Professional Documents
Culture Documents
70:10301041, 2014.
The recognition of clinical supervision as a distinct professional competence and a core compe-
tency in psychology (Fouad et al., 2009; Kaslow et al., 2004), has been transformative, resulting
in increased scholarship on supervision, development of guidelines and regulatory attention,
and generally an increase in the identification of components of effective supervision (Falender
& Shafranske, 2004, 2008, 2012; Ladany, Mori, & Mehr, 2013). More recently, greater attention
has been placed on diversity factors, emphasizing multicultural supervision practice (Falender,
Burnes, & Ellis, 2013; Falender, Shafranske, & Falicov, 2014).
Competency-based supervision (Falender & Shafranske, 2004) is a metatheoretical approach
that is compatible across psychotherapy-focused, feminist, multicultural, and other supervision
models and offers enhanced accountability to ensure client welfare and development of clini-
cal competencies (Farber & Kaslow, 2010). Competency-based supervision has the additional
strength of organizing specific supervisor competencies for practice. In light of its intentional
orientation to the articulation, assessment, and development of specific professional compe-
tencies, the approach is in sync with the competency movement in the United States and with
professional psychology globally as international supervision regulations and training models
are increasingly competency-based (e.g., Psychology Board of Australia, 2013). In this article,
we highlight recent developments and the state of the art in clinical supervision with particular
emphasis on the competency-based approach. We close with consideration of current training
practices in supervision and challenges.
Definitions
Multiple definitions of clinical supervision have been proposed (e.g., Bernard & Goodyear,
2014; Falender & Shafranske, 2004; Milne, 2009), reflecting differing viewpointsrecall the
1,000 blooming flowers of psychology (Fox & Barclay, 1989)and increasing the complexity
of studying, learning, and practicing clinical supervision. Definitions have emphasized different
aspects of supervision, including the nature of the relationship (hierarchical vs. collaborative),
critical factors involved in learning, the nature of the knowledge, skills and attitudes/values
necessary for competence, approaches to assessment and feedback, and the necessity for a
reflective approach for both supervisor and supervisee.
Other definitions have emphasized the functions of supervision, including the need to ensure
protection of the public, monitoring the quality of professional services, and gatekeeping, as
References cited but not in the list are available from the author.
Please address correspondence to: Carol A. Falender, 1158 26th Street, #189, Santa Monica, CA 90403;
E-mail: cfalende@pepperdine.edu
well as its role in enhancing life-long professional functioning. Milne (2009) pointed out that
current definitions are problematic in that they lack specificity, do not account for interprofes-
sional practice (i.e., practice across multiple mental health and medical disciplines), may not
emphasize the critical nature of the supervisory relationship, and generally undermine efforts to
systematically study supervision. As Kavanagh (2011) stated, A competency emphasis requires
clarification of the nature and theoretical grounding of competencies, and of the most effective
methods to train and assess them, including an evaluation of problem based learning approaches
and of optimal modes of supervision (p. 65). An existing challenge is to facilitate a consensus
about supervision (involving a precise, inclusive definition) while accommodating the different
perspectives and varieties of supervision that are blooming.
Falender and Shafranske (2004) defined clinical supervision as
Supervisory Alliance
Alliance is acknowledged as a metatheoretical essential component of supervision. It is the
central feature that influences and (we theorize) is influenced by specific supervisory practices
(best and worst). The alliance is developed through a collaborative process in which goals and
the tasks to achieve these are identified, based in part on the supervisees self-assessment of
competence. The supervisory relationship is grounded in respectful process (CPA, 2009) and
is critical to managing conflicting role demands that can strain the supervisory alliance. The
supervisory relationship is complex, with tension between the duty to protect both the client
(and by extension the public) and the integrity of the profession while ensuring, promoting, and
monitoring the development of requisite competence of the supervisee.
A collaborative relationship emerges around the goals and tasks to achieve them, and ex-
ists within the supervisory power differential. Feminist, cognitive, psychodynamic, and family
systems-oriented psychologists have all described supervisory relationships that are collabo-
rative, with shared communication regarding client work and supervisee progress, and with
a commitment to transparency such that feedback and evaluation are normative and not a
surprise.
The supervisory relationship is strongly connected to outcomes of supervision, at least from
the supervisees perspective (Inman & Ladany, 2008). Pearce, Beinart, Clohessy, and Cooper
(2013) developed and validated the Supervisory Relationship Measure, with factors of safe
base (created by supervisor), supervisor commitment, trainee contribution, external influences
(e.g., stressors, evaluation concerns, past experience of supervision), and supervisor investment,
reflecting the fuller view of the complexity of the supervisory alliance. Both supervisees and
supervisors reported feeling the supervision was a safe base in strong alliances. In addition,
Clinical Supervision: State of the Art 1033
the scale was associated with and predicted supervisee clinical competence and supervisor
satisfaction with supervision.
In contrast, Rousmaniere and Ellis (2013) proposed a distinction between collaborative clini-
cal supervision and the supervisory alliance and noted that in their sample supervisees reporting
a high level of collaboration was rare. The Rousmaniere and Ellis scale deals explicitly with be-
havior and what is discussed in supervision as distinguished from attitudes and values including
respect, fostering autonomy, or empowermenta reflection of the essential tension of the rela-
tionship. The results of the study support the need for supervisor training to ensure a respectful,
competent process. The alliance itself is a function of multiple factors, including the attachment
histories and status of supervisor and supervisee (Gunn & Pistole, 2012), cultural identities of the
participants (Son & Ellis, 2013), theoretical orientation of supervisor and supervisee (Watkins,
2011, 2013), diversity factors including gender (Hindes & Andrews, 2011) and race (Schroeder,
Andrews, & Hindes, 2009), and supervisor style (Ladany, Walker, & Melincoff, 2001).
Identification of strains and ruptures in the supervisory alliance and their repair are central
supervisor competencies with direct effect on the clinical process (Falender & Shafranske, 2013;
Safran, Muran, Stevens, & Rothman, 2008). When the supervisor notices a change in the
supervisory alliance (e.g., a previously active and forthcoming supervisee suddenly becomes
avoidant and withdrawn), the supervisor needs to reflect on the process of supervision that has
occurred recently, weigh approaches to address the behavioral change, and discuss incident(s)
that are indicative of a strain or rupture in the supervisory relationship. Strains or ruptures
may be precipitated by misunderstandings, differing worldviews affecting client care, boundary
conflicts, or even setting characteristics beyond the control of the supervisor (e.g., limited space,
computers, clients). Results of a weaker or strained alliance between supervisor and supervisee
include decreased supervisee disclosure (Mehr, Ladany, & Caskie, 2010), and even a perception
of multicultural incompetence (Singh & Chun, 2010).
In an analysis of the best and worst supervisory experiences, Ladany et al. (2013) concluded
that the best supervisors were associated with supervisees who had a stronger emotional bond
and greater agreement on tasks and goals of supervision, concluding that identified effective
supervisor skills, techniques, and behaviors could be a framework for competence of supervisors.
They also supported the highly interactive constellation of variables between supervisor and
superviseethat empowerment and encouraging autonomy in supervisees was well-received.
They emphasized that supervisors should also be challenging, presenting feedback within the
positive supervisory relationship.
The supervisor who simply affirms supervisee behavior, sits remotely and offers little input,
or is hesitant to reflect or challenge the supervisee is not demonstrating an essential component
of effective supervision: providing ongoing corrective and positive feedback. Many supervisors
harbor concern that feedback will damage the supervisory relationship and is to be avoideda
major misconception addressed later. Exploring supervisee process and behavior during a video
review of a session, the supervisor may reflect upon the clients response to an intervention
and link the feedback to an ongoing supervisee goal (e.g., integrating consideration of the
clients worldview). We turn now to consideration of diversity and personal factors, which play
a significant role in both clinical and supervisory relationships.
Diversity
An ethical imperative underlying all clinical practice and supervision is diversity competence.
We have defined supervision diversity competence as
strategies and skills; and consideration of the larger milieu of history, society, and
socio-political variables. (Falender & Shafranske, 2004, p. 125)
Although greater attention is being directed to diversity, still data are emerging that super-
visors often are not initiating consideration of multiple diversity factors in supervision, nor are
factors of privilege, historical trauma, and oppression being addressed (Falender, Shafranske,
& Falicov, 2014; Hernandez & McDowell, 2010). Specific competence is needed to address the
multiple identities (e.g., race, socioeconomic status, sexual orientation, gender identity, ethnicity,
religion, disability, age) among client, supervisee/psychotherapist, and supervisor to consider
the multiple worldviews and the effects of these upon the assessment and treatment of the
client.
Addressing these diversity competence factors and providing feedback and training when
supervisees do not demonstrate adequate competence are important supervisor responsibilities.
In the collaborative supervisory relationship, the supervisee is empowered to address diversity
issues such as generation (age) and culture to reflect on different perspectives. For example, a
supervisee may note that the presentation or communication style of the adolescent client is
actually not dissimilar to the youths peer group.
Several recent legal decisions provide supervisors guidance when a supervisee challenges
remediation plansresulting in one specific case from refusal to work with a client whose life
style was in conflict with the religious beliefs and values of the superviseeas a violation of his
or her Constitutional rights to freedom of speech and religion (Behnke, 2012; Hutchens, Block,
& Young, 2013). Consensus exists that graduate programs may impose ethical mandates on
students and require them to provide services respectfully and affirmatively to clients regardless
of their sexual orientation and diversity status. Supervisors should ensure clarity of rules and
policies regarding gatekeeping and referrals of cases assigned to supervisees; provide clear, direct
written and verbal feedback about supervisees ethics and professionalism; identify performance
issues; develop a remediation plan with specified behaviors and timelines; carefully document
each step; and continuously assess suitability to enter the profession of psychology including the
supervisees professionalism and ethical compliance (Falender & Shafranske, 2013a; Johnson
et al., 2008).
Standards of professionalism and ethical practice, including in the context of working with
clients who vary in diversity identity from the supervisee, need to be engrained in graduate
training programs. Trainees should be expressly advised that the expectation is not to give up
their personal and/or religious values, but that they are expected to attain both demographic
competency [in regard to all forms of diversity, e.g., age, gender, ethnicity, religion/spirituality,
and sexual orientation] and demonstrate the competence of dynamic worldview inclusivity
(Bieschke & Mintz, 2012, p. 202).
or idiosyncratic acts or patterns of therapist experience or behavior appear (Kiesler, 2001, pp.
10611062).
Gaining awareness of and managing countertransference reactions is an important clinical
responsibility (Gelso, Hayes, & Hummel, 2011) and a competency to be developed in clinical
supervision (Shafranske & Falender, 2008). Exploration of countertransference is a significant
informer of treatment, providing insight into the effect the supervisees personal factors have in
guiding or limiting therapeutic exploration. Supervisees normatively experience varying intensity
of emotional reaction to a client but may feel uncomfortable bringing this to supervision,
instead redirecting the client away from intense material, or simply terminating the therapy.
Given its personal nature, supervisors must be particularly mindful (no matter their theoretical
orientation) to delimit exploration of personal factors and countertransference to their effect
on the supervisees understanding and therapeutic engagement with his or her client and the
supervisory relationship. If the distinction between supervision and psychotherapy is not upheld,
then high risk exists that the dyad slides down the slippery slope of engaging in treatment
(Frawley-ODea & Sarnat, 2001; Shafranske & Falender, 2008).
The quality of the supervisory working alliance appears to affect the likelihood of coun-
tertransference disclosure (Shafranske & Falender, 2013). In addition to fostering an effective
alliance, it is recommended that supervisors include management of countertransference as
a competency to be developed in the supervision contract; regard countertransference as an
informer of the therapeutic process; model and give examples of their use of countertransfer-
ence; and reinforce supervisee efforts to bring countertransference into awareness. Videotape
review, self-directed journaling, and Interpersonal Process Recall (IPR; Kagan, 1980) facilitate
identification of markers of countertransference. IPR is a supervision technique that entails a
collaborative supervisorsupervisee video review of the client session attending to emotional
and cognitive responsivity of minute sequences of the interaction.
tient to diagnose and develop a treatment plan. The assessment is observed with the supervisee
self-assessing prowess and supervisors rating and providing competence feedback and evaluation
useful in the supervision process. The competency-based frame is a significant tool to enhance
goal setting, assessment feedback, and evaluation of targeted competencies.
The supervision contract is not a static document, nor are its components. The evolving
nature of professional practice, clinical training and supervision, and societal changes necessitate
ongoing reflection on establishing clear and reasonable standards and expectations. One example
of the need for ethical responsiveness to cultural changes is found in the use of the Internet
including social networks and search enginesand the boundary issues that ensue from such
use. These issues are discussed in the following section.
Clinical Supervision: State of the Art 1037
Internet
The Internet has brought new challenges to clinical supervision, often reflected in the competence
and worldview perspective differences between supervisees and their supervisors. Supervisees
may be highly fluent in all aspects of social networking and search engines and consider them
intrinsic in all interactions (Myers, Endres, Ruddy, & Zelikovsky, 2012). For example, supervisees
may use search engines to obtain information about clients or supervisees, they may connect
(or friend) clients on social networks, and/or they may text or e-mail clients. Although most
supervisees believe it is unethical and inappropriate to use search engines or social networks
to find client information, the vast majority of supervisees have nevertheless reported that they
did access such informationalthough most reported the search or contact was planful and the
client was aware of the search (DeLillo & Gale, 2011).
The supervisor is responsible for ensuring that attention to standards of professionalism
and ethical problem solving are brought to bear on emerging Internet issues. Some proposed
areas to discuss or incorporate into the supervision contract (derived from DeJong et al., 2012)
include acknowledging different generational attitudes (e. g., among supervisor, supervisee,
and client[s]) toward digital media; modeling and discussing Internet professionalism explicitly,
enlisting active learning including role play and vignettes derived from the supervisees to ensure
understanding and ethical compliance in Internet practice (e.g., netiquette, boundaries, safety
issues); discussing and providing readings and guidelines on professionalism and ethics; and
ensuring a professional online footprint with the understanding that the boundaries between
professional and personal are vastly diminished with Internet search engine access. As with all
supervision practice, Internet practices should be guided by the ethical principles and code of
conduct and emerging standards that are articulated in supervision contracts.
ES: Is that what, in fact, happened? How emotionally engaged was she, when you
were asking the questions?
CB: [Described the interaction in depth and concluded]: Well, she stayed in the
affect for maybe, like three or four minutes, but I wish it couldve been longer.
CB was aware that she had become uncomfortable and thought it would be useful to learn
about how she might have better addressed and harnessed the affect in the session. ES then
asked CB to share her thoughts about the role of affect in therapy in general and in this case
1038 Journal of Clinical Psychology: In Session, November 2014
specifically. This intervention aimed at assessing and exploring her knowledge before turning
to an exploration of skills. She briefly described the importance of emotion and obtaining a
balance between thinking and feeling. ES summarized that one of the clinical goals was helping
the client to develop greater competence in being able to feel her affects, to modulate them
appropriately, and to express them. Here the supervisor shifted emphasis from exploring the
supervisees beliefs and reactions to teaching. The supervisorsupervisee dyad then returned to
a discussion of the clinical interaction and CB described the clients obvious discomfort, wiping
her tears and looking up at the ceiling in an effort to stop crying.
CB: I think she was wanting to escape it; I could tell, you know, that she was really
wanting this not to happen. And she was confused by it, made me kind of feel like I
needed to fix that for her and take away the painful affect, while also trying to find
out why, and help her, like, un-muddle her confusion at the time. [She described
the questions she asked and posited that she might have colluded with her client by
taking her away from her feelings, as if they were unacceptable].
[ES then framed the discussion by exploring whether she believed her interventions
reflected responsive or reactivity, drawing upon a transtheoretical model of counter-
transference (Shafranske & Falender, 2012), which had been introduced earlier in
supervision. CB reflected that her responses seemed to reflect both and commented]:
CB: .Though I might say that my rationale and reasoning was based on the CBT
model, I think a lot of it was my own kind of wanting to save her from her from her
feeling uncomfortable, which made me feel uncomfortable that I couldnt help her
right then.
ES: I really appreciate you talking about this [intended to compliment and reinforce
her self reflectivity, willingness to talk about her reactions, and professional values
the ability to reflect and to use supervision effectively involves a supervisees values
and professionalism], and you know most of our clinical decisions are probably
going to be a confluence of personal reactivity plus a reactive responsiveness plus
our training... Id imagine its not one or the other, its usually a combination of
both [A form of self-disclosure and teaching aimed at normalizing her experience
and encouraging further exploration.]
CB reflected further and noted that her reactions might have been caused in part by her
similarity to the client in age, gender, and shared developmental issues. ES then introduced a
psychoanalytic notion about intersubjective conjunctions and disjunctions and the challenges
involved therein [teaching function aimed at enhancing knowledge regarding personal factors
and the mutual influence of multicultural identities.] Later in the session, ES asked if there was
something else he could do that would be helpful and CB suggested that he give an example of
how he would have dealt with such a situation [explicitly focusing on skills].
ES: Well there were probably moments I reacted like you did [intending to further
normalize and to model openness]. . . . Things get stimulated and so we may notice
ourselves doing things like asking a lot of questions, or shifting focus, maybe intellec-
tualizing, so I think thats certainly something I can recognize in myself [and] doing
that sometimes. It might be very subtle [rather than in dramatic moments]. . . . [ES
then described a clinical interaction with a client who had been terribly abused] I
found myself welling up with feeling, and what I found was helpful was actually
to move more into her experience, rather than to worry about my eyes filling up
with tears. . . . I relaxed for a moment, took a deep breath and tried to enter more
Clinical Supervision: State of the Art 1039
into her world. And if I wanted to ask a question, it wouldnt be like a series of
questions, it might be like, tell me more in order to bring in the processing of the
experience in the moment.
This led to further consideration of possible actions the therapist might have taken and the
session ended with a summary of the major points, including discussion of countertransference
management as a competence (knowledge) and further reinforcement of the supervisees excellent
use of supervision (skills and values). The supervisor was mindful to consider each of the
components of competenceknowledge, skills and attitudes/valuesand to situate the discussion
as congruent both to her training goals and with the Competencies Benchmarks (knowledge;
Fouad et al., 2009).
The movement toward evidence-based clinical supervision (Milne, Sheikh, Pattison, & Wilkin-
son, 2011), another aspect of transformation, provides normative inclusion of outcome assess-
ment in clinical supervisiondetermining and studying input to the supervision process, requi-
site training, and outcomes of supervisee competence and client symptom reduction. We would
add ongoing consideration of client self-report of outcomes in the supervision session (Reese
et al., 2009). That is, evidence-based clinical supervision refers to specific practices (skills) that
are supported by evidence as well as to systematic analysis of efficacy. In their review of dissem-
ination and implementation of evidence-based practices in child and adolescent mental health,
supervision and fidelity were the factors with most empirical support (Novins, Green Legha, &
Aarons, 2013).
Kaslow et al. (2012) proposed that psychologists need to enlist transformational leadership
skills to change the nature of training and to encourage the implementation of competency-
based clinical supervision. Such a strategy would assist in changing the conception that clinical
supervision is adequately conducted based on personal experience or through osmosis. Instead
it would reinforce the concept that supervision is a distinct professional competency requiring
specific training and comprising specific and systematic supervision including all the component
knowledge, skills, and attitudes associated with effective supervision practice. A result will
be increased accountability, attention to supervisee competence development, and support to
address or to remediate competencies that are not developing sufficiently.
Substantial evidence exists that such transformation is overdue. Failure to orient focus on
competence jeopardizes client welfare as well as professional development. The transformation
will require, in addition to a commitment to the model, significant efforts to ensure that human
resources (i.e., allocation of sufficient professional time) are made available for training and
supervision. Although the trajectory of such transformational change is complex, implemen-
tation of explicit competency-based approaches to clinical supervision is essential to meet the
responsibilities of clinical training.
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