Utilizing Supervision for Supporting Home-Based Family Therapy Module

Module Sections:

Introduction & Pre-Test

Welcome to the Utilizing Supervision Course

Welcome!

The purpose of this course is to provide therapists with specific tools necessary to search for and obtain an appropriate level of supervision that will support their home-based work. The tools are provided to inform ways to explore the depth and breadth of support that involvement in supervision can provide.

The purpose and function of supervision is designed to support key stakeholder roles and interactions focused on providing effective therapeutic work. The stakeholders involved with therapy include the following: clients, therapists, supervisors, agencies/institutions, the profession, and the public. The supervisor represents the pivotal role that guides and informs therapists' work. The supervisor's role provides a vital gate-keeping function and reports to the licensing board, professional association, and/or educational institution that authorize the credentialing of a clinician. The supervisor also provides the administrative and therapeutic oversight necessary to ensure safe, ethical, and effective treatment with clients. Supervision provided beyond the credentialing process offers clinicians continued clinical support, skill development, and accountability. Since therapy can be difficult, taxing work, therapists commonly experience burnout at some time in their career. Furthermore, providing in-home therapy often involves unique stressors leading to therapist burnout.

This module is developed to highlight the varying points of view and responsibilities that distinguish the supervisee and supervisor roles and functions. You will have multiple opportunities to compare and contrast the differences and consider implications of the roles and functions on improving your clinical work and training. We believe increased insight will inform and influence supervisees' and supervisors' utilization of the supervision relationship and process.

Supervision provided to home-based family therapists recognizes and responds to the unique challenges of providing therapy in the home. During this module, we will be exploring ways supervision assists clinicians to translate the therapeutic skills and interventions used in the office to home-based work. The module will also explore ways supervision addresses the distinctive stresses a clinician experiences while doing that work.


Module Objectives

Throughout this module, you will…

  • Learn the ways that supervision assists and guides therapists
  • Develop greater awareness of points of view of the supervisory relationship and a supervisor's varied roles
  • Determine when the therapist should request additional supervision
  • Know how supervision addresses varying needs at different levels of clinical experience
  • Explore ways to utilize the supervisory oversight to improve clinical outcomes
  • Identify ways to use supervision to address issues arising within therapy that are specific to home-based work

Scope of the Issue

What Is Supervision?

Supervision involves a supervisor and a supervisee relationship focused on overseeing and supporting a therapist's work (White & Russell, 1995). The American Association for Marriage and Family Therapy (2002) suggests that supervision must include a sustained relationship between a therapist and supervisor involving face-to-face meetings focused on exploring the therapist's development and provide oversight to the therapist's caseload. The National Association for Social Workers (2008) defines supervision as "regular accountability to a supervisor for your assigned work and must have been received as an employee within an agency or organizational setting." According to the American Psychological Association (2000), "The [supervisor] provides appropriate professional role models and engages in actions that promote the interns' acquisition of knowledge, skills, and competencies consistent with the program's training goal."

Goals of Supervision

The primary role of supervision is to provide a gate-keeping function that ensures public safety, protects the integrity of the profession, and enhances clinician welfare (Russell, DuPree, Beggs, Peterson, & Anderson, 2007). The self-reflective activity of supervision is initiated and facilitated by the supervisor-supervisee relationship. Each has a distinct role, and when they collaboratively work together, the relationship is designed to enhance and perfect the work of therapy over time.

The supervisor-supervisee relationship is intended to accomplish the following goals:

  • Ensure an appropriate level of care that minimizes the risk and maximizes the benefits of the therapy process
  • Evaluate the therapy and supervision processes
  • Guide and evaluate the clinician's professional and conceptual development
  • Promote therapist's self-care

Each of the goals will be addressed in greater detail throughout this module. The goals are accomplished through specific, incremental tasks.

Tasks of Supervision

The tasks performed within supervision facilitate accomplishing goals of the supervisory process. Supervisors review clinical cases through consultation or direct observation. The supervision process focuses on supporting clinician's work through the following tasks: review of documentation, providing administrative oversight, addressing ethical and legal issues, attending to self-of-therapist, therapist self-care, contextual issues, and developing clinical and professional skills.

Supervision employs varying degrees of consultation and observation of the therapist's cases: discussion of a case focusing on a therapist's report of a case, review of video or audio recording, or the supervisor joins an in-home session for live observation. Each experience provides varying levels of support. The supervisor is able to explore the therapist's conceptualization, case management, and relationship with the client system.

Documentation review provides an opportunity to examine the therapist's written expression of reflections about the therapy progress extending from initial to final assessment of the process. The therapist uses the first three types of documentation to describe the client system, give legal authorization for the work to occur, and provide clients feedback on the current status of the presenting issues.

  • Client information
  • Releases of information
  • Client self-report instruments

The remaining elements of the documentation reflect the progressive conceptualization, planning, and articulation of the therapeutic focus and ways to measure outcome.

  • Assessments (formal and informal)
  • Treatment plan
  • Progress notes
  • Termination summary
  • Reports to agencies and other providers on the therapeutic team

The documentation provides the therapist with a means to reflect upon the progress at each point in the therapy process and then to forecast subsequent steps that will facilitate client's change.

  • Additional supervisory tasks focus on specific aspects of the therapy and supervision processes:
  • Review the clinician's use of integrated theories and models of therapy
  • Review ethical issues informing therapist decision-making (Storm & Haug, 2002)
  • Consider varying contextual issues that intersect and influence the clients' process of change (Lappin & Hardy, 2002; White & Russell, 1995)
  • Examine the challenges the self-of-the-therapist issues that impact the therapist's role, the therapist's relationship with the client system, and effectiveness of therapy
  • Raise questions to increase therapist's awareness of the isomorphic effects among the client, therapist, and supervisor roles (Liddle, 1991)

Pre/Post Test

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Establishing a Common Ground

Models of Supervision

Models of Supervision

Among the clinical disciplines, several models have been developed reflecting varying approaches to supervision. Each model:

  • Conceptualizes the purpose of supervision
  • Describes guiding assumptions of the process
  • Suggests specific approaches

Morgan and Sprenkle (2007) reviewed the varying approaches to supervision and identified three main categories of supervision approaches including:

  • Clinical models
  • Conceptual models reflected in developmental models and social-role models
  • Objectives-based and feminist approaches that have influenced the development of supervisory models

As you review the varying types of supervision, we are hoping that you will become increasingly aware of the priorities for and expectations from effective supervision. We encourage you to consider the types of supervision you have received and ways to explore differing approaches that will provide you with a well-balanced supervisory experience over time.

In the next section we will provide a common list of objectives that can be used to guide your efforts to obtain the broadest-reaching supervisory experiences.


Clinical Models

Supervision approaches based on principles from specific clinical models were originally developed by those with no formal supervision training. Early in the development of clinical supervision, supervisors tended to focus on the work of therapy as a guiding framework for providing supervision. Supervisors used their own predominant therapy model to inform their understanding of change processes and the interventions necessary for assisting clients to bring about those changes.

Examples of clinical models used in supervision include:

  • Bowen's transgenerational
  • Structural-strategic
  • Narrative

The main concepts of the clinical model would inform the supervision process and examination of the therapist's clinical work. For example, a Bowenian supervisor would explore possible connections between a therapist's role in his/her family of origin with a role demonstrated while working with a client system. The transgenerational frame would guide the types of questions asked of the supervisee that would facilitate a search for triangles, levels of differentiation, and the presence of chronic anxiety occurring throughout the processes of therapy and supervision.

Journal
- How does your specific model(s) of supervision influence your expectations from supervision?
- How does your specific model(s) of supervision influence your engagement in supervision?


Conceptual Approaches

The following conceptual models provide a comparison of the different approaches to the supervision process. These models are provided for you to consider the variety of ways to conceptualize supervision, approaches to providing supervision, and the varying ways to measure outcomes you expect from supervision. Conceptual approaches, divided into developmental and social-role models, focus specifically on the interactions between supervisors and supervisees.

Developmental Models

Developmental models of supervision assume that there needs to be a degree of fit between the type of supervision that is provided and the supervisee's current level of experience (Halloway, 1995; Stoltenberg & Delworth, 1987). Furthermore, the approach to supervision is adjusted as the needs of the therapist change throughout predictable stages of development.

These models attempt to provide a framework that assists a supervisor's ongoing assessment of the therapist's professional and clinical skills. The assessment provides guidance for determining the most appropriate and useful types of supervisory interventions. For example: a supervisor working with a beginning therapist may use a directive approach that provides specific intervention ideas, whereas work with an experienced therapist may be collaborative and focus on more conceptual issues.

Journal
- Describe your current level of clinical experience.
- Considering your current level of clinical experience, how could supervision best address your current clinical needs?


Conceptual Approaches Continued

Social-Role Models

Social-role models focus on the varying functions and roles of supervisor and supervisee. Bernard and Goodyear (1998) described effective functions of a supervisor as supporting a supervisee's ability to focus on process, conceptualize complex cases, and personalize clinical approaches to therapy. Combining the roles of teacher, counselor, and consultant, a supervisor utilizes multiple approaches that help the therapist to build knowledge, experience support, and explore varying approaches and perspectives throughout the work of therapy.

Halloway (1995) further addressed the contextual dimensions of the supervisory and therapeutic processes. She suggested that effective supervision enhances and integrates a greater awareness of the influences of supervision and therapy occurring in varying contexts. Supervision and therapy occuring in educational settings, agencies, or private practices suggest varying roles and degrees of support.

An example of a unique dilemma occurs when the supervisor has the dual role of supervisor and instructor providing a grade. Another example that poses a dilemma occurs when a clinical supervisor also has an administrator role over the therapist responsible for promotion decisions. The dual roles can impact the degree to which a supervisee is willing to reveal vulnerabilities and questions about one's work. Furthermore, the roles of an agency supervisor would naturally differ from those of the contracted, off-site supervisor who has no direct administrative accountability.

The context also impacts the work of therapy. A therapist bound by agency policies versus the autonomy of a private practice clinician may affect a therapist's decision-making at varying points during the therapy process.

Journal
- Describe one way a supervisor has been most supportive of your clinical work.


Objectives-Based Approach

The objectives-based (Cleghorn & Levin, 1973; Tomm & Wright, 1979) and feminist approaches (Prouty, Thomas, Johnson, & Long, 2001; Wheeler, Avis, Miller, & Chaney, 1978) focus on the role of the therapist throughout the therapeutic and supervisory interactions. A greater awareness of the existence and roles of culture, gender, power, and justice influence perspective-taking and decision-making that occur throughout supervision and therapy.

Skill-Based Objectives

Ivey & Ivey (2007) suggest using a "microskills" approach focused on specific skills that are built upon a foundation of ethical and multicultural awareness and competence. Supervision would address the development of the following skills:

  • Attending behaviors
  • Open and closed questions
  • Client observations
  • Encouraging, paraphrasing, and summarizing
  • Reflection of feeling
  • Confrontation
  • Focusing
  • Reflection of meaning
  • Influencing
  • Skills integration

A microskills approach places a priority on attending to the incremental parts of interaction sequences that have a cumulative effect of defining the relationships between supervisor and supervisee or therapist and client. The nature of those relationships directly impacts the effectiveness of the work that is accomplished through those relationships.

Journal:
- List two "microskills" that you have spent time developing in the past year.
- List two "microskills" that you would like to focus on developing in the coming year.
- How could your supervisor assist you in developing those skills?


Feminist Approaches

Feminist approaches to supervision prioritize the use of collaborative and empowering approaches to therapist training and learning. Feminist-informed supervision collaboratively emphasizes issues such as gender, culture, power, and justice influencing therapeutic and supervisory relationships.

Prouty, Thomas, Johnson, & Long (2001) conducted interviews of supervisors and supervisees to explore feminist supervision methods. They discovered three common approaches including the use of intentional contracting as well as varying combinations of collaborative and hierarchical methods. Supervisors contracted with supervisees to develop clear expectations concerning the therapist's goals and responsibilities in supervision coupled with a mutual evaluation process. Supervisors and supervisees using a feminist approach engage in a series of conversations throughout the supervision process that addresses each other's' expectations and the progressive accomplishment of supervisory goals. Additionally, supervisors expressed their intentions to provide an appropriate level of direction and guidance that matches a therapist's expectations and level of development.

Supervisors noted that a feminist approach does not always indicate the use of a collaborative, egalitarian approach. They described examples involving safety and ethical issues with a beginning therapist often require a more hierarchical, directive approach. Also, therapists requesting specific direction were often met with a greater degree of supervisory direction. While a supervisor using a feminist approach is more directive, he or she continues to search for ways to further empower the therapist throughout the process of supervision and in therapy. A resulting tension exists between the supervisors attempts to provide direction and guidance with efforts to fortify an egalitarian relationship with the supervisee.

The hallmarks of a feminist approach involve a continual awareness and attention given to power dynamics as well as gender and broader contextual issues influencing therapy and supervision processes (Morgan & Sprenkle, 2007). Supervisors and therapists engaged in feminist-informed supervision intentionally and overtly address contextual issues. Each makes deliberate attempts to broaden the scope of general theoretical frameworks and therapeutic conceptualizations.

Journal
- What is a question you could ask your supervisor to help you to explore contextual issues involving the family's ethnicity or social economic status (SES)?
- How might gender issues be influencing family member assumptions about the involvement in therapy?


Common Factors of Supervision

We turn now to the common factors of supervision. A distillation of the factors across models will help you to further identify elements contributing to an integrated, supportive, and tailored supervision approach.

Morgan & Sprenkle's (2007) study revealed several common factors across supervision models. The common factors are described in three main categories: the emphasis of the supervision, the specificity of the supervision, and the supervisor-supervisee relationship.

Emphasis

They noted that supervision ranges on a continuum between emphasizing the development of a clinician's ability to effectively work with specific clinical issues while at other times the focus is on issues related to a therapist's ability to adhere to ethical and legal standards of practice.

Clinical Competence Blue Arrow Professional Competence

The continuum includes a variety of activities along the continuum often attending to both the development of clinical skills and the development of a therapist's professional identity.

Specificity

Morgan & Sprenkle (2007) describe another continuum illustrating varying levels of supervisory focus. The supervisor addresses clinical and supervisory issues ranging from idiosyncratic or particular to nomothetic or general.

Idiosyncratic/Particular Blue Arrow Nomothetic/General

Supervision addressing particular areas of focus attends to a therapist's response to a specific family system, the unique challenges arising within that work, or within the supervisory process.  Supervision addressing general areas of focus addresses broader theoretical, ethical, and legal issues.

Relationship

Finally, supervisor and supervisee involvement in supervision ranges from collaborative to directive.  This range reflects the tension maintained throughout the supervision process described in the previous section.

Collaborative Blue Arrow Directive


Common Factors: Supervisory Roles

The resulting matrix incorporates all three continua illustrating the varying types of supervision provided throughout the supervision process.

Figure 1 - Supervisory Roles (Morgan and Sprenkle (2007))Figure 1 - Supervisory Roles (Morgan and Sprenkle (2007))

The supervisor provides differing types of roles to match the developmental level of the therapist as well as to address a range of supervisory or therapeutic issues. Each role suggests adjustments to the supervisor's approach, level of involvement, focus of supervision, and nature of the supervisor-supervisee relationship. Examples of supervisor roles include:

  • Coach – The supervisor focuses on addressing specific clinical issues within a particular case or specific supervisory moment.
  • Teacher – The supervisor focuses on knowledge development and conceptualizing broad clinical issues.
  • Mentor – The supervisor facilitates the therapist's professional development addressing specific therapeutic interactions, self-of-therapist issues, and the supervisory relationship.
  • Administrator – The supervisor attends to the therapist's development of broad ethical, legal, and other professional standards of care.

Journal
- Note a time when your supervisor has provided varying types of supervision:

  • Coach
  • Teacher
  • Mentor
  • Administrator

Typical Dilemmas of Supervision

Despite the potential wealth of knowledge, resources, and guidance that supervision provides, certain dilemmas may arise within the supervisory relationship. Typical issues include: supervisors and supervisees involved in multiple relationships, therapists experiencing pressures to accumulate "billable" hours, supervisor's limited access to raw data (live or taped sessions) of the therapist's clinical work, supervisor's limited experience with HBFT, and potential problems associated with limited awareness varying contexts. Each situation poses specific dilemmas that may potentially challenge the supervisory relationship and the therapist's investment in the process.

Multiple Relationships

Storm, Peterson, & Tomm (2002) describe three types of multiple relationships that supervisors and supervisees experience:

  1. A mentoring relationship
  2. Overlapping professional and personal boundaries
  3. Combining supervision and therapy

They note that these multiple relationships can involve certain dangers while also enhancing the relationship between supervisor and supervisee. The inherent danger of multiple relationships suggests that the scope of supervision reaches beyond the stated expectations of the supervision contract.

Dangers arise when the supervisee feels exploited when asked to perform duties that are clearly outside of the scope of the supervisory relationship and for which the supervisee is unable to say no for fear of reprisals. Potential harm arises from the supervisor's inherent power of her/his evaluative and gatekeeping position (Russell et al., 2007). Crossing boundaries to include personal engagements such as having lunch together, visiting one another during time off, or the supervisee receiving therapeutic service can leave the supervisee feeling powerless to address potential conflicts of interest. The evaluative power of the supervisor places the supervisee in an untenable position. The supervisee may have difficulty reinforcing professional boundaries for fear that her/his efforts may jeopardize her/his position or upcoming pay raise.

The nature of the mentoring relationship may broaden the professional scope of practice and supervision to include additional teachable moments for the supervisee. Supervisor and supervisee involvement in other professional duties can potentially expand the scope of supervision to address broader professional issues influencing the supervisee's professional development. Prouty et al. (2001) describe the challenges associated with balancing between collaborative and hierarchical approaches to supervision. Extra care must be taken at the outset of the relationship setting clear, shared expectations to prevent the relationship from becoming exploitative.

Required Billable Hours

Therapists in agencies requiring quotas for "billable" hours each week often discover that they must choose between meeting that standard or including supervision sessions. Therapists often struggle to prioritize their involvement in supervision because supervision is not considered a "billable" hour. Therapists are faced with weighing the cost of getting behind with their quota while spending that time in supervision. The immediacy of meeting the current demands of the agency has the potential to take precedence over the perceived long-term benefits of supervision. The demands can outweigh the perceived benefits of receiving support, guidance, and strengthening the supervisory relationship.

Eighty-seven percent of therapists involved with the HBFT Partnership report receiving an average of at least 1 hour of supervision per week (see Figure 2). However, therapists attending the Core Training repeatedly note that despite their interest in nurturing a relationship with their supervisor, the demands of the job often take precedence over supervision.

Figure 2 - Percent of therapists receiving supervision per weekFigure 2 - Percent of therapists receiving supervision per week


Supervision Dilemmas Continued

Supervisor Access to Observing Therapy

The nature of HBFT taking place in the family's home limits the supervisor's access to direct observation of the therapist's work with the family. Fifty-one percent of therapists involved in the HBFT Partnership report that supervisors never accompany them on home visits and 41% report supervisors accompany them once per year (see Figure 3). Therapists have also reported that their supervisors would most likely accompany them on a home visit if requested (Macchi & O'Conner, 2005-2008).

Assuming that most therapists do not videotape or audio record their sessions, the supervisor's limited access to raw data of therapy sessions suggests that most supervision is conducted as self-report or case consultation. Storm, Todd, Sprenkle, & Morgan (2001) note that there are differences of opinion among supervisors as to their preferences for each type of supervision. They note that each has merit and, used together, could offer diverse experiences for enhancing the supervision process.

Figure 3 - Percentage of supervisor-accompanied visits to homesFigure 3 - Percentage of supervisor-accompanied visits to homes

Supervisor HBFT Experience

Therapists describe the challenges that arise when they are seeking supervision from a supervisor who does not have HBFT experience. While the supervisor may still draw from clinical and supervisory experience to provide support and oversight of the clinician's work, the unique experiences of the home environment offer additional challenges to the supervisory process. To overcome these obstacles, a supervisor and supervisee can review two articles* (Macchi, O'Conner, & Petersen, 2008; Stinchfield, 2004) followed by subsequent discussions about the unique challenges of providing HBFT. As stated earlier, we would encourage the therapist to also request that the supervisor accompany him/her on a home visit.

Contextual Challenges

White & Russell (1995) and Storm et al. (2001) describe the importance of a supervisor and supervisee intentionally attending to the varying contexts of supervision and therapy. A lack of awareness of varying contexts leads to blind spots and biases that undermine the quality and effectiveness of supervisory support. They note the need for supervisor, supervisee, and family awareness of values empowers and supports each one involved. They further suggest the need for clarity of policies and procedures that support growth and development throughout the supervisory and therapeutic processes. A prime example of a supportive environment is inherent in a clear supervisory contract explicitly addressing the supervisor's and supervisee's expectations for supervision (Prouty et al., 2001).

*Links to (Macchi, O'Conner, & Petersen, 2008; Stinchfield, 2004) can be found in the resource section at the bottom of this page.


Therapist-Supervisor Vignette

Janette, a Home-Based Family Therapist, has been practicing in a community mental health center for ten years. She enjoys the work but finds that there are times when she experiences increased stress when the agency policies and, subsequently, her supervisor's (Susan) expectations of her change.

One afternoon, Janette returns to the office after a difficult session with a family in their home. Janette asks Susan for an impromptu supervision meeting to discuss the session. Susan graciously agrees.

Janette begins by describing ways the family appeared resistant to her efforts. She notes that the family members each seemed to question everything she was suggesting but also offered no alternative suggestions. Janette notes that she has faced this type of situation before with other families but that this experience felt different. Susan asked a series of questions that helped her to better understand the situation, the topics discussed, and the challenges as Janette perceived them.

After 45 minutes of exploring the situation together, Susan discovered that Janette had repeatedly dismissed each suggestion she had made and noticed that the conversation had migrated toward Janette's frustrations over the recent agency policy changes affecting her therapeutic work. Susan decided to shift the focus of conversation to overtly address the agency policies and the impact of those changes on both of their roles. After acknowledging their shared experiences of change, the two experienced a greater sense of collaboration as they returned to discussing Janette's family work.


Forming a Unified Framework

Differing Expectations and Agendas

Differing Expectations and Agendas

Using a delphi method surveying supervisors and supervisees in the field of MFT, White & Russell (1995) reviewed varying descriptions of supervision to determine common factors. Coupled together with Morgan & Sprenkle's (2007) work, the following descriptions reflect a unified framework describing the varying dimensions of the supervisory process.

Each section reflects qualities, tasks, and challenges associated with a factor contributing to the supervision process. Each factor has qualities, or traits, that reflect the descriptive aspects that provide a resource to the process. The tasks reflect the responsibilities and accomplishments that are achieved throughout the process. The challenges reveal the potential and anticipated issues requiring advanced planning and expected adaptations to the process of supervision. The supervisor and supervisee factors have an additional description of skills each needs to address the tasks and challenges throughout supervision.

We would encourage you to use the framework to consider each aspect of your supervision and then take steps to confirm or adapt your expectations, engagement, and evaluation of supervision. In the Applying the Framework section on the following pages, we will use the framework to address the therapist-supervisor vignette exploring the various dimensions of their supervision session.


Using Strategies and Techniques

Introduction of Strategies and Techniques

Several authors (Lawson, 2005; Snyder & McCollum, 1999; Zarski, Greenbank, Sand-Pringle, & Cibik, 1991; Zarski & Zygmond, 1989) offer specific suggestions for maximizing the usefulness and effectiveness of in-home supervision. The following list of strategies and techniques first describes the essential elements of a supervision structure that establishes supervisory expectations, improves therapist's awareness of self, guides therapist's use of supervision, and highlights the guidance that supervision offers. Secondly, the list points out ways to identify, apply, and further develop specific therapeutic skills.

Supervision Structure

Supervision Structure

The development of a supervision structure suggests the importance of establishing and utilizing a supervision contract that encompasses each of the following areas. The contract defines supervision as broader than case consultation, focusing additionally on self-of-the-therapist issues, therapist self-care, and provides for opportunities to reflect on the supervision process.

  • Determine Shared Expectations of Supervision
    • Define rules and boundary-setting of supervision
    • Establish consistent supervision times
  • Awareness of Self
    • Prioritize therapist's experienced autonomy
    • Use of therapist's reflective journal to explore the experiences in session and share observations within supervision
    • Use therapist assessments such as ProQOL to monitor
      • Therapy fatigue, compassion fatigue
      • Compassion satisfaction
      • Burnout
      • Balancing between professional and personal experiences
  • Use of Supervision
    • Supervision preparation
      • Identify criteria used to request live versus taped supervision
      • Identify rules and roles of therapist and supervisor during the home visit
        • Discuss the differences between the therapist's focus on the family and the supervisor's focus on the therapist
      • Request supervisor's alternative perspectives of family issues, treatment progress
      • Discuss appropriate times when the supervisor will intervene
      • Debrief session
        • Transitions of beginning and ending session in the home
        • Examine observations and experiences of joining, conceptualizations, and interventions
    • Review the use of intervention skills
      • Note successes
      • Identify potential alternative approaches
  • Guidance of Supervision
    • Establish guidelines for establishing and terminating home-based work
    • Determine family's readiness to change
    • Identify current safety concerns and discuss safety issues associated with the family issues and community contexts
    • Monitor current therapeutic issues and concerns

Therapeutic Skills

The structure and process of supervision facilitates the development of therapeutic skills throughout the of phases of therapy. Supervision that facilitates development accesses theoretical foundations, clinical experiences, and evaluative feedback. The process of supervision encompasses both directive and collaborative approaches.

  • Balance session between use of talk therapy and activities and exercises with the family
  • Discuss use of home environment to access and use information gathered about the family in their environment
  • Identify and prioritize family issues
  • Review ways to make sense of all of the information that home environment affords
  • Discuss the impact of the home environment on the therapist
  • Review the systemic framework used to conceptualize the family issues
  • Identify treatment goals
  • Assess the process of therapy
  • Assess the outcomes of therapy
  • Explore therapist and family worldviews and the interactions occurring between the two

Sample Questions

Sample Questions for Supervision Structure and Therapeutic Skills Development

  1. Questions to ask your supervisor
    • What could I be doing to make this situation worse/better?
    • What am I missing?
    • Do I seem overly critical?
    • Can we have a conversation of each of our expectations of supervision?
  2. Questions to ask yourself
    • What might be behind the family's behavior that I find frustrating?
    • What could I learn about this family that could impact my opinion of them?
  3. Questions your supervisor should be asking you
    • What might the client be feeling about this interaction?
    • Are there aspects of working with this family/in this job that have become more stressful for you?
    • How are you balancing the different aspects of your life (personal and professional obligations)?
    • How are you taking into consideration the family's and your differing worldviews?

Applying the Framework & Post-Test

Threapist-Supervisor Vignette

Therapist-Supervisor Vignette

Janette, a Home-based Family Therapist, has been practicing in a community mental health center for ten years. She enjoys the work but finds that there are times when she experiences increased stress when the agency policies and, subsequently, her supervisor's (Susan) expectations of her change.

One afternoon, Janette returns to the office after a difficult session with a family in their home. Janette asks Susan for an impromptu supervision session to discuss the session. Susan graciously agrees.

Janette begins by describing ways the family appeared resistant to her efforts. She notes that the family members each seemed to question everything she was suggesting but also offered no alternative suggestions. Janette notes that she has faced this type of situation before with other families but that this experience felt different. Susan asked a series of questions that helped her to better understand the situation, the topics discussed, and the challenges as Janette perceived them.

After 45 minutes of exploring the situation together, Susan discovered that Janette had repeatedly dismissed each suggestion she had made and noticed that the conversation had migrated toward Janette's frustrations over the recent agency policy changes effecting her therapeutic work. Susan decided to shift the focus of conversation to overtly address the agency policies and the impact of those changes on both of their roles. After acknowledging their shared experiences of change, the two experienced a greater sense of collaboration as they returned to discussing Janette's family work.


Common Factors

COMMON FACTORS

Supervisor Factors

 

Qualities and skills

Personal maturity, emotionally healthy, enjoys supervisory responsibility, provides a role model, possesses technical and relationship skills

Tasks

Coach, teacher, mentor, administrator

Challenges

Establishes a collaborative and hierarchical balance that matches the supervisee development and is responsive to varying therapeutic issues

Supervisee Factors

 

Qualities and skills

Personal maturity, emotionally healthy, accepts role as supervisee, cognitive abilities, possesses technical and relationship skills

Tasks

Remains teachable, constant learner, provides ethical and legal practice, uses supervision to support clinical work

Challenges

Proactively manages stressors and the potential for burnout and compassion fatigue, maintains appropriate professional and personal boundaries

Supervisor-Supervisee Relationship Factors

 

Qualities

Positive, trusting, respectful relationship

Tasks

Use of warmth, humor, support, and genuineness

Challenges

Minimizes the influences and potential exploitation of multiple relationships

Supervisory Interaction Factors

 

Qualities

Open discussions, shared insights and perspectives, responsive 

Tasks

Utilizes various techniques to facilitate the growth and development of the supervisee, establishes a contract that explicitly addresses supervisor and supervisee expectations of the interactions within and the outcomes of supervision

Challenges

Indirect communication, avoidance of personal or professional issues, roles lack clarity

Contextual Factors

 

Qualities

Values, supervision contract, agency policies, collegial relationships

Tasks

Intentionally address assumptions, biases, and meaning of varying contexts of practice and supervision, collaborative contracting

Challenges

Lack awareness of supervisory, agency, family, community variables


Applying the Therapist-Supervisor Vignette

Consider each of the dimensions from the grid on the previous page and how Janette and her supervisor Susan are managing them.

Supervisor factors: Susan recognized the change in the supervision experience and assessed that Janette may have been experiencing additional stress from a situation outside of her control (agency policy change). She provided the opportunity for Janette to discuss this frustration before moving back to the clinical case. Susan was empathic and helped Janette process the additional stressors.

Supervisee Factors: Although client resistance was familiar to Janette, she recognized her frustration was greater and sought supervision. Janette was able to accept Susan's challenge that something else may be impacting her work and engage in the discussion.

Supervisor-Supervisee Relationship Factors: A trusting and respectful relationship was evident in how Janette and Susan processed both the client stressors and the agency stressors. Susan raised the additional issue and Janette was willing to address it within this relationship.

Supervisory Interaction Factors: Both women shared their frustration about change and were able to move forward from it. They were able to discuss how each of them experienced role changes and how it could be impacting the clinical work. This provided the foundation to return to a more positive case consultation process.

Contextual Factors: In the brief description, the reader has the impression that Susan was able to manage the tension her role as an administrator (supporting agency administrative policy) and her role as a clinical supervisor (recognizing the therapist's stress and supporting her).


Post Test

Click the link to respond to the following survey:

Audio Companion: Utilizing Supervision