"CE Corner" is a continuing education article offered by the APA Office of CE in Psychology.
To earn CE credit, after you read this article, purchase the online exam at www.apa.org/ed/ce/resources/ce-corner.aspx.
Upon successful completion of the test — a score of 75 percent or higher — you can immediately print your CE certificate.
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CE credits: 1
Learning objectives: After reading this article, CE candidates will be able to:
- Identify certain types of harmful supervision.
- Describe the guidelines and training available to help supervisors improve their oversight.
- Discuss several keys to successful supervision of psychology graduate students.
Several times a year, "CE Corner" presents an ethical quandary and asks ethics experts to offer insights on how to address it. Here is this month's vignette:
It's easy to identify bad behavior among supervisors overseeing the work of psychology graduate students, predoctoral interns and postdoctoral fellows in health service, says Michael V. Ellis, PhD, a professor of educational and counseling psychology at the University at Albany in New York.
Some supervisors exploit their supervisees, threatening not to pass them if they don't babysit their children or do their yard work, according to stories trainees and psychologists have shared with Ellis, as well as narratives of harmful supervision collected for a recent special issue of Clinical Supervisor (Vol. 36, No. 1, 2017). Some supervisors humiliate supervisees, yelling at them in public. Others sexually harass trainees, initiate sexual relationships or do drugs with them. "One supervisee reported being physically assaulted by the supervisor," says Ellis.
This kind of abusive behavior among supervisors is shockingly common, says Ellis. In a study he co-authored, 35 percent of 363 supervisees reported they were receiving harmful supervision (Counseling Psychologist, Vol. 42, No. 4, 2014).
Even more common is benign neglect, that research showed. Among the same sample of supervisees, 93 percent reported they were receiving inadequate supervision.
Whether harmful or simply insufficient, poor supervision undermines supervision's twin goals: training future psychologists and protecting the public. To avoid those problems, supervisors must recognize that supervision is a distinct skill that requires specific training, says Rodney K. Goodyear, PhD, who chairs the department of counseling and human services at the University of Redlands in Redlands, California. "There's an assumption that if you're a decent therapist, you'll be an OK supervisor," says Goodyear. "We now realize that we cannot count on that being the case."
To improve supervision, APA's Board of Educational Affairs released Guidelines for Clinical Supervision in Health Service Psychology in 2014. These evidence-based, aspirational guidelines outline the competencies supervisors need to provide high-quality supervision of clinical services provided by students at practicum sites, predoctoral interns and postdoctoral fellows. In 2015, the Association of State and Provincial Psychology Boards (ASPPB) updated its own Supervision Guidelines for Education and Training Leading to Licensure as a Health Service Provider, which offer guidance to both supervisors and supervisees as well as to psychology boards developing supervision regulations. There's also a growing body of evidence about best practices (see "Additional Resources" at the end of this article).
Supervision experts offer this advice for strengthening your supervision skills:
Get formal training and seek feedback
Although APA accreditation requires doctoral programs and internship sites to train students in supervision, that doesn't always happen, says Carol A. Falender, PhD, a clinical professor of psychology at the University of California, Los Angeles, who chaired APA's guidelines task force and participated in ASPPB's. And while some states require continuing education in order to be a supervisor, many supervisors have never received any formal training. When Falender asks psychologists about the biggest influence on the way they supervise their trainees, most report that they draw mostly on their own experiences with supervisors during their training. "It's kind of the osmosis theory—that they learned how to supervise by having it seep in somehow," says Falender. "Some supervisors just wing it, addressing whatever seems particularly important that week, but not systematically thinking about all the aspects of supervision."
Instead of using what Falender calls that "haphazard, catch-as-catch-can method," she urges supervisors to get formal training in supervision, including such areas as professionalism, diversity, feedback and evaluation, and ethical, legal and regulatory concerns. APA often offers supervision workshops at its annual convention, and state, provincial and territorial psychological associations may offer continuing education sessions as well. You can also hire others, whether trusted colleagues or supervision experts found online, to provide feedback on recorded sessions between the supervisor and supervisee. You can even ask supervisees for feedback, once you've built a relationship of mutual trust.
Use an informed consent process
One common mistake supervisors make is not being clear about the expectations they have for their trainees, says Goodyear, who served on APA's guidelines task force. To avoid unpleasant surprises, build a relationship of mutual trust from the get-go by laying out responsibilities and expectations for both sides of the supervisory partnership in a contract, he suggests.
ASPPB's guidelines suggest that contracts include:
- The goals of supervision.
- The structure of supervision, including the number of hours per week and the method of supervision.
- The supervisor's duties and responsibilities, such as assuming responsibility for the supervisee's clients, providing ongoing and end-of-supervision written feedback and outlining what will happen if the supervisee doesn't meet specified competency criteria.
- The supervisee's responsibilities, such as coming to supervision with case notes and other materials, alerting the supervisor to high-risk client situations and their own emotional reactions and incorporating feedback into their practice.
Monitor supervisees directly
While psychology as a field doesn't require the supervisor to actually observe or hear what the supervisee does in clinical sessions, that's the only way to monitor trainee performance effectively, says Ellis, a member of APA's guidelines task force. APA's guidelines recommend that supervisors sit in on supervisees' therapy sessions or review video or audio of sessions rather than relying on supervisees to accurately describe their work and alert supervisors to any challenges they're experiencing. Supervisees may not even be aware they are making mistakes or having problems they should report, Ellis points out. "The research is not extensive but is substantial enough to conclude that what therapists believe they're doing is not necessarily what they are doing," he says. "They can miss significant events that occur during the session."
Unfortunately, says Ellis, too few supervisors take the time for this kind of direct monitoring. "According to the most recent data I've seen, about half of supervisees leave their doctoral programs and get licensed without their supervisors ever seeing what they do in therapy," he says.
That type of neglect doesn't just hamper supervisees' growth, it can also put supervisors at risk, Ellis warns. "If we're not monitoring what supervisees are doing, how are we protecting clients from harm?" he asks, adding that he has seen cases where tapes revealed supervisees blaming clients or even yelling at them. Because of those legal risks, documenting what your supervisees are working on, what feedback you have provided and other supervision activities is critical. "In a court of law," says Ellis, "if it's not written down, it doesn't exist."
Supervisors must also adhere to several ethical guidelines, as spelled out in APA's Ethics Code.
Maintaining appropriate boundaries is one key issue, says Emil Rodolfa, PhD, a professor at Alliant International University's California School of Professional Psychology, who was part of ASPPB's supervision guidelines task force. Running out of time during a supervision session can result in one common boundary issue. To find additional time, a supervisor might suggest taking the supervisee to lunch or dinner to continue their discussion. But that doesn't just put confidentiality at risk, since it's difficult to have a private conversation about confidential information in a restaurant setting. It can also push a relationship boundary and put the supervisee in a difficult position, says Rodolfa. "Supervisees are in a relationship where they have less power than their supervisors," he says. "They can have trouble saying ‘No, I don't want to go out to lunch or dinner.'" Supervisees may fear the consequences of saying no or just want to protect their supervisors from feeling rejected, he adds.
Supervisors should also ensure that supervisees understand the limits to confidentiality when it comes to the information they share during supervision sessions, says Rodolfa. Supervisees should know, for example, that the supervisor may have to report problematic interactions with clients to the agency, or may have to involve others if a supervisee's performance is inadequate. "It's really important to clarify upfront where their information may potentially go," says Rodolfa.
Another potential ethical challenge is providing supervision feedback via phone, email or other technologies, says Rodolfa, who is researching "telesupervision." Although his research is still preliminary, he says, "what we've found is that not many people do it, and those who do have not had much training in the use of technology for supervision." One hurdle is the difficulty of building a strong relationship online or over the phone, he says.
Give timely feedback
Failure to give good, consistent feedback to trainees is an all-too-prevalent problem, says Goodyear. "Data show that supervisors don't give feedback nearly as often as they believe they do," he says. And because such conversations can be difficult, he adds, supervisors can be vague about their criticism when supervisees are struggling, even though these are the very supervisees who need such feedback the most. Instead, says Goodyear, supervisors should be direct and specific, basing their feedback on observations rather than judgment by saying something like, "I observed you doing this; I wonder if it might be better if you did it differently next time," instead of, "You did a really bad job."
Don't just focus on the negative, recommends Nicholas Ladany, PhD, dean of the University of San Diego's School of Leadership and Education Sciences. "We ask supervisees to bring in some of their biggest challenges, but by definition that's a biased sample," says Ladany. Also ask the supervisee to point to sessions they believe went well, he says, which allows the supervisor to understand how supervisees see their work.
It's also critical to address problems immediately, says Arpana G. Inman, PhD, who chairs the department of education and human services at Lehigh University in Bethlehem, Pennsylvania. "Don't wait for a semester to go by, and you haven't said anything," says Inman, who co-hosts APA's DVD series on supervision along with psychologist Hanna Levenson, PhD, of Berkeley, California. "There shouldn't be any surprises at the end of the period of evaluation."
Supervisors should make themselves vulnerable, too, adds Inman. "It's really important for supervisors to disclose some of their own challenges, dilemmas they've dealt with, perhaps mistakes," she says. "Research has shown that the more supervisors self-disclose about these kinds of issues, the easier it is for supervisees to feel vulnerable and share their own challenges."
Be aware of diversity issues
Diversity is another potential hot spot, say Inman and others, noting the complexity of interactions among the supervisee, supervisor and client. It's less about demographic differences, such as race or sexual orientation, and more about "identity awareness," says Inman, explaining that supervisors and supervisees should consider how their race, gender or other characteristics—and any discrimination or privilege they've experienced related to those characteristics—may be affecting their interactions with others. It's important to remember that each individual has multiple cultural identities, she says, adding that it's important for supervisors to acknowledge the privilege as well as oppression inherent in these identities. "Even as a person of color, I might not be aware of how my heterosexual privilege plays out, and so I might engage in microaggressions," she says.
Supervisors who aren't as aware of structural racism or other contextual cultural issues may wind up with frustrated supervisees who don't get as much out of the process as they should, warns Inman. To avoid that problem, she says, supervisors should get cultural competence training if they're not as up on racial issues, sexual identity or other diversity-related topics as they should be. They should also be upfront in addressing these issues with supervisees by acknowledging any differences in cultural identities. "Given the power differential, it's incumbent on the supervisor to bring these issues to the forefront right away," she says.
Manage conflict effectively
Disagreements within supervisory relationships are common, say Goodyear and others. Trainees may take issue with supervisors' assessments of their skills or their supervision style, for example. Other conflicts may be more personal than professional, such as differing personalities or simple misunderstandings.
Often supervisees are reluctant to bring up problems, says Falender. "Supervisees are depending on supervisors signing off on their hours so they can proceed to the next level of their training," she says. "They can be quite wary about raising any issues that might make the supervision relationship difficult or challenge the supervisor in any way." Instead of bringing up an issue, she says, supervisees may withdraw, stop complying with their supervisors' suggestions or even become hostile.
Supervisors can be equally loath to address conflicts head-on, says Ladany. "When conflict is heightened, it often doesn't get discussed," he says. That's a shame, since conflict can be a learning experience for supervisees, he says.
To repair a rupture, wait until both parties are calm, suggests Falender. Then undertake a multi-step process: Think about what caused the strain, decide whether it's significant enough to act upon, take responsibility for any missteps, validate the supervisee's experience, collaborate on a plan of action and move on.
Take supervision seriously
Supervisors may feel free to come to sessions late, cancel sessions unexpectedly or even ask supervisees to receive supervision while the supervisor picks up his or her dry cleaning, says Goodyear. They shouldn't, he emphasizes. "Supervisors should treat sessions as seriously as they would therapy sessions," he says.
If a supervisee's performance is so poor it affects patient care, adds Ladany, supervisors need to remember their gate-keeping function—protecting the public by keeping those who are incompetent from joining the profession. "The ultimate litmus test for supervisee competence is whether you would refer a member of your family, whom you liked, to this supervisee for care," he says. "If the answer is no, there's something really wrong about moving the supervisee on."
APA Psychotherapy Supervision DVD Series
Levenson, H., & Inman, A., co-hosts, 2017 and 2016
Fundamentals of Clinical Supervision, 5th Edition
Bernard, J.M., & Goodyear, R.K., 2014
Supervision Essentials for the Critical Events in Psychotherapy Supervision Model
Ladany, N., & Friedlander, M.L., 2016
Supervision Essentials for the Practice of Competency-Based Supervision
Falender, C.A., & Shafranske, E.P., 2016
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