Amy Maricle is a blogger, Board Certified Registered Art Therapist, and also a Licensed Mental Health Counselor in Foxboro, Massachussetts. It was about two years ago she and I and began chatting about the clinical supervision that she and I provide. Today I have asked her to share her thoughts with you about one of the many judgement calls that clinical supervisors have to make each and every time we meet with our supervisees.
(If you are interested in writing a guest post, check out the guidelines here.)
________________
A Guest Post by Amy Maricle, LMHC, ATR-BC
Supervisees often come to outside supervision looking for a place to discuss issues that don’t feel safe or timely to discuss with an in-house supervisor. Time is precious, so supervisees need to get the most out of sessions as possible.
Especially for newer clinicians, while their agenda is often clinical, it is just as frequently non-clinical topics, such as:
- Problem solving relationships with coworkers,
- Understanding agency culture and policies,
- Time management, or
- Self-care and boundaries.
With so much time dedicated to these topics, when do clinical supervisors discuss clinical issues? When do we grapple with how to treat Josh’s anxiety or Jenna’s cutting? Is the other stuff even important? Isn’t the clinical work the “real” work we should be doing with supervisees?
When do we talk about the clients?
In my practice, and my own supervision, I have found “professional development” issues to be an important part of overall growth. If we do not assist clinicians to develop skills to be effective team players or to understand the philosophy and process driving agency policy, they likely won’t be effective therapists.
Parallel Process
When discussing agency issues in supervision, I look for the intersections between “organizational” and “clinical” issues.
- Does the adolescent treatment center tend to be reactive to crises? Are staff somehow “cliquey?”
- Is the geriatric center experiencing some “dementia,” perpetually repeating the same unsuccessful interventions with residents?
Identifying these connections can assist therapists in understanding psychological process at the organizational level and, armed with this knowledge, help therapists work more effectively within their system both with coworkers and clients.
Self-Care and Boundaries
In my first year internship, I worked in a long-term treatment facility with women survivors of trauma and addictions. I loved the work, but I gave too much initially and experienced secondary trauma. This was ultimately a gift, as it taught me the importance of consistently monitoring my boundaries with my work. Setting up good habits from early on can help prevent burnout and secondary trauma throughout our careers. Clinical supervisors should be helping supervisees assess their self-care and risk for burnout or secondary trauma on a regular basis.
Imagine a typical scenario: Your supervisee comes to session discussing her overwhelming workload and struggles with time management. No doubt clinicians working in community agencies are overtaxed. You assist her in thinking through prioritization, time management squares, to do lists, and possibly asking for support with her supervisor. After covering all the nuts and bolts, though, you might also think together about whether or not any clinical issues might be at play here.
- Is she spending too much time with clients?
- If so, what is her fear or hesitation in setting clear and predictable limits with her time?
- Is she trying to “save” the client in some way?
- Is she making herself too available without allowing the client some space to grow?
These are incredibly important areas of clinical growth, and also important red flags for therapist burnout and secondary trauma that you can pay attention to together.
It is important to also inquire about her self-care more generally:
- What do you do for fun?
- Have you spent time with friends, family, and your partner this week?
- Have you spent your own money on office supplies?
- Have you made time to take care of the intense feelings that came up during the last group?
Good self-monitoring will allow therapists to self-correct when needed and work through these issues in supervision or therapy when stress or trauma has gotten the best of them. The National Child Traumatic Stress Network has a good facts sheet with links to helpful articles and self-assessments.
Supervision: An Evolving Collaboration
In supervision, I try to strike a balance between discussing “agency” and “clinical” issues by taking a bird’s eye view of supervision topics. I also try to be as collaborative as possible in supervision. When I feel that purely clinical issues are “losing out” to more agency-focused topics, I name that. Keeping an eye on the supervisee’s needs and goals will help us to identify the next step in supervision and hopefully keep the supervisee growing clinically and professionally.
Do you find that professional and clinical growth overlap in some way? What are the issues you find that supervisees most often bring to supervision? How are supervisors helping therapists keep focused on self-care?
_____________________
Amy Johnson Maricle, LMHC, ATR-BC
About the Author: Amy Johnson Maricle, LMHC, ATR-BC is a psychotherapist and art therapist in Foxboro, MA. She loves helping teens and adults find ways to live happier, healthier, and smarter.
Great topic. As a clinical supervisor in private practice, this topic is not discussed enough on the supervisor level. In peer consult groups we mainly discuss clinical issues and our role as a clinician, but rarely do we discuss our role as a supervisor and professional development as a supervisor. I look forward to other people’s comments.
Hi, Robin! It’s great to have you back here! I’ve missed your voice! I completely agree. Even though the trend in the field is for clinical supervisors to have considerable training specific to supervision, here in Colorado, clinical supervisors aren’t required to have any training in clinical supervision! That’s why I’m so glad that Amy brought up this subject and chose to focus specifically on this balancing act that supervisors do in deciding what to talk about and when. It’s a recurring judgement call that every clinical supervisor is called upon to make.
Hey, Robin! Where is your little gravatar?
Hi Robin:
Thanks so much for your comment. I agree that this is an issue that is rarely addressed. The times that it has been addressed, I have really only heard people addressing the need to get the supervisee “back on topic.” I know as a supervisor, I often feel this tension between wanting to let someone vent and problem solve all these critical and ancillary issues, and doing the “real work” of clinical discussion. I think though, particularly for newer therapists, this is part of the developmental curve, and learning to see the parallel process that plays out from families or clients in systems is critical if you hope to not get caught up in it. And, of course, self-care, in my opinion, should almost always be a topic in regular rotation. Thanks again for your input, Robin.
This is a wonderful topic. I remember when I was supervising a master-level intern. I had worked with the same person during her practicum, so we were not new to one another, but the first few weeks were simply focused on getting through what needed to be done in terms of paperwork (because the basic skills for our intake process were already there because they had been worked on in practicum with a supervisor in the room). After that, there was a big shift to working on some clinical issues and “broadening the toolbox,” so to speak. At the same time, I know that I was immediately talking about burnout (yes, from day one) because I felt the prevention was important. Later in supervision sessions, there was probably a typical 70/30 split between talking about client-related issues and professional development issues. Closer to her graduation, the split was probably the reverse. It was very interesting to see the change in her supervision needs.
HI Lauren:
I agree that at each stage of development as a therapist we have different needs in supervision. There are definitely moments when clinical and then professional/organizational issues move to the fore. Ultimately, these parts all come together to help us be the most effective therapists. We can’t do great clinical work in a void – we need to deal with coworkers, referring agencies, psychiatrists, parents, and all the other people surrounding our clients, effectively.
You are absolutely right that we do not work in a void and cannot provide therapy there. I never thought about it in those exact terms, but that’s a wonderful way to put it.
Another thing you just reminded me of is that I like to ask my supervisees to keep an eye on the major news stories. Now, I realize that not everybody prefers to watch the news, but I’m talking about five minutes or so of major headlines. There have been news-related events that I expected to discuss in session that never came up at all, and there have been others that came up much more frequently than I ever would have imagined, and there have been some that even came up without my own conscious thought that this particular story might be something that would, come up in session. Of course, none of us can know everything that we can always ask our client to explain what they saw on the news that is bringing up feelings of [insert emotion], but I find it easier if I at least have some knowledge. Sometimes it’s as easy as starting out by saying “Yes, that has definitely been in the news over the past few days. We weren’t involved in that particular situation, so it’s difficult for us to know all the details of exactly what happened. Can you tell me what this brought up for you?” I suppose I could use the same phraseology if I had no idea what they were talking about, but it’s much more genuine (and undoubtedly perceived as such) when I actually do know what they are referring to. Usually, news-related discussions seem to either be very short because the client just wants to someone to hear their opinion, are very long because something on the news has triggered a much deeper issue for a client.
HI Lauren:
Given that the anniversary of 9/11 is upon us, I think that this is a great reminder for supervisees, and all of us. I too have been surprised a few times by what does and does not seem to touch my clients.
Yep, I’ve been there, too – thinking that the latest newsworthy event would be brought into the clinical hour only to find that it was a quite different event that I had overlooked entirely. And, it’s not always the crime-related events. This week it was the definition of marriage and a few months back it was the Affordable Health Care Act that showed up in my office.
Hi, Lauren! Thanks for dropping in to chat! I really appreciate you talking about the percentages of time spent focused on client and professional development issues. That’s helpful for others to see as they consider their own breakdown of attention.
Thank you for brining up a great and timely topic (as school is starting)! I am an art therapist in private practice, as well as a clinical instructor who supervises many graduate student interns. I find it is very helpful to spend some time in the beginning of class and with new supervises on these “non-clinical” topics.
In fact, thinking back on my own supervision as a new professional, some of the most meaningful support I received was on just these sorts of topics. My career may have taken a different turn if this supervisor had not been open to helping me explore and grow around how to find personal and professional balance without the help of the teachers and other students I had relied on in school.
HI Lynette!
Thanks for reading and commenting. 🙂 I think you make a good point about how critical this kind of support truly is. You are right, if you attend a good program for graduate school, there is a lot of holding and support. Leaving this nest can be jarring, and without good support, I can see how you might have jump ship! I am so glad you got it!
Hi, Lynette! Welcome to Private Practice from the Inside Out and thank you for taking time to drop in and chat!
It’s so easy to complain about our experiences with less-than-ideal experiences in supervision; I appreciate you underscoring the value of choosing really strong supervisors to further your professional growth. Great counselors don’t necessarily make great supervisors. While it’s important to know the what counselors need to know, it is a different skill set that is required to support the professional development of another.
As a psychotherapist and supervisor I like both approaches … i loved to get supervised during my professional training in Munich/Germany and now I have many supervises and also love to learn from their fresh experiences.
Thanks for your post … a very good and interesting website!
All the best,
Martin
Hi, Martin! Welcome to Private Practice from the Inside Out! I see that your website is in German and I’m wondering what it is that you are doing in Germany. Care to share? I love hearing from non-American perspectives so that we can all learn from each other.
Hi Martin
I too love how supervisees keep me “fresh” and on my toes. I find that the old saying about learning as you teach to be so true. I find too that what I have to say reminds me to follow my own advice!
Cheers!
Amy
Ha ha ha – Amy, that’s so true! – If I’m teaching it, I really am more likely to follow those best practices! That’s a great point!
“When do we talk about our clients” caught my eye. This is beside the point of the actual article, but: however you decide to use your supervision time, please don’t talk about clients in or after AA meetings or other non-professional gatherings. It’s astonishing how many identifying details practicing therapists let slip; at times, I’ve been tempted to contact the client with a heads up about their privacy being violated.
NotATherapist, thank you so much for pointing this out. I, too, have been in restaurants or at social gatherings with colleagues only to have them start describing their interactions with their clients. Not only is that completely unprofessional, it’s also unethical and, often, illegal! After all, if you don’t have your client’s permission to be discussion them with another professional, you’ve just broken confidentiality – and I doubt they ever intended for that discussion to take place within earshot of others in very public places. Thanks for the reminder!
Thank you for your comment, NotaTherapist. It’s a shame when people do not follow the rules of confidentiality and restrict these important consultations to a private supervision session with another therapist who is bound by the same rules of confidentiality. These consultations, when done appropriately, are a part of ethical and responsible practice. Chatting at dinner is not a part of that. I echo Tamara’s comments about that. Be well, Amy
Hello!
I am a newly licensed PC starting a private practice. In the state of Ohio, supervision is required to be able to diagnose. Of course, if I want to accept insurance, I have to be able to provide some form of diagnosis. My question is, how often does one typically meet with his/her supervisor? If we only meet once a week, or maybe even once a month, how does diagnosis work? I do not necessarily want to shell out $100 a week for supervision, but then again I would want to process insurance as soon as possibly to collect payment. Lastly, does the supervisor even have to check off on every diagnosis or is this just something reviewed on an “as we meet” basis to ensure that I am on track? ANY insight is greatly appreciated! I love this site – very helpful!
Hi, Holly! Welcome to Private Practice from the Inside Out. Perhaps you will have some counselors from Ohio chime in here to give you some guidance. That would be great. However, you really need to get information about any restrictions on diagnosing and required supervision directly from your licensing board in your particular state. Sometimes counselors with good intentions can give faulty information.
What I can tell you is that every state in the USA has it’s own set of restrictions, conditions, and laws that regulate how, when, and where mental health professionals can practice (and even those vary from discipline to discipline). When I supervised counselors-in-training in Texas, supervision was structured such that they met with their clinical supervisor weekly. Here in Colorado, clinical supervision is structured somewhat more loosely and, instead, must only occur “evenly” throughout the period of supervision.
Because clinical supervisors in every state are legally and ethically responsible for everything a counselor-in-training does with clients while under a supervisor, diagnoses, progress notes, assessments, referrals, interactions, and all other aspects of client care need to be “run by” a supervisor. As your supervisor begins to trust your clinical and professional judgement, s/he may choose to loosen the strings a bit – but don’t count on it.
And, as for wanting to collect insurance reimbursements, I am not aware of any managed care company that is willing to reimburse for services provided by someone who is unable to practice independently. Perhaps this is different in Ohio?
Finally, here is a blog post I wrote a while back about Clinical Supervision and “Money Gouging.”
HI Holly:
I am really glad that you raised this question, thanks for your comment! In addition to the ethical/legal dimensions of diagnosis and payment, which Tamara already addressed, I hear another important aspect of this topic. Who is providing private practitioners with clinical, ethical, and emotional support in private practice?
I think this is an important question to ask. I really believe in assembling a team of people who can support you in all aspects of your work. Business coaches will tell you that if there is something you are not good at, or can’t do on your own, hire someone else to do it. So for example, I don’t mind doing my bookkeeping, so I do my own, but I am clueless about tech stuff, and so I hire someone for that. However, no matter how good a clinician you are, you can’t be your own supervisor.
The key part of any therapist’s support team should be a supervisor. Some may be able to find a good peer or peer supervision group with whom to consult regularly about clinical and business issues, and do well with this. Especially being newly licensed, and new to private practice though, I would encourage you to think of paid supervision as part of the cost of running your business. You are investing in your print materials, your marketing, your networking lunches, and your website, so should you also be investing in supervision.
I look at the cost of supervision as part of the cost of running my business successfully and ethically. A good supervisor who knows private practice will help point out new blind spots that come up in private practice. Working with clients independently is very different from working on a team at a hospital or in a community agency. If you are used to working as part of a clinical team, private practice is a big shift.
Combining therapy and business also brings up a whole host of new issues that you may have never faced before. (Especially if you have not worked as a fee for service clinician.) Suddenly clients coming and going has a new emotional and financial meaning for you: your finances depend on having a certain caseload, and clients seeking you out or leaving can make you feel like you are a great therapist or a terrible one. (Rightly or wrongly.) We need to make sure that the clinical decisions we are making are driven by the client’s needs, not ours. It’s important to have someone supporting you, educating you, and helping you check yourself clinically and ethically.
I wish you all the best in your new endeavor!
Amy
Amy, thank you so much for taking the time to pick up on and address this issue! It’s such an important one and you are so on target. Every psychotherapist should plan on continuing consultation / supervision throughout his her career. Here’s a post explaining the difference between supervision and consultation. And, here’s how you can find your own clinical supervisor.
When I initially commented I clicked the “Notify me when new comments are added” checkbox and
now each time a comment is added I get several
emails with the same comment. Is there any way you can remove me from that service?
Appreciate it!
Mind Power, I have no idea. Let me see if I can get my web guru to address this.
There are 2 wonderful books that have helped me. The first is Between Therapists. The second is The Artist as Therapist. Both are written by art therapist, /professor, Dr. Art Robbins. The tenet of both books is that as a therapist, we go inside ourselves to a part that resonates with our client. For example, we all have ‘black hole’ part, a crazy part.
When I supervise, I ask my supervisees to relate from this part. I, myself, dip into my insecurities as a ‘good enough therapist’ to help me resonate with the often unspoken words of a new art therapist supervisee.
HI Claudia:
You make a great point about how important it is to stay in touch with our own emotions and reactions, not just in therapy, but also in supervisory relationships. When I notice myself thinking, “I don’t know enough to help this person” it’s always a cue that I’m trying to hard, and it’s often indicative of an important emotional reaction in the supervisee that I need to notice. I will check out those books too.
Cheers,
Amy
Hi, Claudia! Thanks so much for dropping in to hare these books! They both sound excellent and I can’t wait to check them out!
Hello everyone, I have a question and it may sound silly. I’m planning to do individual supervision as part of my private practice. Individual is easy to do since I receive individual supervision when I receive my LCSW. But how do you do group supervision?? I mean how do you mange discussing cases with two or three other supervisees in a one hour session?? My fear is that one of the supervisees might get more of supervision than the other. I know there are advantages of group supervision but at the same time I don’t want to short change the supervisees since they are paying out of pocket and it’s my time and experience I’m giving. Is there a format to follow to ensure everyone gets something out of the session. I’m very excited to hear feedback from anyone.
In my home state of New York, LMSW supervisee must obtain 100 supervision hours and 2,000 clinical contact hours in at least 3 yrs period. Just an FYI to anyone who is reading this.
Hi, Wendy! Thanks so much for posting this question here.
When I offer group supervision, it is often as an adjunct to individual supervision.
I may or may not be the primary supervisor for the individuals in the group but I stipulate that (and they contract to) being in individual supervision at the same time.
That ensures that therapists-in-training are getting the 1:1 time necessary to thoroughly review their work with their caseloads in depth.
Then, in my group, I tend to facilitate them thematically.
By that, I mean that I may address self-harm or suicide or intakes or paperwork or informed consent or whatever – one group at a time.
And, we’re talking about the participants reactions to / concerns with these specific topics as they relate to their clinical work.
Does that make sense?