Two Kinds of Supervision

Supervision is at the heart of teaching and learning how to be a mental health professional. Therapy brings about change through a special kind of "helping" relationship, and we learn to foster and harness that kind of relationship through our relationships with supervisors.

We all receive supervision throughout our training, in graduate school, and leading up to licensure. However, ethical guidelines require that we continue to make use of supervision - or consultation, supervision's less hierarchical cousin - throughout our careers. Unfortunately, not all agencies that employ mental health professionals make supervision a priority, and not all supervision is created equal.

Indeed, there are two main categories of supervision that professionals receive once they have graduate and are out in the field:

1) Administrative Supervision

Administrative supervision is perhaps the most readily-available kind of supervision. It focuses on ensuring that workers are meeting requisite standards and following established protocols. An administrative supervisor is concerned with how programs are operating, whether workers are showing up on time, presenting themselves professionally, and completing all the paperwork needed to keep the agency in business. Administrative supervisors are also typically responsible for things like performance evaluations.

2) Clinical Supervision

Clinical supervision is what most of us think of when we think about supervision. This is the kind of supervision that focuses on the clinical work: how we understand what is going on for our clients, how we can connect with and help them, and what might be getting in the way. It helps us recognize and think about what may be going on underneath the surface of our clinical encounters. It gives us a place to express our own feelings, identify our own biases and issues that may be triggered in our work, so that these things don't "leak out" when we're with a client. It may help us recognize a need for more self-care, or our own therapy. It helps us develop a deeper understanding of theory and practice so that we can intervene more skillfully.

Most agencies provide administrative supervision as a matter of course. Whoever is your "boss" is probably technically providing administrative supervision. When licensed supervisors are available, many agencies will provide clinical supervision for employees working toward licensure. After all, agencies typically benefit from this arrangement, both because they are more competitive when vying for the best new graduates, and because they stand to receive added reimbursement for services provided by licensed professionals. Of course, there is not always a supervisor available who has the kind of license an employee needs for their own licensure. When this happens, the employee may be able to negotiate with their employer for an appropriate supervisor to be found in another program, department, or even outside the agency. However, sometimes it is necessary for newer graduates to find and pay for their own outside clinical supervision.

Logistically, it is easiest when your administrative supervisor (your "boss") also provides clinical supervision. Practically, however, this is not always possible...or even desirable. It may be that your boss has a different kind of license than you need, or that the agency does not prioritize clinical supervision, or that your boss's area of expertise is not quite what you need. You may have reservations about revealing difficulties to the person who will be completing your performance evaluation. Or you may benefit from the perspective of someone who has a little more distance from the program or agency setting.

I was grateful in my early years of practice to have a clinical supervisor who was removed from the program where I worked, who could stand outside the politics, and who was supportive of me, rather than another agenda. I left a different job because my supervisor took expression of emotion during supervision as a reflection of my sessions with clients, rather than as a healthy way of ensuring my emotions did not enter into my work with clients. Currently, I have a supervisor who is better able to blend administrative and clinical. Thus, my experience suggests that much depends on the supervisor, and the setting.

What has your experience been? How have you experienced supervision at its best and at its worst? How have administrative and clinical supervision been combined or separated for you? What recommendations would you make to agencies and the profession as a whole?

You Catch More Flies With Honey

A few weeks ago, I wrote about accepting feedback, and part of what makes that difficult. However, it's also worth reflecting on what makes giving feedback also a challenge.

The most obvious answer, of course, is that many people are uncomfortable with conflict and fear that even well-meant negative feedback will be received with some degree of defensiveness, hurt, or anger. It's not really an irrational fear - any of those responses are definitely possible, while it is not possible to control what response you receive.

It's also true that most of us do not have the luxury to avoid giving feedback. We give feedback to our supervisees, sometimes our supervisors, and yes, even clients. In the case of clients, feedback may take the form of confrontation (e.g., highlighting discrepancies between a client's words and behavior), or redirection of inappropriate or detrimental behavior.

We provide feedback in order to be helpful: to facilitate growth and/or prevent harm. We may undertake it in the most nonjudgmental and kindhearted of mindsets...but the other person does not know what our mindset is, and many of our clients (and more than a few of us) may have insecurities that make them (us) vulnerable to criticism. Any sort of feedback can affect self-esteem, depending on how the receiver internalizes it. So, while one person may think, "Oops, she's right, I should have done that differently," another person may think "I should have known better than to make that mistake. She must think I'm an idiot."

Now, as I said above, it isn't possible to control the other person's reaction - to make sure, for example, that they think like person #1 rather than person #2. However, there are some strategies that we can use to make our feedback easier to hear. These strategies all seem to fall into the category: "You catch more flies with honey than with vinegar."

1) The feedback sandwich
Perhaps the most straightforward strategy is to "sandwich" a piece of negative feedback between two pieces of positive feedback: praise, criticize, praise. The positive feedback makes the negative feedback easier to hear, perhaps because it protects against a precipitous drop in self-esteem that might accompany negative feedback alone.

2) Empathic feedback
Any negative feedback is easier to hear when it is said in the kindest possible way, in an empathic and understanding tone, with explicit recognition of the person's best intentions, and assurance of ongoing positive regard (i.e., that you still respect the person and that their good qualities are not negated by the feedback).

3) Focus on concrete behaviors rather than personal qualities
We've all heard this advice when it comes to child-rearing: discipline should emphasize that a behavior is wrong, not that the child is "bad." The same principle can be applied to adults. Feedback is most effective when it focuses on a concrete behavior that the person can identify and change, rather than either vague feedback that does not suggest a specific change, or feedback focused on something that the person cannot easily changed (e.g., shyness).

4) The VCR technique
From the book Teens Who Hurt, this strategy suggests that feedback may be more effective when structured as follows: V - begin by validating, i.e. expressing understanding of the other person's perspective, and acknowledging a strength or positive quality (kind of like the feedback sandwich). C - next comes challenge, i.e. provide the corrective feedback, ideally building upon the information contained in the validation. R - finally, request, i.e. identify a specific behavioral corrective action.

How do you think about giving feedback? What strategies do you find make it easier for someone to hear and respond positively to feedback?

Accepting Feedback - The Role of Identity

It's impossible to do this work perfectly, so it's inevitable that we'll all sooner or later face criticism of one form or another from supervisors and clients (often more frequently than we'd prefer). Whatever euphemism we use (e.g., constructive criticism, feedback), these conversations are inherently difficult. Our responses, both internal and external, determine whether such conversations lead to positive results (professional and/or personal growth, mutual learning, improved rapport) or negative results (damage to relationships, self-esteem, and self-efficacy).

In the book Difficult Conversations, the authors argue that all interpersonally challenging conversations share a common structure, with three threads:

1) The "What Happened?" Conversation, which involves debate over what "really" happened (i.e., the Truth), what each person's intentions were, and where to place blame.

2) The Feelings Conversation, which involves whether and how each participant's feelings are addressed

3) The Identity Conversation, in which each participant determines what the current issue says about them, and how they see themselves in light of the current issue.

I tend to think the first two threads are easier to manage - after all, social workers have plenty of experience addressing emotions, and have practice (albeit with varying degrees of success) considering competing constructions of reality. Because the third thread happens deeper in the psyche, and plays on any lingering insecurities or self-doubts (we all have them!), I find it the hardest part of difficult conversations to manage. However, managing this third thread has a significant benefit, both in how we feel afterward, and in making the other two threads easier to navigate.

Criticism is hard to hear because it poses a threat to our sense of self - typically by causing us to question our own competence, goodness, or worthiness of love. To some degree, it is inevitable that feedback will challenge our identities. However, it's also possible to reduce our vulnerability to these challenges, and the intensity of the distress we feel as a result. 

1) Develop an awareness of your identity issues and vulnerabilities. Notice what elements or types of feedback unbalance you, and explore the feelings and thoughts you have during these moments to identify patterns - aspects of identity that are vulnerable to upset. 

2) Avoid all-or-nothing thinking. Our sense of self is more likely to be thrown off by feedback if we think we are either competent or incompetent, good or evil, worthy or unworthy of love - one extreme or the other, with no middle ground. We are more threatened by feedback if we're trying to hold onto a completely positive identity that leaves no room for flaws (which means we have to respond to negative feedback with denial to maintain our identity), or if we go to the opposite extreme, exaggerating the negative feedback so that it defines who we are - if I'm not perfect, then I must be worthless. The solution is to develop a more complex self-image that includes a range of both positive and negative qualities, and resist the impulse to make any one quality, positive or negative, the only element of identity that matters.

3) Accept that you sometimes make mistakes (we all do), your intentions are complex and sometimes mixed, and you have contributed to the problem in one way or another. Admitting these things requires a balanced, rather than all-or-nothing, self-image, and admitting them to ourselves makes it easier to admit them to another person. 

4) Put the current issue in perspective by asking yourself what significant this will have for your identity in the future - next week, next year, in ten years.

5) Remember that there may be identity issues at stake for the other person, too.

Of course, it's impossible to do these things perfectly (that would be another all-or-nothing expectation!), but working on them does lessen the intensity of distress we experience when we do receive feedback, and therefore allows us to respond more skillfully, and learn what we can from the encounter. 

How do you cope with the identity implications of feedback or criticism? 

Supervision - An Evolving Process

Earlier this year, I got my coveted "independent" license - meaning I am officially qualified to practice clinical social work without a more experienced clinician supervising me. Having this license means that a lot more professional opportunities are open to me...but it does NOT mean that I'm no longer supervised. 

That may not seem very logical (since the whole point is "independent" practice), but this is social work, people! We consider clinical supervision a pillar of professional development, and believe professional development is never "finished" as long as we're still practicing, so.... The only social workers I know who don't have some sort of supervision are either in private practice, or are the highest ranking clinical staff in their agency or department.

I have learned, however (through some uncomfortable trial and error) that supervision does change post-licensure (or did for me, at least). Now, that may  not be as true for people who continue with the same job and supervisor pre- and post-licensure - but these people might experience a similar change when they do ultimately move into a different position. 

To explain what I think changes, it's helpful to first look at how supervision operates in previous stages of professional development. Obviously, that begins as students, and supervision is definitely different for students than for staff. Students are there to learn new skills, and are not expected to know what they're doing the same way staff do. They're expected to make more mistakes, and to have more questions. As a result, supervision is also somewhat more structured because students are asked to provide examples of their clinical work in the form of process recordings. (Did I hear a collective shudder?) Supervisors therefore have a better idea of what students are doing, saying, thinking and feelings while they're with clients, and students come to supervision with some questions and dilemmas already identified. 

Hopefully, students' field placements provide them with some solid, positive experiences of supervision that teach them how to make the most of the supervisory process. However, the process has to change somewhat once the student graduates and becomes an employee. For one thing, every student swears that she will never write another process recording after graduation! As employees, they are also expected to have a foundation of expertise and function with appropriate autonomy and efficacy in their roles. Consequently, in most settings, supervisors can only assess what kind of work staff are doing through their notes, case presentations, and discussions in supervision. However, since most new staff still feel like they're muddling through, they are likely to have a lot of questions and curiosities, and request more feedback, all of which gives some structure to supervision, and makes the process feel beneficial to both supervisor and supervisee.

Now fast forward a few years. With more experience, clinicians are more confident and have fewer questions for their supervisors. However, they've also been trained to make the most of supervision, and are therefore likely to use the time to discuss their most challenging cases and clinical dilemmas, especially those where their own reactions have the potential to get in the way if not addressed. If the supervisor is already familiar with the clinician's work, or has another window into how they're doing with the cases that are going smoothly, this shift may not cause any difficulties. However, if the supervisor doesn't know the clinician well and has limited other exposure to their work, there is a risk that the supervisor may extrapolate, and get the impression that the challenges and reactions raised in supervision are bigger or more global problems than they are.

It's helpful for me to remember two things, in this post-licensure version of supervision: 1) the supervisor has limited other exposure to my work, and doesn't know what is going well unless I tell her; and 2) supervisors also want to feel good about their work, so including some positive feedback and letting my supervisor know what I've taken away from supervision and found helpful makes the whole process more positive for both of us.

Have you noticed any changes in how you use supervision over the course of your career? What suggestions do you have for making it successful, particularly after you've become an experienced clinician?

Making the Most of Supervision

Supervision in the mental health professions is a strange practice. I don't know of any other fields where each student or employee has a designated time each week during which they meet with their supervisor for the purpose of professional development. However, "supervision" is a vague concept that is defined differently in different settings and by different supervisor/supervisee dyads. As a result, it can be hard to know what it's "supposed to" be.

It may help to think about the goals of supervision from both sides of the coin. For the supervisee, supervision is a source of support for what can be very draining work, an opportunity to learn and hone skills, process reactions to clinical challenges, problem-solve and strategize next steps. For the supervisor, supervision is the only opportunity to find out what the supervisee is really doing with clients - how they're thinking and feeling about cases, what interventions they favor, and what they may miss or omit. It's also a chance to convey administrative information, workload and documentation issues, and so on. And last but not least, a way to support supervisees, which keeps morale up, and decreases turnover.

Based on these goals, each member of the dyad should prepare for a supervision session by identifying agenda items. The supervisor may not always have specific things to put on the agenda, if there are no administrative issues at hand, but the supervisee should always have items on his or her agenda:

• Cases he or she would like help understanding and/or planning interventions
• Issues of transference and countertransference, or other strong reactions that may affect the work
• Issues about schedule and workload, time-management and overall stress-level

Each supervisor and supervisee comes to supervision with their unique personalities, varying theoretical orientations, depth of knowledge/expertise, and expectations based on past supervision experiences. Therefore, it's important to begin a new supervisory relationship by discussing what each person is bringing to the relationship, and developing a tentative structure that will work for both parties. It's also important to maintain ongoing communication about how things are working - it's much better to address any issues as they arise, and before they become barriers or points of contention!

Even while talking about the expectations each person brings into the relationship, it's important to try to leave those expectations at the door, recognizing that this supervisory relationship will be different from other experiences of supervision, and giving each other the benefit of the doubt. We should also each know our own hot-buttons, and have done our own work to keep ourselves from projecting onto our supervisor/supervisee, or reacting to something other than what's happening in the here and now. The same as when we're working with clients, communication, empathy, and self-awareness are crucial.

What are your tips for making supervision work? Have you had terrific or awful supervision experiences? Have you found ways to turn a not-so-good supervision experience into a productive one?