1. Describe the multicultural issue facing clinicians today.
2. Describe supervisee resistance and identify ways to counteract it.
3. Recognize and describe the need for a group supervision approach for trainees.
4. Identify the methods for reviewing counselor-client sessions including live supervision.
5. Describe the term enactment as it pertains to sexually acting out clinicians.
Making the Decision to Be a Supervisor
Supervision of the psychotherapy, testing, or other psychological work done by a psychological intern or other person should never be taken lightly. Additionally, any therapist who decides to be a supervisor should have excellent skills, training, and experience in any modality and for any issue which may arise with the patient. When the supervisor finds s/he is lacking in training or experience, s/he should immediately seek advice from a professional who is knowlegeable and experienced in that modality or the issue from treatment. Not to do so is to risk the license of both the supervisor and the supervisee.
The supervisor should know the supervisee well though personal contact, interviews, and/or classwork. All supervisees should have letters of reference from relevant sources and those sources should be checked for veracity as well as possible. The supervisor should be aware that the supervisee will be working under his or her guidance. If ethical or legal problems arise, it could impact the license of the supervisor.
History of Problem: This is a true story which occured some time ago. The supervisor was known to me. He was a well-respected supervisor from an excellent APA approved doctoral program and often did supervision of post-doctoral interns.. The supervisor and the intern had known each other fairly well and felt they could enter into a supervisory relationship which would be beneficial to both. Unfortunately, the supervisee was not honest nor ethical. He engaged in a sexual relationship with one of his patients. He did not disclose this to his supervisor. The patient changed therapists and sued the supervisor for failing to properly conduct supervision. The supervisor's license was suspended by the licensing board for failing to properly supervise the intern. The intern moved to a different State, no charges were brought against him. He completed his supervision with another supervisor who was not knowlegable of his past and continues to be a licensed psychologist.
I supervised many pre-doctoral interns and a few post-doctoral interns prior to deciding the risk was too great. I agreed to supervise a post-doctoral intern who had shown great promise prior to his Ph.D. Within the first week, I began to get telephone calls from my referral sources asking me if the man I had sent to them was a psychologist. When I investigated this further, I found he had handed out business cards that indicated he was a licensed psychologist. I terminated the supervisory relationship and informed the State Licensing Board. No charges were brought against either of us. He is now licensed in another state.
Never, under any circumstances, decide to supervise someone who was previously your patient or could be construed as having a doctor-patient relationship with you. It is considered a dual relationship and is both unethical and action can be taken legally to convict you of malpractice.
The bottom line is you can learn a great deal about how to do supervision from this class and others you take as well as learning skills through practice. But always be extremely careful about who you select to supervise and always be certain that they are behaving in a manner that is ethical. If you choose, you can observe or tape sessions with the supervisee and patients until you feel the work being done meets ethical and legal standards. The transition to having the supervisee report on work done should be gradual and you should continue to check thoroughly on whether the behavior described seems appropriate for the patient. The patient is the person for whom the supervision is done and the patient is the one who ultimately needs to be protected against unethical and illegal behavior.
Resistance in Supervision
Implicit in the definition of supervision is an ongoing relationship between supervisor and supervisee; the supervisee's acquisition of professional role identity; and, the supervisor's evaluation of the supervisee's performance. Although the goal of helping the supervisee develop into an effective counselor may appear simple, it can be anxiety-provoking experience. Supervision-induced anxiety causes supervisees to respond in a variety of ways, with some of the responses being defensive. It is these defensive behaviors, which serve the purpose of reducing anxiety, that are referred to as resistance.
Although the purpose of this writing is to describe supervisee resistance and identify ways to counteract it, we want to stress that supervisee resistance is common. While resistance can be disruptive and annoying, the supervisor must keep in mind that resistance is not synonymous with "bad person" or "bad behavior." Instead, resistance occurs because of the dynamics of the supervision process and, in fact, can be an appropriate response to supervision (e.g., supervisor conducting therapy instead of supervision). In other instances, resistance is a response to anxiety whereby it becomes the supervisor's role to deal with anxiety so that the need for resistance will be reduced or perhaps eliminated.
Supervisee resistance, consisting of verbal and nonverbal behaviors, is the supervisee's overt response to changes in the supervision process. Liddle (1986) concluded that the primary goal of resistant behavior is self-protection in which the supervisee guards against some perceived threat. One common threat is fear of inadequacy; although supervisees want to succeed, there is a prevalent concern of not "measuring up" to the supervisor's standards. Other supervisee resistance occurs because supervision is required. Supervisees may not accept the legitimacy of supervision because they perceive their skills to be equal, if not superior, to their supervisor's. Supervisee resistance may be a reaction to loss of control and can evolve into a power struggle between supervisor and supervisee. Supervisees may fear and be threatened by change, and consequently, respond with defensive behaviors. The fact that supervision has an evaluative component can provoke anxiety because a negative evaluation by a supervisor may result in dismissal and/or failure to receive necessary recommendations. Supervisee resistance also may result from the supervisor failing to integrate multicultural information into the supervision sessions. Regardless of form, resistant behaviors are coping mechanisms intended to reduce anxiety.
Resistance often takes the form of "games" played by supervisees who either consciously or unconsciously attempt to manipulate and exert control over the supervision process. Although all supervisees do not play games, many do. Kadushin defined four categories of supervisee games. Manipulating demand levels involves games in which the supervisee attempts to manipulate the level of demands placed on him/her. Often the supervisee uses flattery to inhibit the supervisor's evaluative focus. Redefining the relationship occurs when the supervisee attempts to make the relationship more ambiguous. For example, in the game of self-disclosure, the supervisee would rather expose himself/herself instead of counseling skills. Reducing power disparity occurs when the supervisee focuses on his/her knowledge. In this game, the supervisee tries to prove the supervisor "is not so smart." If successful, the supervisee can mitigate some of the supervisor's power. In controlling the situation, the supervisee prepares questions to direct supervision away from his/her performance. Other means for controlling supervision include requesting undue prescriptions for dealing with clients, seeking reassurance by reporting how poorly work is progressing, asking others for help to erode supervisor authority, or selectively sharing information to obtain a positive evaluation. A more hostile and angry form of control involves blaming the supervisor for failure.
In describing supervisee games, Bauman discussed five types of resistance. Submission, a common form of resistance, occurs when the supervisee behaves as though the supervisor has all the answers. Turning the tables is a diversionary tactic used by the supervisee to direct the focus away from his/her skills. "I'm no good" occurs when the supervisee pleads fragility and appears brittle; the attempt is to prevent the supervisor from focusing on painful issues. Helplessness is a dependency game in which the supervisee absorbs "all" information provided by the supervisor. The fifth type of resistance projection, is a self-protection tactic in which the supervisee blames external problems for his/her ineffectiveness.
Although resistance is a common occurrence in supervision, counteracting resistance is not simple. Two major factors influence methods used for counteracting resistance. First, the relationship is critical. A positive supervisory relationship grounded by trust, respect, rapport, and empathy is essential for counteracting resistance. The second factor in counteracting resistance is the way the supervisory relationship is viewed. Supervisors viewing the relationship as the focal point in supervision usually advocate full exploration of conflicts. In contrast, supervisors viewing therapeutic work as the primary supervisory focus advocate a more limited exploration of conflicts.
Viewing resistance as a perceived threat, Liddle advocated that the conflict be openly discussed. First, she stated the focus should be on identifying the source of anxiety or threat. Next, the focus should be on brainstorming to locate appropriate coping strategies for dealing with the conflict. Kadushin stated that the simplest way to cope with supervisee resistance exhibited in games is to refuse to play. He concluded it is more effective to share awareness of game-playing with the supervisee and focus on the disadvantages inherent in game-playing rather than on the dynamics of the supervisee's behavior.
Bauman discussed several techniques for managing supervisee resistance. Interpretation, the most direct confrontation, includes describing and interpreting the supervisee's resistance. Although less confrontive, feedback is also a form of direct confrontation. Clarification uses restatement to aid the supervisee in understanding his/her behavior. Generalizing resistance to other settings takes the focus away from the supervisory relationship and helps the supervisee recognize his/her maladaptive behaviors. Ignoring resistance is recommended only if the behavior can be eliminated without confrontation. Role-playing and alter-ego role playing, although more threatening, may be helpful in identifying the cause of resistant behavior. Audio taping supervision sessions is helpful for managing resistance. Bauman noted that the success of a technique is dependent on the personalities of supervisor and supervisee and on the interaction between them. If confrontation is deemed inappropriate, Masters suggested positive reframing for reducing resistance. Positive reframing includes: empowering the supervisee, increasing the supervisee's self-esteem, and modeling effective methods of coping with thoughts, feelings, and behaviors.
Regardless of purpose, resistance in supervision is a common experience and will be encountered irrespective of the supervisor's skill level. The supervisor who believes he/she can proceed through the supervision process without encountering resistance is setting an unrealistic expectation. Although usually annoying, supervisee resistance should not be perceived as a negative encounter or maladaptive behavior. On the contrary, an effective supervisor who is knowledgeable about the dynamics behind supervisee resistance can redirect the resistance to create a therapeutic supervision climate. In essence, the ability of the supervisor to take resistance and turn it into a supervisory advantage may be the hallmark for determining success or failure in supervision.
Ethical and Legal Dimensions of Supervision
In recent years, it has become generally accepted that supervision draws upon knowledge and skills that are different than, and go beyond, those of psychotherapy. Similarly, the ethics and legal imperatives regarding supervision both encompass psychotherapy issues and go beyond them. Furthermore, because supervision is a triadic rather than a dyadic relationship, the supervisor must always attend to the need for balance between the counseling needs of clients and the training needs of the counselor.
With the increase of litigation in American society over the past generation, ethics and law have become intermingled. It is important for the supervisor to remember, however, that ethics call the supervisor to a standard of practice sanctioned by the profession while legal statutes define a point beyond which a supervisor may be liable. For our purposes here, the functional interconnectedness between ethics and the law will be accepted.
Competence is an increasingly complex issue as mental health and supervision have become more sophisticated enterprises. Implications of both counselor competence and supervisor competence will be described here briefly.
By definition, a supervisee is a person who is not yet ready to practice independently. It is for this reason that supervisors are held responsible for what happens with clients being seen by the supervisee. At the same time, counselors must be challenged in order to become more expert. This, then, is the supervisor's tightrope: providing experiences that will stretch the counselor's ability without putting the client in danger or offering substandard care. Whenever a close call must be made, supervisors must remember that their obligation is to the client, the public, the profession, and the supervisee -- in that order. Therefore, the supervisor continually decides if the supervisee is good enough on a consistent basis to work with any particular client.
First, the supervisor needs to know everything, and more, than is expected of the supervisee. Secondly, the supervisor must be expert in the process of supervision. It is not enough that clients are protected as a result of supervision; the contract between supervisor and supervisee dictates that supervision must ultimately result in better counseling skills for the supervisee. In order to accomplish this, it is generally accepted that the supervisor receive training in performance of supervision as well as supervision of supervision.
For both counselors and supervisors, any dual relationship is problematic if it increases the potential for exploitation or impairs professional objectivity. There has been greater divergence of opinion about what constitutes an inappropriate dual relationship between supervisor and counselor than between counselor and client. Ryder and Hepworth, for example, stated that dual relationships between supervisors and supervisees are endemic to many educational and work contexts. Most supervisors will, in fact, have more than one relationship with their supervisees (e.g., graduate assistant, co-author, co-facilitator). The key concepts remain "exploitation" and "objectivity." Supervisors must be diligent about avoiding any situation which puts a supervisee at risk for exploitation or increases the possibility that the supervisor will be less objective. It is crucial, however, that supervisors not be intimidated into hiding dual relationships because of rigid interpretations of ethical standards. The most dangerous of scenarios is the hidden relationship. Usually, a situation can be adjusted to protect all concerned parties if consultation is sought and there is an openness to making adjustments in supervisory relationships to benefit supervisee, supervisor and, most importantly, clients.
As part of the mandate of competence, the supervisor must determine not only if the supervisee has the knowledge and skill to be a good counselor, but if he or she is personally ready to take on clinical responsibility. The issue of personal readiness can lead the supervisor to blur the roles of supervisor and therapist in an attempt to keep the supervisee functional as a counselor. This is problematic for two reasons: (1) it compromises the objectivity of the supervisor, especially in terms of evaluation; (2) it may allow an impaired counselor to continue to practice at the risk of present and future clients.
Informed consent is key to protecting the counselor and/or supervisor from a malpractice lawsuit. Simply, informed consent requires that the recipient of any service or intervention is sufficiently educated about what is to transpire, the potential risks, and alternative services or interventions, so that he or she can make an intelligent decision about his or her participation. Supervisors must be diligent regarding three levels of informed consent: (1) the supervisor must be confident that the counselor has informed the client regarding the parameters of counseling; (2) the supervisor must be sure that the client is aware of the parameters of supervision (e.g., that audiotapes will be heard by a supervision group); and (3) the supervisor must inform the supervisee about the process of supervision, evaluation criteria, and other expectations of supervision (e.g., that supervisees will be required to conduct all intake interviews for a counseling center in order to increase interview and writing skills).
Due process is a legal term that insures one's rights and liberties. While informed consent focuses on the entry into counseling supervision, due process revolves around the idea that one's rights must be protected from start to finish. Again, supervisors must protect the rights of both clients and supervisees. An abrupt termination of a client could be a due process violation. Similarly, a negative final evaluation of a supervisee, without warning and with no opportunity to improve one's functioning, is a violation of the supervisee's due process rights.
Confidentiality is an often-discussed concept in supervision because of some important limits of confidentiality both within the therapeutic situation and within supervision. It is imperative that the supervisee understands both the mandate of honoring information as confidential (including records kept on the client) as well as understanding when confidentiality must be broken (including the duty to warn potential victims of violence) and how this should be done. Equally important is a frank discussion about confidentiality within supervision and its limits. The supervisee should be able to trust the supervisor with personal information, yet at the same time, be informed about exceptions to the assumption of privacy. For example, supervisees should be apprised that at some future time, their supervisors may be asked to share relevant information to State licensure boards regarding their readiness for independent practice; or supervisors may include supervision information during annual reviews of students in a graduate program.
Supervisors should not shun opportunities to supervise because of fears of liability. Rather, the informed, conscientious supervisor is protected by knowledge of ethical standards and a process that allows standards to be met consistently. There are three safeguards for the supervisor regarding liability: (1) continuing education, especially in terms of current professional opinion regarding ethical and legal dilemmas; (2) consultation with trusted and credentialed colleagues when questions arise; and (3) documentation of both counseling and supervision, remembering that courts often follow the principle "What has not been written has not been done".
As gatekeepers of the profession, supervisors must be diligent about their own and their supervisees' ethics. Ethical practice includes both knowledge of codes and legal statutes, and practice that is both respectful and competent. "In this case, perhaps more than in any other, supervisors' primary responsibility is to model what they hope to teach".
Strategies and Methods of Effective Supervision
A variety of strategies and methods are available to supervisors for use with counselors whom they supervise. This summary is designed to acquaint supervisors with techniques for enhancing the counseling behavior of their supervisees while also considering individual learning characteristics as depicted by the supervisee's developmental level.
To improve a supervisee's skills in working with clients, some form of assessment must be done while counseling is taking place (rather than with clients who have terminated). Using strategies that examine a supervisee's counseling behavior with current clients allows a supervisor to correct any error in assessment, diagnosis, or treatment of the client, and thus increases the probability of a successful outcome.
Whether the supervisor's purpose is to improve a supervisee's skills or to ensure accuracy, actual counselor-client interaction must be examined. Although the traditional method of counselor self-report is often used, this form of data-gathering is notoriously inaccurate. The more reliable forms of data-gathering are review of a client's case history; review of results of current psychodiagnostic testing, including a structured interview (such as a mental status exam); and, particularly, examination of the counselor-client sessions via methods such as audiotape, videotape, and observation through a one-way mirror or sitting in the session.
Of the methods for reviewing counselor-client sessions, the use of live supervision (observation via television or one-way mirror) provides an opportunity to give a supervisee immediate corrective feedback about a particular counseling technique and to see how well the counselor can carry out a suggested strategy. Live supervision is effective for learning new techniques, learning new modalities (e.g., family counseling), and gaining skills with types of clients with whom the counselor is unfamiliar. A live supervision strategy can be supplemented by review of a session immediately following the session or delayed a day or more.
Supervision conducted immediately following a counseling session or delayed a day or two could use an audiotape or videotape of the counseling session or use non-recorded observation through a one-way mirror or television system. Supervisors are advised to review audio or videotapes of a supervisee's counseling session prior to the supervision session in order to plan a strategy of intervention. The supervisee also should review the tape to prepare questions and discussion topics.
In immediate and delayed supervision sessions, the supervisor should focus on what the supervisee wanted to do with the client, what he/she said or did, and what he/she would like to do in future counseling sessions. Regardless of when the review of the counseling session is conducted (live, immediate, or delayed), the supervisor will have examined an actual work sample of the supervisee and no longer must rely solely on self-report. This examination is likely to aid in the supervisor's credibility in reporting on a supervisee's competence to school or agency administrators regarding retention or promotion, to state licensing officials, or to courts, should that be necessary.
Although group and peer supervision are powerful approaches, individual supervision is likely to be the main form of reviewing supervisee performance. When using individual supervision, a supervisor must consider most carefully the developmental level of the supervisee. Specifically, how skilled is the supervisee in general and specifically with the type of client in question, how anxious is the supervisee when reviewing his/her work, and what is the supervisee's learning style? Although these factors may vary somewhat independently, it is likely that less skilled counselors will be somewhat anxious. Additionally, developmental level has been conceptualized as cognitive or conceptual level and has been associated with challenging a supervisee to grasp increasingly more sophisticated concepts.
With novice supervisees, a high degree of support and a low amount of challenge or confrontation is advisable. When learning style is considered, a micro-training approach focusing on specific skills might be used, demonstrated by the supervisor, and then practiced in the supervision session by the supervisee in a role-play. However, some novice or anxious supervisees learn best by a macro approach; that is, having a clear overview of the goals of the session, expected role of the counselor, client typology, and specific client characteristics such as race, gender, culture, socioeconomic status, family background, and personality characteristics. For these supervisees, use of written case study materials or an IPR (Interpersonal Process Recall) approach might be better than a micro-training approach.
With more competent supervisees, the focus may be placed on more advanced skills or on more complex client issues. Either a micro or macro approach may be used. Using videotape is suggested for these supervisees, as they are more likely to be able to assimilate the larger amount of data provided by videotape compared to that provided by audiotapes, which are suggested for use with less competent supervisees.
With more skilled and more confident supervisees, exploration of issues usually found to be threatening also may be examined. Such issues include relationship of theoretical orientation to technique employed, personal style, counselor feelings about the client, and learning new and innovative techniques or modalities (individual, group, or family counseling).
Developmentally, a supervisor should expect that supervisees progress to more independent functioning whereby supervisees pick the clients and client issues which they wish to review as well as the personal issues or client dynamics they wish to examine. Audio or videotape segments can be selected for review rather than listening to entire tapes. At this more advanced stage of supervision, the supervisor may feel more like a colleague or a consultant than a teacher, which allows the supervisor to share more examples of his/her own counseling experience conveyed either through self report or via audiotapes. With more skilled and confident supervisees, collaboration such as co-leading a group or co-counseling with a family can be conducted. Although such collaboration strategies have been advocated for novice counselors, maximum benefit more likely may be achieved by supervisees who are more confident in their skills and who have developed basic skills sufficiently to be able to perceive and learn the complex skills that a supervisor is likely to use when working with a group or family.
Supervision for the clinical/counseling functions of counselors in schools and agencies should focus on actual work samples. Using a micro-training versus a more macro approach should depend on what works best for a particular supervisee, along with the supervisee's level of skill and confidence.
Fostering Counselors' Development in Group Supervision
A counselor's learning and continued development typically is fostered through concurrent use of individual and group supervision. Group supervision is unique in that growth is aided by the interactions occurring among group members. Counselors do not function in isolation, so the group becomes a natural format to accomplish professional socialization and to increase learning in a setting that allows an experience to touch many. Supervision in groups provides an opportunity for counselors to experience mutual support, share common experiences, solve complex tasks, learn new behaviors, participate in skills training, increase interpersonal competencies, and increase insight (MacKenzie, 1990). The core of group supervision is the interaction of the supervisees.
Collaborative learning is a pivotal benefit, with the supervisees having opportunities to be exposed to a variety of cases, interventions, and approaches to problem solving in the group (Hillerband, 1989). By viewing and being viewed, actively giving and receiving feedback, the supervisee's opportunities for experimental learning are expanded; this characterizes group supervision as a social modeling experience. From a relationship perspective, group supervision provides an atmosphere in which the supervisee learns to interact with peers in a way that encourages self-responsibility and increases mutuality between supervisor and supervisee.
Groups allow members to be exposed to the cognitive process of other counselors at various levels of development (Hillerband, 1989). This exposure is important for the supervisee who learns by observing as well as speaking. Finally, hearing the success and the frustrations of other counselors gives the supervisee a more realistic model by which they can critique themselves and build confidence.
Models of Group Supervision
Bernard and Goodyear summarized the typical foci of group supervision: didactic presentations, case conceptualization, individual development, group development, organization issues, and supervisor/supervisee issues. Models for conducting group supervision detail experiential affective approaches designed to increase the supervisees' self-concept and ability to relate to others, and/or cognitively focused activities, such as presenting cases which broaden the counselor's ability to conceptualize and problem-solve. While the literature provides information on how to conduct these activities, less obvious are the reasons why certain activities are selected and when the activities are most appropriate to use.
Borders offered a model that details reasons with the suggested activities. Groups may be used to increase feedback among peers through a structured format and assignment of roles (e.g., client, counselor, and other significant persons in client's life) while reviewing tapes of counseling sessions. "Role-taking" encourages supervisees to assume more responsibility in the group as feedback is offered from several viewpoints.
Models provide almost no attention to how the supervisor is to make judgments about the use of "group process." The supervisor has little guidance about how to use the collective nature of the group to foster counselor development.
Similarly, the development of the group has not been the focus of researchers--only a few empirical studies have been conducted to examine group supervision. Holloway and Johnston (1985), in a review of group supervision literature from 1967 to 1983, suggested that peer review, peer feedback, and personal insight are all possible to achieve while doing supervision in groups. Focus on the development of the group is not apparent in these studies, yet the term "group supervision" is defined with an emphasis on the use of group process to enhance learning.
As above indicates, the group supervision format requires that supervisors be prepared to use their knowledge of group process, although how this is to be done is very unclear. A recent naturalistic study of four groups across one semester provided some initial insights. Werstlein (1994) found that guidance and self-understanding were cited by supervisor and supervisees as the most important "therapeutic factors" (Yalom, 1985) present in their group. In addition, the initial stages of group development were apparent. Less noticeable were the later stages of group development which are characterized by higher risk behaviors that increase learning (Werstlein, 1994). Clearly, additional work is needed to clarify the process variables of group supervision and the role of the group leader (supervisor).
Supervisor as Group Leader
Based on existing group supervision literature and small group literature, the following guidelines are offered to supervisors who wish to address process in group supervision:
1. Five to eight supervisees meeting weekly for at least one and one half hours over a designated period of time (i.e., semester) provides an opportunity for the group to develop.
2. Composition of the supervision group needs to be an intentional decision made to include some commonalities and diversities among the supervisees (i.e., supervisee developmental level, experience level, or interpersonal compatibility).
3. A pre-planned structure is needed to detail a procedure for how time will be used and provide an intentional focus on content and process issues. This structure can be modified later in accordance with group's climate.
4. A pre-group session with supervisees can be used to "spell-out" expectations and detail the degree of structure. This session sets the stage for forming a group norm of self-responsibility and does not interfere with group development.
5. Supervisors may use "perceptual checks" to summarize and reflect what appear to be occurring in the here-and-now in the group. Validating observations with the supervisees is using process. Be active, monitor the number of issues, use acknowledgements, and involve all members.
6. Supervisees' significant experiences may be the result of peer interaction that involves feedback, support, and encouragement (Benshoff, 1992). Exploring struggles supports learning and problem-solving.
7. Bernard and Goodyear (1992) provided an excellent overview of the group supervision literature. Many ideas are available for structuring case presentations and the entire group sessions. Also, reviewing materials on group facilitation with a particular focus on dealing with process is essential.
8. Competition is a natural part of the group experience. Acknowledge its existence and frame the energy in a positive manner that fosters creativity and spontaneity.
In preparation for group supervision, communicate the following to the supervisees about how to use group process:
1. Learning increases as your listening and verbal involvement increases. Take risks and reveal your responses and thoughts.
2. Decrease your personalization of frustration by sharing with your peers. You will be surprised how often other supervisees are experiencing the same thoughts and feelings.
3. Intentionally look for similarities as you contemplate the relationships you have with your peers in the group with the relationships you are having with clients. Discuss similarities and differences.
4. Progress from client dynamics to counselor dynamics as you present your case. Know ahead of time what you want as a focus for feedback and ask directly.
Integration of knowledge and experience is greatly enhanced by group supervision. Existing literature emphasizes the importance of a structure that outlines procedures for case presentation and supervisee participation; less obvious are approaches to address group development. It is essential the we fill in these gaps in the literature by systematically gathering data that establishes the unique aspects of using groups for supervision.
Spirituality, Religion and Supervision
Counselor competency, conceptualization of spirituality, cross-cultural awareness, and the similarity of clients' and counselors' values form a foundation for developing effective intervention and supervision strategies. Spirituality and religion are important aspect of client diversity in psychotherapy and supervision. Despite the emphasis on spirituality in supervision and psychotherapy literature, scholars report finding little emphasis in the counselor supervision literature regarding spirituality and the supervision process. Because the counselor supervision literature addresses a wide variety of client, counselor, and supervisor issues, it is unfortunate that little attention has been given to the issue of spirituality and religion. How is it possible to educate counselors to competently and effectively address spiritual issues in the counseling process if religion and spiritually issues are not addressed in the counselor supervision process?
The following vignettes provide a starting point for the consideration of issues of spirituality in supervision.
A 22-year-old woman came to counseling for help in deciding whether or not to terminate her pregnancy. The father of the child wanted to be a part of the child’s life. He was willing to support the mother and child but did not want to get married. The patient struggled with guilt over the pregnancy and had not told her parents because of their religious beliefs. The patient clearly indicated that she believed abortion was wrong, and she did not want to damage her relationship with God. She felt tremendous stress and had not been sleeping well. She was emotionally upset about the pregnancy and did not want to continue with the pregnancy because of the impact the birth of a child would have on her future relationships and career choices.
A patient with whom your supervisee has been working for several months has shown significant improvement in his ability to cope with work-related stress. He has frequently described how he felt supported by several friends with whom he shared similar spiritual beliefs. The client asked your supervisee's opinion about the role of spirituality in the resolution of his problem. Even though the patient had openly described the spiritual discussions he has had with his friends, the counselor had not offered commentary related to the issue of the client's spirituality. Because the patient wanted to understand the reasons for his improvement and to synthesize his improvement with his spirituality, he wanted to understand the therapist's insight.
Your supervisee is currently on practicum assignment. She has recently read, on her own initiative, several articles on the topic of spirituality and the impact of prayer in promoting well-being. While listening to an audiotape of a therapy session, you hear the trainee spend part of the most recent counseling session praying with the client. On the tape, the client indicated intense gratitude for the counselor's care and concern. Although the client seems to have benefited from the counselor's actions, you feel uneasy about the situation.
Most supervisors adapt the same theoretical model that they use in their practice to the supervision hour. The analytic model of supervision would focus on the working through process.When the supervisor and supervisee have different theoretical orientations transference and countertransference issues are more likely to occur. Most supervisors adapt the same theoretical model that they use in their practice to the supervision hour.
Factors in Supervision
The purpose of this article is to help supervisors and supervisees enhance their awareness of spiritual values in the supervision process and to promote the integration of spirituality with the counselor supervision process in order to improve the competency of counselors in dealing with this aspect of client diversity. Consideration of the following factors related to counseling and psychotherapy can enhance the preparation of counselors and supervisors to deal with situations similar to the ones previously outlined.
Mental health professionals are invested in ensuring that the public is served well. Organizations such as the American Psychiatric Association (1995) and the Council for Accreditation of Counseling and Related Educational Programs invest significant ongoing effort in publishing and enforcing codes of ethics and practice guidelines, with emphasis on the recognition of and appropriate accommodation of human diversity and respect for clients' rights. In addition, there has been a particular emphasis on directing training programs to ensure that graduates have attained adequate skills to competently deal with clients' spirituality and religious values. Therefore, the counselor's main responsibility is to provide the utmost respect for the client and to do no harm. This respect extends to all aspects of the person, including his or her religious and spiritual values. Except for institutions that are church affiliated or programs that are of an explicitly religious nature, counselor education programs do not typically offer courses that address spirituality.
Supervisors may wish to consider several options for responding to the vignettes presented at the beginning of this article. In dealing with Situation 1. it may be useful to discuss with the counselor her or his beliefs about abortion in terms of the moral implications as well as in terms of the client's emotional functioning and the relationship she has with the baby’s father. The supervisor may wish to review with the counselor the community-based resources (e.g., crisis pregnancy counseling, adoption, and medical clinics) that can be useful to the client. It is also important to direct the counselor to explore past personal experiences that may contribute to countertransference into the counseling session. Furthermore, it may be important for the supervisor to seek consultation regarding countertransference issues.
In supporting the counselor in Situation 2, the supervisor may want to role play with the supervisee a variety of responses for use in the session. The counselor likely needs to engage in self-exploration regarding a personal position on the issue of the role of spirituality in mental health. You can encourage dialogue in supervision about whether spirituality should be integrated and synthesized into or compartmentalized and separated from the counseling process.
In Situation 3, it is important for the supervisor to explore why feelings of unease were experienced. It may be necessary for the supervisor to review information with the counselor about policies and procedures as they relate to particular agency requirements and limitations for including spiritual practices, such as prayer, in the counseling session. Because prayer, as an intervention, seems to have been beneficial for the client, it seems unreasonable to summarily prohibit it; rather, it seems important to establish clear expectations for the counselor to discuss such interventions with his or her supervisor prior to their implementation in session, thus helping to assure the supervisor that the counselor can competently use the desired intervention.
Definition of Spirituality
In addition to supervised experience, competence is enhanced, in part, through knowledge and understanding. Having a basic understanding of spirituality is needed to form a foundation for gaining skills in the supervision process. Counselors and supervisors need to understand how religion and/or spirituality are significant components of being human. At this point, it should be pointed out that although religion and spirituality are interrelated, they are not synonymous. Since the "beginning of time," those things that we consider transcendent have affected the way we view the universe and the way we give credit for the outcomes of our actions. Spirituality is not only a significant and integral part of human experience, but spirituality is also an integral part of human development.
Spirituality may be defined as: the animating force in life, represented by such images as breath, wind, vigor, and courage. Spirituality is the infusion and drawing out of spirit in one's life. It is experienced as an active and passive process. Spirituality is also described as a capacity and a tendency that is innate and unique to all persons. This spiritual tendency moves the individual towards knowledge, love, meaning, hope, transcendence, connectedness, and compassion. Spirituality includes one's capacity for creativity, growth, and the development of a values system. Spirituality encompasses the religious, spiritual, and transpersonal.
Religion, on the other hand, has been defined as the logical outcome and organized attempt to give a framework to the sense of awe for the transcendent. Religion also tells its adherents what life is about and how one is to live that life. Both religion and spirituality can be found across cultures and are expressed in dynamic and diverse ways.
For counselors, it is not always easy to approach clients' concerns regarding spirituality or religion. Historically, counselors have been encouraged to focus on a secular approach to counseling that emphasized a negativistic bias regarding the influence of spirituality or religious values on psychological well-being Counselors tend to take a detached view of the spirituality of clients. This means that in a counseling session, counselors may avoid issues that deal with spirituality or religious practice. Addressing such issues with clients had several benefits by helping counselors in the following ways: (a) better understand the [client's] psychological conflict, (b) design interventions that are more acceptable to the [client] and congruent with their world view (and thus more likely to be complied with), (c) identify healthy religious resources that may bring comfort and support, (d) recognize psychological roadblocks that prevent the [client] from utilizing potentially powerful spiritual resources, and (e) strengthen the therapeutic relationship (because this demonstrates sensitivity to an area that may be very meaningful to the client.
Information regarding the impact of the similarity of client and counselor values, as well as cross-cultural elements in the counseling process, can further help counselors and supervisors appreciate the importance of client spirituality.
A goal of counseling is to promote client welfare and the evidence is clear that counseling and psychotherapy help clients to improve. Although counselors and clients may generally share the goal of improvement, there may be sharp differences in opinion about what constitutes significant improvement and about what factors contribute to improvement. There is evidence that individuals in the current culture in the United States consider spirituality and/or religion to be important and helpful parts of their daily lives. There is a growing amount of literature that supports the positive impact of spirituality or religious practices on the well-being of individuals in a variety of circumstances. Evidence suggests that progress toward mental well-being and emotional health is enhanced by a positive focus on spirituality.
In spite of the growing amount of literature on spirituality, counseling professionals and supervisors continue to struggle with the acceptance of spirituality as a significant part of the counseling process. This discrepancy between counseling professionals and the clients they serve perpetuates barriers, particularly because clients may be suspicious of what they may consider an unfriendly environment that will discount, negate, or conflict with their religious values or spiritual world view. To further illustrate the point about barriers, consider the perspective of Worthington (1986) regarding the position of clients who espouse conservative Christian perspectives on spirituality. These potential clients may be reluctant to receive intervention from "secular therapists" because they fear therapists may (a) neglect religious concerns; (b) deal with religious beliefs and events as pathological or psychological; (c) fail to discern religious language and ideas; (d) presume that religious clients share nonreligious cultural norms; (e) promote therapeutic conduct that contradicts clients' own particular sense of morals; or (f) make presumptions, explanations, and suggestions that clients' account of revelation is not valid epistemology. Rather than emphasize the apparent disparity between counseling professionals and clients, it is important to focus on ways to shrink the gap. The development of counselor awareness and of the ability to deal with the cultural diversity of clients has been an area where counselors have gained significant ability to encourage and promote the welfare of clients.
When contemplating the challenges presented in the vignettes at the beginning of this article, several issues are apparent. First, how does the counselor effectively attend to the spiritual issues presented by the client in the immediate situation? Second, how does the counselor present these issues in the supervision process? Third, how does the supervisor respond to these issues in the supervision process? We recognize that factors such as counselor competency, culture, one's conceptualization of spirituality, and the similarity of clients' and counselors' values form a foundation for developing effective intervention and supervision strategies.
The development of counselor competency is enhanced through the acquisition of specific skills. Skill development is critical because spirituality is a central part of the human experience that pervades virtually all aspects of psychological and emotional functioning. Several suggestions aimed at helping counselors become more competent in addressing spiritual issues in the counseling process: (a) help the client to feel that his or her religious values are an accepted part of the therapeutic process; (b) view religious values as part of the solution to the client's problem, not just as part of the problem; (c) become more educated about cultures, religious values, beliefs, and practices and strive to understand how these issues are integrated with psychological theory and counseling practice; (d) become involved with community or professional activities that promote interactions with persons from diverse cultures who have a variety of religious values; (e) explore and evaluate personal religious values; (f) be aware of what counselor resistance toward or cautious maneuvering around religious issues may convey to clients; and (g) develop a simple straightforward language to use in communicating with clients about religious values.
To strengthen a foundation for developing effective supervision strategies, we are calling for an infusion of spirituality into the supervision process. Regarding the application of these ideas to supervision, we urge counselors, trainees, and supervisors to (a) engage in dialogue regarding the nature of spirituality, its definition, and its relevance to counseling and particularly to supervision; (b) spend regular time in self-examination and contemplation regarding personal experiences in spiritual matters; and (c) develop specific scientific bases for the inclusion of spirituality in the supervision process. This final area includes at least two sub components. First, it is essential to expand existing models of supervision to include a place for spirituality as it relates to the client, supervisee, and supervisor. Second, it is necessary to derive specific hypotheses from these models and put the hypotheses to empirical test.
Multicultural Issues in Supervision
Perhaps two of the most important changes within counseling and counselor education in the past twenty years have been (a) recognition of the need for a multicultural perspective in all aspects of counseling and education and (b) the evolution of supervision models and practices. Recently, these changes culminated in two sets of competency and standards statements that will most certainly guide counselor preparation and evaluation of counselor practice. The Association for Multicultural Counseling and Development (AMCD) approved a document outlining multicultural counseling competencies and standards and the Association for Counselor Education and Supervision adopted comprehensive standards for eleven aspects of counseling supervision. Now counselors are recognizing the need to consider multicultural issues in supervision and methods of multicultural supervision.
The multicultural perspective will become essential as we move into the twenty-first century. It is projected that by the year 2010 twelve of our most populous states, containing about half of the nation's young people, will have significant minority populations. Thus, the supervision triad of client, counselor, and supervisor will most likely contain persons of differing racial-ethnic backgrounds who are confronting problems and concerns in a diverse social environment.
Controversy surrounds the inclusiveness or exclusiveness of the term multicultural so, for clarity, multicultural in this paper will be defined as in the AMCD Standards, referring to visible racial-ethnic groups, African-Americans, American Indians, Asian Americans, Hispanics and Latinos, and Whites. Currently, very little descriptive and even less research literature on multicultural supervision is available. This paper will summarize two different aspects of multicultural supervision: the inclusion of multicultural issues during supervision and the multicultural supervisory relationship.
Bernard and Goodyear (1992) advocated that the supervisor is responsible for assuring that multicultural issues receive attention in supervision. Generally, whenever the client is a minority group member, and sometimes when either the supervisee or supervisor is a minority person, supervisors will recognize the relevance of addressing cultural concerns. However, all counseling and supervision contacts have cultural, racial-ethnic aspects which shape core assumptions, attitudes, and values of the persons involved and which may enhance or impede counselor effectiveness. Majority cultural patterns and the culture of counseling and psychotherapy are often accepted by the supervisor and counselor without thought, what Bernard and Goodyear (1992) label the "myth of sameness" (p. 195). Recent work on white racial identity has underscored the need for majority counselors to develop an awareness of being White and what that implies in relation to those who do not share White group membership. Thus, regardless of apparent "sameness", at some point in all supervision, and preferably early in the process, multicultural issues must be explored.
Logical extensions of this view of multicultural supervision are models that advocate supervision as a method to assist multicultural counselor development. As reviewed by Leong and Wagner (in press), these models propose that supervisees move in stages from minimal racial-ethnic awareness, to awareness of discrepancies between cultures and within self, and then to development of a multicultural identity. The supervisor's role is to promote supervisee growth by challenging cultural assumptions, encouraging emotional expression, and validating conflict of attitudes and values. These multicultural models lack empirical support, but seem to integrate well with developmental models of supervision and direct the supervisor to assess the multicultural awareness level of each supervisee.
A number of supervision techniques have been proposed to insure that the cultural dimension is addressed, though none have research support. Planned discussion of culture and the culture of counseling; exploration of supervisee and supervisor cultural backgrounds; required use of videotape (which provides visual recording of nonverbal cultural components); modeling by the supervisor; inclusion of cultural considerations on all intake, case management, and other written supervision reports; and experiential exercises are methods that can be used in individual and group supervision.
Multicultural Supervisory Relationship
While the above section dealt with the multicultural "content" of supervision, the multicultural supervisory relationship is the "process" of supervision. ACES counseling supervision standard 4 addresses the knowledge and skills related to the supervisory relationship. Only one substandard of nine directly addresses multicultural issues, noting the "supervisor demonstrates knowledge of individual differences with respect to gender, race, ethnicity, culture, and age and understands the importance of these characteristics in supervisory relationships". The second half of Standard 4.1 is the difficult piece, as there is a paucity of empirical knowledge about the dynamics and experiences of the multicultural supervisory relationship. Leong and Wagner (in press), critiqued the four studies published to date and concluded: (1) race can have a profound influence on the supervisory process, particularly in terms of trainee's expectations for supervisor empathy, respect, and congruence, (2) race can influence a trainee's perception of supervisor liking, and (3) there are some circumstances under which race does not seem to influence supervision.
These conclusions point to the critical importance of the initial sessions in the multicultural supervisory relationship. Cultural differences in world view and communication styles may particularly affect supervisee perceptions of the supervisor as supportive and empathic. Such perceptions have been associated with satisfaction in multicultural supervision. Early discussion of supervisor and supervisee racial-ethnic backgrounds and expectations about supervision may help establish a base for the development of trust and empathy.
Another critical dimension of the multicultural supervisory relationship is the management of power. The supervisor is viewed as having expertise and has the responsibility of evaluating the supervisee, both contributing to an unavoidable power differential in the relationship. In situations of a minority supervisee and a White supervisor or a White supervisee and a minority supervisor, both participants may attribute power to majority group membership. This additional perceived power differential and past experiences with power abuses by Whites may make trust formation difficult and result in cautious, guarded communication. This, in turn, may result in the opposite of the personal self-disclosure and openness to feedback required in supervision.
Early and recurring discussion of supervisor and supervisee expectations of performance, orientation as to how to best use supervision, and clear statements of evaluation criteria are methods to promote fairness and share the evaluative power. Such discussions should be coupled with exploration of how expectations of performance and perceptions of fairness in evaluation may be altered by each person's cultural background. The supervisor will need to continue to consider the influence of minority experiences of oppression and prejudice on perceptions of power throughout the supervision process.
While there is some convergence of opinion, the identified issues and suggestions for interventions in multicultural supervision are currently based on personal experiences rather than empirical study. A consistent theme in the literature is the critical role of the supervisor: in promoting cultural awareness; in identifying cultural influences on client behavior, on counselor-client interactions, and on the supervisory relationship; and in providing culture-sensitive support and challenge to the supervisee. This is a daunting responsibility! As all supervision is some form of multicultural supervision, supervisors will need to be proficient in the multicultural competencies identified by Sue et al. (1992). All supervisors-in-training should work with supervisees from racial-ethnic groups other than their own and receive supervision of multicultural supervision. Likewise, experienced supervisors will need to seek continuing education, consultation, and focused supervision of supervision with a multicultural emphasis to meet gaps in experience and education.
Multiculturalism has been defined as the fourth force in psychology, one which complements the psychodynamic, behavioral and humanistic explanations of human behavior. Pedersen defined multiculturalism as "a wide range of multiple groups without grading, comparing, or ranking them as better or worse than one another and without denying the very distinct and complementary or even contradictory perspectives that each group brings with it" . One of the most important debates within the field has to do with how this definition relates to specific groups within the context of a culture. Pedersen's definition leads to the inclusion of a large number of variables, e.g., age, sex, place of residence, education, socioeconomic factors, affiliations, nationality, ethnicity, language, religion, making multiculturalism generic to all counseling relationships. Locke, among others, advocates a narrower definition of multiculturalism, particularly as it relates to counseling. The narrower view is one where attention is directed toward "the racial/ethnic minority groups within that culture".
Regardless of how one defines the term or the degree to which the concept is restricted or broadened in a particular context, multiculturalism encompasses a world of complex detail. Hofstede (1984), identified four dimensions of cultures. These dimensions are:
1. Power distance--the extent to which a culture accepts that power in institutions and organizations is distributed unequally.
2. Uncertainty avoidance--the extent to which members of a culture feel threatened by uncertain or ambiguous situations.
3. Individualism--a social framework in which people are supposed to take care of themselves and of their immediate families only. Collectivism refers to a social framework in which people distinguish between in-groups and out-groups, expecting their in-group to look after them, and in exchange for that owe loyalty to it.
4. Masculinity/Femininity--the extent to which the dominant values within a culture are assertiveness, money and things, caring for others, quality of life, and people.
A number of generic counselor characteristics are necessary, but not sufficient, for those who engage in multicultural counseling. To be effective, a counselor must be able to:
1. Express respect for the client in a manner that is felt, understood, accepted, and appreciated by the client. Respect may be communicated either verbally or nonverbally with voice quality or eye contact.
2. Feel and express empathy for culturally different clients. This involves being able to place oneself in the place of the other, to understand the point of view of the other.
3. Personalize his/her observations. This means that the counselor recognizes that his/her observations, knowledge, or perceptions are "right" or "true" only for him/herself and that they do not generalize to the client.
4. Withhold judgment and remain objective until one has enough information and an understanding of the world of the client.
5. Tolerate ambiguity. This refers to the ability to react to new, different, and at times, unpredictable situations with little visible discomfort or irritation.
6. Have patience and perseverance when unable to get things done immediately.
Counselors bring with them their own degree of effectiveness with these generic characteristics. They also bring with them their cultural manifestations as well as their unique personal, social and psychological background. These factors interact with the cultural and personal factors brought by the client. The interaction of these two sets of factors must be explored along with other counseling-related considerations for each client who comes for counseling. The effective counselor is one who can adapt the counseling models, theories, or techniques to the unique individual needs of each client. This skill requires that the counselor be able to see the client as both an individual and as a member of a particular cultural group. Multicultural counseling requires the recognition of: (1) the importance of racial/ethnic group membership on the socialization of the client; (2) the importance of and the uniqueness of the individual; (3) the presence of and place of values in the counseling process; and (4) the uniqueness of learning styles, vocational goals, and life purposes of clients, within the context of principles of democratic social justice.
The Multicultural Awareness Continuum was designed to illustrate the areas of awareness through which a counselor must go in the process of counseling a culturally different client. The continuum is linear and the process is developmental, best understood as a lifelong process.
Self-awareness. The first level through which counselors must pass is self-awareness. Self-understanding is a necessary condition before one begins the process of understanding others. Both intrapersonal and interpersonal dynamics must be considered as important components in the projection of beliefs, attitudes, opinions, and values. The examination of one's own thoughts and feelings allows the counselor a better understanding of the cultural "baggage" he or she brings to the situation.
Awareness of one's own culture. Counselors bring cultural baggage to the counseling situation; baggage that may cause certain things to be taken for granted or create expectations about behaviors and manners. For example, consider your own name and the meaning associated with it. Ask yourself the cultural significance of your name. Could your name have some historical significance to cultures other than the culture of your origin? There may be some relationship between your name and the order of your birth. There may have been a special ceremony conducted when you were named.
The naming process of a child is but one of the many examples of how cultural influences are evident and varied. Language is specific to one's cultural group whether formal, informal, verbal, or nonverbal. Language determines the cultural networks in which an individual participates and contributes specific values to the culture.
Awareness of racism, sexism, and poverty. Racism, sexism, and poverty are all aspects of a culture that must be understood from the perspective of how one views their effect both upon oneself and upon others. The words themselves are obviously powerful terms and frequently evoke some defensiveness. Even when racism and sexism are denied as a part of one's personal belief system, one must recognize that he/she never-the-less exists as a part of the larger culture. Even when the anguish of poverty is not felt personally, the counselor must come to grips with his or her own beliefs regarding financially less fortunate people.
Exploration of the issues of racism, sexism, and poverty may be facilitated by a "systems" approach. Such an exploration may lead to examination of the differences between individual behaviors and organizational behaviors, or what might be called the difference between personal prejudice and institutional prejudice. The influence of organizational prejudice can be seen in the attitudes and beliefs of the system in which the counselor works. Similarly, the awareness that frequently church memberships exist along racial lines, or that some social organizations restrict their membership to one sex, should help counselors come to grips with the organizational prejudice which they may be supporting solely on the basis of participation in a particular organization.
Awareness of individual differences. One of the greatest pitfalls of the novice counselor is to over generalize things learned about a specific culture as therefore applicable to all members of the culture. A single thread of commonality is often presumed to exist as interwoven among the group simply because it is observed in one or a few member(s) of the culture. On the contrary, cultural group membership does not require one to sacrifice individualism or uniqueness. In response to the counselor who feels all clients should be treated as "individuals," I say clients must be treated as both individuals and members of their particular cultural group.
Total belief in individualism fails to take into account the "collective family-community" relationship which exists in many cultural groups. A real danger lies in the possibility that counselors may unwittingly discount cultural influences and subconsciously believe they understand the culturally different when, in fact, they view others from their own culture's point of view. In practice, what is put forth as a belief in individualism can become a disregard for any culturally specific behaviors that influence client behaviors. In sum, counselors must be aware of individual differences and come to believe in the uniqueness of the individual before moving to the level of awareness of other cultures.
Awareness of other cultures. The four previously discussed levels of the continuum provide the background and foundation necessary for counselors to explore the varied dynamics of other cultural groups. Most cross-cultural emphasis is currently placed upon African Americans, Native Americans, Mexican Americans or Hispanics, and Asian Americans. Language is of great significance and uniqueness to each of these cultural groups, rendering standard English less than complete in communication of ideas. It is necessary for counselors to be sensitive to words which are unique to a particular culture as well as body language and other nonverbal behaviors to which cultural significance is attached.
Awareness of diversity. The culture of the United States has often been referred to as a "melting pot." This characterization suggests that people came to the United States from many different countries and blended into one new culture. Thus, old world practices were altered, discarded, or maintained within the context of the new culture. For the most part, many cultural groups did not fully participate in the melting pot process. Thus, many African American, Native American, Mexican American, and Asian American cultural practices were not welcomed as the new culture formed.
Of more recent vintage is the term "salad bowl" which implies that the culture of the United States is capable of retaining aspects from all cultures (the various ingredients). Viewed in this manner, we are seen as capable of living, working, and growing together while maintaining a unique cultural identity. "Rainbow coalition" is another term used in a recent political campaign to represent the same idea. Such concepts reflect what many have come to refer to as a multicultural or pluralistic society, where certain features of each culture are encouraged and appreciated by other cultural groups.
Skills/Techniques. The final level on the continuum is to implement what has been learned about working with culturally different groups and add specific techniques to the repertoire of counseling skills. Before a counselor can effectively work with clients of diverse cultural heritage, he or she must have developed general competence as a counselor. Passage through the awareness continuum constitutes professional growth and will contribute to an increase in overall counseling effectiveness, but goes much further than that. Counselors must be aware of learning theory and how theory relates to the development of psychological-cultural factors. Counselors must understand the relationship between theory and counselors' strategies or practices. Most importantly, counselors must have developed a sense of worth in their own cultures before attaining competence in counseling the culturally different.
PREVENTION OF BOUNDARY VIOLATIONS
Prevention of boundary violations is a laudable goal, but attaining it is unfortunately about as likely as eliminating crime and poverty. The point of view described in this article leads to several suggestions, though. The prevention of boundary violations depends, in large measure, on education of therapists, clergy, and other professionals. It is important that training programs include peer discussions and readings orienting trainees to the field's standards. There are numerous publications addressing the field's standards and the boundaries of clinical work. Such readings and peer discussions not only educate trainees to the field's standards, but also offer practical tips about warning signs of impending boundary violations. However, it is not enough to identify warning signs and teach that boundary violations are wrong because they violate our code of ethics. We would do well to educate therapists and other professionals to think of their dyadic work as located within their discipline's larger, supraordinate context. The educational process should help individuals join the values of their field, not simply be trained in a discipline that they are then authorized to practice independently. It is the recognition that we carry out our work in a larger context, that we have joined a field and joined its values, and that we and our patients each have a role that is subordinate to the larger task of treatment, that stands to help therapists and other professionals learn to reorient themselves when they begin to become lost in the work.
One concrete way of helping professionals stay aware of the larger context is through supervision or other perspectives on the dyad from outside it. Prevention of sexual misconduct depends on making easily available to therapists, clergy, and other professionals the possibility of consultation with others in the field, particularly at times of impasse. Therapists who routinely present their work to others in consultation, supervision, peer discussion groups, or case presentations are probably at less risk of becoming isolated and lost in the dyad in their work. This is not a simple matter in the current clinical climate, where financial pressures have squeezed treatment settings and therapists in a way that leaves little room for clinical conferences or case discussion.
Educating practitioners and students about central psychodynamic notions like transference, countertransference, and enactment, and teaching them the importance of accepting and tolerating the transference offered by the patient, seems wise. In therapeutic work, if the transference fits, wear it—even if it hurts! Awareness of the concept of enactment, in particular, has a double benefit. First, it teaches therapists about an inevitable therapeutic phenomenon that places them at risk for sexual misconduct but that also offers an opportunity to deepen their work. Second, knowledge of the concept of enactment reminds therapists that we are all inevitably vulnerable human beings. This awareness serves to minimize the unhelpful we/they split that can provide a false sense of security to therapists who believe that sexual misconduct can't happen to them. Unfortunately, in psychiatry today little is taught to residents about psychodynamics, much less about the complexity of tolerating intense transferences and the importance of enactment. These trends in training, coupled with the current focus on behavioral and symptom-focused treatment approaches that exclude attention to transference and countertransference, do not help. Despite all the good that comes from a focus on patient satisfaction, this trend may have the unfortunate effect of reinforcing therapists' inclination to refuse negative transferences.
It seems wise to cultivate humility in ourselves as clinicians and teachers of younger professionals, emphasizing the inevitability of our own fallibility in this complex work. However great our expertise, we remain fallible human beings, doing our work along a fine and fragile boundary.
Supervisors have an ethical and legal responsibility to monitor the quality of care that is being delivered to the supervisee’s clients.
Organizational Clinical Supervision
Clinical supervision has become an organizational function with its own conceptual framework and methodology. Key competencies for effective clinical supervision represent an array of knowledge and skills pertinent to the clinical, administrative, and evaluative responsibilities of a clinical supervisor. Before the framework can be described in more detail, definitions of two key terms are needed: clinical supervision and competency.
A number of definitions for clinical supervision have appeared in the published literature. Two of the most popular are the following: 1. Clinical supervision is a disciplined, tutorial process wherein principles are transformed into practical skills, with four overlapping foci: administrative, evaluative, clinical, and supportive (Powell, 2004, p. 11). 2. Supervision is an intervention that is provided by a senior member of a profession to a more junior member or members of that same profession. This relationship is evaluative, extends over time, and has the simultaneous purposes of enhancing the professional functioning of the more junior person(s), monitoring the quality of professional services offered to the clients that she, he, or they see, and serving as a gatekeeper of those who are to enter the particular profession (Bernard and Goodyear, 2004, p. 8).
After reviewing the available literature, the following is a consensus definition of clinical supervision: A social influence process that occurs over time, in which the supervisor participates with supervisees to ensure quality clinical care. Effective supervisors observe, mentor, coach, evaluate, inspire, and create an atmosphere that promotes self-motivation, learning, and professional development. They build teams, create cohesion, resolve conflict, and shape agency culture, while attending to ethical and diversity issues in all aspects of the process. Such supervision is key to both quality improvement and the successful implementation of consensus- and evidence-based practices.
Marrelli and colleagues (2004, p. 4) define competency as follows: [A] measurable human capability that is required for effective performance [composed] of knowledge, a single skill or ability, a personal characteristic, or a cluster of two or more of these attributes.
Competencies are the building blocks of work performance. The performance of tasks requires the simultaneous or sequenced demonstration of multiple competencies. A competency-based model, as presented in this document, provides a framework for under- standing, learning, and implementing the multiple functions and tasks of clinical supervision.
Becoming an effective and fully competent clinical supervisor is a developmental process. As knowledge and skills are accumulated over time, the supervisor’s proficiency incrementally increases. This document describes competencies required to reach mastery as a clinical supervisor. It establishes a set of expectations for clinical supervision and describes the capabilities of a fully proficient clinical supervisor, and provides a standard toward which organizations and supervisors are encouraged to strive.
The nature of the relationship between supervisor and supervisee is unique. It can be characterized as highly charged and intense. When one person is in a position of power and authority over another, tension, discomfort, and conflict can arise. It is crucial that clinical supervisors understand the nature of this relationship and exercise supervisory responsibilities in a respectful, fair, and objective manner.
Competencies for Clinical Supervisors It is important, too, for supervisors to understand the developmental process of supervisees (e.g., how they learn, how skills are developed over time) and how to establish a spirit of learning and personal development in an organization. Service improvement occurs most effectively when service providers have the freedom to practice new skills in an environment marked more by support and mentoring than by critical judgment.
The clinical supervision competencies identified in the pages that follow are presented under two major headings: foundation areas and performance domains. Foundation areas identify the broad knowledge and concepts essential to supervisory proficiency. The competencies representing these foundations of supervision are grouped into five areas: FA1: Theories, Roles, and Modalities of Clinical Supervision; FA2: Leadership; FA3: Supervisory Alliance; FA4: Critical Thinking; and FA5: Organizational Management and Administration. Performance domains identify the specific responsibilities and abilities essential to protecting client welfare, improving clinical services, developing a competent staff, and fulfilling an organization’s mission and goals.
The competencies relating to these specifics of supervisory practice are grouped into five domains: PD1: Counselor Development; PD2: Professional and Ethical Standards; PD3: Program Development and Quality Assurance; PD4: Performance Evaluation; and PD5: Administration.
Clinical supervision is distinguished from administrative supervision in some models of supervisory practice, and many believe that administrative duties take precious time away from the provision of direct supervision to clinical staff. However the two kinds of supervision significantly overlap in real-world practice; Powell (2004, p. 11) identified “administrative” as one of four “overlapping foci” of clinical supervision. The Task Force members believe strongly that this document would not be complete if it did not address elements of organizational and administrative functioning. Unlike the other competencies described in this document, the extent to which clinical supervisors are expected (or have the authority) to perform the administrative functions varies greatly from organization to organization. Few supervisors have responsibility for performing all of the administrative activities included. However, as supervisors move to other organizations, their administrative activities may well change. It is important that clinical supervisors understand the range of administrative competencies that may be expected of them.
Effective clinical supervisors are skilled, experienced clinicians. It is important that supervisees believe that their supervisors have substantial knowledge and skill to pass along. However, knowledge and skill as a counselor are not enough to ensure success as a clinical supervisor.
The specific tasks, responsibilities, and roles of supervisors vary depending on agency mission, target population, theoretical model, treatment modality, and general structure. However, some basic competencies are common to a variety of settings and professional disciplines. These basic concepts are reflected in the foundation area competencies in this document. They are common across the variety of disciplines and interest groups that provide care for clients with disorders. Clinical supervisors in treatment settings are expected to be familiar with the knowledge described in the transdisciplinary foundations. The framework used here identifies five foundation areas in clinical supervision:
FA1: Theories, Roles, and Modalities of Clinical Supervision;
FA3: Supervisory Alliance;
Critical Thinking and Organizational Management and Administration.
Each contains several competencies that, taken together, define the work of the clinical supervisor.Although some similarities exist between counseling and supervising, there are many important differences. Clinical supervision has its own knowledge base, and supervisors must understand different theoretical perspectives. They also must understand the roles clinical supervisors are expected to fill and the various modalities, or ways of implementing supervision, that are available.
Evaluation should focus on the supervisees’ professional work, not personal issues
Understand the role of clinical supervision as the principal method for monitoring and ensuring the quality of clinical services. Appreciate the systemic role of the clinical supervisor as a primary link between management and direct services. Understand the multiple roles of the clinical supervisor, including consultant, mentor, teacher, team member, evaluator, and administrator. Be able to define the purpose of clinical supervision specific to the organization’s clinical and administrative contexts, including supervisory goals and methods. Be familiar with a variety of theoretical models of clinical supervision, including (but not limited to) psychotherapy-based, developmental, multicultural, integrative, and blended models. Be able to articulate one’s model of supervision. Be familiar with modalities of clinical supervision, including individual, group, direct observation, and consultation. Be familiar with the current research literature related to recommended practices in clinical supervision. Be familiar with the literature regarding multiple learning strategies (e.g., instructions, demonstrations, role plays, critiques). Recognize the importance of establishing with the supervisee a productive, healthy learning alliance focused on improving client services and job performance. Understand and reinforce the complementary roles of members on a multidisciplinary team. Understand the importance of assessing needs and carefully planning and systematically implementing individual and group supervisory activities that promote clinical and program service improvement.
Foundation Areas FA2: LEADERSHIP Introduction Leadership is an important element of clinical supervision. Leadership may be defined as a bidirectional social influence process in which supervisors seek voluntary participation of supervisees to achieve organizational goals, while providing leadership in the management structure of the agency. Leaders mentor, coach, inspire, and motivate. They build teams, provide structure, create cohesion, and resolve conflict. In addition, leaders build organizational culture, facilitate individual and organizational growth and change, and foster a culturally sensitive service delivery system by consistently advocating, at all levels of the organization, the need for high-quality clinical care for all patients or clients of the agency. The Competencies Use a leadership style that creates and maintains an environment based on mutual respect, trust, and teamwork. Be a role model by taking full responsibility for one’s decisions, supervisory practices, and personal wellness. Seek job performance feedback from supervisees, peers, and managers to improve supervisory practices.
Create, regularly assess, and revise a personal leadership plan to provide direction for one’s continuing professional development. Seek out and use leadership mentors to assist with one’s personal development, knowledge acquisition, and skill development. Understand the historical context and use that understanding to participate in developing the agency’s guiding vision and its related mission, principles, and sense of purpose. Clarify agency vision, mission, and service goals and objectives for the supervisee. Interpret agency mission, policies, procedures, and critical events. Effectively communicate those interpretations to supervisees and foster an organizational climate that pro-motes continuous improvement and excellence in client care. Understand, monitor, and ensure compliance with State and Federal regulations and accrediting body standards for the delivery of treatment. Recognize the safety and security issues facing the organization and participate in enforcing and enhancing organizational policies that ensure the safety and security of clients, personnel, and facilities. Understand and acknowledge the power differential inherent in the supervisor– supervisee relationship, using power fairly and purposefully avoiding the abuse of power. Proactively structure and schedule clinical supervision activities. Teach, mentor, and coach in the context of the organization’s core values. Provide honest feedback—positive, constructive, and corrective.
Guide through motivational empowerment rather than control. Facilitate work through team building, training, coaching, and support. Plan and organize for orderly workflow, controlling details without being overbearing. Empower and delegate key duties to others while maintaining goal clarity and commitment. Delegate mindfully, considering both the supervisee’s professional development and the agency’s needs. Encourage supervisee participation in communicating observations, ideas, and suggestions to agency management.
Supervision allows for third-party discussion of therapy sessions
Section III: Foundation Areas FA3 SUPERVISORY ALLIANCE Introduction Clinical supervision takes place in the context of the supervisor–supervisee relationship. A positive supervisory alliance includes mutual understanding of the goals and tasks of supervision and a strong professional bond between supervisor and supervisee. To be effective, a supervisor must have a clear understanding of the nature and dynamics of this relationship. The Competencies familiar with the literature about supervisory alliance, including key factors that strengthen or compromise the supervisory alliance, supervisory contracting, and relational issues (e.g., transference and countertransference). Understand the complex, multilevel, and bidirectional nature of the supervisory triad of client, counselor, and supervisor. Maintain an awareness of potential dual relationships and boundary violations within the triad. Recognize that the supervisor–supervisee relationship develops over time and that the stage of relationship development influences the rules, roles, and expectations of the alliance.
Conceptualize the supervisor–supervisee relationship as a learning alliance that provides for role induction, includes agreement on goals and tasks, and recognizes the bond that develops between the supervisor and the supervisee. Understand the value of mentoring as a dynamic way of forming an alliance, teaching counseling skills through encouragement, and giving suggestions for accomplishing goals. Create an explicit supervisory contract that clarifies expectations and goals, the relation- ship’s structure and evaluative criteria, and the limits of supervisor–supervisee confidentiality. Present as a credible professional who possesses knowledge and expertise relevant to the setting and the population being served. Model ethical behavior vis-à-vis the supervisee and reinforce ethical standards in the relationship between the supervisee and the supervisee’s clients. Be continually alert to the effects of one’s interpersonal style on the supervisee. Maintain appropriate boundaries in forming and maintaining a safe and trusting professional relationship. Attend to cultural, racial, gender, age, and other diversity variables essential to a productive supervisor–supervisee relationship. Understand, recognize, and know how to ameliorate the effects of personal counter- transference triggered by the supervisee’s interpersonal style, the supervisee’s developmental issues, or the supervisee’s unresolved personal issues. Recognize interpersonal conflict and supervisory impasses, accept appropriate responsibility, and actively participate in resolving difficulties.
Section III: Foundation Areas FA4: CRITICAL T HINKING Introduction Critical thinking refers to the cognitive processes of conceptualizing, analyzing, applying information, synthesizing, and evaluating. Supervisors are expected to use critical thinking to make sound decisions and solve problems on a regular basis; they also must help supervisees hone critical thinking skills. The Competencies Understand the various contexts (e.g., organizational, political, societal, cultural) in which supervision is conducted. Analyze and evaluate agency issues and policies to better understand, clarify, and participate in the continuous improvement of agency and staff performance and service outcomes. Evaluate and select written and oral communication strategies appropriate to the audience and purpose. Select, adapt, implement, and evaluate appropriate problem solving, decision-making, and conflict resolution techniques. Apply experience, insight, and lessons learned to new situations.
Apply critical thinking to information gathering by evaluating the content of the information and the credibility of its source. Ask supervisees relevant and clarifying questions and listen critically for content and underlying issues in their self-disclosure. Help supervisees develop skills in case conceptualization and analysis of client– counselor interactions. Negotiate, communicate, and document the resolution of conflicts or disagreements and strategies for resolving performance problems. Document outcomes. Develop sound criteria for self-evaluation and clarify personal beliefs, values, and biases. Help supervisees develop sound criteria for self-evaluation and clarify their beliefs, values, and biases.
Section III: Foundation Areas FA5: ORGANIZATIONAL MANAGEMENT AND A DMINISTRATION Introduction Management can be defined as the process of working with and through others to achieve organizational objectives in an efficient, legal, and ethical manner. Administration, in the context of this document, is the day-to-day implementation of the organization’s policies and procedures. Although clinical supervision is distinguished from administrative supervision in some models of supervisory practice, the two significantly overlap in the real world. Virtually all clinical super- visors have responsibility for some management and administrative activities, but the scope of these activities can vary widely depending on the organization.
The Competencies Recognize that organizational and managerial skills and tasks enhance clinical supervision. Understand and consistently apply agency policies, procedures, organizational structure, and communication protocols. Understand the legal demands and liabilities inherent in supervisory and clinical ser- vices, including the vicarious liabilities incurred in supervising interns and students. Be familiar with and abide by current principles, laws, ethical guidelines, and agency policies regarding personnel management. Learn to implement effective disciplinary and administrative management techniques that enhance clinical supervision and accomplishment of the organization’s mission. Understand and ensure supervisee compliance with State program licensing requirements and with other State and Federal laws and statutes. Understand and ensure supervisee compliance with the substance use disorder treatment standards of the organization’s healthcare accrediting body (e.g., Commission on Accreditation of Rehabilitation Facilities, Joint Commission on Accreditation of Health- care Organizations).
Monitor and maintain the human and technical resources needed to meet organizational and program objectives. Evaluate and contribute to improving the organization’s cultural proficiency. Possess and continually improve organizational and time management skills. Understand and work within the organization’s budgetary constraints. Effectively apply technology, within agency and regulatory limits, for communication, program monitoring, report writing, problem solving, recordkeeping, case management, and other activities. Ensure the maintenance, storage, and security of employee records and protected health information consistent with the organization’s policies and procedures, government regulations, and ethical principles.
Section IV: P ERFORMANCE DOMAINS Performance domains identify specific areas of clinical supervision practice that are essential to protecting client welfare, achieving agency goals, and improving clinical services. To ensure high-quality service delivery, supervisors work to develop and maintain competence among direct service staff while adhering to high professional and ethical standards. Supervisors provide supervisees with appropriate feedback while facilitating knowledge and skill development.
To accomplish these tasks, supervisors must gather objective information on which to base an evaluation of their supervisees’ performance. Supervisors also perform administrative tasks that preserve and build the organizational culture. The framework used here identifies five performance domains: PD1: Counselor Development; PD2: Professional and Ethical Standards; PD3: Program Development and Quality Assurance; PD4: Performance Evaluation; and PD5: Administration. The competencies listed within each performance domain identify the specific abilities and responsibilities that clinical supervisors must master to be effective in the essential roles they play in the service delivery system. Counselor development and performance evaluation are discussed here as two separate performance domains because each requires a distinct set of competencies. It is important to note, however, that each is integral to the other. Performance evaluation without a counselor development process would not necessarily lead to improved counselor proficiency. Similarly, counselor development activities in the absence of performance evaluation would likely be untargeted, general, and of less value to the counselor.
Section IV: Performance Domains PD1: COUNSELOR D EVELOPMENT Introduction The continuous development of staff clinical skills is key to the delivery of high-quality client care. Counselor development is a complex process that involves teaching, facilitating, collaborating, and supporting counselor self-efficacy. Supervisors must facilitate this process in the con- text of a collaborative supervisor–supervisee relationship and within professional, ethical, and legal guidelines. Supervisors also must consistently maintain a multicultural perspective. The Competencies Teach supervisees the purpose of clinical supervision and how to use it effectively. Ensure that comprehensive orientation is provided to new employees, including in areas such as the organization’s client population, mission, vision, policies, and procedures.
Build a supportive and individualized supervisory alliance that respects professional boundaries. Maintain a constructive supervisory learning environment that fosters awareness of one- self and others, motivation, self-efficacy, enthusiasm, and two-way feedback. Conceptualize and plan individual and group supervision activities, incorporating supervisees’ preferred learning styles, cultures, genders, ages, and other appropriate variables. Encourage supervisees to examine their views regarding culture, race, values, religion, gender, sexual orientation, and potential biases. Help supervisees develop skills of empathy and acceptance specific to working with culturally diverse clients. Provide timely and specific feedback to supervisees on their conceptualizations of client needs, attitudes toward clients, clinical skills, and overall performance of assigned responsibilities. Create a professional development plan with supervisees that includes mutually approved goals and objectives for improving job performance, how goals and objectives will be met (including the respective responsibilities of the supervisor and the supervisee), a timeline for expected accomplishments, and measurements of progress and goal attainment. Implement a variety of direct supervisory activities (e.g., role play, live supervision/observation, review of audiotaped and videotaped sessions, presentation/discussion of case studies) to teach and strengthen supervisees’ theoretical orientation, professional ethics, clinical skills, and personal wellness.
Help supervisees recognize, understand, and cope with unique problems of transference and countertransference when working with clients with substance use disorders. Acknowledge supervisees’ development and celebrate accomplishments through frequent rewards and recognition. Encourage and help supervisees develop a personal wellness plan to manage their stress and avoid compassion fatigue and burnout.
Section IV: Performance Domains PD2: PROFESSIONAL AND E THICAL STANDARDS Introduction Supervisors work in a complex environment subject to professional, statutory, and regulatory guidelines. This domain identifies competencies related to protecting the public, clients, and staff members. It also describes the development of supervisors’ professional identity and integrity in the context of professional supervisory practice. The Competencies Be familiar with relevant professional codes of ethics (see Appendix B), client’s rights documents, and laws and regulations that govern both counseling and clinical supervision practices. Ensure that supervisees are familiar with generally accepted professional codes of ethics, State and Federal statutes regarding duty to report (e.g., child abuse) and duty to warn (e.g., threat of physical violence against a reasonably identifiable victim or victims),
Federal confidentiality (e.g., 42 Code of Federal Regulations, Part 2) and privacy (e.g., Health Insurance Portability and Accountability Act) rules and regulations, and other legal constraints on the counseling relationship. Follow due process guidelines when responding to grievances and ensure that supervisees know their rights as employees and understand the organization’s employee grievance procedures. Ensure that supervisees are familiar with client’s rights and understand client grievance procedures. Ensure that supervisees inform clients about the limits of confidentiality (e.g., child abuse reporting, specific threats of violence). Ensure that supervisees inform clients about supervision practices (e.g., direct observation, session transcripts) and obtain documented informed consent from clients as appropriate (e.g., signed releases for audio or video recording of sessions). Learn about supervisees’ cultures, lifestyles, beliefs, and other key factors that may influence their job performance.
Use and teach supervisees an ethical decision making model, such as that described by Corey and colleagues (2002), as a guide for supervisory and clinical practice. Understand the risks of dual relationships and potential conflicts of interest in the supervisor–supervisee relationship and maintain appropriate relationships at all times. Help supervisees develop awareness of possible dual relationships in the client– counselor relationship. Monitor supervisees’ clinical practice to enhance their competence and ensure their ethical treatment of clients. Provide timely consultation and guidance to supervisees in situations that present moral, legal, and/or ethical dilemmas. Ensure that supervisees maintain complete, accurate, and necessary documentation at all times, including detailed descriptions of actions taken in critical situations.
Clinical Supervisors Intervene immediately and take action as necessary when a supervisee’s job performance appears to present problems. Report supervisees’ ethical violations to the appropriate professional organizations and State bodies as required. Maintain familiarity with consensus- and evidence-based best practices in the treatment of substance use disorders. Build supervisory competence by actively participating in professional organizations and in a variety of relevant professional and educational activities. Seek supervision and consultation to evaluate one’s personal needs for training and education, receive and discuss feedback on supervisory job performance, and implement a professional development plan. Practice only within one’s areas of clinical and supervisory competence. Develop and maintain a personal wellness plan for physical and mental health and en- courage supervisees to develop and maintain personal wellness plans.
Introduction Program development is the process of guiding the natural evolution of a service delivery organization to maximize the potential of its staff and resources to meet the needs of the population it serves. Quality assurance (QA) is the process of designing, implementing, monitoring, and improving a program’s activities to ensure maximum effectiveness and efficiency of services within the limitations of the agency and its operating environment. The extent to which clinical supervisors are responsible for program development and QA activities varies, depending on the size, structure, and mission of the organization. However, all clinical supervisors have some responsibility for these activities. The Competencies Structure and facilitate staff learning about specific consensus- and evidence-based treatment interventions, program service design, and recovery models relevant to the organization and the population it serves.
Understand the limitations of addiction treatment in general; its relationship to sustained, long-term recovery; and the specific limitations of the models or design in use by supervisees. Understand and be able to apply principles of technology transfer to assist in the adoption and implementation of new clinical practices. Identify, develop, and obtain appropriate learning and treatment resource materials that meet the needs of the agency, its clients, and supervisees. Plan and facilitate in-service training and other organizational activities that support application of empirically based clinical interventions that are responsive to needs of the agency, clients, and supervisees. Understand the balance between fidelity and adaptability when implementing new clinical practices.
Be familiar with the methods used to analyze the organization’s developmental needs and clinical outcomes, including regular needs assessments. Advocate within the agency for ongoing quality improvement, including strategies for enhancing client access, engagement, and retention in treatment. Understand the organization’s QA plan and comply with all monitoring, documenting, and reporting requirements. Develop program goals and objectives and counselor development plans that are consistent with the organization’s QA plan. Solicit, document, and use client feedback to improve service delivery. Provide diversity training and other experiences that empower one to become an advocate for the organization’s target population and an agent of organizational change. Build and maintain relationships with referral sources and other community programs to expand, enhance, and expedite service delivery. Develop skills to advocate for clients throughout the entire continuum of care. Page 36
Section IV: Performance Domains PD4: Introduction Counselor evaluation is central to the assurance of high-quality client care. It is a professional and ethical responsibility of clinical supervisors to regularly monitor the quality of supervisees’ performance, to facilitate improvement in supervisees’ clinical competence, and to assess supervisees’ readiness to practice with increasing autonomy. As such, this domain is closely related to Counselor Development (PD1). The competencies in each are distinct yet highly complementary and interactive.
The Competencies Communicate agency expectations about the job duties and competencies, performance indicators, and criteria used to evaluate job performance. Understand the concept of supervision as a two-way evaluative process with each party providing feedback to the other, including constructive sharing and resolution of disagreements. Actively encourage supervisees to provide feedback to the supervisor regarding the supervisor’s performance. Assess supervisees’ professional development, cultural competence, and proficiency in the addiction counseling competencies. Differentiate between counselor developmental issues and those requiring corrective action (e.g., ethical violations, incompetence). Assess supervisees’ preferred learning style, motivation, and suitability for the work setting. Use multiple sources of quantitative and qualitative data, direct and indirect observations, and formal and informal methods of assessment to ensure substantiated and accurate evaluation.
Institute an ongoing formalized, proactive process that identifies supervisees’ training needs, actively involves supervisees in conjointly reviewing goals and objectives, and reinforces performance improvement with positive feedback. Communicate feedback clearly, including feedback regarding performance deficits, weak competencies, or harmful activities. Provide timely written notification of all performance problems and ensure that supervisees understand the feedback. Evaluate the competency, including the fidelity, with which supervisees implement research-based treatment protocols. Address and manage relational issues common to evaluation, including anxiety, disagreements, and full discussion of performance problems. Guide and evaluate supervisees’ ability to use a range of evaluative tools (e.g., process recordings, memory work, audiotapes and videotapes, direct observation) and encourage them to use the most effective techniques available in the setting. Skillfully use agency evaluation tools and procedures. Self-assess for evaluator bias (e.g., leniency, overemphasis on one area of performance, favoritism, stereotyping) and conflict with other supervisory roles.
Competencies for Clinical Supervisors Adhere to professional standards of ongoing supervisory documentation, including written individual development plans, supervision session notes, written documentation of corrective actions, and written recognition of good performance.
Section IV: Performance Domains PD5: A DMINISTRATION Introduction Clinical supervisors’ administrative responsibilities are the executive functions of the position, those duties that help the organization run smoothly and efficiently. Administrative responsibilities include following the organization’s policies and procedures (including those related to human resource management), ensuring the maintenance of case records, monitoring case documentation, assisting in financial resource development (e.g., grant proposal writing), and developing relationships with referral sources in the community.
Administrative responsibilities also include program development and quality assurance, which are addressed separately in PD3. Although the competencies described below are administrative in nature, many overlap significantly with clinical functions and serve to ensure the quality of services being delivered within the agency. As noted previously, the range of administrative functions clinical supervisors are responsible for will vary from agency to agency.
The Competencies Participate in developing, maintaining, applying, and revising the organization’s policies, procedures, and forms. Monitor, evaluate, and provide feedback regarding supervisees’ compliance with administrative policies and procedures. Understand and ensure that supervisees understand the organization’s chain-of- command and communication protocols. Monitor, evaluate, and provide guidance regarding the supervisees’ case recordings, including session notes, treatment plans, correspondence, and behavioral contracts. Establish and maintain an efficient and comprehensive recordkeeping system that provides clear, chronological documentation of supervisory activities. Recommend personnel actions to maintain high standards of clinical care (e.g., hiring, performance recognition, disciplinary action, suspension, termination of clinical staff).
Maintain and regularly update clinical staff job descriptions according to agency policies and procedures. Understand and help supervisees understand and manage the relationships among clinical services, fee assessment and collection, and overall fiscal responsibility. Understand and comply with procedures necessary for processing third-party payment claims, if applicable. Participate actively in the organization’s resource development activities (e.g., grant application or proposal writing). Develop and rely on schedules, deadlines, and reminders to meet service needs and ensure completion of assigned projects and tasks. Page 40
Competencies for Substance Abuse Treatment Clinical Supervisors Ensure that supervisees have proper training for using information technology systems and have access to technical assistance and other resources. Obtain regularly scheduled diversity, crisis management, and safety training for oneself and supervisees. Develop and comply with intraorganizational and interorganizational agreements that expand, enhance, and expedite service delivery. Maintain security of all supervisory notes, assessments, and other pertinent documents. Structure and facilitate effective staff meetings.
Section V Ethical Guidelines for Counseling Supervisors Association for Counselor Education and Supervision* Adopted by ACES Executive Counsel and Delegate Assembly March 1993 Preamble: The Association for Counselor Education and Supervision (ACES) is composed of people engaged in the professional preparation of counselors and people responsible for the ongoing supervision of counselors. ACES is a founding division of the American Counseling Association (ACA) and as such adheres to ACA’s current ethical standards and to general codes of competence adopted throughout the mental health community.
ACES believes that counselor educators and counseling supervisors in universities and in applied counseling settings, including the range of education and mental health delivery systems, carry responsibilities unique to their job roles. Such responsibilities may include administrative supervision, clinical supervision, or both. Administrative supervision refers to those supervisory activities which increase the efficiency of the delivery of counseling services; whereas, clinical supervision includes the supportive and educative activities of the supervisor designed to improve the application of counseling theory and technique directly to clients. Counselor educators and counseling supervisors encounter situations which challenge the help given by general ethical standards of the profession at large. These situations require more specific guidelines that provide appropriate guidance in everyday practice. The Ethical Guidelines for Counseling Supervisors are intended to assist professionals by helping them: 1. Observe ethical and legal protection of clients’ and supervisees’ rights; *Reprinted with permission of the Association for Counselor Education and Supervision.
Section VI: Appendices 2. Meet the training and professional development needs of supervisees in ways consistent with clients’ welfare and programmatic requirements; and 3. Establish policies, procedures, and standards for implementing programs. The specification of ethical guidelines enables ACES members to focus on and to clarify the ethical nature of responsibilities held in common. Such guidelines should be reviewed formally every five years, or more often if needed, to meet the needs of ACES members for guidance. The Ethical Guidelines for Counselor Educators and Counseling Supervisors are meant to help ACES members in conducting supervision. ACES is not currently in a position to hear com- plaints about alleged non-compliance with these guidelines.
Any complaints about the ethical behavior of any ACA member should be measured against the ACA Ethical Standards and a com- plaint lodged with ACA in accordance with its procedures for doing so. One overriding assumption underlying this document is that supervision should be ongoing throughout a counselor’s career and not stop when a particular level of education, certification, or membership in a professional organization is attained. DEFINITIONS OF TERMS: Applied Counseling Settings – Public or private organizations of counselors such as community mental health centers, hospitals, schools, and group or individual private practice settings. Supervisees – Counselors-in-training in university programs at any level who [are] working with clients in applied settings as part of their university training program, and counselors who have completed their formal education and are employed in an applied counseling setting. Supervisors – Counselors who have been designated within their university or agency to directly oversee the professional clinical work of counselors.
Supervisors also may be persons who offer supervision to counselors seeking state licensure and so provide supervision outside of the administrative aegis of an applied counseling setting. 1. Client Welfare and Rights 1.01 The primary obligation of supervisors is to train counselors so that they respect the integrity and promote the welfare of their clients. Supervisors should have supervisees inform clients that they are being supervised and that observation and/or recordings of the session may be reviewed by the supervisor. 1.02 Supervisors who are licensed counselors and are conducting supervision to aid a supervisee to become licensed should instruct the supervisee not to communicate or in any way convey to the supervisee’s clients or to other parties that the supervisee is himself/herself licensed. 1.03 Supervisors should make supervisees aware of clients’ rights, including protecting clients’ right to privacy and confidentiality in the counseling relationship and the in- formation resulting from it. Clients also should be informed that their right to privacy and confidentiality will not be violated by the supervisory relationship. 1.04 Records of the counseling relationship, including interview notes, test data, correspondence, the electronic storage of these documents, and audio and videotape recordings, are considered to be confidential professional information. Supervisors should see that these materials are used in counseling, research, and training and supervision
Competencies Clinical Supervisors of counselors with the full knowledge of the clients and that permission to use these materials is granted by the applied counseling setting offering service to the client. This professional information is to be used for full protection of the client. Written consent from the client (or legal guardian, if a minor) should be secured prior to the use of such information for instructional, supervisory, and/or research purposes. Policies of the applied counseling setting regarding client records also should be followed. 1.05 Supervisors shall adhere to current professional and legal guidelines when conducting research with human participants such as Section D-1 of the ACA Ethical Standards. 1.06
Counseling supervisors are responsible for making every effort to monitor both the professional actions and failures to take action of their supervisees. 2. Supervisory Role Inherent and integral to the role of supervisor are responsibilities for: a. Monitoring client welfare; b. Encouraging compliance with relevant legal, ethical, and professional standards for clinical practice; c. Monitoring clinical performance and professional development of supervisees; and d. Evaluating and certifying current performance and potential of supervisees for academic, screening, selection, placement, employment, and credentialing purposes. 2.01 Supervisors should have had training in supervision prior to initiating their role as supervisors. 2.02 Supervisors should pursue professional and personal continuing education activities such as advanced courses, seminars, and professional conferences on a regular and ongoing basis.
These activities should include both counseling and supervision topics and skills. 2.03 Supervisors should make their supervisees aware of professional and ethical standards and legal responsibilities of the counseling profession. 2.04 Supervisors of post-degree counselors who are seeking state licensure should encourage these counselors to adhere to the standards for practice established by the state licensure board of the state in which they practice. 2.05 Procedures for contacting the supervisor, or an alternative supervisor, to assist in handling crisis situations should be established and communicated to supervisees. 2.06 Actual work samples via audio and/or video tape or live observation in addition to case notes should be reviewed by the supervisor as a regular part of the ongoing supervisory process. 2.07 Supervisors of counselors should meet regularly in face-to-face sessions with their supervisees. 2.08 Supervisors should provide supervisees with ongoing feedback on their performance. This feedback should take a variety of forms, both formal and informal, and should include verbal and written evaluations. It should be formative during the supervisory experience and summative at the conclusion of the experience.
Section VI: Appendices 2.09 Supervisors who have multiple roles (e.g., teacher, clinical supervisor, administrative supervisor) with supervisees should minimize potential conflicts. Where possible, the roles should be divided among several supervisors. Where this is not possible, careful explanation should be conveyed to the supervisee as to the expectations and responsibilities associated with each supervisory role. 2.10 Supervisors should not participate in any form of sexual contact with supervisees. Supervisors should not engage in any form of social contact or interaction which would compromise the supervisor-supervisee relationship. Dual relationships with supervisees that might impair the supervisor’s objectivity and professional judgment should be avoided and/or the supervisory relationship terminated. 2.11 Supervisors should not establish a psychotherapeutic relationship as a substitute for supervision. Personal issues should be addressed in supervision only in terms of the impact of these issues on clients and on professional functioning. 2.12 Supervisors, through ongoing supervisee assessment and evaluation, should be aware of any personal or professional limitations of supervisees which are likely to impede future professional performance. Supervisors have the responsibility of recommending remedial assistance to the supervisee and of screening from the training program, applied counseling setting, or state licensure those supervisees who are unable to provide competent professional services. These recommendations should be clearly and professionally explained in writing to the supervisees who are so evaluated. 2.13 Supervisors should not endorse a supervisee for certification, licensure, completion of an academic training program, or continued employment if the supervisor believes the supervisee is impaired in any way that would interfere with the performance of counseling duties. The presence of any such impairment should begin a process of feed- back and remediation wherever possible so that the supervisee understands the nature of the impairment and has the opportunity to remedy the problem and continue with his/her professional development. 2.14 Supervisors should incorporate the principles of informed consent and participation; clarity of requirements, expectations, roles and rules; and due process and appeal into the establishment of policies and procedures of their institutions, program, courses, and individual supervisory relationships. Mechanisms for due process appeal of individual supervisory actions should be established and made available to all supervisees.
3. Program Administration Role 3.01 Supervisors should ensure that the programs conducted and experiences provided are in keeping with current guidelines and standards of ACA and its divisions. 3.02 Supervisors should teach courses and/or supervise clinical work only in areas where they are fully competent and experienced. 3.03 To achieve the highest quality of training and supervision, supervisors should be active participants in peer review and peer supervision procedures. 3.04 Supervisors should provide experiences that integrate theoretical knowledge and practical application. Supervisors also should provide opportunities in which supervisees are able to apply the knowledge they have learned and understand the rationale for the skills they have acquired. The knowledge and skills conveyed should reflect cur- rent practice, research findings, and available resources.
Competencies for Clinical Supervisors 3.05 Professional competencies, specific courses, and/or required experiences expected of supervisees should be communicated to them in writing prior to admission to the training program or placement/employment by the applied counseling setting, and, in case of continued employment, in a timely manner. 3.06 Supervisors should accept only those persons as supervisees who meet identified entry level requirements for admission to a program of counselor training or for placement in an applied counseling setting. In the case of private supervision in search of state licensure, supervisees should have completed all necessary prerequisites as deter- mined by the state licensure board. 3.07 Supervisors should inform supervisees of the goals, policies, theoretical orientations toward counseling, training, and supervision model or approach on which the supervision is based. 3.08 Supervisees should be encouraged and assisted to define their own theoretical orientation toward counseling, to establish supervision goals for themselves, and to monitor and evaluate their progress toward meeting these goals. 3.09 Supervisors should assess supervisees’ skills and experience in order to establish standards for competent professional behavior. Supervisors should restrict supervisees’ activities to those that are commensurate with their current level of skills and experiences. 3.10 Supervisors should obtain practicum and fieldwork sites that meet minimum standards for preparing student to become effective counselors. No practicum or fieldwork set- ting should be approved unless it truly replicates a counseling work setting.
3.11 Practicum and fieldwork classes would be limited in size according to established professional standards to ensure that each student has ample opportunity for individual supervision and feedback. Supervisors in applied counseling settings should have a limited number of supervisees. 3.12 Supervisors in university settings should establish and communicate specific policies and procedures regarding field placement of students. The respective roles of the student counselor, the university supervisor, and the field supervisor should be clearly differentiated in areas such as evaluation, requirements, and confidentiality. 3.13 Supervisors in training programs should communicate regularly with supervisors in agencies used as practicum and/or fieldwork sites regarding current professional practices, expectations of students, and preferred models and modalities of supervision. 3.14 Supervisors at the university should establish clear lines of communication among themselves, the field supervisors, and the students/supervisees. 3.15 Supervisors should establish and communicate to supervisees and to field supervisors specific procedures regarding consultation, performance review, and evaluation of supervisees. 3.16 Evaluations of supervisee performance in universities and in applied counseling set- tings should be available to supervisees in ways consistent with the Family Rights and Privacy Act and the Buckley Amendment.
Section VI: Appendices 3.17 Forms of training that focus primarily on self understanding and problem resolution (e.g., personal growth groups or individual counseling) should be voluntary. Those who conduct these forms of training should not serve simultaneously as supervisors of the supervisees involved in the training. 3.18 A supervisor may recommend participation in activities such as personal growth groups or personal counseling when it has been determined that a supervisee has deficits in the areas of self understanding and problem resolution which impede his/her professional functioning. The supervisors should not be the direct provider of these activities for the supervisee. 3.19 When a training program conducts a personal growth or counseling experience involving relatively intimate self disclosure, care should be taken to eliminate or minimize potential role conflicts for faculty and/or agency supervisors who may conduct these experiences and who also serve as teachers, group leaders, and clinical directors. 3.20 Supervisors should use the following prioritized sequence in resolving conflicts among the needs of the client, the needs of the supervisee, and the needs of the program or agency. Insofar as the client must be protected, it should be understood that client welfare is usually subsumed in federal and state laws such that these statutes should be the first point of reference. Where laws and ethical standards are not present or are unclear, the good judgment of the supervisor should be guided by the following list: a. Relevant legal and ethical standards (e.g., duty to warn, state child abuse laws); b. Client welfare; c. Supervisee welfare; d. Supervisor welfare; and e. Program and/or agency service and administrative needs.
Assessment: Assessment of counselor performance is frequently discussed in professional counseling literature, yet it remains a topic that includes numerous significant issues and few points of agreement. This digest describes some of those major issues and offers recommendations for effective assessment of counselor performance.
The need for assessing counselor performance, although it has not received much specific attention, is evident for several reasons. Counseling usually helps people but also can harm them, for example, through inappropriate counselor-client pairings or through counselor incompetence. Counselor performance assessment is necessary to facilitate good counselor-client matches and/or to remedy incompetence. Assessment of counselor performance thus is inextricably linked to and needed for protection of the public's welfare.
Counselor certification and licensure also are intended to protect the public's welfare. Possession of an academic degree in a counseling specialty is one common credentialing criterion, but academic credentials do not necessarily indicate counseling competence (Hogan, 1980). Therefore, effective assessment of counselor performance is needed in counselor credentialing processes as well.
This need for assessment of counselor performance also relates to the counseling profession itself. A profession evolves positively only when its members continue to improve their functioning. Such development in the counseling profession depends upon having effective methods of evaluating common and innovative ways of functioning. Counselor performance assessment thus has the potential to improve the counseling profession.
Three general areas related to effective counselor performance have been investigated. The first is counselor characteristics, the study of which is based on the belief that "good" counselors have unique and identifiable personal characteristics, and that if identified, those characteristics can be used as counselor trainee selection criteria. This line of reasoning or investigation generally has not proved fruitful. However, it has continued because of the recognition that clients react differentially to counselor characteristics (sometimes irrespective of the counselor's skills) and that those reactions are important components of counseling outcomes. Today, the study of counselor characteristics is refocused and is intended to facilitate "matching" of counselors and clients. Many counselor characteristics are being investigated; however, Hiebert (1984) has suggested this effort would be better invested in defending the worth of counseling services.
Counselor communication skills have been a second area of extensive study. Verbal communication skills have been examined far more than nonverbal skills, but both are important components of effective counselor performance. Because effective communication is at the heart of counseling, assessment of counselors' communication skills is a primary means of assessing counselor performance.
Although key indicators of counselor performance, counseling outcomes have been investigated even less than either of the other areas. This is due to major difficulties in determining significant outcomes as well as in obtaining data from clients after counseling has ended. Nonetheless, the assessment of counseling outcomes is essential for fully effective assessment of counselor performance.
The assessment of counselor performance includes both subjective and objective processes, with the former far more common. Subjective evaluations of counselor performance include the use of rating forms, judgments of counselors' actual counseling activities, and global judgments by supervisors.
Instruments for assessing counselor performance range from highly subjective instruments that often are quickly created and at best have some degree of face validity, to those that have measurable, empirically established psychometric properties. Two of the latter have found particular favor in the counseling profession--the Counselor Evaluation Inventory and the Counselor Rating Form. Each has been shown to be effective for evaluating counselor performance (Biersner, Bunde, Doucette, & Culwell, 1981; Dorn & Jereb, 1985). Moreover, they are suitable for use by different types of persons who might evaluate counselor performance (e.g., clients, counselors, or supervisors). Rating forms have the decided advantage of being structured, efficient means of gathering assessment data.
Assessment of performance during counseling is usually accomplished through review of audio or video tape excerpts. Review of taped excerpts has the advantage of allowing assessment (usually through ratings of skills shown) of actual counselor performance, but it has the disadvantage of inefficiency. There also is much debate about the number and length of excerpts needed for valid evaluations (Lecomte & Bernstein, 1981).
Counselor performance assessments based on supervisors' judgments are becoming more common because of their use in counselor credentialing processes. Unfortunately, such judgments are often clouded by perceptions of the person (as opposed to performance) and hesitancy to give negative evaluations. Subjective, global supervisor evaluations are not particularly effective indicators of counselors' performance levels.
Objective assessments are based on indicators of client behavior change, and data from these provide the strongest indications of counselor performance effectiveness. Unfortunately, counseling impacts infrequently are specified in terms of behavior change, with the result that few good examples of this type of counselor performance assessment exist. In addition, there is some evidence to indicate that subjective and objective measures of counselor performance yield unrelated results (Alexander & Wilkins, 1982).
Counselors and their peers, supervisors, administrators, and clients generally are those who assess counselor performance. Counselor self-assessments are common, but probably most useful to counselors themselves (Eldridge, 1981). Because of high subjectivity, self-assessments generally do not have broad utilitarian value. Peer evaluations of counselors also are used frequently, but the competence of peers to make valid assessments is a significant issue in their use. Supervisors are generally deemed competent to assess counselor performance, but often use criteria different from those of other assessors (Butcher & Scofield, 1984). For example, supervisors often are interested in levels of skills demonstrated, whereas administrators are usually interested in accountable outcomes.
Clients are the group most frequently asked to assess counselor performance, but their evaluations also have limitations. They may not be aware of appropriate evaluation criteria, focus only upon general satisfaction, or resist making negative evaluations of counselors. Nonetheless, as counseling service consumers, their evaluations are important.
Assessments of counselor performance may be made during counselors' preservice training, immediately after counseling, or as long-term follow-up. The vast majority of such assessments are made during training, sometimes to screen out incompetent trainees. More frequently, however, performance assessments made during training are formative in nature, intended to help trainees achieve required levels of competence before graduation.
Assessments of counselor practitioner performance are usually made for accountability purposes and therefore are summative in nature. Although the need for counselor accountability often has been stressed, that need apparently has not prompted much counseling practitioner performance assessment.
Long-term follow-up assessments of counselor performance are rare, probably because of difficulties in obtaining data from clients long after counseling has ended. However, such data are needed to determine if counseling has lasting effects.
The professional literature suggests that more effective assessments of counselor performance can be achieved through the following:
-- Greater emphasis on client behavior change indicators to
provide stronger data for counselor accountability.
-- Use of multiple assessments, including both subjective and
objective procedures, to provide more comprehensive information on
the impacts of counseling.
-- Further development of instruments used to assess counselor
performance to facilitate gathering of data that is theortically and
-- More frequent assessment of counseling practitioner
performance, including long-term follow-up studies, to provide more
data on the "real world" functioning of counselors.
These improvements are needed because effective assessment of counselor performance is essential to further enhancement of the counseling profession and to protection of the public's welfare.
The practice of professional counseling, like that of psychology and social work has its roots in the early humanistic, behavioral, and cognitive theoretical traditions. Lessons from the outcome and process research were only distant voices in the background. This early bifurcation between practice and research evolved into a fairly wide "research-practice gap" that has plagued the practice of professional counseling for the last two decades.
Two major issues make the artificial dichotomy between research and practice not only irrelevant but also potentially harmful to the current and future status of counseling practice and preparation. First, most practitioners know that today's landscape of counseling practice is one dominated by accountability. In fact, many have claimed that accountability is now a primary principle of professional practice--a principle more important than theory congruence or philosophical allegiance (Sexton, Schofield, & Whiston, 1997). In this "era" of accountability, concerns for service costs, intervention effectiveness, and research supported "best practice" are the primary factor in much clinical and administrative decision making. Thus, research, because of its focus on outcome, is now a major factor in the real world "practice" of counseling.
Furthermore, the counseling process and outcome research has grown into an undeniably reliable, valid, and necessary source of clinical practice knowledge. There is no question that much of the early research was irrelevant to practice. It was conducted on isolated issues in settings with little connection to the complex world of the practitioner (e. g. with Psychology 101 students). This research produced contradictory evidence, the presentation of which was most often followed by the caveat, "...our results show that more research needs to be done in this area." However, as one would expect, the methods of clinical research have evolved to the point such that many of the early problems of clinical relevance are no longer of concern. Today there is a large and ever increasing body of applicable and relevant research that is now an invaluable source of guidance for both the general practice of counseling and the application of counseling to specific problems and populations (Sexton, 1997). In fact, the research evidence has become so reliable that the term "best practices" is now defined as approaches to counseling practice that have empirical evidence to support their effectiveness.
Regardless of one's position in regard to the "art vs. science" or "research vs. practice" debate, it seems clear that evidence-based counseling practice is the future of both the preparation of counselors and the practice of professional counseling. The integration of research into practice through an evidence-based approach to counseling actually brings the best elements of practice, clinical experience, and reliable treatment protocols together to serve the task of helping clients with the complex problems they bring to counseling. What follows are a number of the broad implications for both the preparation of counselors and the practice of counseling.
The specific implications of the accumulated body of research on counseling practices are well beyond the scope of this article (see references for further sources). Research has clearly established the efficacy of individual, group, and family counseling for a variety of presenting client concerns (Sexton, Whiston, Bleuer, & Walz, 1997). More important for practice, research now points to a number of very stable trends that support the efficacy of some practices of counseling over others, the differential value of some aspects of counseling over others, and effectiveness of matching certain client problems with specific counseling models (Sexton et. al, 1997). These trends inform counseling practice and preparation and form the basis of an evidence-based model of counseling.
These broad trends can be categorized in two domains each with significant implications for the general practice of counseling: findings about clinical models and findings about the counselor. There has been considerable attention to determining the most valuable clinical models. While counseling is, in most cases, effective, there is no "best" theoretical approach. The outcome research evidence has repeatedly found that theoretical orientation is not a major factor in the outcome of counseling. Instead, the research points to a set of "common factors" that seem to be part of effective counseling regardless of counselor, client, or theoretical orientation. According to Lambert (1991) approximately 30% of outcome is attributable to common factors evident in all therapies regardless of theory. Of the remaining variance, 40% is attributable to factors outside of counseling, another 15% to client expectation, and the final 15% to specific psychological techniques. Most of the current theoretical descriptions of these common factors point to broad areas of: (1) the supportive value of a collaborative counseling relationship (Sexton & Whiston, 1994); (2) the value of learning (through affective experiencing, corrective emotional experiences, and skills acquisition); and (3) action (through behavior change, successful experiences, behavioral regulation, and mastery).
While specific theoretical models do not seem important to positive outcomes, evidence-based counseling intervention protocols are differentially effective with the client problems they were developed to help. These protocols are systematic intervention models, usually manual-based, with an extensive collection of efficacy and effectiveness research in multiple settings, with diverse client groups, across various counselors, that produce clinically significant results both in controlled labs and community settings that last for long periods of time (Sexton, et al., 1997). Called Empirically Supported Treatments (EST), such protocols are available for many individual problems (anxiety disorders, depression, etc.) and family problems (see discussion of Functional Family Therapy in Alexander, Sexton, & Robbins, in press). While the professional and conceptual issues surrounding empirically supported treatments are considerable and the criteria likely to evolve, they are a valuable resource for practicing counselors when faced with certain client problems. EST's also point the way for the future of counseling providing a glimpse into evidence-based counseling practice. As a result, these protocols will need to become a central component of the clinical portion of future counselor education curricula.
A second major domain of counseling research that informs evidence-based counseling practice, focuses on the counselor. The counselor is probably the most studied "object" in our research history. Much of that effort has been guided by a desire to understand how to train successful and effective counselors. From all these efforts we have, however, yet to discover the prototypic effective counselor. In fact, much of what we have discovered is that many of our historic beliefs about the importance of counselor characteristics do not seem to have research support. For example, the current evidence suggests that, all other things being equal, demographic factors (race, gender, age, cultural background), professional identity (counseling vs. psychology vs. social work), and even professional experience (defined as years of practice) are unrelated to counseling outcome. Matching of clients and counselors on these dimensions (e. g. like race counselor and client working together) does not result in increased efficacy. Furthermore, the old adage, "counselor know thy self" does not seem to hold true. There is currently no systematic research that would suggest that counselors improve their work by receiving personal therapy, becoming more self aware, or learning about themselves (Sexton et al., 1997).
What do seem to be important counselor contributions to effective counseling are a level of skillfulness (defined as competence rather than experience), cognitive complexity (ability to think diversely and complexly about cases), and ability to relate and relationally match with the clients with whom they are working (see Whiston & Coker, in press). In addition, it is essential that counselors have the knowledge and ability to assess the presenting "problems" of the client so they can identify the appropriate evidence-based protocols and competently apply those protocols in order to increase the likelihood of successful intervention. The implications of these research trends are dramatic in regard to counselor education. For example, they suggest redirecting efforts from personal awareness to building cognitive complexity and increasing the knowledge of and ability to apply evidence-based counseling protocols.
Evidence-based practice has the opportunity to move the profession of counseling out of its theoretical boxes and historical beliefs into an era of integrated practice in which counselors use the best of available science combined with clinical experience to successfully help a wide variety of clients. Evidence-based practices can provide a source of clinical knowledge that can increase a counselor's effectiveness with clients, become a basis of professional education and counselor development, and serve as a unifying force for the profession that will set the agenda for the next evolution of counseling.
Use of Test:Counselors use tests generally for assessment, placement, and guidance, as well as to assist clients to increase their self-knowledge, practice decision making, and acquire new behaviors. They may be used in a variety of therapies--e.g., individual, marital, group, and family--and for either informational or non-informational purposes (Goldman, 1971).
Informational uses include the gathering of data on clients, assessing the level of some trait, such as stress and anxiety, or measuring clients' personality types. The purpose of non-informational tests is to stimulate further or more indepth interaction with the client.
Although the published literature on testing has increased, proper test utilization remains a problematic area. The issue is not so much whether a counselor uses tests in counseling practice, but when and to what end will tests be used (Corey, Corey, & Callanan, 1984).
Steps involved in the process of using tests in counseling include the following: -- Selecting the test. -- Administering the test. -- Scoring the test. -- Interpreting the results. -- Communicating the results. Selecting. Having defined the purpose for testing, the counselor looks to a variety of sources for information on available tests. Resources include review books, journals, test manuals, and textbooks on testing and measurement (Anastasi, 1988; Cronbach, 1979). The most complete source of information on a particular test is usually the test manual.
Administering. Test administration is usually standardized by the developers of the test. Manual instructions need to be followed in order to make a valid comparison of an individual's score with the test's norm group. Non-standardized tests used in counseling are best given under controlled circumstances. This allows the counselor's experience with the test to become an internal norm. Issues of individual versus group administration need consideration as well. The clients and the purpose for which they are being tested will contribute to decisions about group testing.
Scoring. Scoring of tests follows the instructions provided in the test manual. The counselor is sometimes given the option of having the test machine scored rather than hand scored. Both the positive and negative aspects of this choice need to be considered. It is usually believed that test scoring is best handled by a machine because it is free from bias.
Interpreting. The interpretation of test results is usually the area which allows for the greatest flexibility within the testing process. Depending upon the counselor's theoretical point of view and the extent of the test manual guidelines, interpretation may be brief and superficial, or detailed and explicitly theory based (Tinsley & Bradley, 1986). Because this area allows for the greatest flexibility, it is also the area with the greatest danger of misuse. Whereas scoring is best done by a bias-free machine, interpretation by machine is often too rigid. What is needed is the experience of a skilled test user to individualize the interpretation of results.
Communicating. Feedback of test results to the client completes the formal process of testing. Here, the therapeutic skills of counselors come fully into play (Phelps, 1974). The counselor uses verbal and nonverbal interaction skills to convey messages to clients and to assess their understanding of it.
Confidentiality. The ethical and legal restrictions on what may be disclosed from counseling apply to the use of tests as much as to other private information shared between client and counselor. The trust issue, which is inherent in confidentiality, is relevant to every aspect of testing. No information can be shared outside the relationship without the full consent of the client. Information is provided to someone outside the relationship only after the specifics to be used from the testing are fully disclosed to the client. These specifics include the when, what, and to whom of the disclosure. The purpose of disclosure is also shared with the client and what the information will be used for is clearly spelled out.
Issues of confidentiality are best discussed with the client before conducting any test administration. There should be no surprises when the counselor asks, at a later time, for permission to share test results. Clients who are fully informed, before testing takes place, about the issue of confidentiality in relation to testing are more active participants in the counseling process.
Counselor Preparation. Tests are only as good as their construction, proper usage and the preparation of the counselor intending to use them. The skills and competencies counselors need for using tests in practice are to:
-- Understand clearly the intended purpose of a test.
-- Be aware of the client's needs regarding the test to be given.
-- Have knowledge about the test, its validity, reliability, and the norm group for which it was developed.
-- Have personally taken the test before administering it.
-- Have been supervised in administering, scoring, interpreting, and communicating results of the tests to be given.
Supervision in the practice of providing testing services ideally encompasses all of the above areas of concern. This supervision needs to be conducted by a knowledgeable practitioner with experience in using tests in clinical practice.
Client Involvement in the Testing Process. Throughout the process of using tests in counseling, questions about the client's involvement need to be considered. Will the client have a full and equal partnership with the counselor in deciding on the purpose for which the testing will be done? Will the client have a say in selecting the specific test to be administered? Will the client's opinion have a bearing on the interpretation of the test results?
Counseling has developed in recent years into a humanistic partnership in problem solving and growth. Consistent with this development is the client's participation in decisions regarding all aspects of the counseling relationship. Testing needs to be included here. The counselor uses developed counseling skills to determine client readiness for participation in decision making. Counseling skills will also help determine the client's ability to receive and comprehend results from the testing. In this regard, clients need to realize that tests are no more than instruments for furnishing information about themselves, as well as a guide for the counseling process and future decision making.
The issues of client involvement in the testing process are not clear-cut. Individual assessment of client readiness needs to precede test usage. The personal counseling skills of the practitioner are essential to the entire process.
Computerized Testing. Many of the major tests are now available in a computerized format. This format allows the administration and scoring of the test to occur almost simultaneously. Despite the access to computers in testing, clients continue to need a counselor ready to assist in answering questions that may arise. Counselors need to keep in mind that most tests were not normed using a computer format and that this may affect comparisons of individual scores to the available norms.
Ethics. Standards for the ethical use of tests and assessment instruments are given by both the American Psychological Association (APA) and the American Association for Counseling and Development (AACD). These standards spell out the considerations to take into account when utilizing tests in practice. It needs to be remembered that the primary purpose of using tests in counseling is the information they will provide to the client. Clients will then be better prepared for making decisions about meaningful changes in their lives.
Confidentiality, counselor preparation, computer testing, and client involvement are all issues within the ethical realm. Ultimately, test use by counselors must be seen as an adjunct to the entire counseling process. Test results provide descriptive and objective data which help the counselor to assist clients better in making the choices that will affect their lives. In order to make the best use of available tests in a counseling relationship, the process of testing and the issues which surround the process must be examined.
Peer supervision/consultation (Benshoff, 1989; Remley, Benshoff, & Mowbray, 1987) has been proposed as a potentially effective approach to increasing the frequency and/or quality of supervision available to a counselor. Wagner and Smith (1979) defined peer supervision as a process through which counselors assist each other to become more effective and skillful helpers by using their relationships and professional skills with each other. Counselors can develop their own peer consultation relationships to fill a "supervision void" or to augment traditional supervision by providing a means of getting additional feedback from their peers.
Peer consultation/supervision experiences can offer a number of benefits to counselors (Benshoff, 1989; Remley et al., 1987; Houts, 1980; Seligman, 1978; Spice & Spice, 1976; Wagner & Smith, 1979), including:
*Mutual, reciprocal benefits received through sharing in the peer supervision experience
*Ability to choose one's peer consultant and to determine one's own goals for the supervision process
*Decreased dependency on "expert" supervisors
*Increased skills and responsibility for assessing their own skills and those of their peers as well as for structuring their own professional growth
*Increased self-confidence, self-direction, and independence
*Development of consultation and supervision skills
*Lack of evaluation
*Use of peers as models.
Although several peer supervision models have been proposed, not all of them are "peer" in the pure sense, since some incorporate expert leaders or supervisors in the process (e.g., Wagner & Smith, 1979). One significant approach to peer supervision is a triadic model proposed by Spice and Spice (1976). In this model, counselors work together in triads, rotating the roles of commentator, supervisee, and facilitator through successive peer supervision sessions.
The Structured Peer Consultation Model (SPCM; cf., Benshoff, 1992; 1989) is based on a model for peer supervision proposed by Remley et al. (1987).
This model was developed to provide counselors and counselor trainees with additional feedback and assistance in developing their counseling skills and implementing them effectively with clients. SPCMs have been developed and implemented with a variety of counseling professionals, including counselor trainees, practicing school counselors, and counseling supervisors (Benshoff, 1991).
In the SPCMs, peers work together in dyads to provide regular consultation for one another (usually on a weekly or biweekly basis). The SPCMs include many traditional supervision activities such as goal-setting, tape review, and case consultation. In these models, however, the emphasis is on helping each other to reach self-determined goals, rather on evaluating each other's counseling performance. Other activities that are emphasized include discussion of counseling theoretical orientations, examination of individual approaches to working with clients, and exploration of relevant counseling issues. The SPCMs provide a clear and detailed structure which "walk counselors through" the peer consultation process. This structure is designed to keep peers focused on specific consultation tasks, yet also allow for modifications to fit individual needs and styles.
A growing body of empirical evidence exists to support the potential contributions of peer consultation. As counselors gain skills and experience, they express a preference for collegial supervision relationships (Hansen, Robins, & Grimes, 1982). Seligman (1978) found that peer supervision helped to increase counselor trainees' levels of empathy, respect, genuineness, and concreteness. Wagner and Smith (1979) reported that counselor trainee participation in peer supervision resulted in greater self-confidence, increased self-direction, improved goal-setting and direction in counseling sessions, greater use of modeling as a teaching and learning technique, and increased mutual, cooperative participation in supervision sessions. Houts (1980) described participants in peer consultation teams as reporting greater feelings of professional competency and increased independence and autonomy.
Three studies have been conducted using the SPCMs. In one (Benshoff, 1992), participants overwhelmingly (86%) rated peer supervision as being very helpful to them in developing their counseling skills and techniques and deepening their understanding of counseling concepts. Two aspects of peer supervision were cited as being especially valuable: (1) feedback from peers about counseling approach or techniques, and (2) peer support and encouragement. Another study using an SPCM with counselor trainees (Benshoff, 1989) suggested that, while the model may be useful for counselor trainees regardless of level of counseling experience, participation in peer consultation may have a greater impact on factors such as self-confidence and comfort level (which were not assessed) than on actual counseling effectiveness. A third study, which examined the types of verbalizations used by peer consultants (beginning counselors), confirmed that peer consultants were, in fact, able to use basic helping skills to provide consultation to their colleagues. The most frequently used verbalizations (directives, closed questions, interpretation, minimal encouragers) seem consistent with the developmental level and skills of beginning counselors.
Peer consultation models offer counselors a viable adjunct or alternative experience to traditional approaches to counseling supervision. Research to date provides accumulating support for the value of peer consultation/supervision experiences for professional counselors. Future research needs and directions in this area include:
*identifying and implementing appropriate outcome measures
*utilizing multiple measures (both qualitative and quantitative) to assess the impact and contributions of peer consultation models
*comparing peer models to other supervision and consultation approaches
*developing appropriate research instruments and procedures.
If you are practicing psychotherapy in a private practice, either as an individual or with a group, it is important, if not vital to your practice to bring your patient notes, billing, and forms such as those which provide for informed consent for treatment, authorization for release of notes, rules for disclosures of patient records, and rules for patient’s access to their records. Many of you will find that you have already met the HIPAA regulations.
HIPAA refresher for Supervisiors: All health professionals, including Supervisors and Supervisees, who send information via electronic transmission are considered “Covered Entities” and all HIPAA rules apply to them. What one must do as a Covered Entity to become compliant with HIPAA will be covered in this course. However, this course should not be seen as covering all aspects of compliance.
Individual practitioners may have practices which differ in important ways from the majority of other practitioners and may require additional changes in their operating procedures to become compliant. Also, as the task force continues its work on integrating laws governing the health professions with HIPAA regulations, new laws may become an additional part of what one must do to become or remain compliant. Continue to check with your professional organizations and licensing boards for updates.
Exempt Mental Health Professionals: If you are a health care provider who never transmits electronic data regarding patients you are not required, at this time, to comply with the HIPAA regulations and are not considered a “Covered Entity.” However, HIPAA is very quickly becoming the standard of care by which health care providers’ office practices are regulated. In other words, you may be found to be negligent with your patient’s records and confidentiality if you do not move your office practices into compliance.
Additionally, even though you do not submit bills electronically, a patient, an attorney, or other party to whom you submit bills or information may subsequently forward the information electronically, making you responsible for being a Covered Entity under the HIPAA regulations. For example, a patient may submit a claim electronically or it may be stored by the insurance company electronically which would require that the mental health professional be compliant with HIPAA regulations.
Using a FAX machine is not considered to be the same as using electronic transmission. Therefore, a mental health professional can send sensitive materials over a FAX machine without concern about being considered a Covered Entity. However, if the Faxed materials are subsequently sent via electronic transmission, the mental health professional with whom the material originated can also be considered a Covered Entity and thus required to follow HIPAA regulations. As yet, there is no requirement that the mental health professional who sent the FAX be notified that the information will be sent to others by electronic transmission. Protect yourself. It is not that difficult.
Business Associate: A business associate is a person or entity other than the therapist’s immediate workforce which receives confidential or PHI information from the therapist and provides services to the therapist. Among others, these may include a bookkeeper, lawyer, accountant, collection agency, answering service, computer service, or answering service. Business associates are not considered Covered Entities by HIPAA. The PHI may be given to a business associate only after the therapist has obtained a written contract with that person who notifies them that they must safeguard confidential information and how to do so appropriately. Samples of business associate contracts may be obtained online:
It is ultimately the therapist’s responsibility to be certain that the business associate follows the contract. Any subcontractors hired by the business associate must also sign a written contract agreeing to safeguard the PHI. If a business associate is found to have violated the contract, the therapist will need to make certain that steps are taken to repair the problem. If the problem is irreparable or if additional problems occur, the therapist may have to terminate the business associate and/or report the problem to HHS.
Another therapist to whom patients are referred during one’s absence is not considered a business associate. Additionally, janitorial, plumbing, electrical, or other repairmen are not considered business associates. Any postal service is not a business associate either under HIPAA. Business associate relationships are also not created by federal or state oversight committees such as the Medicare Peer Review. A therapist should not consider other therapists within one’s own practice or a consultant who is used for treatment purposes as a business associate. None of these are considered Covered Entities by HIPAA.
History of HIPAA: HIPAA stands for the Health Insurance Portability and Accountability Act. When this act was initially proposed by Senators Kassenbaum and Kennedy, it was seen as a means to protect individuals who were changing jobs or using a private insurance plan while self-employed from being denied insurance because of previous illness. During the Act’s passage through Congress, it has become quite different than the authors of the initial proposal envisioned.
At this time, HIPAA provides standards for protecting the records and privacy of individuals by making the transmission of electronic claims (billing) secure, by providing rules for the secure storage of patient records, streamlining the insurance billing process, and actually protecting some records for both the therapist and the patient. It is no longer a means for protecting patient records from being denied insurance due to a previous diagnosis or prescription which would be seen by an insurance company as “risky.” People who have had previous illnesses continue to have their insurance applications denied because insurance companies have access to vital data such as the diagnosis, treatment administered, and prognosis. In short, the information provided in the patient’s Protected Health Information is more than adequate for an insurance company to determine whether the patient in question will be covered by an insurance company. Most large group policies are required by law to admit all individuals working within the company to be provided with health insurance, regardless of previous illness. (Senator Nancy Kassenbaum)
The main problem lies with those individuals who must obtain private health insurance. They generally must supply the insurance company to which they apply with information about their previous medical and psychological care and provide permission for the insurance company to access those care records. Obtaining private insurance, such as one would do when self-employed or working for a small company which is not required to cover its employees by law, requires that an individual have a health record which is virtually clean of all major illnesses. It has been my experience that psychotherapy for those conditions covered under the “parity law” which have such diagnoses as varieties of major depressions, schizophrenia, and other such illnesses will cause major insurance carriers to decline coverage to an individual. Within my practice, patients have also been denied coverage for being proscribed Prozac within the last year, having a “sleeping disorder” which the patient reported his wife thought he had but was neither evaluated nor treated. Providing a prospective insurance company with the Private Health Information no longer protects the patient in any way from being denied coverage. In fact, it seems to simplify the records so insurance companies can quickly decide whether or not to cover an applicant.
HIPPA provides standards for the storage of all health care information including the transmission of electronic claims to protect the individuals’ records from others who may have improper access to unprotected electronic transmission. Thus, anyone who is using electronic transmission, including Medicare providers, and providers for insurance which require electronic transmission, must use protected electronic transmission only. The Privacy Rule is the aspect of HIPAA which most concerns psychotherapists now. HIPAA also was designed to streamline the insurance claims process by standardizing both claims and records.
Becoming Compliant with HIPAA: Luckily, for a solo or small group of health professionals, the process of achieving HIPAA compliance is a fairly easy task, particularly if you have already been following the laws for privacy within your field. HIPAA has required many more administrative responsibilities for large corporations such as hospitals and large clinics. They are likely to need a full-time Privacy Officer while within a smaller private practice, you can designate yourself as the Privacy officer and take care of the necessary changes without a great deal of difficulty.
There are, however, several important changes which should be made as soon as possible. It is likely you will need to take and keep two sets of notes, learn new rules about patient’s access to their clinical records, learn the rules about the rights patients now have to amend their records, and develop new forms for Consent for services and Authorization by the patient to have others see their records or otherwise consult with you about your patient. Additionally, there are new rules about how one must secure records in computers. Unfortunately, if you somehow trigger a HIPAA audit, the likelihood of a lawsuit or fines is high. Additionally, you must be in full compliance immediately since there is no grace period.
Because HIPAA may become the general law which is followed by all states, it is likely that if you are not in compliance you will be open to a lawsuit under a state law you may have overlooked or which may have become law since your last law and ethics class.
Steps to HIPAA Compliance:These steps apply only to solo practices or those of small groups and should not be taken to apply to hospitals or large clinics. The rules for these entities are different in important ways.
1. Designate a Privacy Officer: This person is responsible for meeting HIPAA requirements by developing the necessary new documents, computer storage of patient records, training staff to comply with regulations, and review the changes. The privacy officer should post or provide each patient, whether new or continuing with a Notice of Privacy Practices. Additionally, an announcement should be placed in a public area which includes the following:
Our Privacy Officer is (name of person). The Privacy Officer:
(a) Can answer your questions about our privacy practices;
(b) Can accept any complaints you have about our privacy practices;
(c) Can give you information on how to file a complaint.
You can call the Privacy Officer at (enter your office number.)
2. Comply with the Privacy Rule: The Privacy Rule applies to all Protected Health Information (PHI will be explained in 3.)Therapists are required to inform all patients of office privacy policies and how they are implemented. The patient’s records must be secured. Release of patient records for any reason either by the therapist, business associates, or staff cannot be done without informing the patient and obtaining the patient’s consent. These will be explained more thoroughly and suggestions for appropriate forms are available. A list of government sponsored and association sponsored websites will be provided at the end of this course.
3. PHI is Protected Health Information: Information which you have about your patient which identifies them as an individual when it is transmitted is PHI. All such material must be treated with utmost caution and respect for the rights of your patient. When the patient is identified by name, Social Security Number, or other means which make the patient identifiable by others requires that the material be classified as PHI. If the information contains PHI, all past, present, and future physical or mental health diagnoses, treatment of any sort, and billing or payment become confidential material.
It is crucial that all material containing PHI or information which identifies a patient be protected within the office. It is advisable to personally chart the flow of this information through your office. For example:
- Is incoming mail secure and protected from unauthorized disclosure?
- Is the information created within the office stored and protected?
- Is the information recorded in other areas, such as on or off-site billing personnel have storage which is protected from unauthorized disclosure?
- Is all incoming and outgoing electronic transmission secure?
HIPAA also requires that PHI material be available to be legitimately shared, sent out, or given to those who are authorized. If you personally see where the information comes in, is stored, used, created, and released, you will feel more confident that there is protection for these documents all along the line of transfer. It is helpful to some therapists to pretend these are their own personal records when deciding whether or not the records of their patients are securely protected throughout the process.
HIPAA requires that PHI be available within five days to an authorized agency under law.
Patients’ Rights to Their Protected Health Information (PHI): Under the HIPAA regulations, patients have a right to receive a notice about the therapist’s privacy practices. This information should be contained in the paperwork which is done in the first session when the patient is to sign a form in which they “consent” to treatment.
Patients can also restrict the use or disclosure of their PHI. However, there are serious limitations on this. The patient’s consent is no longer required for use or disclosure of treatment, payment, or health care operations or TPO. When the consent requirement was deleted in the published regulations of August 14, 2002, there was a huge protest from those who had fought for patients to have privacy. Essentially, the entire process of treatment, payment and operations of health care is not required to be given to the patient.
While many patients are unaware of the tremendous amount of information revealed about their personal medical and psychological treatment, most clinicians, particularly those who regularly deal with managed care and HMO’s are very aware of the type of information required both about the patient and about the qualifications of the practitioner. While a patient can submit a written revocation of their TPO at any time, the therapist may still use the now revoked consent to obtain payment for the treatment if the therapist has already acted in reliance on their initial consent for treatment. More simply stated, the therapist may bill the insurance company and receive payment for services rendered.
Treatment may refer to the type of psychotherapy received, consultation with other health care providers, and/or referral of a patient from one provider to another. The therapist may act without consultation with their patient in areas such as billing, determining eligibility, managing claims, collection of fees, providing information for the review of medical necessity for treatment, and giving information to insurance companies for the purpose of utilization review. Health Care Operations may include quality assessment, medical review, legal services, having an insurance underwriter review the competence or qualifications for health care professionals, and other matters pertaining to managing the business. The patient has no legal right under HIPAA to this information. Nevertheless, a practitioner may, out of a personal sense of ethical responsibility, provide their patients with information about their own policies and what is required of them by the patient’s insurance company.
Patients essentially lost the right which was the original point of the HIPAA legislation. The National Coalition of Mental Health Professionals and Consumers reported that, “The Bush Administration’s Rule changes in August 2002, ended the right of each American to consent to the release of personal health information , PHI, and gave ‘regulatory permission’ for disclosure of any identifiable health information for treatment, payment, and health care operations (TPO), stipulating that the treating professional should determine the minimum necessary information to be disclosed to meet TPO requirements, and that the patient must be advised of that professional’s privacy policies.”
The patient must authorize any use of PHI or Psychotherapy notes other than TPO or those situations which require disclosure with or without the patient’s permission. This usually occurs when a patient is applying for a new insurance policy or is changing physicians or health groups. It has been my experience that when information is released to a large provider of health care, such as the Veteran’s Administration system for continuation of a patient’s care, the PHI is passed throughout the care system; including not only the treating physician but also hospitals and other health care units have access to this information. A patient may see this release of health care information as useful in providing their current health care providers with a complete record of their previous treatment. Other patients may feel threatened by having information dispersed so widely.
Patient’s Access to Their PHI: Patients have access to their health information contained in their PHI and may request amendments to their records. They are to be told that they have these rights. The therapist must act within 30 days of receipt of a request to provide access.
Therapists may charge a reasonable fee for copying and mailing the PHI if it is requested that the PHI be mailed, but not for the time required to find the documents. If the patient requests a summary of the records, a fee may be charged for the time to do this service.
However, a therapist may deny a patient access to their PHI if the patient is given the right to have their denial reviewed. There are several reasons why access to the PHI may be denied:
- If the therapist has reason to assume that the life or physical safety of others will be endangered by access to the records.
- If the records make reference to other persons (unless that other person is a healthcare provider) or if access to the information would cause harm to the other person. This may occur if another person has made contact with the therapist and notes of that interaction are in the PHI.
- If access is denied, the therapist must provide a timely, written denial including the basis for the denial, a statement of the patient’s review rights, a description of how the patient may exercise such review rights, a description of how the patient may complain to the provider including the name and number of the contact person or office designated to receive his complaints, and a description of how the patient may complain to the HHS Secretary.
Patients have the right to appeal the denial of access
to their health information to another licensed health care professional who was not involved in the original decision to deny access. This reviewer must be designated by the psychotherapist, and the therapist must comply with the decision of the reviewer.
Disclosure of PHI notes without Permission of the Patient
- When required by law
- To a coroner or medical examiner when required by law
- To show compliance with the Privacy Rule
- To avert serious threat to the health and safety of a person or the public
- For a public health authority
- For a health oversight agency
- For the military or other national security agency
- To comply with Worker’s compensation laws
- When there are victims of abuse, neglect, and domestic violence
- When there is suspicion or evidence of child abuse.
There are other exceptions to the rule of privacy; however, it is best to consult with one’s professional association such as CAPS or CAMFT prior to disclosing information about a patient.
Case Notes or Non-PHI Notes: Information which does not identify the patient and could not reasonably be used to identify the patient is not considered PHI and is not protected by HIPAA. This implies, and is readily translated to mean that a mental health professional’s private case notes are not open to scrutiny by anyone other than the therapist.
This encourages the therapist to keep two sets of records, one which duly provides the information required by HIPAA and a second set of notes which are kept separately from the HIPAA records. They must be kept in a separate file and perhaps in a separate filing cabinet from PHI notes and other medical records. In this way, a therapist can keep track of private, personal notes which are used for therapy purposes from such diverse information as what their patient has been eating lately to what the therapist thinks about a dream but decides it is too soon to interpret to the patient. They can contain other sensitive information such as drug abuse, HIV-AIDS information, and other sensitive information about the patient. There is no requirement that two separate sets of notes be kept but they can certainly be useful to the therapist in the treatment of the patient.
Psychotherapy Notes or “process notes” are excluded from HIPAA regulations since they do not have information such as full names, Social Security Numbers and other information which could reasonably be used to identify a patient. They are the often sketchy notes one makes to oneself while listening to a patient. The therapist’s guesses and hypotheses can be included also in these notes and excluded from those notes controlled by HIPAA.
Psychotherapy notes also cannot be used by Insurance companies to determine the patient’s eligibility for treatment or payment. While no records are completely immune from disclosure, these records are far more protected under the HIPAA regulations than they have been previously. When a patient releases information for reimbursement or other purposes, the Psychotherapy Notes are not released. This legislation supports the previous Supreme Court’s 1996 Jaffee v. Redmond decision which affirmed the importance of confidentiality and privacy to develop trust and other aspects of a therapeutic relationship.
Psychotherapy Notes specifically may not include medication prescription and monitoring. They may also not include starting and stopping times of the sessions and modality and frequency of the treatment. They must also not include a diagnosis, functional status, treatment plan, results of clinical tests, symptoms, prognosis, or progress in treatment since those parts of the record are to be a part of the general record or the PHI controlled by HIPAA. Thus the distinction between the very private Psychotherapy Notes and the ironically much more public notes which identify the patient, the diagnosis, and the prognosis is maintained.
To clarify this distinction further, a psychoanalytically based treatment to document an intervention in a PHI, HIPAA regulated file, which does not contain Psychotherapy Notes may read:
Interpretations were made regarding the onset of the patient’s current symptoms and were accepted and used by the patient with some success to further his understanding.
Psychotherapy Notes, in contrast may read:
Some success today. Discussed his attachment to his mom and feelings that she needed him to talk with while father went to sleep early. Discussed details of his plans to seduce her--I was feeling like his mother in the countertrans. \ he slipped and called me the first part of his M.s name then corrected it. New Girl he likes sounds nice.
The patient’s insurance company, managed-care, or Medicare may need information similar to the first example to document that the patient is making progress in treatment and why. They do not need the private information which occurs in the consulting room. HIPAA protects this information if the therapist is willing to make separate folders for their patients. The patient is able to talk about shameful thoughts, acts, and memories while the therapist can take private Psychotherapy Notes on these which remain private but would cause damage or harm to the patient if revealed. Additionally, the patient must authorize the therapist to share the Psychotherapy Notes with other clinicians. If several therapists or others such as physicians are involved in a case, the general notes or medical records can be shared. Only the patient, the subject of the notes, can authorize sharing of the Psychotherapy Notes.
Disclosure of Psychotherapy Notes:The Psychotherapy Notes can only be disclosed without the patient’s authorization under certain circumstances:
- When mandated by law.
- To defend the therapist against charges brought by the patient.
- For training or supervision
- For oversight of the therapist
- Under the Tarasoff Law and under HIPAA to avert a serious and imminent treat to the health or safety of a person or the public, The disclosure may be made to only the person or persons who can reasonably be expected to prevent or reduce the threat. The person who is threatened must also be notified in this disclosure.
Therapists cannot disclose Psychotherapy Notes they receive from another
therapist to any other therapist without authorization from the patient. This is not the case with general Protected Health Information or PHI which may be re-disclosed or sent as part of the record and is routine treatment.
If a patient authorizes the release of their Psychotherapy Notes to a NON-COVERED person or entity with whom the therapist does not have a business contract, that person or entity may release them to whomever they please without any need for the patient’s authorization. For example, if a patient releases their Psychotherapy Notes to someone who has convinced the patient that they will write their biography, but they are not a health provider, or other Covered Entity, the “biographer” may release the Psychotherapy Notes to whomever he or she pleases.
Patients have NO right to review their Psychotherapy Notes. Under the HIPAA rules, they have many rights regarding their general record or PHI including reviewing it. However, a patient can request to have an entire record transferred to another therapist or someone else and then may see the Psychotherapy Notes. Again, keep the Psychotherapy Notes separate from other notes and psychotherapists are not required to keep Psychotherapy Notes at all so they may be destroyed after they cease to be useful to the psychotherapist.
Patient’s Rights to Amend Their Private Health Information: Under the HIPAA regulations, patients can review their PHI and amend statements in the PHI which they consider to be incorrect. However, the therapist can refuse to amend the PHI if it is not part of the designated PHI record set; if it is not available for inspection; if the therapist thinks the record is accurate and complete; or if the record was not created by the therapist and the creator is no longer available. If the patient provides a reasonable basis to believe that the creator of the PHI is no longer available to act on the request, the therapist must address the request as if he or she created the information.
If the therapist refuses to do the requested amendment, he or she must provide the patient with a timely, written denial which explains the patient’s right to submit a written statement of disagreement, the patient’s right to have the denial notice sent out with subsequent disclosures of the PHI, and how the patient may make a complaint to DHHS. Although the patient has the right to disagree, the therapist has the right to provide the patient with a written rebuttal both to the patient and to be entered in the PHI. All subsequent disclosures of the PHI would contain the rebuttal.
The therapist must develop a procedure for granting and denying requests to amend the PHI. Under HIPAA regulations, the therapist must respond within 60 days after receiving the patient’s request to amend the record but may request an additional 30 days if the patient is given notice.
If the therapist determines that the record should be changed according to the requested amendment, he or she must make the amendment; notify the patient; ask the patient who else should be notified of the amendment; and provide the amended information to those identified by the patient. However, all information and communication relating to granting or denying requests by the patient to amend the PHI must be included as part of the record. Changes resulting from a patient’s request to amend the record do not exclude any prior information or part of the record it is simply added to it.
Records of Minors: HIPAA generally intends not to interfere with state laws regarding parental control and access to their children’s mental health treatment. The parents in general are the representatives of their children and thus have access to the PHI concerning their children. The parent may release the PHI to whomever they deem suitable with or without the permission of their children.
The only exceptions to this rule are if a court makes the determination that the parent does not have the right to access their child’s PHI; if someone other than the parent is legally authorized to make decisions for the minor; when the parent, or other person legally acting as the parent, consents to an agreement of confidentiality between the minor and the health care provider. Also, if a state law allows a minor access to mental health services without the consent of the parent, the minor has the same rights as an adult patient regarding their PHI. State laws which recognize this right supercedes the HIPAA regulations and the specific situations to which this may apply are beyond the scope of this class.
Non-Compliance: It is important to recognize that a HIPAA compliance audit can be conducted at any time without any cause. No one needs to file a complaint or does there need to be any apparent problem. The department of Health and Human Services HHS is the body which will eventually have enforcement power. Any person who believes their rights have been violated by having a therapist who is not compliant with HIPAA can contact HHS and file a complaint which immediately is to trigger an investigation. Once this investigation has begun, the HIPAA rules apply not only to the particular difficulty which was found initially but to the therapist’s entire practice.
The most likely causes for an audit are when a therapist electronically transmits Protected Health Information (PHI) through filing a health care claim; inquiring about the status of a claim; inquiring about eligibility of enrollment; obtaining advice about a health care payment or remittance; attempting to coordinate payments; confirming a referral; or creating the first report of an injury. Clearly, some of these are done more frequently by the therapist while others are more frequently initiated by an insurance company or a patient. Therapists who use billing and collection services may also trigger application of the Privacy rule. The therapist is responsible, in other words, for the actions of everyone with whom they contract to be certain that the electronic transmissions they create are secure.
The consequences of failing to be in compliance with HIPAA can be severe. Fines of up to $250,000 and imprisonment for up to ten years or both can be levied against an individual who knowingly perpetrates “wrongful disclosure of individual, identifiable, health information. Additionally the Office of Civil Rights at the US Department of Health and Human Services can initiate administrative action against non-compliant therapists. Patients can also file lawsuits if a therapist is non-compliant because their private health information is endangered. There may also be civil penalties but these cannot exceed $25,000 in one year.
Because any or all of these things would make a normal therapist pack his or her bags and head for a country without an extradition treaty, it is important to become compliant with the HIPAA regulations as soon as possible. Also, it is likely that the HHS will enforce HIPAA in a way which is educational rather than punitive unless there is evidence that the clinician profited in some manner by unlawfully transmitting Protected Health Information.
Problems within HIPAA: This is a new set of laws which are designed by the US Congress to regulate the healthcare industry. Because of this, states, which have regulated healthcare previously, have a variety of laws which are usually similar to those of HIPAA, but different enough that there is an ongoing task force to determine which laws should be changed so that Federal and State law governing the privacy of healthcare are more closely the same. When state laws are more restrictive the HIPAA rules do not preempt state laws. Additionally, all states will continue to investigate and regulate therapists with regard to confidentiality, ethics, and integrity.
Although HIPAA went into effect in April 2003, and was to become the law of the land by October 16, 2003, it is clear at this time (November 2003) that this has not yet occurred. Those healthcare providers who have small practices and have used electronic transmission of billing provided by Medicare have been told that the new software is not yet complete to replace the system which has been offered for free to practitioners with a small number of Medicare patients. The pre-HIPAA software continues to be adequate to submit billing for now.
Additionally, HIPAA does not give clear black and white rules about when therapists may and may not disclose information. Perhaps some of these rules will eventually be decided through case law. Your issue, as an individual clinician is to make certain that you are not the one whose name appears in the case law which will eventually be cited.
HIPAA, at this time, does not create a national data bank for offenders. However, if you are successfully sued by a patient for failing to follow HIPAA and failing to protect the confidentiality of records, you will find yourself in the National Data Bank anyway.
Psychotherapists who work on a fee-for-service, out-of-pocket, cash only basis 100% of the time and who never bill insurance either directly or by providing their patients with the means to bill their own insurance carrier can, so far remain free of the HIPAA regulations.
HIPAA is a long, rambling, complex set of laws. In many places it is unclear and difficult to interpret. If one looks at the law with a particular question in mind, the problems become very difficult indeed. HIPAA will continue to change. It is necessary to stay in touch with one’s professional organizations to stay current with the law.Clinicians who disclose personal circumstances to clients open the door to boundary problems
Author: Eric Digest, K. Gates, PhD
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