and the co-created world, is no mean feat. The challenge is to include in our teaching experiences “that of which we speak” (Bugental, 1978, 1987; Havens, 1974, 1989; Margulies & Havens, 1981; Ornstein, 1968; Signell, 1974).

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Being open means being present and aware to the alert immediacy of oneself within one’s environment (Bugental, 1981). Presence means I am in what I am doing; I am not objectifying myself or my client knowingly or unknowingly. During role-play, when one person embodies a version of another and is simultaneously immersed in differentiating the two, alert immediacy is vital to the tension of union and separation. Heidegger’s (1984) definition startles: presence is “having arrived to linger awhile in the expanse of unconcealment” (p. 34). This captures the phenomenal sense of giving my body and mind over to enact another. In my bodily felt-sense during role-play, my client lingers awhile, unconcealed to my seeing, as I discover what is felt behind the actions I usually see in our sessions together. This lingering, in the presence of another, teaches presence. When one is present there is a waiting, a letting be, a stillness for whatever may come. From within, waiting in stillness, one feels awareness moving, especially the letting be for the rising into and falling away from unconcealment. In the actual role-play, the stillness is not easily felt by the beginner, but in time, the therapist learns to develop this lingering, this stillness in motion, while the client, the issues of the client’s concern, and the changes in the therapist unconceal and then conceal in the therapeutic process. This presence has a paradoxical nature. Awareness itself, especially when open, is swiftly moving and is “lively, vigorous attentiveness” (Levin, 1985, p. 50). To become aware and to focus (Gendlin, 1974), one becomes still, quiet, serene, open to emergence, and lets form within the eye of attention whatever is present or important. Careful step-by-step discovery of this level of the therapeutic work is important in supervision. Subjective presence arises pre-reflectively in bodily felt-sensing when one is open. Thus, role-play can be an introduction to the experiential qualities of openness. Standing as an opening and allowing the unknown to emerge is active (as opposed to theoretical), experiential (as opposed to conceptual), and somatic (as contrasted to cognitive). The “Meld" Immersion, which is the capacity to maintain dual consciousness, and is a condition which provides the therapist control, at some point collapses. The Meld ensues and is quite different. Suddenly, the therapist feels “captured” or “lost” from him or herself, lost from the immersion. The therapist, taken unaware, senses a mixture of surprise, discomfort, defensiveness, fear, the unknown, shock, breathlessness, and a loss of observing neutral consciousness. The therapist feels out of control. Yet, the therapist’s intense reactions at this moment are not necessarily apparent through the screen of the role-play. The therapist’s goal shifts to recovering the capacity to move. To the extent that the therapist makes efforts to conceal the discomfort, fear, and loss of observing consciousness from the supervisor, he or she is not able to get help at this point. In Immersion, the therapist can shift horizontally to an observing-consciousness, by means of the sorting-out processes. In the Meld, any attempt at shifting horizontally does not succeed. The melded experience drives the therapist deeper than he or she expects to go in the supervision. A vertical dimension of depth is introduced. PRACTICAL APPLICATIONS IN SUPERVISION

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Reflection on the Role-Play At some point, either therapist or supervisor will stop the role-play. The reflective period which follows allows both therapist and supervisor to conjointly pool their attention as two to their experience with a third person, the rendition of the role-played client. Hidden from the supervisor and barely conscious to the therapist, the lost, confused sense of the Meld lives in the therapist as discomfort and a drive to regain the capacity to distinguish self from the other, the role-played client. During the role-play of Nora, this moment of the Meld came when, as “Nora,” I was upset at being misunderstood and, as myself, I knew that I too would have misunderstood her. It was not until much later that I could see that I was frozen by the failure of my best efforts to reach her. Reflection during supervision covers the usual goals of supervision. For the supervisor, despite orientation, this is the chance to add his or her directly experienced felt-sense of the client. as role-played by the therapist, to work with parallel process and the therapist’s blocks, and to pool observations with the therapist’s as the two begin uniting their experience with theory. The therapist can unravel the various levels of awareness perceived behind the enactment of the role-play, as well as bring forward the inner experience of the client behind the defensive structure, to find out how the supervisor responded to the client’s resistance. The therapist’s part in the interrelating is available for probing. But, all the while, the therapist is trying to resolve the Meld. In my experience as consultee, supervisor and as observer in group consultation, this generally is lived in a pre-conscious way—even among those of us who are familiar with this research. Avoiding theoretical formulations, staying with the experience of the therapist, reflectively pooling the awarenesses generated in both therapist and supervisor, encourages the “return” to the phenomenon (Shapiro 1985). The reverberations of the experience arise slowly, letting both therapist and supervisor, find nuance, calling forth whatever their shared attention and goal makes important, and allows them to compare their reflected-upon experience to their theoretical stance. This phenomenological openness is a state of waiting for disclosure, for revealing of the unexpected, for freshly seeing the expected. It is the most likely mode for allowing a sense of “Ah hah! Now I know what I already knew but wasn’t aware of” to emerge during the supervision. In my research, if this revelation did not arrive during the supervisory hour, the therapist remained concerned—in the Meld, so to speak—and did not release the distress and tension until the “Ah hah” realization came to consciousness. At that moment, the therapist knew what was important to the therapy for her or him and for the client and regained a sense of separateness. Intersubjectivity The meaning that is brought to conscious awareness in the separation from the Meld tends to be relational in regards to the therapy. In the case of Nora, my recovery depended on feeling how flummoxed I was by being blinded in the face of her dramatic exteriority. I was losing faith in her soul without realizing it. Through the literature of imagining (Casey, 1976 Giorgi, 1987), of felt-sense (Gendlin, PRACTICAL APPLICATIONS IN SUPERVISION

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1962, 1974, 1981, 1996) , of acting (Stanislavski, 1936/1989), and of parallel process (Ogden, 1982; Wolkenfeld, 1990), I have postulated that the experience that is brought to presence in the role-play itself is an analogue, or image, of the nexus lived internally where the self and other intertwine within the therapist as experiences in the ongoing therapy. Therapy is mutually undertaken and lived by therapist and client. In the case of role-play, the therapist may be bringing to presence the therapist’s version of that lived mutuality. That which steers the therapist to present this client at this time is the pre-consciously felt urge to bring to consciousness that which is alive and confusing within the interrelated field, the “conjunction” of the therapy journey. Intersubjectivity in this situation implies a lived interconnectedness, a joining, and entrance into the world of another lived in a tension to discern precisely and with increasing complexity the differences between self and other. According to the philosopher Emmanual Levinas (1969, 1991), herein lies the living creation of our subjectivity, where we are drawn toward the life of another and yet will neither serve nor understand unless we recognize the unutterable differences between us. This is also related to Buber’s (1965) dialogical philosophy. Resistance and Defense: example of theoretical reflection Role-play may provide an experience of what a client feels prior to verbal expression. In this area, resistance feels necessary and defense forms. As theoretical concepts, resistance and defense are considered useful in existential theory and serve as an example for reflexive conceptualizing. Bugental (1981) suggests that resistance is of the present gestalt of a client’s life. It is a confusing error to think of the resistance as directed against the efforts of the therapist. The therapist needs to recognize that the resistance is much more significant than that. It is the way the patient forms his symptoms and meets his life. It is the manner in which the patient forestalls authenticity in his own being (p. 91). It is important to note here that I do not confine the observation to the client alone. While distinguishing between self and other during the role-play, the therapist’s limitations are also enacted; his/her defenses are equally operative. Role-play can open the therapist to the role-played nuances of this meeting behind and within the structure of the client and therapist. In this vignette, at least, the felt-sense of the client within her walls was one of being misunderstood along with intense loss and fear. So the panic and deflection that I experienced in our sessions became a “wall” to ward off abandonment. For my client the “wall” was fear, fear in hiding. She was not “resisting” in the usual interpersonal sense of that word. She was hiding. And in session, I cannot find her. The role-playing itself ducks behind the vicissitudes of the interpersonal realm encountered from the “outside,” instead the experiencing lies within the realm of what generates a “wall” or a symptom. And it is not a generalized, theoretical formulation, but an immediately perceived experience. Respect for our need to and capacity for defending our most important and tender selves is vital to the beginning therapist who is prone to feeling threatened by the ways a client wards off the therapist’s best effor