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Clinical Supervision: The State of the Art

Carol A. Falender and Edward P. Shafranske


Pepperdine University
Since the recognition of clinical supervision as a distinct professional competence and a core compe-
tence, attention has turned to ensuring supervisor competence and effective supervision practice. In
this article, we highlight recent developments and the state of the art in supervision, with particular
emphasis on the competency-based approach. We present effective clinical supervision strategies,
providing an integrated snapshot of the current status. We close with consideration of current training
practices in supervision and challenges.  C 2014 Wiley Periodicals, Inc. J. Clin. Psychol.: In Session

70:10301041, 2014.

Keywords: clinical supervision; competency-based supervision; supervision

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

JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 70(11), 10301041 (2014) 


C 2014 Wiley Periodicals, Inc.

Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.22124


Clinical Supervision: State of the Art 1031

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

a distinct professional activity in which education and training aimed at develop-


ing science-informed practice are facilitated through a collaborative interpersonal
process. It involves observation, evaluation, feedback, facilitation of supervisee self-
assessment, and acquisition of knowledge and skills by instruction, modeling, and
mutual problem-solving. Building on the recognition of the strengths and talents
of the supervisee, supervision encourages self-efficacy. Supervision ensures that (it)
is conducted in a competent manner in which ethical standards, legal prescriptions,
and professional practices are used to promote and protect the welfare of the client,
the profession, and society at large. (p. 3)

In addition, they added metafactors or superordinate values: integrity-in-relationship, high-


lighting the major supervisory responsibility of modeling and embracing integrity in practice;
ethical, values-based practice, attentive to values and beliefs across the supervision triad of
client, supervisee/psychotherapist, and supervisor; appreciation of diversity and multiple cul-
tural identities among the same triad; and science-informed, evidence-based practice, attentive to
outcomes that have been identified as essential to supervision practice (Falender & Shafranske,
2004).
More specifically, Falender and Shafranske (2007) defined competency-based supervision as
an approach that explicitly identifies the knowledge, skills and values that are assembled to
form a clinical competency and develop learning strategies and evaluation procedures to meet
criterion-referenced competence standards in keeping with evidence-based practices and the
requirements of the local clinical setting (p. 233). This definition provides a structure for estab-
lishing goals and the means to achieve the goals of supervision and to initiate a collaborative
process of supervisee self-assessment, evaluation, planning, and monitoring. A foundational
premise of this and other competency-based approaches is that through the incorporation of
the competence model, clinicians will be encouraged and enabled throughout their professional
careers to self-assess, directing attention to specific knowledge, skills, and attitudes/values re-
quired for contemporary practice (many of which build upon existing competencies). Such a
model is based upon foundational and functional competencies identified by the profession (e.g.,
Benchmarks, Fouad et al., 2009; Hatcher et al., 2013) as the structure and vehicle for training,
monitoring, and evaluation.
There has been movement toward greater accountability and advocacy for advancing empiri-
cal support for supervision practice, leading to an international movement toward competency-
based clinical supervisionfor example, the American Psychological Association Board of Ed-
ucational Affairs appointment of a Supervision Task Force to develop Guidelines for Clinical
Supervision in Health Service Psychology (APA, 2014). In this article we address effective
clinical supervision, providing an integrated snapshot of the current status.

Effective Clinical Supervision


Effective supervision is defined as practice that encourages supervisee development and auton-
omy, facilitates the supervisory relationship, protects the client, and enhances both client and
1032 Journal of Clinical Psychology: In Session, November 2014

supervisee outcomes. The following statements present a composite of components of effective


supervisor practices:

r Demonstrate respect for the supervisee and client(s);


r Collaboratively assess supervisee competence (with supervisee self-assessment and supervisor
feedback) and develop goals and tasks to achieve these.
r Form a supervisory alliance;
r Identify strains to the supervisory relationship and work to repair them;
r Clarify and ensure understanding of supervisee roles and supervisor expectations.
r Assess, reflect on, and enhance specific supervisee competences;
r Collaboratively construct a supervision contract providing informed consent regarding ex-
pectations and supervisor and supervisee roles and responsibilities;
r Monitor, protect the client, and be a gatekeeper with transparency, sharing assessment of
competencies with the supervisee. Gatekeeping refers to the supervisor responsibility to
ensure the suitability of individuals entering the profession;
r Infuse awareness of the role diversity plays in clinical and supervision practice, including
consideration of the multicultural identities of client, supervisee, and supervisor;
r Reflect on worldviews, attitudes, and biases, and infuse these in conceptualization, assessment,
and intervention;
r Encourage and support supervisee reflection on clinical practice and the process of supervi-
sion;
r Engage the supervisee in skill development using interactive and experiential methods (e.g.,
role play, modeling);
r Attend to personal factors, unusual emotional reactivity, and countertransference and engage
in management of these to inform the clinical process;
r Provide ongoing accurate positive and corrective feedback anchored in competencies;
r Observe directlylive or videoand use observation regularly to provide behavioral, an-
chored feedback on competencies and identified supervisee goals (Falender & Shafranske,
2014).

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

incorporation of self-awareness by both supervisor and supervisee . . . an interactive


encompassing process of the client or family, supervisee-psychotherapist, and super-
visor, using all of their (multiple) diversity factors. It entails awareness, knowledge,
and appreciation of the interaction among the clients, supervisee/psychotherapists,
and supervisors assumptions values, biases, expectations, and worldviews; integra-
tion and practice of appropriate, relevant and sensitive assessment and intervention
1034 Journal of Clinical Psychology: In Session, November 2014

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).

Addressing Personal Factors and Countertransference in Supervision


Personal factors consist of beliefs, attitudes, life experiences, personality and interpersonal styles
that emanate from sources outside of graduate education, clinical training, and professional
practice. Clinical supervision provides the context for novice clinicians to develop appreciation
for the role that personal factors play in their conduct of psychotherapy (Falender & Shafranske,
2004, 2012). Consistent with efforts to gain awareness of the influence and interactions of
multicultural identities in clinical and supervisory relationships, supervision aims to enhance
awareness of the psychotherapists own contributions to the treatment process. Supervisors play
a pivotal role in modeling the importance of personal factors, including the role of diversity,
by drawing attention to the (often subtle) influences affecting both the supervisory and clinical
relationship. Developing awareness of personal factors should be not only included in the
supervision contract but also actively demonstrated by the supervisor in his or her conduct of
supervision.
Countertransference stands out among the potential effects of personal factors on the clinical
process. Originally conceptualized within the psychoanalytic tradition, countertransference is
recognized more broadly as a class of clinical phenomena in which distinctly different, unusual,
Clinical Supervision: State of the Art 1035

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.

Competences, Self-Assessment, Feedback, and Evaluation


Self-assessment is a significant aspect of competency-based clinical supervision as is ongoing
self-monitoring of performance (Epstein et al., 2008). Self-assessment is based on the super-
visees reflective capability to determine competency areas of strength and those in develop-
ment. Skill in self-assessment is key to ensuring continuing competence (Eva & Regehr, 2013).
Regehr and Eva (2006) concluded that self-assessment entails the interaction of cognitive and
metacognitive theory, social cognitions, and reflective practice, and thus has been difficult. Nei-
ther psychologists nor physicians have excelled in self-assessment of competence (Dunning,
Heath, & Sills, 2004; Williams, Dunning, & Kruger, 2013), with poor performers reporting high-
est (and most inflated) views of their performance. However, regular and routine feedback is
highly effective in enhancing accuracy of self-assessment, especially if anchored in behavioral
ratings.
An evolving standard of practice is supervisee ongoing self-assessment combined with faculty
appraisals of supervisee development of competencies, anchored in competencies agreed upon
by the profession (Kamen, Veilleux, Bangen, VanderVeen, & Klonoff, 2010), a technique that
is being adopted in multiple training settings using a frame such as Competencies Benchmarks
(Fouad et al., 2009; Hatcher et al., 2013). The collaborative assessments set the baseline for
development of the supervisory alliance and the supervision contract from which monitoring
and evaluation follow (Falender & Shafranske, 2012). The supervisee first self-assesses on the
competency document (e.g., Fouad et al., 2009) after being informed that it is more desirable
to identify areas to work on because assessment of areas of relative weakness is a competency.
Then the supervisor provides ongoing feedback on the supervisees ratings, ideally from video
or live review of the supervisees clinical work.
Standardized narratives are being used as assessment and feedback devices with some suc-
cess (Regehr et al., 2012). An example is the formalized summative evaluations of competency
using Objective Structured Clinical Examination (OSCE), similar to those conducted forma-
tively and summatively in social work (Bogo et al., 2011) and medicine (Khan, Ramachandran,
Gaunt, & Pushcar, 2013). In these assessments, the supervisee is assigned a standardized pa-
1036 Journal of Clinical Psychology: In Session, November 2014

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.

Ethical and Legal Competencies


The Supervision Contract
The supervision contract integrates all the components of supervision and addresses the ethical
standard of informed consent (Thomas, 2010). This informed consent document combines the
expected competencies of the setting and supervisor with the supervisee self-assessment to ensure
an integrated plan for supervision. The contract lays out the expectations for supervisor and
supervisee roles and responsibilities, the goals and tasks to achieve them specific to the supervisee
(making this a living document that is modified with the supervisees progress to achieve goals
and formulate new ones). The contract lays out the duties of the supervisor, including protection
of the client as the highest priority, clarification of the supervisors multiple and potentially
conflicting roles of client protection and gatekeeper for the profession, and balanced with the
role of enhancing and facilitating the growth and development of competence of the supervisee.
The contract clarifies the potential role conflicts the supervisor and supervisee may encounter
as the supervisor performs these multiple roles.
The contract contains general and setting-specific information as follows:

r Scope of practice under supervision


r Length of contract period
r Specific roles and expectations of the supervisor and supervisee (e.g., self-assessment, pro-
ductivity, frequency of supervision, policies regarding cancellations and emergencies)
r Expected processes (e.g., modeling, role play)
r Expected preparation (e.g., case conceptualizations, timing to provide video recordings to
allow supervisor review, summary of evidence-based practices for individual cases)
r Expectations regarding ongoing and timely supervisor feedback anchored in competencies
and linked to a stated number of live or audio reviews of clinical work and of two-way
feedback (supervisee to supervisor) regarding process as well as progress
r Expected identification of areas of competence not developing normatively, and expectations
for successful completion of the contract and process if expectations are not being met
r Specification of evaluation measures and timing of those
r Specification of limits of confidentiality (e.g., supervisory responsibility to report to training
teams, graduate program, licensing board, and highest duty to maintain of protection of the
client), with reference to ethics standards and code of ethics (APA 2010), relevant state laws
(e.g., duty to warn and protect and child abuse mandatory reporting), and state licensure
regulations and site personnel practices
r Expectation that personal factors and experience will be a part of clinical supervision (previ-
ously stated in recruitment materials as per APA, 2010, 7.04)
r Explication of the possibility that the supervisee will need to seek psychotherapy or other
supportive work should personal issues be beyond the purview of supervision
r Expectations relevant to the needs of specific settings (e.g., boundary expectations, multiple
sites with different responsibilities) and expectations associated with the responsibility for
required documentation of supervision sessions.

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.

Clinical Supervision Illustration


The following illustration is drawn from a supervision session that focused on the management
of countertransference. The supervisee (CB) was a third-year female doctoral student in a
secondary practicum rotation in a university-based outpatient community clinic. Consistent
with the competency-based approach, specific training goals and competence objectives were
discussed and mutually agreed upon at the beginning of the rotation. One of her goals was
to enhance her comfort and skill at integrating principles and techniques from psychodynamic
psychotherapy, particularly in respect to addressing client affect and her own awareness and use
of emotion, to complement her developing strengths in cognitive-behavioral therapy.
She began supervision commenting that she observed in a recent session that she shifted
focus away from the clients immediate emotional experience in asking a series of questions. The
supervisor (ES) nodded approval and asked her to describe a particular moment when these
dynamics began to emerge. CB described the events around the time the client burst into tears.

CB: I noticed from reviewing the videotape [essential to the competency-based


model], that when she [the client] started to cry, I tended to just jump in and ask her
a number of questions... I wasnt clear about the connection she was talking about,
so I asked her a lot of questions. I worry that my quick interventions mightve led
her away from her affect in that moment.

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.

ES: What was that like for you?

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).

Supervisor Training: Status and Challenges


Generally, consensus exists that supervision practice requires specific dedicated training (Bernard
& Goodyear, 2014). Training should begin with enhancing the competence of supervisees to be
effective in that critical role (Falender & Shafranske, 2013a). Even though an accreditation
requirement, individuals in the training pipeline are not consistently receiving adequate or, in
some cases, any supervision training (e.g., in Canada: Hadjistavropoulos, Kehler, & Hadjis-
tavropoulos, 2010; in United States: Crook-Lyon, Presnell, Silva, Suyama, & Stickney, 2011;
Lyon, Heppler, Leavitt, & Fisher, 2008).
When training in supervision is given, there is great variability in its nature and quality. For
example, in Canada accredited training programs reported that although approximately 50% of
programs required some coursework in clinical supervision, the amount and content were highly
variable, with, for example, only 46% addressing liability issues (Hadjistavropoulos et al., 2010).
About a quarter reported peer supervision and an additional 40% an elective with opportunity
for supervision experience. In the United States, Lyon et al. (2008) reported that among interns,
39% completed a course in clinical supervision (26% clinical; 73% counseling) and 61% reported
no coursework in this area. Over half of internships offered no supervision training. Generally,
the major influence on supervision practice was judged by trainees to be the personal experience
of having been supervised (Crook-Lyon et al., 2011) so that requisite supervisor competencies
(Kaslow, Falender, & Grus, 2012) are not being transmitted.
Enhancing both graduate education and training in clinical supervision, including supervision
of supervision, appears necessary given its importance in assuring client welfare, performing
gatekeeping responsibilities, and providing the quality of supervision required for effectiveness.
This requires a commitment of resources within educational and clinical training institutions
at a time when available resources (time, staff, budget) are often stretched to the limit. While
taking into consideration the practical, day-to-day economics in mental health service delivery
and training, it is necessary, given the enormity of responsibility, to ensure that those providing
clinical supervision possess the needed competencies and the time to provide it effectively. A
central concern is that ineffective or insufficient supervision occurs and is not monitored in
current conditions in which a lack of supervisor accountability may exist.

Transforming to Competency-Based Supervision


Discussion of competency-based supervision may be confusing. In reality, a competent approach
to any clinical supervision is competency-based as it entails assessing the supervisees compe-
tencies, adjusting supervision to where the supervisee is currently functioning, monitoring the
supervisees development and ensuring accurate and timely feedback so the supervisee is fully
cognizant of areas needing improvement, and generally attending to client outcomes as an impor-
tant aspect. The transformation to competency-based supervision, occurring across specialties
(e.g., Grus, 2013; Stucky, Bush, & Donders, 2012), is broad-based, with impetus to change view-
points of training in supervision, assessment of supervisor competence, and competency-based
licensure, accreditation.
1040 Journal of Clinical Psychology: In Session, November 2014

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.

Selected References and Recommended Reading


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