Psychotherapy Supervision: Theory, Research, and Practice, 2nd edition

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PSYCHOTHERAPY SUPERVISION THEORY, RESEARCH, AND PRACTICE SECOND EDITION

Edited by

Allen K. Hess Kathryn D. Hess and Tanya H. Hess

John Wiley & Sons, Inc.

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PSYCHOTHERAPY SUPERVISION

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PSYCHOTHERAPY SUPERVISION THEORY, RESEARCH, AND PRACTICE SECOND EDITION

Edited by

Allen K. Hess Kathryn D. Hess and Tanya H. Hess

John Wiley & Sons, Inc.

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∞ This book is printed on acid-free paper. 

C 2008 by John Wiley & Sons, Inc. All rights reserved. Copyright 

Published by John Wiley & Sons, Inc., Hoboken, New Jersey. Published simultaneously in Canada. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 United States Copyright Act, without either the prior written permission of the Publisher, or authorization through payment of the appropriate per-copy fee to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, (978) 750-8400, fax (978) 646-8600, or on the web at www.copyright.com. Requests to the Publisher for permission should be addressed to the Permissions Department, John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, (201) 748-6011, fax (201) 748-6008, or online at http://www.wiley.com/go/permissions. Limit of Liability/Disclaimer of Warranty: While the publisher and author have used their best efforts in preparing this book, they make no representations or warranties with respect to the accuracy or completeness of the contents of this book and specifically disclaim any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives or written sales materials. The advice and strategies contained herein may not be suitable for your situation. You should consult with a professional where appropriate. Neither the publisher nor author shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold with the understanding that the publisher is not engaged in rendering professional services. If legal, accounting, medical, psychological or any other expert assistance is required, the services of a competent professional person should be sought. Designations used by companies to distinguish their products are often claimed as trademarks. In all instances where John Wiley & Sons, Inc. is aware of a claim, the product names appear in initial capital or all capital letters. Readers, however, should contact the appropriate companies for more complete information regarding trademarks and registration. For general information on our other products and services please contact our Customer Care Department within the United States at (800) 762-2974, outside the United States at (317) 572-3993 or fax (317) 572-4002. Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books. For more information about Wiley products, visit our web site at www.wiley.com. Library of Congress Cataloging-in-Publication Data: Psychotherapy supervision : theory, research, and practice / edited by Allen K. Hess, Kathryn D. Hess, Tanya H. Hess.—2nd ed. p. ; cm. Includes bibliographical references and index. ISBN 978-0-471-76921-7 (cloth : alk. paper) 1. Psychotherapy—Study and teaching (Supervision) 2. Psychotherapists—Supervision of. I. Hess, Allen K., 1945– II. Hess, Kathryn D. III. Hess, Tanya H. [DNLM: 1. Psychotherapy—education. 2. Mentors. 3. Psychotherapy—organization & administration. M 18 P979 2008] RC480.5.P778 2008 2008011998 616.89 14–dc22 Printed in the United States of America. 10

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Contents Preface Contributors

ix xiii

PART ONE HISTORICAL CONTEXT 1

Psychotherapy Supervision: A Conceptual Review Allen K. Hess

3

PART TWO PERSPECTIVES OF PARTICIPANTS 2

The Dynamics of Change and Outcome in Psychotherapy Supervision: A Note on Professional Identity Paul M. Lerner 3 The New Supervisee: Order from Chaos Ryan Weatherford, Tiffany O’Shaughnessy, Yoko Mori, and Anju Kaduvettoor 4 On Being Supervised Tanya H. Hess and Allen K. Hess 5 Supervising International Students in Counseling and Psychology Training Johanna E. Nilsson and Chia-Chih DC Wang 6 The Transition from Supervisee to Supervisor Lindsey L. Cohen and Crystal S. Lim

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PART THREE PSYCHOTHERAPY ORIENTATIONS 7

Psychoanalytic Supervision Marvin Hyman 8 Supervision of Narrative-Based Psychotherapy Jefferson A. Singer, Jenna Baddeley, and Lisa Frantsve 9 Supervision and Training of Experiential Psychotherapists Alvin R. Mahrer 10 Interpersonal Approaches to Psychotherapy Supervision: A Vygotskiian Perspective Allen K. Hess, Clara E. Hess, and Joel H. Hess

97 114 137

157

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vi CONTENTS PART FOUR 11 12 13 14

Supervision of Couples and Family Therapy Lyn E. Styczynski and Leonard Greenberg Supervision in Therapeutic and Collaborative Assessment Leonard Handler Hypnotherapy Supervision C. Alexander Simpkins and Annellen M. Simpkins Supervision of Paraprofessional Human Service Workers Steven Walfish and Ellis Gesten

PART FIVE 15 16 17

PART SIX 18 19

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DEVELOPMENTAL PERSPECTIVES

The Supervision of Child Psychotherapy Robert M. Leve Supervising Psychotherapy with Adolescents Kathryn D. Hess Supervising Novice Geropsychologists Norman Abeles and Mark Ettenhoffer

265 286 299

SPECIAL POPULATIONS Supervising Psychotherapy of Abuse Survivors Nancy Kaser-Boyd Supervising Substance Abuse Treatment: Specific Issues and a Motivational Interviewing Model Michael B. Madson, Emily E. Bullock, Alayna C. Speed, and Shirley A. Hodges Supervising Therapists Treating the Severely Mentally Ill Bertram P. Karon Clinical Supervision in Correctional Settings Max J. Mobley Teaching Interventions with the Sexually Disordered Barbara K. Schwartz Psychotherapy Supervision and Angry, Hostile, and Violent Patients Allen K. Hess Supervision in Medical Settings C. Don Morgan, Dana K. Soetaert, and Robin J. Heinrichs

PART SEVEN 25

SPECIAL MODALITIES

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340

359 380 409

432 450

RESEARCH DEVELOPMENTS

State of the Art in the Assessment, Measurement, and Evaluation of Clinical Supervision Michael V. Ellis, Nadia D’Iuso, and Nicholas Ladany Research: The State of the Field Arpana G. Inman and Nicholas Ladany

473 500

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Contents

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PART EIGHT PROFESSIONAL ISSUES 27

Ethical and Legal Considerations in Psychotherapy Supervision Allen K. Hess

521

PART NINE RACE, SEX, AND GENDER CONSIDERATIONS 28 29

Racial and Cultural Aspects of Psychotherapy and Supervision Ivory A. Toldson and Shawn Utsey Gender and Sexual Orientation in Supervision Johanna E. Nilsson, Danah M. Barazanji, Codi L. Schale, and Angela D. Bahner

537 560

PART TEN STATE OF THE FIELD AND ITS FUTURE 30

Summing Up and Moving Forward Allen K. Hess

579

Author Index

591

Subject Index

611

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Preface The first edition of Psychotherapy Supervision (1980, p. 76) was a collection of original contributions attempting to define the as yet uncharted regions of teaching and learning of psychotherapy. The supervision of psychotherapy is an activity that many mental health professionals engage in; however, as with many high frequency activities, it has gone largely unnoticed. Carl Rogers (1957) came closest to recognizing psychotherapy supervision in his description of experiential techniques and human qualities that encourage psychotherapists to develop. Rogers’ early recognition of the issues involved in training psychotherapist has gone unheeded and the current status of the field still can be accurately summarized by his quote; “Considering the fact that one-third of present day psychologists have a special interest in the field of psychotherapy, we would expect a great deal of attention might be given the problem of training individuals to engage in the therapeutic process. . . . For the most part this field is characterized by a rarity of research and plentitude [sic] of platitudes.”

Issued a quarter century later, the second edition is published at a time when great changes have occurred. As Watkins (1997) indicated more than a decade ago, “Since then [publication of Hess, 1980] the field of psychotherapy supervision has continued to develop, with the growth of new models, research, and practice (e.g., Watkins, 1996, in press, p. ix).” His Handbook was a major comprehensive resource in the field. It is timely that a new generation of supervisors and supervisees have a comprehensive resource that captures the early excitement of this field as well as the latest research and theory. Psychotherapy supervision now appears to be in its robust adolescence, with areas of great growth and areas that have not previously been addressed. For example, supervision seems to have found a congenial home in the American Psychological Association’s Division 17 (Counseling). Yet its application to major clinical concerns seems lacking. That is, which specific problems must the student and supervisor consider when sending the student to a geriatric, a child, or a prison facility? What sort of issues arise when treating the addicted, the abused, and the severely mentally ill? What clinical and personal experiences does the student bring to psychotherapy that help or hinder both service provision and supervision? Is the supervisor skilled enough in the area to provide support? What onsite resources and personnel are available for clinical teaching and backup? The second edition ventures from the warm confines of a good childhood to see the clinical application of psychotherapy and its supervision as a robust adolescent. Part One, Historical Context, contains one chapter, a conceptual review of psychotherapy supervision. This is a historical account of the major ideas and literature enriching the field that orients the reader to subsequent chapters. ix

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x PREFACE Part Two, Perspectives of Participants, features views from participants. Chapter 2 is Paul M. Lerner’s final work. Anyone who met him or read Dr. Lerner’s work will immediately find an old friend, one whom we miss. Chapter 3 by Weatherford, O’Shaughnessy, Mori, and Kaduvettoor and Chapter 4 by Hess and Hess provide student perspectives. Students will find comfort in knowing their colleagues share their fears, hopes, and attempts to learn psychotherapy’s complex ways and to become skilled practitioners. Supervisors will be reminded of how it feels to be a student, searching and in need of guidance. The world has been internationalized, with the United States becoming the center of learning, filling the role that Europe occupied alone the past few centuries. We see increasing numbers of international students in our programs. Our international students pose challenges that require the understanding of our best supervisors, who can find resources in Nilsson and Wang’s chapter. The final chapter in Part Two is both new and a reprise of an important chapter from the first edition. Cohen and Lim describe the issues new supervisors face when trying to help students become skilled. Part Three, Psychotherapy Orientations, contains four chapters. Hyman’s psychoanalytic chapter complements the psychoanalytic chapters in the first edition. The narrative-based psychotherapy chapter introduces the reader to an emerging system with its origins in Allport and Murray, its technological and theoretical development in McAdams, and its psychotherapy application and supervision in Singer. The experiential chapter, new to this edition, shows a technique for personal growth that we hope enlivens the reader as it did us when we reviewed it. The final chapter in Part Three extends interpersonal theory and practice to include the perspective of a long-lost psychologist. Sullivan, Horney, and Buber enriched interpersonal theory, but researchers have applied Vygotsky in educational circles but not in general clinical and counseling circles, eluding psychology’s notice. This chapter extends Vygotsky’s teachings to psychotherapy and its supervision. Part Four, Special Modalities, begins with a chapter on the supervision of couples and family psychotherapy by a couple, Styczynski and Greenberg, who formed an institute. Through their institute they have rendered more than a quarter century of treatment and teaching. Finn, Fischer, and Handler developed a method of testing that engages the patient therapeutically in the assessment process. In his chapter, Handler shares his clinical wisdom in applying this technique. The Simpkinses’ hypnotherapy supervision chapter shares Eriksonian techniques of hypnosis and supervision. The Simpkinses learned at Erikson’s feet some 30 years ago, have applied these techniques to many clients, and have taught them to a number of students. Part Four concludes with a chapter concerning a ubiquitous service provider who does not get much attention in the professional literature: the paraprofessional. Walfish and Gesten tell us about the learning needs of lay workers and paraprofessionals working with suicide hotlines, substance abusers, and school systems. In Part Five, Developmental Perspectives, chapters by Leve, Hess, and Abeles and Ettenhoffer explore supervision issues across the life span specific to age and developmental status. Child, adolescent, and geriatric psychotherapies involve special challenges, so these chapters are essential reading. For example, psychotherapy privilege, limited emancipation, and medication and substance abuse issues lie

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Preface

xi

in wait for the unprepared student. The student clinician and his or her supervisor who have considered the questions raised and the guidance offered in these chapters will provide more effective service. Part Six, Special Populations, leads with a critical chapter by Kaser-Boyd that summarizes her many years treating abuse survivors. Madson, Bullock, Speed, and Hodges introduce supervision of motivational interviewing as a treatment for addicts. This refractory population has frustrated many a clinician’s efforts, so learning about new techniques is always welcome. Karon has a special touch with the severely mentally ill that he learned from John Rosen and has shared with a half century of clients and students. Karon shares his approach with us in his chapter. Mobley’s chapter is needed, as prison populations are proving a growing industry. The mentally ill are being incarcerated at ever-dizzying numbers at the same time that mental health facilities and third-party providers are closing the doors to many people enmeshed in addictions and the criminal world. Some of these clients are sexual offenders, a topic Schwartz addresses in her chapter on therapeutic approaches. Client hostility and anger are not confined to institutions. Hess’s chapter concerns anger, hostility, and violence both in institutions and in the consulting room with outpatient clients. Psychologists engaged in rendering hospital-based services will be enriched by Morgan, Soetaert, and Heinrichs’s chapter, which addresses both the norms of hospital work and how they affect which type of psychotherapy is most effective. Part Seven, Research Developments, tells us that as supervision has been mandated in more settings and the competency movement (see Chapter 1) has grown, so has the need for assessment of psychotherapy supervision. Ellis, Ladany, and D’Iuso provide a survey of the available instruments and their validation bases. Inman and Ladany’s chapter presents a report on the state of the research base for psychotherapy supervision. In Part Eight, Professional Issues, Hess presents some ethical flashpoints specific to supervision. He includes the legal contours and responsibilities entailed in the various relationships in which supervision is conducted. Knowledge of the ethical reasoning and the legal consequences of tortious actions that can arise in the practice of supervision provides a base from which one can practice with a sense of security. In Part Nine, Race, Sex, and Gender Considerations, Toldson and Utsey examine how cultural and racial aspects of individuality in clients, student psychotherapists, and supervisors ennoble supervision rather than serve as deficits or barriers to human understanding. Nilsson, Barazanji, Schale, and Bahner sensitively explore the sexual and gender orientation aspects of the three supervisory parties and how these can present problems or opportunities. In Part Ten, State of the Field and Its Future, Hess offers thoughts about the continued development of this robust professional specialty that all supervisors both in psychology and in allied professions need to know. This need is based on the fact that mental health professionals supervise, often without training and educational support, so when they are assigned supervisees, they may also find themselves practicing beyond their competence. But even more than this, human actualizing needs ought to impel the psychologists to enrich their world of practice

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xii PREFACE and service. How much more of a person can we be when we can positively influence the lives of our students and, through them, a generation or more of our students’ clients? Our gifts can help us touch a piece of the future. We hope you share the excitement we feel in seeing the development of psychotherapy supervision in terms of its theories, research base, and the varied ways it has been applied to professional practice. We are grateful to the many people who have contributed to the field. Patients have helped students learn, students have placed faith in their supervisors, and supervisors have acted as role models and opened up themselves and their work for students to learn. The Wiley team—Patricia Rossi, Kathleen DeChants, Linda Indig, and Pam Blackmon from Publications Development Company of Texas—is an A team and has shepherded this project to its completion. Steven Walfish is an ever-ready editorial resource. And Clara and Joel, who joined us in this book, are the lights of our lives. The response to the first edition of this work has been more than one can expect, for which we are grateful. In fact, many parts of this edition and the first fit together in a complementary fashion and hold a timelessness from which the reader may benefit if a copy of the first edition is available to him or her. We would like to hear from you in order to find out what you find useful and what you would like to see in any future editions. We appreciate working with our talented, informed, and personable chapter authors. ALLEN K. HESS Montgomery, AL KATHRYN D. HESS Montgomery, AL TANYA H. HESS Philadelphia, PA REFERENCES Hess, A. K. (1980). Psychotherapy supervision: Theory, research and practice. New York: Wiley. Watkins, C. E. (Ed.). (1997). Handbook of psychotherapy supervision. New York: Wiley.

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Contributors Norman Abeles, PhD Department of Psychology Michigan State University East Lansing, Michigan Jenna Baddeley, MA Department of Psychology University of Texas—Austin Austin, Texas Angela D. Bahner, PhD Social Science Division Metropolitan Community College—Longview Lee’s Summit, Missouri Danah M. Barazanji, BA Division of Counseling and Educational Psychology University of Missouri—Kansas City Kansas City, Missouri Emily E. Bullock, PhD Department of Psychology University of Southern Mississippi Hattiesburg, Mississippi Lindsey L. Cohen, PhD Department of Psychology Georgia State University Atlanta, Georgia Nadia D’Iuso, MA Department of Educational and Counseling Psychology State University of New York—Albany Albany, New York

Michael V. Ellis, PhD Department of Educational and Counseling Psychology State University of New York—Albany Albany, New York Mark Ettenhoffer, MA Department of Psychology Michigan State University East Lansing, Michigan Lisa Frantsve, PhD Department of Psychology West Haven Veterans Administration Hospital West Haven, Connecticut Ellis Gesten, PhD Department of Psychology University of South Florida Tampa, Florida Leonard Greenberg, PhD Family Therapy Institute of Washington, DC—Boston Campus Boston, Massachusetts Leonard Handler, PhD Department of Psychology University of Tennessee—Knoxville Knoxville, Tennessee Robin J. Heinrichs, MA Department of Psychiatry and Behavioral Sciences University of Kansas School of Medicine—Wichita Wichita, Kansas

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xiv CONTRIBUTORS Allen K. Hess Department of Psychology Auburn University—Montgomery Montgomery, Alabama Clara E. Hess, MS Department of Psychology North Carolina State University Raleigh, North Carolina Joel H. Hess, BA History/UTeach Program University of Texas Austin, Texas Kathryn D. Hess, MS Montgomery Alabama Tanya H. Hess, MA Department of Psychology University of Tennessee Knoxville, Tennessee, and Psychology Intern, Department of Psychiatry Pennsylvania Hospital Philadelphia, Pennsylvania

Anju Kaduvettoor, MEd Department of Education and Human Services, Counseling Psychology Program Lehigh University Bethlehem, Pennsylvania Bertram P. Karon, PhD Department of Psychology Michigan State University East Lansing, Michigan Nancy Kaser-Boyd, PhD, ABAP Geffen School of Medicine University of California—Los Angeles Los Angeles, California Nicholas Ladany, PhD Department of Education and Human Services Lehigh University Bethlehem, Pennsylvania Paul M. Lerner, EdD (deceased) Private Practice Camden, Maine

Shirley A. Hodges, BA, BS Department of Psychology University of Southern Mississippi Hattiesburg, Mississippi

Robert M. Leve, PhD Department of Psychology University of Hartford Hartford, Connecticut

Marvin Hyman, PhD (retired) Private Practice of Psychoanalysis West Bloomfield, Michigan Detroit Psychiatric Institute and Department of Psychiatry and Behavioral Neuroscience Wayne State University School of Medicine Detroit, Michigan

Crystal S. Lim, MA Department of Psychology Georgia State University Atlanta, Georgia

Arpana G. Inman, PhD Department of Education Lehigh University Bethlehem, Pennsylvania

Alvin R. Mahrer, PhD School of Psychology University of Ottawa Ottawa, Canada

Michael B. Madson, PhD Department of Psychology University of Southern Mississippi Hattiesburg, Mississippi

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Contributors xv Max J. Mobley, PhD (retired) Director of Mental Health Services Arkansas Department of Corrections Morrilton, Arkansas

Jefferson A. Singer, PhD Department of Psychology Connecticut College New London, Connecticut

C. Don Morgan, PhD Department of Psychiatry and Behavioral Sciences University of Kansas School of Medicine—Wichita Wichita, Kansas

Dana K. Soetaert, BA Department of Psychiatry and Behavioral Sciences University of Kansas School of Medicine—Wichita Wichita, Kansas

Yoko Mori, MS Department of Education and Human Services, Counseling Psychology Program Lehigh University Bethlehem, Pennsylvania

Alayna C. Speed, BS Department of Psychology University of Southern Mississippi Hattiesburg, Mississippi

Johanna E. Nilsson, PhD Division of Counseling and Educational Psychology University of Missouri—Kansas City Kansas City, Missouri Tiffany O’Shaughnessy, BA Department of Education and Human Services, Counseling Psychology Program Lehigh University Bethlehem, Pennsylvania Codi L. Schale, MA Division of Counseling and Educational Psychology University of Missouri—Kansas City Kansas City, Missouri Barbara K. Schwartz, PhD RULE Program Maine Correctional Center Windham, Maine Annellen M. Simpkins, PhD San Diego, California C. Alexander Simpkins, PhD San Diego, California

Lyn E. Styczynski, PhD Director of Clinical Training The Family Center, Inc. Somerville, Massachusetts Ivory A. Toldson, PhD Department of Education and Counseling Psychology Howard University Washington, DC Shawn Utsey, PhD Department of Psychology Virginia Commonwealth University Richmond, Virginia Steven Walfish, PhD Private Practice Atlanta, Georgia Chia-Chih DC Wang, PhD Division of Counseling and Educational Psychology University of Missouri—Kansas City Kansas City, Missouri Ryan Weatherford, MEd Department of Education and Human Services, Counseling Psychology Program Lehigh University Bethlehem, Pennsylvania

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PART ONE

HISTORICAL CONTEXT

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CHAPTER 1

Psychotherapy Supervision: A Conceptual Review ALLEN K. HESS

THE STORY of psychotherapy supervision begins with the first psychotherapy session. If the first psychotherapist was successful, no doubt he or she was affected along with the client. This sensitivity allows the psychotherapist to learn about the client’s world as well as his or her own world. The joys and perplexities of learning about the client can be seen as the student faces his or her first clients. That is, the supervisee’s fears of schizophrenic patients might be addressed in supervision. This fear might be ameliorated once the student is removed from the immediacy of the clinical session and reflecting during supervision now realizes how terrified the schizophrenic might have been. The student now has the luxury to examine the world from the schizophrenic’s perspective. That is, deciphering the patient’s language gives the student a taste of the patient’s frustrations trying to communicate to others, as the patient’s meanings of words and events keep shifting and people shrink away. Consider the student’s first anxiety disordered patient. The patient may experience the flooding of the senses with feelings of cold sweat, scratchy dry eyes, and a pounding pulse in the presence of what seems to others to be an ordinary situation. Usually others will see the patient’s experiences as silly overreactions. However, the sensitive and supervised trainee can examine his or her own biases by recognizing his or her free-flowing feelings and stereotypes about the patient. Then the student can contrast this stereotype with the human and empathic experience of the person during the first sessions. The need for a safe place to reflect upon the psychotherapy sessions is essential for successful psychotherapy to ensue. This process of clinical learning is embedded in the history of psychotherapy. In Charcot’s illustration of hysteric phenomenon or Freud’s sharing of Bernheim’s hypnosis demonstration with Breuer we see the rudiments, the embryonic hints, of psychotherapy and its supervision. Breuer and Freud conferred about the 3

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4 HISTORICAL CONTEXT hysterical symptomatology they witnessed when their hypnotized patients with conversion reactions remitted their symptoms, only to see these symptoms return when the patients emerged from hypnosis. The patients expressed anger when offered the insight that their symptoms were psychically driven. The anger perplexed Breuer and Freud (1895/1955), leading them to conceptualize resistance and an unconscious world with repression as a key feature of the patient’s world. These consultations or peer supervision allowed for conceptual breakthroughs in the understanding of medical psychology and psychodynamics. Amid these vapors of history, contemporary psychotherapy and its supervision emerged. The balance of this chapter captures some of the individuation of supervision until it became recognized as a professional activity. The story of psychotherapy in antiquity was ably told by Ehrenwald (1956) and its essence distilled by Frank and Frank (1993). We begin our story with the advent of psychoanalysis, the first grand psychotherapy system of the current era, and then trace the other two dominant models of psychotherapy. We trace the emergence of supervision as a field of inquiry and examine the roles that supervision might entail. Next we review the models that have been posited to account for psychotherapy supervisee and supervisor growth, followed by analyzing the role of the supervisor. The final part of this chapter presents recent developments, including a spiral omnibus conceptualization of the educational process upon which successful and growth-oriented supervision rests.

THE SYSTEMS PSYCHOANALYTIC Freud hosted Wednesday evening group meetings in his home. These sessions consisted of both theoretical and case discussions. In effect, group supervision was conducted. These sessions were the central vehicle for the development and conveyance of new ideas and techniques, featuring presentations rotated among an inner circle. Education was and remains a cornerstone in the psychoanalytic edifice. The education committee remains among the most important committees in the psychoanalytic training institutes. Training and control analyses provided refinement for the clinician. Through training analyses, clinicians were to unearth their own blind spots and empathically understand what the psychoanalytic task entailed for the analysand (e.g., realize how much mental work was involved in the seemingly simple request to free associate). How did resistance show itself? When was a person ready for an interpretation? What issues did the analyst-as-analysand have that would weigh upon his or her work? How able was the analyst to see the client’s view of the world? How did the trainee’s personality structure limit his or her ability to see the analysand’s world? These were grist for mill for the training analysis. “The analyst as the analyzing instrument must understand the process from the inside,” as Caligor (1985, p. 120) stated. The training analyst reported to the education committee, creating tremendous anxieties and compromises with regard to the analysis in both the analyst and analysand. This reporting function echoes one of today’s main concerns about psychotherapy supervision.

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Psychotherapy Supervision: A Conceptual Review

5

Control analysis is mandated in all psychoanalytic training. The certificate candidate is required to have at least two control analysis cases, preferably at least one child case, that are supervised by two different analysts, neither of whom is the training analyst (except in the Budapest school of psychoanalysis; Krasner, 1983). The control analyst ought to be a catalyst for the student’s cases and serve as the analyst for neither the client nor the student. Goals include being free to listen to the patient in his or her construction of the world; focusing on transference issues; as well as determining how the student may have blockages in hearing the analysand, thus manifesting countertransference. Group control analyses form part of some training programs so the student can relieve some of the control analysis pressure and compare and contrast his or her own control analysis with peers’ experiences. Such analyses often continue throughout the analyst’s career, accomplishing lifelong education and clarification of one’s own emotions, allowing for personal growth. The prototype was Freud’s ongoing “congresses” with Fleiss. The aim is for ongoing self-discovery because the overarching goal of psychoanalysis for all parties is to “know thyself.” In this way, hidden motivations are unearthed and will not burst through one’s defenses and sabotage one’s way in the world. This is consistent with the third form of educational analysis—personal analysis. Personal analysis is expected and often mandated, both in psychoanalytic programs and in many doctoral programs (particularly those with psychodynamic orientations). Although instructive in terms of the demands it makes on the analysand, the purpose of psychoanalysis is both to help the analysand with uncovering and resolving emotional conflicts and to stimulate personal growth. The only reporting function of the psychoanalyst might be to certify that the student is in personal analysis. Macran, Stiles, and Smith (1999) studied transcripts of interviews with seven practicing psychotherapists about how these therapists’ own personal psychotherapy affected their clinical work. They found that therapists who experienced helpful conditions offered by their own psychotherapists seemed better able to provide these conditions for their clients. Macran et al. organized these therapist effects into three areas: (1) understanding power, boundaries, and humanity in caring for the client; (2) providing trust, respect, and patience; and (3) listening with the third ear, a term Reik (1948) used to indicate a clinical sense based on interpreting subtle cues that provide intuitive understanding or paying attention to the inner experience of the psychoanalyst. This learning regimen—personal, training, and control analyses—provides several important concepts and foci. The successfully trained clinician’s intellect, emotional insight, and observational powers will be finely honed instruments in the service of the client. If one knows one’s self, drives, and blind spots, then one can listen effectively and intervene in the client’s interest and in his or her own self-development. This avoids many ethical concerns (see Chapter 27). Psychoanalytic abstinence refers to the analyst’s refraining from behaviors for his or her own gratification for the greater good of the patient. This concept is crucial for growing a high-functioning clinician and person. The transference and countertransference are clear, and the patient’s analysis is not muddied by the bleeding through of the analyst’s unfinished business. Psychoanalytic incognito reinforces this process. That is, the psychoanalyst turns the relationship from social to asocial by not reciprocating as one would ordinarily do in social discourse (Beier, 1966). If one

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6 HISTORICAL CONTEXT person reveals feelings or information about his or her family or work situation, norms of ordinary social intercourse press the listener to respond reciprocally by revealing similar information about himself or herself. Psychotherapy, particularly psychoanalysis, creates an asocial role whereby such reciprocal revelations might be countertherapeutic. The therapist’s sharing of his or her own revelations would create forces in the sessions that would rob the psychotherapy of its curative elements. Consider a psychotherapist who discusses his or her religious views with a patient who has not yet revealed her questions about abortion or his questions about divorce. Learning of the psychotherapist’s background will influence, channel, exaggerate, or repress the patient’s freedom to bring up issues and inhibit or influence material that might be important in treatment. Sullivan (1962) recognized this as transference jam, whereby the ability of the patient to freely experience and relate experiences is dammed, or jammed, up. This prevents the patient from engaging more deeply, safely, and sincerely in psychotherapy. The issues of the psychoanalyst’s experience and inclinations ought to be considered before accepting the analysand, and if these sensitivities or blind spots influence treatment, they become grist for the mills of training and control analyses. Education and training have been and remain fundamentals of psychoanalysis. This seemingly simple statement has two radical consequences. It is not the medical training that is important, but the analyst’s skills. Thus, Freud could easily champion non-MDs such as Anna Freud; pastor Oskar Pfister; Theodor Reik, PhD; child educator and painter Erik Erikson; engineer Helmuth Kaiser; and lawyer Max Eitingen as easily as he embraced physicians Hans Sachs, Franz Alexander, Karen Horney, Carl Jung, and Alfred Adler (at least initially). When the American psychoanalytic establishment feared what they saw as charlatans invading their domain, they erected a screen that allowed only MDs into psychoanalytic institutes. Freud wrote the well-known “Question of Lay Analysis” in 1926, in which he claimed medical education could impede analysis, being “an arduous and circuitous way of approaching the profession of analysis . . . burdens him with too much else of which he can never make use and . . . diverting his interest and whole mode of thought from the understanding of psychical phenomena” (Gay, 1989, p. 680). Freud favored a curriculum “from psychology, the history of civilization and sociology, as well as from anatomy, biology and the study of evolution. . . . Psycho-analysis is part of psychology: not of medical psychology in the old sense, not of the psychology of morbid processes, but simply of psychology” (p. 680). Sullivan (1962) in the 1920s thought medical training was more of an impediment toward experiencing the patient’s world, that it built barriers by using diagnostic labels and created transference jams when the patient felt alienated from the doctor. For all this trailblazing, one problem bequeathed by this approach is sensed in the above quote from Freud. There is a lack of methodological isomorphism. That is, the method by which one addresses a problem or situation ought to be “the same shape” or isomorphic to the problem. If a woman presents with depression due to domestic abuse, all too often she is given a prescription for medication to address the depression and little else. The method simply is the wrong one for the problem (i.e., domestic abuse) and ignores the root causes and the abuser. Similarly, the problem facing supervisors is a matter of education, not treating all students as analysands. The method of psychoanalysis was created and honed for deeper

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emotional reconstruction. Although many training and control analysts realize this and adjust their supervisory methods to be educative, the whole of this part of the enterprise presents a problem for many analysts, for those calling themselves “psychodynamic,” and for supervisors who are unschooled or have not reasoned the isomorphism issue to its logical conclusion. Namely, the student’s education rather than his or her character restructuring is the primary goal of supervision. This problem is not solely one of psychoanalysis. Ironically, this probing of the student’s psyche may be more common in programs across the theoretical vista. Ironically, many supervisors from behavioral and “third force” or humanistic approaches might be more intrusive, having incorporated perceived psychoanalytic dogma while decrying psychoanalysis. BEHAVIORAL Behavior modification and cognitive-behavioral interventions were taught much like all other procedures. For example, John Watson taught Rosalie Raynor and Mary Cover Jones much like anyone would teach anyone else. That is, he demonstrated or modeled approaches, as in inducing phobic reactions in Albert or in Jones’s desensitizing of Peter’s fears. Through attending classes, reading cases, and exploring phenomena such as breaking complex behaviors into components and chaining simple responses into complex procedures, teachers of behavioral techniques employed techniques true to behaviorism and to regular pedagogy. The bug-in-the-ear technique was a signal innovation, whereby a student had a small speaker in his or her ear and the supervisor watched from behind a one-way window and offered suggestions through a microphone to the ear. More recently, as Boyd (1978) outlined, (a) behavioral techniques are learned skills, with the supervisor reinforcing desired therapist behaviors and extinguishing role-inappropriate behaviors; (b) treatment has identifiable tasks that the supervisor helps identify, apply, and refine; (c) these tasks are definable and no more refractory or less plastic than any other learning tasks; and (d) learning theory principles are thus the mode by which cognitive-behaviorism is taught most efficaciously. In some respects, behavioral notions lend clarity to beginning supervisees inasmuch as supervisors outline most clearly agreed-upon agendas with goals and criteria with ongoing assessments, reducing ambiguity (Rosenbaum & Ronen, 1998). Technical mastery of defined skills that show fidelity to their theory characterizes behavioral supervision. In one respect, behaviorism is economical in its technology. In another, behaviorism aims to convey the technique but neglects a focus common to other perspectives, that of the formation of the identity of the budding professional. This notion simply has no home in the theory proper. However, the effective behavioral supervisor does employ the same clinical sense common to other approaches. For example, Thomas Stampfl presented implosive therapy principles at a national convention to an auditorium of more than 400 people. Afterward, about 20 people gathered around him to hear further thoughts and tips. One socially awkward person told Stampfl that he had tried and tried implosive psychotherapy with clients, but it simply did not work, at least for him. The man’s social dis-ease obvious, Stampfl addressed him with as much care and support as any humanist might,

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8 HISTORICAL CONTEXT applauding him for his knowledge of the technique itself but advising that his next step was to seek a trusted local consultant or supervisor to review his technique and help him make it smoother. Stampfl’s kindness was impressive and his clinical power evident again when he exposed a germ-phobic patient to imagined scenes of waste and malodorous materials. His descriptions were so vivid that he had the audience gagging and gasping. When his patient was asked why she had allowed Stampfl to expose her to her worst fears, she replied, “I trust him.” The clinical sense and psychotherapist personality of Stampfl has been replicated many times over by skilled behavioral therapists who use Rogerian reflection of feelings in exploring patients’ complaints and their functional dynamics. Lazarus’s (1967) case of a sexually inadequate man is another exemplar of how a behaviorist employs clinical sensitivity. After three sessions, during which he facilely avoided his presenting problem, the client called to cancel his fourth session. The following dialogue ensued: THERAPIST: But you haven’t even come out with your real problem. ROY: How do you mean? THERAPIST: Why must you keep up with this pretence [sic]? ROY: What pretence? THERAPIST: You know what I’m getting at. ROY: You psychologists think everyone’s insane. THERAPIST: Things like anxiety and sexual problems have little, if anything, to do with insanity. ROY: [After a long pause] All right! I’ll come in and see you tomorrow. (p. 243) The clinical sensitivity demonstrated by Lazarus was not encapsulated within the behavioral theory itself. Ron Doctor, in teaching behavior modification, used to advise his students to learn the basics of Rogerian communications to establish rapport that would enable the client to engage in behavior therapy. Although the behavioral therapist may feel more efficacious as patients relinquish symptoms and function more effectively, there is no particular part of behaviorism that attends to anything resembling a “psychotherapist identity.” Perhaps Lazarus’s (1996) insight was most telling: It is not theory but technique that occurs in psychotherapy (and its supervision). ROGERIAN If possible, Rogers (1942a) was even more resolute than psychoanalysts in holding that the psychotherapist is the instrument of change. Psychoanalysis involves using a complex technique in order to accomplish a complicated goal, that of personality restructuring. With client-centered psychotherapy, it is essential that the psychotherapist be congruent, empathically understanding, and unconditional in positively regarding the client for client change to be all but inevitable. The goal is for client-determined change in self-regard. The barriers to change are mitigated, if not eliminated, by the psychotherapist being psychologically available in the here and now. This allows the client to experience himself or herself in a benevolent way, perhaps for the first time in his or her life. So, keeping the psychotherapist

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in the here and now and having the client take responsibility for his or her experiences as they are experienced formed the core of Rogers’s system from the outset. Small wonder, then, that this approach has a history steeped in supervision, most particularly that of the experiential being of the student. Rogers combined the best of the scientist and the humanist. As a youngster he experimented in his garden plot to find the conditions of optimal growth for his plants. As a young psychologist he brought the same approach to the consulting room by seeing which nutrients could produce human growth. Rogers (1942b) brought the then-new voice recorder into psychotherapy, and by doing so violated the sanctity of the psychotherapy session, resulting in allegations of unethical behavior. Yet Rogers marks the beginnings of psychotherapy research, an area that has blossomed since his daring assessment of the process of personality change. Rogers (1975, p. 3) recounted: I cannot exaggerate the excitement of our learning as we clustered about the machine which enabled us to listen to ourselves, playing over and over some puzzling point at which the interview clearly went wrong, or those moments in which the client moved significantly forward.

Rice (1980) viewed client-centered psychotherapist training as addressing attitudes or assumptions about human nature and self-attitudes of the psychotherapist. Does the clinician have the need to resort to unconscious conflicts, or does he or she have faith that the client will orient toward growth, healing, and actualization? Does the clinician have the courage to risk simply being with the client and not relying on diagnostic labels or resorting to unraveling the mysteries of the client’s defensive work? Rice termed the concept of prizing, or valuing, the client, and in supervision prizing the student’s experiencing that involves taking the risk that the human instinct is toward beneficence, ceteris paribus. Although evaluation issues mandated by the agency must be discussed beforehand, they pale into paper jottings when contrasted with the moment-to-moment assessing that goes on between people. When this ebb and flow leads the client (or student in supervision) to see that his or her utterances do not provoke rebuke, correction, and critique, and the client realizes that he or she is really listened to and valued, then trust is established and exploration of more core feelings becomes possible and inevitable. The task of supervision is to ensure that listening skills are refined and that the student can discover his or her own blocks to listening. E M E R G E N C E O F S U P E RV I S I O N A S A S P E C I A LT Y World War I marked the establishment of psychological testing as the United States faced the daunting prospect of having to process millions of young men for military service. This entailed classifying recruits for vocational abilities and for leadership potential, as well as assessing retardation and mental disabilities. By World War II, psychologists as assessors were well ensconced. The need to treat shell shock (the World War I term; the World War II term was battle neurosis) became apparent. The years following World War II saw the veteran’s hospitals supporting the establishment of the Boulder model of the scientist practitioner and employing

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psychologists as psychotherapists. This emerging role was accented by the psychologist’s ability, and even penchant, for conducting research on assessment and treatment. As a result of the Korean Conflict, the term combat fatigue entered our lexicon as a way for us to understand another generation of soldiers requiring help. The accreditation program of the American Psychological Association (APA), established at the onset of the Korean Conflict, accelerated psychology’s involvement in treatment. Education and training guidelines became more central to the accreditation process. Still, training remained confined to the preferred procedures of the various theoretical orientations. The growth of the psychologist-as-psychotherapist accelerated, and licensing laws were enacted. Perhaps the sense of psychology as an independent profession can be seen by older clinicians insisting that new academicians get licensed, because licensing was a hard-won and new development in our field, even if the assistant professor was not going to practice. It can be seen as well in the language in the Jenkins v. United States (1962) decision, which addressed the role of the clinical psychologist independent of medicine. Before Jenkins, psychologists’ findings were treated as if from a laboratory technician or nurse at the physician’s service. Physicians testified to both nursing reports and psychologists’ findings. Jenkins held that “a psychologist’s competence to render an expert opinion based on his findings as to presence or absence of mental disease or defect must depend upon the nature and extent of his knowledge” (Hess, 2006, p. 655). Some of this ferment was described in more detail by Henley and Robertson (1988) and by Reisman (1976). Ekstein and Wallerstein (1963) contributed to the emergence of supervision by emphasizing the context within which supervision occurs. In the psychoanalytic training institute, the education committee is the most important committee in determining who is to be awarded a certificate of analysis and who is to receive faculty status as a training, control, or supervising analyst (analogous to universities awarding graduate teaching status to professors). In light of this powerful influence on supervision, Ekstein and Wallerstein introduced the concept of the clinical rhombus. This refers to the analysand, the analyst, the supervisor, and the agency as a hovering presence in the supervisory sessions. Within a few years, two important sets of works establishing excellent training syllabi were published. Carkhuff (1969) produced two volumes that are exemplars for training psychotherapists. They amalgamated the best of clinical approaches with sound pedagogy and supported the assertions with a research base. At the same time, Kell and Mueller (1966; Mueller & Kell, 1972) wrote about their experiences training more than 100 students in Michigan State University’s clinic. Their work centered on recognizing psychotherapy impasses and the anxieties causing these blockages. The clients’, students’, and supervisors’ anxieties as impediments to psychotherapy were spelled out clearly. Reading these two sets of works is both exciting and fruitful, even decades later. Gilmore’s (1973) work seemed to escaped notice, too. She devoted her work to an Eriksonian model of supervisee development. In this model, Gilmore described the three tasks of living for clients (i.e., work, relationships, and loneliness; note the similarity to Adler, 1931) and how the counselor needs to master understanding, sincere acceptance (note similarity with Rogers, 1942a), and communicate to be

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effective in affecting client change. She then described her structured semester practicum devoted to teaching these change elements to student counselors. In the first edition of this volume (Hess, 1980), experts (a) examined psychotherapy supervision across theoretical orientations and teaching modalities; (b) presented stage theories of supervision; (c) gave voice to the new supervisor and the new student; (d) examined supervision for children, adolescents, and the aged; (e) viewed supervising modalities such as family and marital psychotherapy, crisis intervention, and group psychotherapy; and (f) expressed professional concerns such as legal issues and those relating to racial, ethnic, and cultural status. Watkins (1997) deemed this volume foundational in establishing psychotherapy supervision as a field. A few years after Hess (1980), Counselor Education and Supervision, until that time the only journal with supervision in its title, was joined by The Clinical Supervisor. These developments seemed to affirm supervision as a field in and of itself and, to a degree, independent of the various schools or orientations of psychotherapy. Two developments occurred next. The 1980s and 1990s saw the APA codes of conduct and ethical principles devote more attention to supervision. And the emergence of supervision was seen in a set of noteworthy publications. The interested reader can see supervision treated as invisible or, to use Alonso’s (1985) term, the quiet profession, indicating the emergence of supervision from anonymity to recognition. The 1992 code of ethics for the first time paid explicit attention to supervisees, as well as other student concerns such as inclusion in publications (Fisher & Younggren, 1997). In the 2002 code of ethics, supervision received attention as its own section (APA, 2002). Specifically, Section 7 described standards for education and training, particularly concerning students being required to reveal private information (Section 7.04), mandated psychotherapy (Section 7.05), timely and criterion-based evaluation (Section 7.06), and forbidden sexual relations (Section 7.07, in tandem with Section 3.05 on multiple relationships). Alonso (1985) sought to write a single “plain talk” (p. viii) text on the “subspeciality” (p. vii) of supervision. Originating from a psychodynamic approach, she included supervisor impasses such as the supervisor’s (a) need to be admired, (b) need to rescue, (c) need to be in control, (d) need for competition (toward the student), (e) need to be loved, (f) unresolved conflicts left from his or her own training experiences, (g) intrusions from his or her current personal life, and (h) conflicts with the agency. Alonso addressed cross-disciplinary supervision problems and concluded by approximating a process–communications approach. Her attempt to write a plain-talk volume succeeded. Robiner and Schofield (1990) scoured the literature and categorized publications into eight themes: (1) books; (2) administrative, ethical, and legal issues; (3) evaluation; (4) internship; (5) professional standards and training; (6) supervisee development and perspectives; (7) supervisor and relationship issues; and (8) supervision research, technique, and theories. This lent weight to the sense of an accumulating critical mass of theory, research, and practice that society associates with establishing a field of science and practice. Following this crystallization of the literature, Ellis and Ladany reviewed the research on supervision (Ellis & Ladany, 1997; Ellis, Ladany, Krengel, & Schult, 1996; see also Chapters 25 and 26), as did Freitas (2002). These authors collected and analyzed studies and distilled the

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findings to guide both practitioners and future researchers in effectively serving supervisees and supervisors. Perhaps few have reviewed a literature and provided more elegant an analysis than Worthington (1987/2006), an opinion shared by the editor of a relatively new journal who reprinted Worthington’s review of research on whether experience in supervision matters. This review distinguished proactive supervision, which is planned, has clear goals, is guided by the supervisor, and tends to instruct the student in a particular approach; from reactive supervision, which uses critical incidents in encountering dilemmas that students in training meet in their psychotherapy sessions and is more reflective of student readiness to learn a particular element of treatment or deal with an issue of identity formation as a psychotherapist. In the developmental models section that follows, we examine more of Worthington’s work. His review presaged other important developments in the 1990s. Bernard and Goodyear (2004) and Falender and Shafranske (2004) published their first two editions and Holloway (1995) examined supervision from a systems approach. No more signal event occurred than when Watkins (1997) determined that the field had sufficiently matured to warrant his editing the Handbook of Psychotherapy Supervision. Bernard and Goodyear (2004) integrated research with specific practice recommendations, taking an education and evaluation tack rather than espousing a particular approach. Using Bloom’s taxonomy, they described supervisory activities, assessment strategies, and models of supervision in the first part of the book. They then focused on the supervisory relationship, including the dyad and how the supervisor can use various leads to encourage the student to reveal dynamics in himself or herself as well as what he or she thinks is going well and poorly in psychotherapy. They discussed the discomforting confrontation needed with the incompetent psychotherapist, whether the incompetence is shown at the onset of the student’s career or is a result of later career problems such as burnout, substance abuse, or other causes. Bernard and Goodyear provided a thorough summary of the literature regarding negative supervisions that might arise from supervisee deficits or from supervisor deficiencies such lack of interest, inability to see one’s student flourish and even exceed the supervisor in psychotherapy adeptness, use of ridicule, lack of encouragement, and failure to see the student as anything but a student. They concluded with a description of contextual and organizational factors within which supervision occurs and appended a useful “toolbox” of documents (contract and supervisee’s “bill of rights”) and measures they had found in the literature. The measures they included are useful but ought to be taken as suggestive because most need cross-validation studies. The Falender and Shafranske (2004) volume fits well within the competency movement that was expressed in the APA code of ethics. Falender and Shafranske considered competence as a function of input variables such as skill and ability that lead to measurable outcome variables such as accomplishing defined objectives, in the form of “a task, duty or role” as per Roe (2002, p. 195). Four competencies concerned Falender and Shafranske: (1) relationship integrity, (2) ethics, (3) cultural sensitivity, and (4) scientifically driven practice. They ended each chapter with a useful set of competencies pertinent to the chapter topic and provided useful checklists drawn from the research literature that might help guide supervision

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contracting, process, and evaluation. As these checklists were derived from the research literature, questions of validation of the measures need to be explored before the checklists are used to draw conclusions in other clinical settings. Yet they have heuristic value and have a theoretical basis founded in the text. Holloway (1995) embraced a systems theory and weaved in the story of her struggles in developing her approach. She fortified the concepts with dialogue and with research support. Discussion of how the student and supervisor respond to institutional imperatives while grappling with intrapsychic needs and the interpersonal adjustments each make in supervision provides guidance for supervisors, both new and experienced. Based on her experiences with group supervision, Holloway ended with a set of supervisory stories nonetheless acknowledging that the group is another level in the systems model. Within this group supervisory context, she provided supervisor stories by which the experienced clinician can continue his or her development while serving students. Watkins (1997) edited the first volume using the word Handbook in its title. The Handbook of Psychotherapy Supervision was intended to provide a comprehensive update of the first edition of this volume (Hess, 1980) as well as add the best features of Bergin and Garfield’s classic Handbook of Psychotherapy and Behavior Change (1994). It did. Watkins’s Handbook provided various definitions of supervision and described research methods and factors affecting supervision in Part I, reviewed various models of supervision in Part II, addressed various learning formats in Parts III and IV, reviewed research in Part V, and concluded with a survey of ethnic factors. A major publisher saw fit to support a handbook, and the publication of Watkins’s volume marked the conclusion of the field’s early growth. The subsequent publication of the second and third editions of the Bernard and Goodyear and Falender and Shafraske volumes showed psychotherapy supervision as its own corpus (a legal standing) with theory, research, and practice. More recently, the APA Presidential Task Force on Evidence-Based Practice (2006) coupled with the APA Task Force on the Assessment of Competence (Rubin et al., 2007) issued a set of papers that grappled with integrating the scientific bases of psychology and practices more coherently. The former committee’s goals included assuring the public, third-party payers, and our professional analysts themselves that we are rendering efficient services. The latter committee examined the concepts undergirding competence, its historical roots, and its measurement and identified and worked with professionals in need of remediation. These reports have provided much food for thought and might help guide standards of practice in the future. This excursion through concepts of supervision leads us to examine the roles supervisors might find important for use in various settings with students in different stages of professional growth. T H E S U P E RV I S O R ’ S R O L E S One useful approach to understanding supervision is a role analysis of the functions and expectations invested in the supervisor. Hess (1980) described six roles that encompass the supervisor’s functions, to which two more might be added. In typologies, every effort ought to be made to minimize role overlap so functions are distinct and not confused. Nonetheless, the reader might see some role conflation.

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Presents specific goals and content within a curriculum for competency or mastery.

Reviews cases focusing on recognizing the session’s events and guiding future interactions.

Consults with peers to gain support or for a critical review that does not jeopardize one’s career.

Maintain standards and ensures mandated guidelines (e.g., for accreditation) are met.

Helps student psychotherapist apprehend the client’s perspective and tasks.

Focuses on linking explicit or semantic learning (content) with procedural knowledge while building confidence and hope and benignly correcting.

Enables student to attain skills, builds higher order judgment skills, and establishes a psychotherapeutic identity .

II. Teacher

III. Case review

IIII. Collegial peer

V. Monitor

VI. Psychotherapist

VII. Coach

VIII. Educator

A role superordinate (and inclusive of the other roles) that is careful to see that cognitive and emotional growth proceed apace with skill development.

Trusted elder who has walked in the student’s shoes; may be a cotherapist.

Secure and trusted model in which doubts and hopes can be expressed without external consequence.

Censor; censures and corrects.

Shared intimacy and trust.

Elder, experienced to younger, less experienced.

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Superordinate to subordinate.

The listener can choose to tune out, to become an acolyte, or to choose some middle range of engagement with the lecturer.

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Conveys global conceptual schemes and demonstrates technique. Generates enthusiasm and provides an ideal or model.

Goal

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Model

Table 1.1 Models of Psychotherapy Supervision

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Table 1.1 lists each role with a brief description of the learning goals such a role might encompass and the nature of the relationship. It is important for both the student and the supervisor to realize the role structures within which they are functioning, as role confusion can result in dramatic and untoward consequences. For the time being, consider the student with selfdoubt who mistakenly thinks he or she is in a trusting relationship with a monitor or case reviewer, gatekeeper, or teacher who sees his or her role as evaluative. The student might think a self-revelation is safe, but the supervisor in the evaluative role might not share that assumption. Instead, the student’s confidence may be sorely misplaced and what the student might think was a private communication meant to gain some support or even guidance about fitness for the profession or for a particular kind of client now becomes fodder for a faculty review committee. This type of mistake can lead to career complications that are disastrous for the student. Consider, too, a clinic director who contested a workshop presenter. He insisted on supervising his staff’s clinical work as if he were a case reviewer, colleague, or even psychotherapist while ignoring the fact that he determined staff raises, promotions, and even terminations. He boldly asked anyone there whether they disagreed. None did. At the break, more than a third of the staff came up to the presenter while the director left the room; the staff showed the pain of being forced into the role conflict of revealing flaws and then being financially (raises) and positionally (promotions) penalized as being less competent. The strain on the staff was painful to the presenter. In this vein, then, I present the major roles of supervision. I. LECTURER MODEL The lecturer is an authority presenting his or her theory or technique. The lecture is an economical way for people, in sizable numbers, to learn of a theory or technique from an expert. People with little prior exposure to the ideas or writings of the lecturer might gain an appreciation and become enthusiastic, particularly when case material or even in vivo demonstrations are presented. The lecture model is safe for the novice in that he or she can without notice participate emotionally or engage in withdrawal. The novice is not presenting and is secure from inquiry. Of course, this format has drawbacks in that the audience member is limited in his or her contact with the lecturer. The lecturer is limited by having to tailor the talk to a generic audience. Although individual nonverbal responses might be seen, response to these reactions is limited perhaps to a question-and-answer period. The audience member’s issues lie largely unaddressed at that time. Nonetheless, the amount of knowledge and the sense and excitement of the theory or approach are paramount in this model of learning. II. TEACHER MODEL The teacher is charged with covering a particular content area most frequently within a course structure that takes its place in a larger curriculum. Specific content and some skill demonstration or practicum elements might be incorporated in the course or seminar. The student is presumed to be a neophyte and subordinate to

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the teacher. The process involves evaluation of the student, and the outcome of that evaluation may determine the student’s fate in the program. The structure is formal, and the degree of exchange between the teacher and the student is limited by the role structure. The teacher is expected to present the content domain; the student is expected to be able to recite that domain. III. CASE REVIEW MODEL Case review approaches what most people think of when the term supervision is used. It involves the more experienced clinician going over cases with the junior staff member or the student so that the student’s cases are reviewed with a focus on the student’s learning. The student is obliged to have cases reviewed as part of a degree program or continuing education function of an agency. The goal is for the psychotherapist to master skills and render increasingly better service to patients. There is some evaluative function, but this is merely a reporting function secondary to the goal of the student psychotherapist’s skill development. In agencies, this model can have tremendous morale-boosting effects as long as reporting or evaluative functions remain secondary or even tertiary in prominence. IV. COLLEGIAL-PEER MODEL The collegial-peer model involves a relationship of reciprocity and shared intimacy with no formal obligations to evaluate and the expectation of privacy regarding discussions. Often colleagues are the perfect foils for letting off steam from the stresses of human service delivery. Anxious moments; fears of failing a client; and frustrations with supervisors, agency policies, and agency politics can be safely shared. Sometimes solutions or tips from a colleague may help the student negotiate a problem. For example, a student might solicit tips from a trusted colleague who has just finished supervision with someone to whom the student is assigned for a new rotation. The bonding of peers as graduate students can lead to lifelong support systems and collegiality in publishing, career establishment, and work in associations and societies. V. MONITOR MODEL The monitor is an increasingly common identity, that of some panel or individual who inspects files for minimally adequate recordkeeping and, upon occasion, monitors minimally acceptable service delivery. This often involves an agent internal to the agency but most often is driven by external monitors. The external source often involves censures and sanctions. Thus, the monitor is no supervisor in the sense of developing a student’s skills, but this role has a severe impact on the student, as he or she can get into trouble and be flagged by the agency and supervisors for remediation. In that sense, the monitor influences the student’s career and becomes part of the student’s evaluation. Many agency rating forms include a category or two concerning the student’s scrupulousness in attending to professional responsibilities, such as record-keeping, driven by the monitoring function.

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VI. PSYCHOTHERAPIST MODEL Much of the literature on supervision mentions the psychotherapist role. As it has from the beginning of supervision as a field, discovering the blind spots of the psychotherapist in training casts the supervisor in a psychotherapist role. Yet thoughtful psychologists recognize the role strain for the student being evaluated for a training program and having demands for self-revelation placed upon him or her in a patient role. It is as if the student is being asked to testify against himself or herself with no ability to know how this personal information might influence or even terminate his or her career. A further complication for the supervisor is that the processes of supervision and psychotherapy are similar, if not identical. That is, both the psychotherapist and supervisor are actively listening, interpreting, guiding, allowing some freedom to experiment and err, giving permission, and withholding judgments. It is no wonder that parallel process, or the similarity of issues between the patient and psychotherapist that are then recreated in the supervisory hour, has been noted repeatedly. The temptation for the supervisor is to reveal this phenomenon to the supervisee, which is not the optimal way to use parallel process. First, it casts the student in the patient role with the label seeming to have a weight of its own that aborts rather than stimulates discussion. Second, the more positive use of parallel process is to let the student play out the issue, asking him or her for solutions but modeling the solution when the student is at an impasse. For example, if a student faces client resistance in the form of the client’s lateness to each session, and then this otherwise punctual student comes late to supervision, the supervisor might best just observe this phenomenon. If it recurs, the supervisor might begin a testing-the-limits approach by asking what the student has tried with the patient, or what has worked and what has been frustrating. Often, parallel process is a way of asking how the supervisor might deal with the patient in an area of sensitivity to the student. The critical difference between psychotherapy and supervision is that the end toward which the supervisor ought to be moving is the student becoming a more competent psychotherapist. This acting out in supervision might well be an indication of the level of trust the student has toward the supervisor. How the supervisor handles parallel process, as a colleague teaching the student or as one who makes each learning opportunity a psychotherapy event, can determine whether a supervision becomes successful or stilted. These issues of self-revelation and multiple roles are addressed further in Chapter 27 on ethics, and parallel process as a learning opportunity is discussed in Chapter 10 on interpersonal theory.

VII. COACH MODEL The coach role features two elements of supervision not centrally addressed by the other roles. First, much of the learning in supervision is procedural learning. That is, semantic learning concerns what one can glean from a book or lecture. It refers to things one learns. Procedural learning concerns how a skill is exercised. Teaching someone to knit, to swim, or to swing a golf club involves procedural learning, or the sequencing and timing of a series of movements into a skilled performance. Second, the type of teaching is individualistic and more intimate. Teaching a skill

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such as swimming may involve holding the person afloat; teaching golfing may involve touching the hands, arms, hips, and feet to ensure correct kinesthesia; and teaching knitting may require placing another’s fingers a certain way. These examples are meant to call attention not to physical contact, but to another type of closeness involved in procedural learning: the student demonstrating and the supervisor or coach correcting in a positive way. This involves sensing a student’s frustration when he or she tries a suggestion and fails and giving the immediate encouragement that students require in the face of psychological overload and consequent failure. This model of supervision is ironic in the light of the personal coaching movement. Perhaps good supervisors have been good coaches all along. The purchasing of supervision by already-credentialed psychotherapists seeking to acquire new skills or to “correct their golf swing” and perform better might fit well in this model. Of course the neophyte learning skills for the first time needs encouragement in facing the bewildering display of stimuli. VIII. EDUCATOR MODEL The educator and eductor roles are overarching. That is, they encompass almost all of the functions of the aforementioned roles. The emphasis of this role set is to ensure that the major function of the supervisor is educational and eductive. In the first case, the supervisor is an educator, instructing in cognitive, affective, and performance spheres using a variety of techniques that suit both the student and his or her learning needs. The eductor is one who elicits, draws, or educes from the student’s latent talents and abilities what has not been evidenced before. Thus, the eductor makes sure the foundations are available internally and externally for the student and then provides encouragement and permission to fail so the student can learn. The student’s latent skill set ought to be assessed and available, and the circumstances ought to be optimal for the student to succeed. Ethical problems might arise because there is a conflict between the obligation for the patient to benefit from the treatment and the fulfillment of the student’s learning needs. Also, the step between the student’s current functioning and the clinical problem he or she is facing ought to be large enough to provide a learning experience. However, if the step is too large, the student faces anguish and failure, benefiting neither the client nor the student. In another sense, the supervisor tries to help the student learn how to help the client see relationships that are not “one bridge too far” or that exceed the client’s grasp. Ensuring that the client and the student see or educe relationships (Carson, 1969), in a parallel sense, is the supervisor’s task in this role. D E V E L O P M E N TA L M O D E L S Typologies are the earliest forms of theory once a scientific field has been realized. Perhaps this is so because the field’s domain needs mapping. Also, differentiation between elements within the domain needs to be understood (e.g., how this type of supervisee might benefit from support, whereas that one could use confrontation at a particular stage in his or her development as a psychotherapist). Finally, typologies reduce confusion by sorting like types together. It is a short conceptual gap between typologies and stage theories. Thus, stage theories are among the

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earliest of typologies, as Linnaeus’ biology classification system and Kraepelin’s constitutional psychiatric typology illustrate. Worthington’s (1987/2006) previously mentioned tour de force deserves attention in this section. Worthington presented two extensive tables that summarize models of student and supervisor growth. In the rich set of findings, Worthington addressed supervisor and supervisee growth models, as did Hess (1980), in two ways. The proactive approach might seem to best fit beginning supervisees. This statement must be qualified in that learning seems to reflect a spiral omnibus model, wherein there is a set of skills of differing levels. One might address student listening skills on a lower level, then move to another area such as how to cope with severely psychopathological clients, then move to how to offer an interpretation or analyze a dream or identify behavioral targets to change and establish a baseline. Then the student might need to return to listening skills, albeit at a more advanced level, and then move to learning how to time an interpretation so the patient can metabolize it. Thus, the spiral omnibus model has supervision moving in an ascending spiral depending on the student’s learning needs and the supervisor’s ability to identify and meet those needs (see both below and Chapter 10 on Interpersonal Theory). Worthington found complications to researching the supervisory process— including the supervisor’s perception that he or she is providing a supportive counseling setting when he or she is actually employing the teaching role. This tells us to use caution in taking self-report data on face value. Also, as supervision is not often taught as part of the supervisor’s education, he or she might be concerned or confused about supervisory stages and techniques. This confusion about his or her own performance might compromise the supervisor’s ability to center the supervision on the student’s performance and learning needs. This confusion will limit the dual functions of support and instruction that beneficial supervision provides, as the supervisor might be preoccupied with sorting out what is going on with him- or herself, preempting focus on the student. Inspiring confidence is one of two key elements Wampold (2007) found in effective psychotherapy. He saw a credible explanation coupled with a set of adaptive responses consistent with that explanation as the critical vehicles for conveying a patient from anguish to well-being. The patient can build a new narrative (see Chapter 8) and take concrete actions or receive permission to try out new behaviors and experience new thoughts and feelings. Would the supervisory process be much different if we can expect a brighter client and more focal discussion facing the supervisor during a supervisory session? Worthington (1987/2006) stated that interns, in contrast with both less and more advanced supervisees (a curvilinear function), receive more critical comments, and their supervisors more often raise parallel process and countertransference concerns. Advanced supervisees see a shift in the supervisor bringing up relevant supervisor issues and experiences as the supervision becomes more collegial. Of interest is that supervisor attraction and skillfulness are positively correlated, and years of experience pale in importance compared to supervised supervision experience. Perhaps the old adage about the two teachers with 25-year careers is worth recounting. One was burned out, and the other was fresh as a daisy. The tired teacher had had 1 year of experience 25 times, whereas the refreshed teacher had

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had 25 new and different years of experience—a new one each year. The renewal of psychotherapists and supervisors remains an important challenge. RECENT DEVELOPMENTS As psychotherapy supervision grew in the past 3 decades, two noteworthy developments occurred. Psychotherapy is a clinical activity, and clinical activities have traditionally focused on clients with problems. However, the client in supervision is putatively normal at the least and, given the selection criteria and ratios in our doctoral programs, often quite gifted. Also, over the years, counseling psychology has moved from its origins in guidance and counseling toward treating some of the traditional clinical clients. Yet supervision finds a home more with APA’s Division 17 (Counseling) than with Division 12 (Clinical). It is as if the fit of Division 17’s training of normal people, traditionally a counseling focus, has led counseling psychology to host more workshops; counseling books are more likely to include supervision; courses in supervision are more often found in counseling departments; and counseling journals publish supervision articles, particularly research articles. It is good that supervision has found a home and has grown into a robust adolescence in counseling. What might have been sacrificed is centering on the student as the client at the expense of seeing the student apply various techniques to particular client problems and types. For example, Searles and Sullivan devoted time to treating severely mentally ill patients and training psychotherapists to work with this group of people. Counseling programs are less likely to include the application of psychotherapy to various patient types than clinical programs are. In this regard, this volume includes a focus on the strengths of counseling in training students and chapters that concern specific clinical problems (e.g., Chapter 20 on treating the severely mentally ill or Chapter 22 on treating the sex offender). As mentioned previously, the bulk of research in supervision is the fruit of counseling psychologists and appears in counseling journals. It is exciting to see how researchers struggle with challenges such as adapting methodologies to fit the types of problems psychotherapy supervision poses. For example, validating assessment tools will have to take a new tack that may not center on nomothetic approaches. This is because there are few interns or practicum students at a particular locale, so validating instruments with classical psychometric operations might pose problems with no solutions. Thus, critical incidents and work samples are two strategies that research on assessment might employ. Process rather than content measures may be a fruitful avenue to explore. Time series designs and statistics allow a case-based analysis in the natural laboratory of the consulting room (Borckardt, Nash, Murphy, Moore, Shaw, & O’Neil, 2008) and ought to be applied simultaneously to both patient-psychotherapist and student-supervisor dyads. And the ultimate question of whether the supervision results in better patient outcomes still needs addressing. One other question merits a bit more consideration. Hess (1986) noted the spiral omnibus form of inquiry. Using the Stanford–Binet Intelligence Scale structure as a model, we address a skill, such as vocabulary or hand–eye coordination, at levels from basic up to more advanced. The dimension may range across mental age levels (as vocabulary does), or different tasks may tap it at different levels. In like

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fashion, supervision of the beginning student might focus on basic Rogerian listening skills. Also, supervision might involve behavioral observations of the client and psychoanalytic sensing of resistances. Supervision might attend to forming the student’s inchoate identity as a psychotherapist. On a more intermediate level, the supervisor might work with the student to develop his or her ability to listen for deeper meaning from a Rogerian active listening position. Supervision might spiral to the intermediate level in helping the patient set goals for behavior change, trying a modest change and assessing the success of this behavioral intervention. The student’s morale as a psychotherapist may fluctuate based on a number of factors. These four dimensions, as an example, might each claim primacy in a particular session or as the student progresses through stages from novice to accomplished psychotherapist. At the advanced level, the Rogerian dimension might focus on teaching the student to be able to confront the client without feeling either frightened or conflicted but rather feeling exploratory in a safe environment. The psychodynamic focus may offer an interpretation and assess the degree of resistance, and then reconceptualize how to set the client up so that the next interpretation is more facilitative. Behavioral focus of supervision may entail encouraging the client to transfer what he or she has learned so that the client can initiate, establish a baseline and intervention, and recalibrate the intervention with minimal supportive guidance from the psychotherapist. The dimension of the psychotherapist’s identity can be seen by the more collegial, consultative tone of successful supervision. We revisit this model to some degree in Chapter 10 on interpersonal theory. Many of the issues raised here are addressed in the chapters that follow. I hope these chapters serve as a platform for the reader’s clinical and research work and lead to continued personal and professional growth.

REFERENCES Adler, A. (1931). What life should mean to you. Boston: Little, Brown. Alonso, A. (1985). The quiet profession: Supervisors of psychotherapy. New York: Macmillan. American Psychological Association. (2002). Ethical principles for psychologists and code of conduct. American Psychologist, 57, 1060–1073. American Psychological Association Presidential Task Force on Evidence-Based Practice. (2006). Evidence-based practice in psychology. American Psychologist, 61, 271–285. Beier, E. G. (1966). The silent language of psychotherapy: Social reinforcement of unconscious processes. Chicago: Aldine. Bergin, A. E., & Garfield, S. L. (Eds.). (1994). Handbook of psychotherapy and behavior change (4th ed.). New York: Wiley. Bernard, J. M., & Goodyear, R. K. (2004). Fundamentals of clinical supervision (3rd ed.). Boston: Allyn & Bacon. Borckardt, J. J., Nash, M. R., Murphy, M. D., Moore, M., Shaw, D. & O’Neil, P. (2008). Clinical practice as natural laboratory for psychotherapy research: A guide to case-based time-series analysis. American Psychologist, 63, 77–95. Boyd, J. (1978). Counselor supervision: Approaches, preparation, practices. Muncie, IN: Accelerated Development. Breuer, J., & Freud, S. (1955). Studies on hysteria. The standard edition of the complete psychological works of Sigmund Freud (Vol. 2, pp. 1–305). London: Hogarth Press. (Original work published 1985) Caligor, L. (1985). On psychoanalytic training (a symposium): On training analysis—or sometimes analysis in the service of training. Contemporary Psychoanalysis, 21, 120–129. Carkhuff, R. R. (1969). Helping and human relations: A primer for lay and professional helpers (Vols. I & II). New York: Holt, Rinehart & Winston. Carson, R. C. (1969). Interaction concepts in personality. Chicago: Aldine.

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Ehrenwald, J. (Ed.). (1956). From medicine man to Freud: An anthology. New York: Dell. Ekstein, R., & Wallerstein, R. S. (1963). The teaching and learning of psychotherapy. New York: Basic Books. Ellis, M. V., & Ladany, N. (1997). Inferences concerning supervisees and clients in clinical supervision: An integrative review. In C. E. Watkins (Ed.), Handbook of psychotherapy supervision (pp. 447–507). New York: Wiley. Ellis, M. V., Ladany, N., Krengel, M., & Schult, D. (1996). Clinical supervision research from 1981 to 1993: A methodological critique. Journal of Counseling Psychology, 43, 35–50. Falender, C. A., & Shafranske, E. P. (2004). Clinical supervision: A competency-based approach. Washington, DC: American Psychological Association. Fisher, C. B., & Younggren, J. N. (1997). The value and utility of the 1992 ethics code. Professional Psychology, 28, 452–462. Frank, J. D., & Frank, J. B. (1993). Persuasion and healing: A comparative study of psychotherapy (3rd ed.). Baltimore: Johns Hopkins University Press. Freitas, G. J. (2002). The impact of psychotherapy supervision on client outcome: A critical examination of 2 decades of research. Psychotherapy: Theory/Research/Practice/Training, 39, 354–367. Gay, P. (Ed.). (1989). The Freud reader. New York: Norton. Gilmore, S. K. (1973). The counselor-in-training. New York: Appleton-Century-Crofts. Henley, R. W., & Robertson, M. H. (1988). A career in psychology: From training to employment. Madison, CT: International Universities Press. Hess, A. K. (1980). Psychotherapy supervision: Theory, research and practice. New York: Wiley. Hess, A. K. (1986). Growth in supervision: Stage of supervisee and supervisor development. Clinical Supervisor, 4, 15–67. Hess, A. K. (2006). Serving as an expert witness. In I. B. Weiner & A. K. Hess (Eds.), Handbook of forensic psychology (3rd ed., pp. 652–697). Hoboken, NJ: Wiley. Holloway, E. L. (1995). Clinical supervision: A systems approach. Thousand Oaks, CA: Sage. Jenkins v. United States, 307 F. 2d 637 (D. C. Cir. 1962) en banc. Kell, B. L., & Mueller, W. J. (1966). Impact and change. New York: Appleton-Century-Crofts. Krasner, R. F. (1983). Contemporary psychoanalysis, XIX [Abstract]. Psychoanalytic Quarterly, 55, 204. Lazarus, A. A. (1967). The treatment of a sexually inadequate man. In L. Ullmann & L. P. Krasner (Eds.), Case studies in behavior modification (pp. 243–245). New York: Holt, Rinehart & Winston. Lazarus, A. A. (1996). The utility and futility of combining treatments in psychotherapy. Clinical Psychology: Science and Practice, 3, 59–68. Macran, S., Stiles, W. B., & Smith, J. A. (1999). How does personal therapy affect therapists’ practice? Journal of Counseling Psychology, 46, 419–431. Mueller, W. J., & Kell, B. L. (1972). Coping with conflict. New York: Appleton-Century-Crofts. Reik, T. (1948). Listening with the third ear. New York: Farrar, Straus. Reisman, J. (1976). A history of clinical psychology. New York: Irvington. Rice, L. N. (1980). A client-centered approach to the supervision of psychotherapy. In A. K. Hess (Ed.), Psychotherapy supervision: Theory, research and practice (pp. 136–147). New York: Wiley. Robiner, W. N., & Schofield, W. W. (1990). References on supervision clinical and counseling psychology. Professional Psychology: Research and Practice, 21, 297–312. Roe, R. A. (2002). What makes a competent psychologist? European Psychologist, 7, 192–202. Rogers, C. R. (1942a). Counseling and psychotherapy: Newer concepts in practice. Boston: Houghton Mifflin. Rogers, C. R. (1942b). The use of electrically recorded interviews in improving psychotherapeutic techniques. American Journal of Orthopsychiatry, 12, 429–434. Rogers, C. R. (1975). Empathic: An unappreciated way of being. Counseling Psychologist, 5, 2–9. Rosenbaum, M., & Ronen, T. (1998). Clinical supervision from the standpoint of cognitive-behavior therapy. Psychotherapy, 35, 220–230. Rubin, N. J., Bebeau, M., Leigh, I. W., Lichtenberg, J. W., Nelson, P. D., Portnoy, S., et al. (2007). The competency movement within psychology: An historical approach. Professional Psychology, 38, 452–462. Sullivan, H. S. (1962). Schizophrenia as a human process. New York: Norton. Wampold, B. E. (2007). Psychotherapy: The humanistic (and effective) treatment. American Psychologist, 62, 855–873. Watkins, C. E., Jr. (1997). The handbook of psychotherapy supervision. New York: Wiley. Worthington, E. L., Jr. (2006). Changes in supervision as counselors and supervisors gain experience: A review. Professional Psychology, 18, 189–208; Training and Education in Professional Psychology, 8, 133–160. (Original work published 1987)

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PART TWO

PERSPECTIVES OF PARTICIPANTS

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CHAPTER 2

The Dynamics of Change and Outcome in Psychotherapy Supervision: A Note on Professional Identity PAUL M. LERNER

WHEN I am asked to speak or write about supervision or teaching, the following story, an episode from the television series The Wonder Years, almost always pushes its way into my consciousness. Kevin Arnold, a 13-year-old ninth grader, raises his math grade from a D to a C with his teacher’s assistance. Satisfied with his accomplishment, but needing something more, he approaches his teacher, Mr. Collins, after class seeking recognition and praise. To his dismay, however, rather than offering praise, Mr. Collins instead points out that a C grade indicates average work and then expresses his belief that Kevin could do better. Beyond noticing this potential in Kevin, Mr. Collins also offers him the opportunity to fulfill it, suggesting they do additional work outside class. With considerable reluctance, Kevin grudgingly accepts the offer. To his surprise, as they meet regularly over the next several months, his interest in math deepens. So does his relationship with Mr. Collins. Slowly, Kevin begins to realize that it is not the subject matter that has captured him so much as the person of the teacher—Mr. Collins’s availability, devotion, and quiet passion.

Dr. Lerner dedicated this chapter to the lasting memory of Ruth Easser, MD. Between the writing of this chapter and its editing, Dr. Lerner passed away at the airport on his way to the annual meeting of the Society of Personality Assessment. As was typical of Paul’s craftsmanship, little editing was needed. We were privileged to know Paul, albeit all too briefly.

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Several days before an all-important midterm exam, Mr. Collins unexpectedly, and without explanation or justification, informs Kevin that he no longer will be available for extra help. Taken back by the abrupt rejection and fearful of the impending exam, Kevin pleads with him, finally screaming in desperation, “I thought you were my friend!” Seemingly unmoved, Mr. Collins calmly responds, “I am not your friend Mr. Arnold; I am your teacher.” Painfully disappointed, Kevin intentionally fails the exam and mocks it by writing on his answer sheet disparaging comments such as “So what,” “Who cares?” and “Factor this.” Over the ensuing weekend, however, his anger quiets and is replaced by more troublesome feelings of guilt. This leads him, on the following Monday, to seek out Mr. Collins to apologize. Unable to find Mr. Collins, Kevin is finally taken aside by the principal, who hesitantly tells him that Mr. Collins passed away over the weekend. When you are 13 years old, you do not understand death. You regard it as something distant and removed and imagine it as a mysterious dark cloud that descends on the elderly and on strangers, not on your middle-aged math teacher. But when it does visit your school and spirits away your special teacher, then you are left alone to wallow in your own sadness and loneliness. The exams, several days later, are handed back; however, something odd has occurred. Kevin’s exam is not there. Instead, there is a blank exam with Kevin’s name on it and a note, written by Mr. Collins before he died, indicating that Kevin’s exam was misplaced and that he should retake it. Kevin is given a second opportunity. As he retakes the exam, Kevin’s thoughts turn to Mr. Collins and their relationship. He remembers how Mr. Collins had treated him like a man and how he had reacted as a boy. How he had disappointed Mr. Collins; and now he would not. Virtually sensing Mr. Collins’s presence in the classroom, Kevin recognizes that whereas he had thought he needed his teacher for the answers and for praise, now he is on his own. As he hands in his completed exam, he calmly yet confidently says to the substitute teacher, “You don’t have to grade it—I know it is an A.” And finally, as he leaves the room, Kevin looks back over his shoulder at Mr. Collins’s desk. Imagining Mr. Collins sitting there as he once had, he whispers, just loud enough for each of them to hear, “Good job, Mr. Collins.” Although the story, in a narrow sense, pertains to teaching and the teacher–student relationship, in a broader sense it has relevance for various forms of training, including supervision. In what follows I make use of vignettes as both springboards and as frameworks for discussing the mechanisms of change and growth in supervision and what I consider important goals or outcomes. MECHANISMS OF CHANGE AND GROWTH Like psychodynamic psychotherapy or psychoanalysis, insight and selfunderstanding are major vehicles for promoting growth in supervision. However, even more fundamental, in my judgment, is the role of internalization. Beginning with Freud, the concept of internalization has occupied a pride of place in psychoanalytic theory. Based on a number of strands in Freud’s writings, it has been discussed from several perspectives including the significance of inadequate or distorted internalizations in psychopathology (Blatt, 1974; Kernberg, 1975), the

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The Dynamics of Change and Outcome in Psychotherapy Supervision 27 function of internalizing mechanisms as defenses (Klein, 1935), and the role of internalization as a basic process for growth and development (P. Lerner, 1998). It is this last consideration I discuss here. In his 1923 article “The Ego and the Id,” Freud invoked the term introjection to account for the process by which external experiences are transformed and recreated on the terrain of inner experience. More specifically, in his exposition on superego development he described how the guiding, restraining, and punishing functions initially imposed on children by their parents in time become part of the child and are later experienced not as other-regulators but as self-regulators. Theorists (Kernberg, 1976) subsequent to Freud replaced the term introjection with internalization and conceptualized introjection as a particular type of internalization. For psychoanalysts, internalization—the process whereby external experiences are transformed into inner experiences—occurs in the context of an object relationship. Fueling the process is the quality of the affective relatedness (i.e., love, respect, fear, guilt) between the participants. One internalizes not just the personhood of the other and the nature of the relationship, but also roles, functions, values, and attitudes. For instance, and in specific regard to functions, as a result of internalization the individual is increasingly able to do for himself or herself what others earlier had done for him or her. Furthermore, when a child internalizes a parent, he or she also internalizes the sense of being (or of not being) seen, defined, and valued by that parent (Cohen & Sherwood, 1991). Because internalization involves transforming functions, attitudes, and any number of external experiences, it is, as Loewald (1962) pointed out, structure building. From this perspective, psychic structures, including cognitive ones, are, in part, based on and modified by internalized object relations (Kernberg, 1976; H. Lerner & Lerner, 1986). This psychoanalytic conceptualization of internalization as a mediating process for growth, change, and development is especially consistent with Piaget’s theory of cognitive development (Gill & Klein, 1967; H. Lerner & Lerner, 1986). Both emphasize the progressive internalization and structuring of external experiences, and both focus on the continuous growth, reorganization, and revision of existing internal structures. For instance, the time period that psychoanalysis pinpoints as the beginnings of emotional object constancy and consolidation of individuality coincides precisely, in Piaget’s theory, with the internalization of learning skills (Mahler, Pine, & Bergman, 1975). Also, basic to both models is increasing autonomy from the environment. Not only are there important similarities between the psychoanalytic concept of internalization and Piaget’s theory of cognitive development, there are significant differences as well. Piaget and most other learning theorists accord virtually no attention to the interpersonal relationship between the subject and the object (i.e., parent–child, teacher–student). In contrast, psychoanalysis places the relationship at the center of the internalizing process. Aspects of the relationship—including the affective quality of relatedness, the object’s capacity to hold and to contain, the object’s consistency and continuity, and the quality of fit between self and other—are all seen as crucial. Yet another distinction between the concept of internalization and Piaget’s theory and other theories of learning involves the notion of loss. Several

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psychoanalytic theorists take Freud’s (1917/1957) model of mourning as a metaphor for understanding internalization, whereas others (Schwaber, 1981) regard the loss or the threatened loss of an object as a necessary precondition for internalization. References to the intimate connection between loss, or what Frankiel (1994, p. 36) referred to as “shifts in relation to the object,” and internalization appeared in several of Freud’s writings. In “Mourning and Melancholia,” for instance, he characterized the melancholic’s identification with the abandoning object in this way: Thus the shadow of the object fell upon the ego and the latter could henceforth be judged by a special agency, as though it were an object. In this way an object-loss was transformed into an ego-loss, and the conflict between the ego and the loved person into a cleavage between the critical activity of the ego and the ego altered by identification. (Freud, 1917/1957, p. 249)

And in his paper “The Ego and the Id,” he wrote, “The character of the ego is a precipitate of abandoned object cathexes and contains the history of these object choices” (Freud, 1923/1961, p. 23). Theorists since Freud have extended several of his initial insights in interesting and important directions. Schwaber (1981), for example, suggested that the loss might not simply be that of the object but also of an earlier mode of relating to the object. Bloom-Feshbach and Bloom-Feshbach (1987) pointed out that lesser forms of loss, such as separation, not only prompt internalization but also foster representation. Along these same lines, H. Lerner and Lerner (1986) studied the relationship between separation and representation. It was their contention that not only were the two intimately related, but separation was a prerequisite condition for representation. The story about Kevin Arnold and his relationship with his math teacher illustrates in a more concrete and up-close way the internalizing process and the place of loss in that process. The changes one sees in Kevin, such as his learning of math and his ability to perform at a higher level, clearly were not just the result of his growing interest in math. Kevin’s interest in math did deepen. However, such changes were occasioned and stewarded by his evolving relationship with Mr. Collins. Initially, Kevin sought Mr. Collins’s praise and approval—his love, if you will. Yet what Kevin received back and grew from was not the praise but his teacher’s time, emotional availability, expectations, and passion. Like a “good-enough” parent (Winnicott, 1960), Mr. Collins knew Kevin well; indeed, better than Kevin knew himself. He gave Kevin not what was asked for, but what was needed. Mr. Collins tended their relationship. He defined boundaries (i.e., “I am not your friend; I am your teacher”), set higher expectations, provided Kevin the opportunity to fulfill those expectations, and saw Kevin as he was and as he could be. Although the relationship served as the basis for Kevin’s changing, the changes themselves were precipitated by the loss of Mr. Collins—first the rejection and then the abandonment. Following the loss, Kevin identified with Mr. Collins and internalized Mr. Collins’s attitude toward him and the functions he had provided.

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The Dynamics of Change and Outcome in Psychotherapy Supervision 29 Underlying Kevin’s external behavioral change was a more fundamental internal change. Kevin’s self-representation shifted from that of an average student to one of an outstanding student. He was now able, based on his own accomplishments, to supply for himself the love he previously had sensed he needed from others. With respect to Kevin’s supplying for himself the love he had sought from Mr. Collins, there is another point to be made. It seems to me that inextricably interwoven with loss is reclamation. When asked the goal of treatment, Freud likened psychoanalysis to The Netherlands, noting that it was a country that was losing land to the sea, but it was also finding innovative ways to reclaim that land. From this perspective, then, implicit in loss is the opportunity and motivation, overt or hidden, to reclaim what has been lost. It should come as little surprise that when I was in psychoanalytic training, one of my profound experiences involved the loss of a supervisor. My first supervisor was Ruth Easser, an extraordinary woman whose contributions, professional and personal, were documented in O’Neil’s (2004) book The Unsung Psychoanalyst. Tall and gangly, like a sprouting adolescent, Ruth radiated beauty when she spoke. A remarkable clinician, she combined an uncanny empathy with an astute clinical savvy. As a theoretician, her article “Empathic Inhibition and Psychoanalytic Technique” (Easser, 1974), originally presented as the S´andor Rado´ Lecture at the Columbia Psychoanalytic Institute, predated and anticipated several of Kohut’s (1977, 1984) contributions. Toward the end of our supervision, unexpectedly, Ruth mentioned that she would be having surgery. The surgery was too little and too late; her cancer had metastasized. When she returned to work, we continued with the supervision, first in her office, then her home, and finally in her bedroom. I felt deeply honored to be selected as a pallbearer at her funeral. I learned much from Ruth Easser—about psychoanalytic theory, about the multiple layers of relationships in analytic treatment, and about women. However, over the years, what has stayed with me and felt most compelling have been aspects of her personhood: her relentless pursuit of truth, her unflinching courage, and her unwavering commitment to patients and supervisees. Internalization as a model of and explanation for growth and learning has significant implications for supervision. First, it reminds us that meaningful change takes place in an interpersonal context. Supervisors, beyond imparting clinical theory and specific techniques, need to attend to their relationships with supervisees. Second, supervisees identify with and internalize considerably more than their supervisors’ knowledge and skills. They internalize their supervisors’ entire beings; they embrace values, ideals, passions, and attitudes, including supervisors’ attitudes toward them. Internalization, and hence learning, presupposes a clear distinction between self and other concerning personhood and clarity regarding respective roles, functions, responsibilities, and goals. A mutually shared goal involves the supervisees’ eventual capacity for and sense of autonomy. Progressively, knowledge and talents originating in supervisors become a part of and accessible to supervisees. In time, supervisees are increasingly able to do for themselves those functions they initially looked to their supervisors to perform.

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With internalization, the most important changes are internal rather than external, although they may be reflected in external behavior. Therefore, successful training is gauged not just in terms of external markers, such as amassing so much knowledge or functioning more effectively, but also in terms of internal benchmarks, such as shifts in sense of self, movement toward professional identity, and greater sensitivity and awareness in relating to and coming to know the other. In the next section I identify and discuss several of the more important changes that I attempt to foster, encourage, and contribute to in my supervisees. Even though I present these changes as hoped-for outcomes, I recognize that such goals represent ideals and that supervisees, regardless of level, are in the process of becoming. S U P E RV I S O RY G O A L S An overarching goal I hold with regard to supervisees is assisting them in their movement toward a sense of professional identity. The concept of identity is elusive; it is something one feels or senses and, as such, is not easily definable. Yet philosophers, psychologists, and writers wrote about it long before it was popularized. William James (1920) wrote in a letter to his wife: A man’s character is discernible in the mental or moral attitude in which, when it came upon him, he felt himself most deeply and intensely active and alive. At such moments there is a voice which speaks and says: “This is the real me!” (p. 199)

Freud spoke of the Jewish aspects of his identity but once. In an address to the Society of B’nai B’rith in Vienna, he commented: What bound me to Jewry was (I am ashamed to admit) neither faith nor national pride, for I have always been an unbeliever and was brought up without any religion though not without a respect for what are called the “ethical” standards of human civilization. Whenever I felt an inclination to national enthusiasm I strove to suppress it as being harmful and wrong, alarmed by the warning examples of the people among whom we Jews lived. But plenty of other things remained over to make the attraction of Jewry and Jews irresistible—many obscure emotional forces, which were the more powerful the less they could be expressed in words, as well as a clear consciousness of inner identity, the safe privacy of a common mental construction. Beyond this there was a perception that it was to my Jewish nature alone I owed two characteristics that had become indispensable to me in the difficult course of my life. Because I was a Jew I found myself free from many prejudices which restricted others in the use of their intellect; and as a Jew I was prepared to join the Opposition; and to do without agreement with the compact majority. (Freud, 1926/1959, pp. 273–274)

For James, character, by which I believe he was referring to identity, was mental and moral, came over you quite unexpectedly, and was almost palpable. For Freud, identity was somewhat different: It involved ethnic and cultural origins, was both personal and public, and was known to and shared by those who belonged to a common community or group. For both, it came about through recognition and reflection, not aspiration, and it was experienced as vitalizing, organizing, and deeply authentic.

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The Dynamics of Change and Outcome in Psychotherapy Supervision 31 Erikson (1968), aware of the elusiveness and complexity of the concept, described it, all at once, as a conscious sense of individual uniqueness, an unconscious striving for a continuity of experience, and a solidarity with group values and ideals. He considered identity as beginning early in life, reaching a normative crisis and consolidating during adolescence, and culminating only when the individual’s need for mutual affirmation waned. There is consensus that a sense of professional identity is an important, however difficult and challenging, goal of clinical training. Unfortunately, however, in most training programs comparatively little attention is paid to professional values and attitudes. Although such programs emphasize, and rightly so, psychotherapeutic techniques, theories of treatment, and in some instances clinical thinking, little emphasis is accorded how one works as an expression of his or her values and attitudes. For those who provide psychological treatment, one’s professional identity consists in part of ethical standards and theoretical allegiance (e.g., psychoanalytic, cognitive-behavioral). There is another component, one that extends beyond ethical guidelines and cuts across theoretical persuasions. It is an aspect of professional identity that is not formalized, but instead is typically transmitted, unwittingly and often unintentionally, through supervisees’ identification with their supervisors. What I have in mind here is professional identity as reflected in one’s attitude toward and approach to patients. As a supervisor and as a psychoanalyst I attempt in words and in actions to impart to supervisees an approach to treatment steeped in a humanistic-clinical attitude. By humanistic, I am referring to the humanness of the therapist as expressed in his or her compassion, concern, and therapeutic intent toward the patient. Therapists remain continually aware that the individuals who seek our help are in pain and are suffering, and that our task is to understand the nature of their difficulties and to assist them to get well. Supervisees ought to know that regardless of how provocative, obnoxious, or alienating a patient behaves or how repulsive we perceive their past behavior, as professional psychologists we attempt to maintain a concern for the patient’s self-esteem, self-regard, and dignity. I recognize that there are certain patients who stir such intense counterreactions for particular therapists that it makes treating that patient virtually impossible. When I have suggested this to supervisees, they typically react with first surprise and then relief. I often share with them the case of a well-to-do businessman who, in preparing for bankruptcy, placed all of his assets in his wife’s and children’s names and traded in his Mercedes for a new BMW. Although I decided not to treat the patient, I point out to supervisees that I still had the responsibility of not only finding the patient another therapist, but of dealing with him in a respectful way. A humanistic attitude is further expressed in our belief that the patient has rights in the treatment situation—the right to remain separate, the right to confidentiality, and the right to be helped. It is my experience that supervisees, regardless of level, struggle to fully grasp the notion of separateness. For instance, to appreciate and accept that a patient’s decisions are his or her decisions, even though those decisions may involve questionable judgment and result in undesired consequences, requires of supervisees capacities, including patience, sitting still, and confidence in the therapeutic process, that come about only with years of experience.

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A third aspect of a humanistic attitude involves the ways in which we describe and think about our own patients and those of our supervisees. Diagnostic labels provide a shorthand, convenient way of communicating; nonetheless, they can lead to misunderstandings, and, even more important, they convey to students the notion that one is treating a form of psychopathology rather than a person. Therefore, when I discuss a patient with a supervisee I attempt to use a level of language (Mayman, 1963) that is descriptive and pitched as close as possible to the patient’s experience. For example, rather than referring to a 32-year-old, single, female patient as a “narcissistic personality with schizoid features,” I suggest to the supervisee that the patient reminds me of Holly Golightly, the main character in Truman Capote’s Breakfast at Tiffany’s, as she too blithely glides through life, allowing little to touch or affect her. With regard to the clinical dimension of a humanistic-clinical attitude, this first includes being receptively open and nonjudgmental. The term analytic neutrality has been mistakenly assumed to imply abstinence and deprivation. In practice, it refers to the therapist’s “evenly hovering attention” and unhampered attunement to an individual’s reactions with the intent of understanding and not judging those reactions. The importance of maintaining a nonjudgmental attitude is well illustrated by the following case. A 37-year-old woman, married and childless, was referred for treatment following a brief period of hospitalization. One month previously she had had an intense depressive episode involving feelings of depersonalization and suicidal ideation. Although the patient had been moderately depressed for several years, the acute episode followed a heated confrontation with her husband in which he had admitted his unwillingness to have a child but then refused to discuss the issue further. She experienced his reluctance as banishing her to a life of emptiness and meaninglessness. Her husband, a successful businessman 23 years her senior, had three older adolescent children from an earlier marriage. At the beginning of our first session the patient asked me what I thought of her desire to have a baby. Mindful that virtually everyone in her life—family, close friends, and even the hospital staff—had empathized with her husband and told her she was being foolish and potentially destructive, I responded that I considered her desire to have a child quite legitimate but that I was not clear as to its possibility. As I understood it, the patient was asking me not only how I judged her desire to have a baby, but also how I judged her. My response was twofold. On the one hand, I did not feel it would have been helpful to judge her. On the other hand, I tend to regard desires as nothing more or less than desires and, as such and unlike behavior, not something to be externally judged. In retrospect, I believe that my nonjudgmental stance permitted the unfolding of a solid working alliance. A second feature implicit in a clinical attitude is a careful and continuous attunement to boundaries. Several authors (Chassequet-Smirgel, 1992; Greenson, 1967) have written of the therapeutic frame, by which they meant the structural features that provide the framework for treatment to occur. The treatment frame consists of the place where sessions will be held, the time duration of sessions, the agreed-upon fee, the way in which missed appointments will be handled,

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The Dynamics of Change and Outcome in Psychotherapy Supervision 33 and how the participants are to refer to each other (e.g., by last name, first name, title). In addition, roles, although subject to distortion, are relatively prescribed and confidentiality is safeguarded. The therapeutic frame, as Chassequet-Smirgel (1992) in particular noted, permits the expression and containment of certain psychic phenomena, regulates the attitudes and expectations of the participants, and allows for the activation and observation of an array of interpersonal transactions. I have found that not only has this aspect of treatment been relatively neglected in training, but for supervisees, establishing and maintaining the frame is often troublesome. A supervisee was assigned a female patient for long-term treatment. He began the treatment by introducing himself by title and referring to the patient by her last name. The patient, an attractive and charming woman several years older than the supervisee, immediately reacted. She complained that titles and surnames were formal and distancing and suggested that they refer to each other by first name instead. He hesitantly agreed. The patient’s reaction could be understood at various levels; however, it was only later in supervision that the supervisee could see that one level involved the patient’s tendency to question and then redefine the treatment frame, his own readiness to bend, and the potential effects of this on the treatment. A third aspect of a clinical attitude involves one’s willingness and capacity to accord full importance to each session with a patient. To do this, one needs to be emotionally available and not hindered by internal and external distractions. Freud (1912/1958) had this in mind when, in his discussion of the use of countertransference reactions, he indicated that the analyst “must turn his own unconscious like a receptive organ toward the transmitting unconscious of the patient . . . so the doctor’s unconscious is able . . . to reconstruct [the patient’s] unconscious” (pp. 115–116). Maintaining this type of unimpeded, receptive attentiveness, especially for newer supervisees, is no easy matter. At the least it demands any number of capacities of supervisees, including the ability to listen; the capacity to quietly hold in mind the patient’s offerings; a tolerance for ambiguity and not knowing; and a willingness to experience, without acting upon, a variety of highly charged feelings. The last feature of a clinical attitude is the clinician’s meaning-seeking orientation. I am referring here to the therapist’s unwavering pursuit of meaning, understanding, and truth. Meaning-seeking from a psychoanalytic perspective includes, yet goes well beyond, the “whats” and “hows” of behavior; it also includes the “whys.” Implicit in a meaning-seeking orientation are two general principles. The first involves the therapist “sitting still.” By this I mean the therapist maintains an interested, concerned, and empathic presence in the face of demands from the patient for immediate answers and ready solutions. The second principle, one closely related to the first, involves viewing time as an ally and urgency as a foe. This principle recognizes that many of our patients view time in a distorted way and that time itself is a vehicle of change. Given the fluidity, flux, and reactivity of contemporary life, and the insistence that change be magical, quick, and effortless, when I share this orientation of sitting still and taking one’s time, I imagine new supervisees regard me as old fashioned and out of step.

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Nonetheless, over the years, I, and I believe many of my supervisees, have found these two principles related to meaning-seeking to be quite helpful. They serve as reminders that before many of our patients can make use of treatment, they need the therapist to become a constant object (Cohen & Sherwood, 1991). Therefore, during the beginning phase of treatment the therapist’s task is to create a context in which an object tie can be experienced. When I have presented the following case in seminars to novice therapists, my therapeutic stance based on the principles of sitting still and making use of time has inevitably provoked heated discussion. A 34-year-old divorced woman sought treatment soon after the painful termination of a relationship with a married man 5 years her junior. With the realization that her highly romanticized involvement with younger, married, or otherwise unavailable men was becoming a distinct pattern, she became preoccupied with the thought that she was destined to spend the remainder of her life unmarried and essentially alone. Most striking in her history was the number of early losses. When she was 5 her father died of a brain tumor, over the next several years her maternal grandmother died and her older sister married and moved to a distant city, and when she was 15 her mother died of a stroke. Thus, by adolescence, the patient had lost most of her immediate family and was essentially raising herself. Before beginning treatment, the patient prepared an elaborate log in which she chronicled all of the major events in her life. Then, for the first 11 months of treatment, she did little other than read to me from her log. Mindful of the many intrusions and interruptions in her life, during this period I said little, and the infrequent responses I did offer involved attempts to empathize with her experience and recognize the immense pain and sadness that had accompanied her much of her life. She responded to my comments with genuine but muted gratitude—as if they were unexpected, unsolicited, mildly intrusive, yet nonetheless precious gifts. It was not until the 11th month of treatment, with our first extended separation, that this opening phase came to an abrupt and dramatic end. On my return from the break, my receptionist informed me that the patient had come for her session several days earlier. She had apparently mixed up the dates when I would be back in my office. An orderly and well-organized individual, the mix up was quite out of character. On resuming treatment, the patient did not mention her lapse regarding dates. Instead, she reminded both of us where she had ended before the break and immediately picked up with the unfinished theme. About halfway through the session I interrupted her monologue, something I had refrained from doing previously. I mentioned what my receptionist had told me about the possible confusion in dates, pointed out that this was unlike her, and suggested that the mix up was likely related to her feelings about our separation. The patient literally dissolved before me. She began whimpering and sobbing with an intensity I had seldom seen before. After several minutes, she regained her composure and shared with me the excruciating pain she had experienced during the separation. I heard of her failed efforts to quiet and contain intense feelings of emptiness, loneliness, and isolation. Most troublesome was her unbearable and

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The Dynamics of Change and Outcome in Psychotherapy Supervision 35 persistent thought that I would never return to her. This had led her to explore the newspapers on a daily basis, first examining the headlines to see reports of a plane crash and then turning to the obituaries. During the next several weeks, we explored these more spontaneous and genuinely painful feelings and thoughts. As we did, the patient began, for the first time, to grieve her father’s death of 30 years earlier. When I discuss this case with younger therapists, they typically take issue with what they consider my passive stance of allowing the patient to simply read to me for 11 months. As I see it, my sitting still and using time as an ally were necessary. It was the symptomatic act (mix up of appointment) that signaled to me that an object tie had been established and that I could then be more active and begin to bring issues into our relationship. I also point out to these therapists that if I had been more active and confrontational earlier, in all likelihood the patient would have terminated. To briefly recap, in this chapter I have suggested that a major goal of supervision involves supporting supervisees’ need to attain a professional identity. The aspect of professional identity I have so far discussed relates to an underlying humanisticclinical attitude. Of course, other ingredients also go into that mixture we refer to as professional identity. One such ingredient that I have found invaluable relates to having a comprehensive and cohesive conceptual atlas that includes maps for understanding personality functioning, different forms of psychopathology, and the process of treatment. Toward the end of graduate school, as part of a psychotherapy practicum, I saw a woman, the wife of an Air Force pilot, whose husband had been killed in a tragic training accident. Because she was still raw from the recency of the accident, and because of my capacities to listen and to empathize with her pain, beginning with our first session she laid her immense grief and suffering squarely in my lap. Unfortunately for each of us, I felt quite at sea, not knowing how to think about, never mind help her deal with, her loss. That case, and too many like it, was a constant reminder that despite having had solid training, I lacked and needed a meaningful framework that would allow me to grasp and understand another’s inner world as well as my own. It was those types of experiences that prompted me to seek postdoctoral training in a setting steeped in psychoanalytic theory and then, later, to complete formal psychoanalytic training. Psychoanalysis, then, as a theory of personality, a theory of psychopathology, and a theory of treatment, has become my atlas. I recognize that students and beginning psychologists, the majority of our supervisees, will not complete their supervisory experience with a full grasp of a complex, comprehensive, highly nuanced theoretical structure. Understanding, applying, and claiming as one’s own a major psychological framework such as psychoanalysis requires intensive study, years of experience, and an up-close familiarity with historical and contemporary literatures. Nonetheless, supervision does provide a unique opportunity to acquaint supervisees with a way of thinking about a person and about psychic phenomena. In helping supervisees conceptualize a case, psychoanalytic supervisors, out of necessity, will expose those supervisees to any number of core psychoanalytic concepts and formulations such as psychic determinism, the role of

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unconscious processes, the importance of childhood experiences, the value of a developmental perspective, and an appreciation of who the person is rather than what he or she is. Then, too, supervisees will learn of the multilayered language of psychoanalysis: the differences among the language of metapsychology, the language of clinical theory, and the language one uses with a patient (Mayman, 1963). A relatively experienced therapist, quite competent and well trained in cognitive-behavioral treatment, sought consultation with respect to a case she felt had bogged down. The patient, a 50-year-old single, strikingly attractive woman, had retired from the armed services 4 years earlier having attained the rank of major. Upon leaving the service, it was her dream and plan to retire to a home she had purchased in Switzerland. Owing to an illness in her family, she put her plans on hold and instead moved back to her parents’ home. Her younger, married sister, who lived next door to the parents, had been diagnosed with an inoperable brain tumor. Within 6 months her sister died and then over the next year and a half each of her parents died. After sorting out family matters, the patient hoped to follow through with her original plans of relocating to Switzerland. However, as time progressed she found herself becoming increasingly anxious, fearful of travel, and besieged by a number of vague physical ailments. It was for these reasons she sought treatment. Her therapist targeted these symptoms but noted that after 6 months, not only was the patient not improving, but her symptoms were getting more disabling. The patient was becoming more anxious and agoraphobic. It was at this point that the therapist asked for consultation. After listening to several sessions it seemed to me that because of the therapist’s exclusive emphasis on symptoms, the issue of loss (in this instance multiple losses) had not been addressed. I indicated to the therapist an opening in the material that would lead to the matter of the patient’s losses and also acquainted the therapist with Freud’s (1917/1957) work “Mourning and Melancholia.” In particular, I drew the consultee’s attention to Freud’s attunement to the nature of the relationship preceding the loss and to his remarkably useful quote that an individual “cannot see clearly what it is that has been lost . . . he knows whom he has lost but not what he has lost in him” (p. 245). The therapist made good use of the formulations, and both the treatment and the patient became unstuck. Genuinely excited about having a deeper understanding of her patient and desiring more than a brief taste of psychoanalytic theory, the consultee decided to extend the supervision. This particular supervisee was more experienced and firmly committed to a specific perspective. Her interest was in personality dynamics and not in technique. She stands in contrast with students and less experienced clinicians whose more pressing goals are to learn what to do and how to do it. Even with this latter group I stress theory, pointing out my belief that understanding should precede action. We do discuss technique, however my emphasis on listening and empathic attunement, especially during the early stage of treatment, is not always consistent with their agenda. It is my belief that having an atlas is indispensable given the nature of our work. More than simply a road map for navigating the difficult terrain of treatment, such a framework, as noted previously, affords one a sense of professional identity and

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The Dynamics of Change and Outcome in Psychotherapy Supervision 37 of place. For me, having attained a psychoanalytic mindedness and thinking of myself as a psychoanalytic clinician has been sustaining. Another ingredient of professional identity, one related to the issue of an atlas or conceptual framework, involves assisting supervisees in finding their own therapeutic voice. Soon after completing psychoanalytic training, I was referred a 19-year-old former college student for treatment. For reasons that were not readily apparent, he had unexpectedly dropped out of the university at the end of his freshman year. I accepted the referral with a mixture of delight and apprehension owing to the person of the referrer, who was the young man’s father. A senior analyst in our institute, he had been one of my favorite teachers. I deeply respected and liked him. As I have described elsewhere (P. Lerner, 2005), the beginning of treatment, especially for me, was difficult. Unintentionally, yet unavoidably, I brought his father to mind in the treatment. It was as if I had set his father on my shoulder and kept him perched there overseeing his son’s therapy. Recognizing that my own countertransference reaction needed to be addressed, I told the patient in an empathic way that I, not he, had allowed his father into the treatment setting and that it was affecting our relationship and my capacity to be with him. I also wondered if he, too, had permitted his father to exert too great an impact on his life. Following the gradual ousting of his father from my office, the treatment took off. Soon after termination, I reflected back upon the treatment, taking stock of the changes that had occurred in each of us. Because we were both adolescents, so to speak, it was not surprising that we had grown along somewhat parallel lines. He became increasingly more self-directed and more of his own person. I began developing my own analytic style and analytic voice. Earlier held stereotypes of how an analyst should behave and certain analytic stances that felt more pasted on than real were increasingly giving way. I was not rejecting my training, but rather integrating what I had learned into a way of being with a patient that felt right for me. Clearly, to ascribe my own professional growth to this one treatment experience would be inaccurate. Nevertheless, this particular case has come to represent those changes. As I see it, supervisees need to find their own therapeutic style and voice. The challenge for supervisors, much like for parents, is to permit and assist supervisees in growing in ways that are natural and important for them. In referring his son to me for treatment, my former teacher had assigned a task that he himself could not fulfill; that is, helping his son in making the transition from older adolescence to young adulthood. I took from this experience and from my former teacher the lesson that students and supervisees might possess talents that their teachers and supervisors do not have, and it is the latter’s responsibility to respect and nourish those capacities. It seems fitting to end this chapter with a brief discussion of Freud’s (1937/1964) paper “Analysis Terminable and Interminable.” The paper was written and published in 1937, when Hitler and Nazism were ascending to power in Germany and much of the world was still gripped in the throes of an economic depression. The article, more so than earlier ones, hinted of a sense of pessimism regarding the therapeutic efficacy of analysis. In this work, Freud wrote of the limitations of

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analysis, the difficulties of the procedure, and the obstacles to growth and change. He indicated that such factors as the strength of instincts (especially aggression), weaknesses in the ego, and the quantity and quality of early trauma, all place limits on a patient’s capacity to change and on the permanence of those changes. In that same work Freud also wrote that analysis does not cease when it ends. In an analogous way, even though at some point supervision formally ends, at best, it never stops. By this I mean that a basic outcome of supervision is supervisees’ internalizing of their supervisors’ reflective, meaning-seeking attitudes, thereby being capable of doing for themselves what the supervisors had previously done for them. In analytically informed work, such an attitude is turned toward not only the patient’s narrative, but also toward one’s own subjective counterreactions. As a vast literature beginning with Freud (1912/1958) has demonstrated, such reactions constitute a wealth of information.

CONCLUSION In this chapter I have discussed the dynamics of change and hoped-for outcomes attendant upon supervision. Recognizing the role of insight and self-understanding, I have suggested that more fundamental changes come about through internalization, including an identification with aspects of one’s supervisor. Internalization, as contrasted with other models of growth and development, draws attention to the interpersonal relationship, including the nature of affective relatedness, and the issue of loss. Beyond internalizing knowledge and skills, supervisees also internalize the person of the supervisor. A particularly important outcome, and one emphasized here, involves assisting supervisees in attaining a professional identity. This type of identity, as I see it, includes an underlying value system that fits the clinical situation; an atlas that contains conceptual road maps for understanding personality, psychopathology, and the treatment process; and a sense of one’s own therapeutic voice. I have also noted that, like treatment, supervision can and ought to be interminable. That is, once supervision has ended, supervisees continue to do for themselves what their supervisors had done for them. In this respect, and as 13year-old Kevin Arnold recognized, our teachers, supervisors, and mentors never truly die; they can live on in our memories forever.

REFERENCES Blatt, S. (1974). Levels of object representation in anaclitic and introjective depression. Psychoanalytic Study of the Child, 29, 107–157. Bloom-Feshbach, J., & Bloom-Feshbach, S. (1987). The psychology of separation and loss. San Francisco: Jossey-Bass. Chassequet-Smirgel, J. (1992). Some thoughts on the psychoanalytic situation. Journal of the American Psychoanalytic Association, 40, 3–26. Cohen, C., & Sherwood, V. (1991). Becoming a constant object in psychotherapy with the borderline patient. Northvale, NJ: Aronson. Easser, R. (1974). Empathic inhibition and psychoanalytic technique. Psychoanalytic Quarterly, 43, 557–580. Erikson, E. (1968). Identity, youth, and crisis. New York: Norton. Frankiel, R. (1994). Essential papers on object loss. New York: New York University Press.

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The Dynamics of Change and Outcome in Psychotherapy Supervision 39 Freud, S. (1957). Mourning and melancholia. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 14, pp. 237–260). London: Hogarth Press. (Original work published 1917) Freud, S. (1958). Recommendations for physicians practicing psychoanalysis. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 12, pp. 109–120). London: Hogarth Press. (Original work published 1912) Freud, S. (1959). Address to the Society of B’nai B’rith. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 20, pp. 273–274). London: Hogarth Press. (Original work published 1926) Freud, S. (1961). The ego and the id. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 19, pp. 22–59). London: Hogarth Press. (Original work published 1923) Freud, S. (1964). Analysis terminable and interminable. In J. Strachey (Ed. & Trans.), The standard edition of the complete works of Sigmund Freud (Vol. 23, pp. 209–270). London: Hogarth Press. (Original work published 1937) Gill, M., & Klein, G. (1967). The structuring of drive and reality: David Rapaport’s contributions to psychoanalysis and psychology. In M. Gill (Ed.), The collected papers of David Rapaport (pp. 8–34). New York: Basic Books. Greenson, R. (1967). The technique and practice of psychoanalysis. New York: International Universities Press. James, W. (1920). The letters of William James. Boston: Atlantic Monthly Press. Kernberg, O. (1975). Borderline conditions and pathological narcissism. New York: Aronson. Kernberg, O. (1976). Object relations theory and clinical psychoanalysis. New York: Aronson. Klein, M. (1935). A contribution to the psychogenesis of manic-depressive states. In M. Klein (Ed.), Contributions to psycho-analysis (pp. 282–310). London: Hogarth Press. Kohut, H. (1977). The restoration of the self. New York: International Universities Press. Kohut, H. (1984). How does analysis cure? Chicago: University of Chicago Press. Lerner, H., & Lerner, P. (1986). Contributions of object relations theory towards a general psychoanalytic theory of thinking. Psychoanalysis and Contemporary Thought, 9, 469–513. Lerner, P. (1998). Training in assessment: Internalization and identity. In L. Handler & M. Hilsenroth (Eds.), Teaching and learning personality assessment (pp. 107–118). Mahwah, NJ: Erlbaum. Lerner, P. (2005). On developing a clinical sense of self. Journal of Personality Assessment, 84, 21–24. Loewald, H. (1962). Internalization, separation, mourning, and the superego. Psychoanalytic Quarterly, 31, 483–504. Mahler, M., Pine, F., & Bergman, A. (1975). The psychological birth of the human infant. New York: Basic Books. Mayman, M. (1963). Psychoanalytic study of the self-organization with psychological tests. In B. Wigdor (Ed.), Recent advances in the study of behavior change (pp. 97–117). Montreal, Quebec, Canada: McGill University Press. O’Neil, M. (2004). The unsung psychoanalyst: The quiet influence of Ruth Easser. Toronto, Ontario, Canada: University of Toronto Press. Schwaber, P. (1981). Freud and the twenties. Massachusetts Review, 10, 133–147. Winnicott, D. (1960). The theory of the parent infant relationship. International Journal of Psychoanalysis, 41, 385–395.

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CHAPTER 3

The New Supervisee: Order from Chaos RYAN WEATHERFORD, TIFFANY O’SHAUGHNESSY, YOKO MORI, and ANJU KADUVETTOOR

A NOVICE trainee’s first supervision experience is simultaneously exciting and anxiety provoking. There are many challenges for the student and his or her supervisor, and the experience can feel confusing or even chaotic at times for both parties. The developing trainee will look to the supervisor for guidance and support through this ambiguous experience. Meanwhile, the supervisor must tap his or her memory of his or her own experience as a supervisee in an attempt to understand the unique aspects of this relationship. This chapter discusses strategies that provide a sense of order for new supervisees amidst this chaotic experience. Topics for discussion include addressing role expectations and supervisee anxiety, facilitating productive supervisory discourse and learning, managing countertransference, and taking into account cultural considerations. Suggestions for supervisors are integrated throughout the discussion.

R O L E E X P E C TAT I O N S As students begin their first clinical experience, they must navigate many potentially conflicting roles such as student, therapist, supervisee, and colleague (Holloway, 1984; Ladany & Friedlander, 1995). Students are required to simultaneously exhibit their competence while sharing their weaknesses and growth edges with their supervisor, who is in turn responsible for evaluating supervisees’ skills and preparedness to practice (Olk & Friedlander, 1992). Howard, Inman, and Altman (2006) found that new trainees experience struggles around consolidating their multiple responsibilities into a cogent professional identity. When these struggles are combined with the complexity of clinical supervision, which can change rapidly from a collegial interaction to a managerial focus (Ladany, Friedlander, & Nelson, 40

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The New Supervisee: Order from Chaos 41 2005), the new supervisee may initially be overwhelmed or experience heightened anxiety while attempting to integrate these new roles. ROLE CONFLICT AND ROLE AMBIGUITY The two primary themes investigated in the literature regarding supervisee role expectation are role conflict and role ambiguity (Van Sell, Brief, & Schuler, 1981). Olk and Friedlander (1992) defined role conflict as struggles that arise when a supervisee is required to engage in activities that are incongruent with his or her personal judgment or to engage in multiple roles that require opposing behaviors. Alternatively, role ambiguity is “a lack of clarity regarding the expectations for one’s role, the methods for fulfilling those expectations, and the consequences for effective or ineffective performance” (Olk & Friedlander, 1992, p. 390). Role conflict occurs less frequently than role ambiguity for the novice supervisee (Olk & Friedlander, 1992), therefore the focus of our discussion is the latter. Role ambiguity experienced by novice supervisees may limit the supervisor’s ability to build an effective supervisory working alliance, defined as mutual agreement on the goals and tasks of supervision in addition to an empathic bond (Bordin, 1983). In light of the extant literature (e.g., Bernard & Goodyear, 1998; Holloway, 1995; Muse-Burke, Ladany, & Deck, 2001) emphasizing the importance of establishing a strong working alliance to achieve positive outcomes, it is incumbent on the supervisor to work toward alleviating as much ambiguity as possible within the relationship. Ladany and Friedlander (1995) found that goal setting, discussion of expectations, and agreement on the tasks of supervision are important in reducing the level of confusion and role conflict experienced by new supervisees. They found that a stronger rating of the supervisory alliance predicted significantly less role ambiguity and role conflict. Additionally, Nelson and Friedlander (2001) found that lack of clear role expectations was predictive of conflictual supervision. Supervisors can work to alleviate role ambiguity by clearly discussing expectations at the outset of the supervisory relationship as well as continuing to address these issues as they arise. Showing students a 10-min explanatory video regarding the goals of supervision and the theory behind the supervisory process can help provide supervisees with a clearer conceptualization of supervision (Bahrick, Russell, & Salmi, 1991). In this study, students initially expressed confusion regarding supervisor role expectations and a decreased tendency to reveal their concerns about counseling to their supervisor. However, after completing the role induction, they identified their own needs and viewed the supervisor as providing more structure. Additionally, students perceived the supervisory relationship as more closely paralleling a client–counselor relationship in which they would feel comfortable expressing their needs to the supervisor. Absence of ethical guidelines regarding supervisee behavior could also add to supervisee confusion (Worthington, Tan, & Poulin, 2002). Worthington et al. found that in spite of the lack of guidelines, supervisors and supervisees typically agreed on what constituted ethical behavior in supervision, although they disagreed on the seriousness of certain behaviors (e.g., failing to complete records on time and consulting with someone other than the supervisor to challenge his or her authority). Because of the lack of professional standards for supervisee behavior in

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supervision, it is especially important for the supervisor to outline trainee expectations. Supervisors can work as advocates in establishing a set of guidelines for beginning supervisees. ISSUES OF CONTROL AND POWER Control and power are central to role expectations in the supervisory relationship. Quarto (2002) found that novice supervisees felt they had less control over the process of supervision than their more experienced counterparts. When supervisees feel less control, it may be difficult for the supervisor to truly establish the mutually agreed-upon goals and tasks that are essential to a strong working alliance. Newer supervisees viewed supervisor control of the relationship as related to helping them understand their clients but did not perceive that control was related to developing rapport. Quarto suggested that it might be difficult for novice supervisees to learn from their supervisors when struggling with feelings of diminished power or control in the relationship. New supervisees expect supervisors to hold and use power in the relationship (Murphy & Wright, 2005). Through qualitative analysis, Murphy and Wright found that supervisees were more likely to disclose information when their supervisor set clear boundaries without abusing his or her power in the relationship. Boundaries and responsible use of power also helped supervisees feel safe in the relationship. It is interesting that some of the interviewees reported concerns regarding a lack of critical feedback from their supervisor while appreciating their supervisor for using evaluation to help discover their areas for growth. ORGANIZATIONAL STRUCTURE ISSUES A supervisee’s position within the organizational structure of his or her training setting also affects role expectations. There are often formal and informal policies and procedures within an organization that the student must learn to navigate. The supervisor can serve as a mentor and guide to the new trainee as the latter learns his or her role and expectations in the organization. A helpful study found that students felt more prepared to handle the politics and organizational demands at their training site when they engaged in an extended simulation of the professional environments they would be entering (e.g., counseling center or community agency) prior to their practicum experience (Schwitzer, Gonzalez, & Curl, 2001). Further exploration of these types of simulations may help to alleviate the organizational role ambiguity often experienced by new supervisees. Additional struggles can arise for new supervisees if they are having conflicts with their supervisor and are unaware of the process for working to resolve these issues. At times, students receive inadequate supervision or fewer hours than agreed upon in the training contract, yet they may not report these matters given their uncertainty about to whom to voice their concerns or how doing so may influence their evaluation or future references (Gross, 2005). It is crucial to advise new supervisees of the process for resolving their conflicts within the organization and to ensure that they understand their rights. Empowering trainees to address their concerns and defining clear expectations can make for a smoother first training experience.

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The New Supervisee: Order from Chaos 43 ADDITIONAL SOURCES OF CONFUSION When surgeons learn to perform a new procedure, they are able to observe a master surgeon before they themselves engage in the task. Our field is unique in that our boundaries of confidentiality and the distinct differences each client brings to a session make comparable direct observation and specific instruction nearly impossible. Academic training paired with observation of intakes and therapy sessions can provide insight into the inner workings of a therapy session, but a great deal of hands-on learning still awaits. Regardless of the training and preparation a trainee receives, he or she cannot script what clients will say or how they will react. This has led many in our field to label psychotherapy as both an art and a science (see Soldz & McCullough, 2000). This ambiguity and uncertainty can undoubtedly contribute to increased levels of anxiety and confusion. It may be hard for the supervisor to recall the intensity of the confusion and uncertainty he or she felt at the start of training. There are several resources supervisors can suggest for their trainees in order to help alleviate some of this anxiety and to help demystify the therapy process. Two books that we have found especially useful are Letters to a Young Therapist (Pipher, 2003) and The Gift of Therapy (Yalom, 2002). We read these texts as beginning therapists and recommend them to our current supervisees.

S U P E RV I S E E A N X I E T Y Graduate students qualitatively indicate feelings of intense anxiety throughout their training (Skovholt & Ronnestad, 1992). As we indicate throughout this chapter, the new supervisee is particularly vulnerable to anxiety. The trainee engages in two distinct roles—therapist and supervisee—each with its own unique sources of concern. Although anxiety may be beneficial to the supervisee’s motivation to improve, it can also affect his or her performance. Friedlander, Keller, Peca-Baker, and Olk (1986) contended that supervisee performance is inversely related to anxiety level. Similarly, Yerkes and Dodson’s (1908) inverted-U hypothesis suggests that a moderate level of anxiety increases performance, whereas severe anxiety hinders it. A supervisor can help the new supervisee achieve this balance by identifying the sources of anxiety for him or her and evaluating their potential helpful or harmful influences on performance. Evaluations are a common source of anxiety for the new supervisee. The trainee’s first experience with formal or informal evaluation elicits many questions that the supervisor should handle with care. Consider the following example. Miguel receives his first formal evaluation midway through the semester. He is uncertain how others view his therapeutic work at this point. He recalls a few rewarding moments of connection with his clients and a great deal of confusing moments. He is hoping for a glowing endorsement from his supervisor, with sentiments such as “You’re a natural. . . . You’re going to be a great therapist. . . . You’re way ahead of the game.” Yet he fears the worst: “You’re not getting it. . . . Your work doesn’t look like therapy yet. . . . I’m not sure you picked the right profession.” During the supervision session, his supervisor Loretta asks Miguel to read over the evaluation for a few moments. A few numbers and comments stand out: a low score on differentiating content from process, a suggestion to engage

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in more exploration of his theoretical orientation. Miguel feels his face getting hot and his heart rate increase. He starts to feel disappointed in his performance and anxious about how his supervisor perceives him. Loretta reflects on her work with Miguel. Overall, she feels he is doing very well. She is pleased with Miguel’s comfortable and warm style with clients. She feels he has utilized well the basic counseling skills of empathic listening, reflection of feelings, and open-ended questions. She recalls a few of the growth edges they have discussed so far, including his difficulty understanding the process with clients. She writes a positive evaluation noting a few growth edges. When she gives the evaluation to Miguel in session, she is surprised to see his disappointment and notices he focuses on the few low scores and growth edges without acknowledging the variety of strengths she has outlined. This example illustrates one potential reaction to anxiety experienced during the evaluation process. We might expect other reactions to a supervisee’s first evaluation, such as a focus on only the positive aspects of the evaluation or little reaction at all. This first evaluation experience is important for the supervisee, given that the evaluation process is the primary source of learning in supervision (Holloway, 1992). Attending to the supervisee’s anxiety related to evaluation is important for the learning that takes place in the evaluation session as well as the way the supervisee approaches evaluation in the future. Upon further reflection, Loretta might realize that she could have explained the importance of including growth edges on an evaluation prior to the evaluation session with Miguel and possibly been more direct with her formative evaluations. Not addressing the anxiety may cause the supervisee to engage in more impression management, a common coping mechanism for anxiety (Bernard & Goodyear, 2004). A supervisee may try to generate a positive evaluation from the supervisor through nondisclosure, such as discussing only clients who are doing well or submitting tapes that only demonstrate strong performance. Supervisor observation (i.e., two-way mirror or audio-/videotaping) is another common source of anxiety for supervisees. In a review of the literature, Ellis, Krengel, and Beck (2002) found that observation causes increased supervisee anxiety and decreased performance. Yet they did not find a relationship between anxiety and audiotaping in two studies. This result is encouraging to the supervisor, suggesting that the indispensable practice of observing a supervisee’s work does not generate an overall sense of anxiety in the supervisee. However, anxiety about observation may arise at particular points in the supervisory relationship. Giving the first tape to a supervisor may raise a number of questions (e.g., How will my work compare to that of other beginning trainees? What are my supervisor’s expectations of my work at this time? How will the supervisor provide feedback about my tape?). Supervisors should also be aware of other anxiety-provoking scenarios related to observation, such as which taped session to submit for evaluation. Supervisors must also be mindful of a supervisee’s feelings of anxiety in session. Hill, Charles, and Reed (1981) found that although trainees’ observable levels of anxiety in session are low throughout their training, trainees qualitatively report more anxiety during their first practicum experience. Hill et al. described the early stage of counseling experience as “sympathy,” in which the trainee is overinvolved and feels responsibility for a client’s concern. Often, this desire to help the client

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The New Supervisee: Order from Chaos 45 comes from a new supervisee’s feeling of anxiety. The client may even welcome the opportunity to allow the supervisee to take responsibility for his or her concerns. Therefore, it is important for the supervisor to be aware of such reactions to anxiety. While normalizing the supervisee’s response, the supervisor can also enhance the trainee’s understanding of the process of therapy. The supervisor who is skilled at managing supervisee anxiety is an asset to new trainees. The skilled supervisor understands when to allow the supervisee to sit with his or her anxiety and when to step in to help resolve these struggles. There are a few tools the supervisor can use when encountering supervisee anxiety. One tool is the use of structure. Supervisors may approach sessions related to evaluation and tape feedback in a more direct way. For example, interpersonal process recall (Kagan & Kagan, 1997)—whereby the supervisor and supervisee listen to an audiotape and stop the tape at important moments in the session—can be an effective way to structure a session and can allow a supervisee to explore his or her emotional reactions to a tape in a supportive and nonjudgmental way. Structure is particularly important to the group supervision format, in that it is helpful for supervisees to understand group rules related to case conferences, feedback from peers, and agenda setting. Similarly, the use of clear role induction is an important tool for the supervisor. A clear explanation of the use of formal and informal evaluation as well as observation helps reduce the ambiguity related to these processes. The supervisor should also consider the supervisory relationship when handling supervisee anxiety. Relationship building should occur before, during, and after situations that are likely to evoke supervisee anxiety, such as evaluation or feedback. The relationship is crucial to the communication between supervisor and supervisee (Bordin, 1983). A strong supervisory relationship should survive miscommunications and anxiety that occur during evaluation or feedback. The supervisor may consider checking in on a supervisee’s level of anxiety before and after the evaluation or feedback process, especially during the supervisee’s first experience with these procedures. The use of process comments or “here-and-now” interventions may be helpful in these circumstances. A supervisor should also balance the use of supporting and challenging in the interventions (Bernard & Goodyear, 2004). Daniels and Larson (2001) demonstrated that positive feedback decreases anxiety and increases self-efficacy, whereas negative feedback increases anxiety and decreases self-efficacy. Referring again to the inverted-U model of anxiety, a supervisor may consider utilizing support or challenge to manage the supervisee’s anxiety in the needed direction. A supervisee with too little anxiety about his or her counseling work may need more challenging; a supervisee with too much anxiety may benefit from more support.

S U P E RV I S I O N D I S C O U R S E SUPERVISEE NONDISCLOSURE At times, new supervisees may not discuss the various feelings, thoughts, and behaviors elicited in the supervisory relationship, although these may be potentially helpful in facilitating the supervisee’s development. Trainees often do not

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disclose information that involves negative and positive feedback related to supervisor performance, personal concerns, evaluation, clinical mistakes, and general client observations (Ladany, Hill, Corbett, & Nutt, 1996). According to Ladany et al. (1996), trainees do not disclose negative and positive reactions to their client, countertransference issues, sexual attraction in the clinical or supervisory relationships, supervision setting issues, and observations of supervisor appearance. Furthermore, supervisees do not feel comfortable talking to their supervisors about the quality of supervision, the setting, personal issues, racism, disagreements about treatments, and disorganization (Pisani, 2005). Multiple process variables influence nondisclosure. Supervisees attribute their nondisclosure to perceived unimportance of the information, personal nature of the information, negative feelings (e.g., embarrassment, shame, and discomfort), and a poor supervisory working alliance (Ladany et al., 1996). Supervisees are more likely to disclose information in an individual supervision setting, when they choose their own supervisor, and when they receive supervision outside the clinical setting (Webb & Wheeler, 1998). A weak supervisory alliance and anxiety regarding evaluation may also be related to supervisee nondisclosure (Stoltenberg, 2005; Webb & Wheeler, 1998). SUPERVISOR FEEDBACK AND DISCLOSURE While attending to supervisee disclosure, supervisors must also be aware of their own disclosure in supervision. Accurate and honest feedback is crucial for the development of counselors in training. Yet delivering critical and personal feedback is a source of stress for some supervisors, which might explain Hoffman, Hill, Holmes, and Freitas’s (2005) findings. They discovered that supervisors regretted not giving feedback to their supervisees and wished they were able to give their supervisees difficult feedback. The authors reported that supervisors may give overly positive evaluations of their trainees in order to avoid confrontations as well as to see that others considered them effective supervisors. Supervisors found it easier to give feedback regarding clinical issues and found it more difficult to give the trainee feedback related to the supervisory relationship, supervisee personality, and professional behavior of the supervisee. Supervisors also stated that supervisee openness to feedback influenced the ease of the feedback process. From the trainee perspective, supervisor feedback in the form of evaluation can heighten the anxiety of the novice supervisee working to forge a professional identity (Bernard & Goodyear, 1998). Positive feedback about counseling skills helps reduce trainees’ anxiety and increases their level of perceived self-efficacy (Daniels & Larson, 2001). Although the use of a two-way mirror or audio-/videotaping in supervision has been noted as a source of anxiety for supervisees, Ellis et al. (2002) found that the presence of these training devices did not significantly increase anxiety or account for decreased performance, even in a first session with a difficult client. Supervisor self-disclosure can facilitate feedback in the supervision process and outcome of supervision, especially in the areas of working alliance, trainee disclosure, and learning (Ladany & Walker, 2003). However, supervisor self-disclosure should not be excessive and should be done in the service of the supervisee in

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The New Supervisee: Order from Chaos 47 order to make the intervention more meaningful. Ladany and Lehrman-Waterman (1999) found that supervisors perceived as more interpersonally attractive made more frequent self-disclosures. Additionally, trainees perceive a stronger emotional bond with supervisors who discuss their own counseling struggles. S U P E RV I S E E L E A R N I N G P R O C E S S A metaphor that can be useful in understanding the learning process of new supervisees is the Johari window (Lufts & Ingram, 1955, as cited in Drejer, 2000). The window divides an individual’s awareness into four quadrants: open (known to self, known to others), blind (unknown to self, known to others), hidden (known to self, unknown to others), and unconscious (unknown to self, unknown to others). In supervision, there are skills and qualities of the supervisee that are known by the trainee about himself or herself and known to the supervisor, professors, or peers. For instance, a trainee knows that he or she knows how to complete a suicide assessment, and the supervisor recognizes this skill as a known area of competence for the supervisee and therefore not an area of focus in supervision. However, this could also include an open discussion of skill deficiencies in supervision, such as uncertainty about the best treatment approach for an anorexic client. Generally, skill proficiencies and deficiencies are discussed openly and addressed collaboratively. Drejer noted that individual learning occurs within the open area of consciousness; therefore, a general goal for supervision should be to increase awareness of strengths and growth edges in order to allow for open discussion of these topics. In the blind area of the window, the supervisee is unaware of his or her strengths or growth edges whereas the supervisor is aware of these and consequently needs to initiate discussion. This could include countertransference issues or other types of skills that the supervisee does not know are strengths or areas for improvement. As the supervisor raises awareness of these issues, he or she is able to discuss them openly with the supervisee. Due to the nature of the training experience, it is normal for many of the trainee’s growth edges to be initially located in the blind area. This is, in essence, why supervision is a mandatory portion of training programs: It helps the supervisee recognize his or her blind spots and work toward growth. With regard to both the open and blind areas of awareness, it is important for supervisees to understand that it is okay that there is still much for them to learn. It is okay to feel the need to run to the library or do database searches about specific presenting problems and effective interventions. It is important that the supervisor not penalize novice trainees for expressing their absence of knowledge on specific issues or the application of theory to practice. If supervisees do not feel comfortable sharing their struggles or growth edges, they may begin operating in the hidden area of awareness. The hidden area of awareness involves aspects of the self that the individual hopes to hide from others. For example, the supervisee may be aware of his or her struggles and growth edges but is actively hiding them from the supervisor. The supervisor and supervisee need to work together to develop a supervisory relationship wherein the supervisee can move these aspects of self into the open area. The unconscious area involves information that is unknown to both self and others.

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This could include unconscious bias or unexplored aspects of the self that may arise later in supervision as a new event or situation brings this information to light. If the supervisor and supervisee keep the Johari window metaphor in mind, they can work together to move more aspects of the developing professional identity into the open area and work collaboratively on identified goals and growth edges. SKILL BUILDING Skill deficits and development are important areas to address in supervision with beginning trainees. New supervisees may experience anxiety about facilitating a therapeutic discussion. Some supervisees may speak to their clients in a conversational manner, jumping from surface topic to surface topic instead of delving more deeply into the main issues. Others may disclose their opinions freely without considering the impact on the client. Some supervisees may engage in these behaviors because they are not clear about the goals and process of therapy. As supervisees transition to using a different role than the one to which they are accustomed (e.g., from being a helpful friend to being an effective therapist), they must learn a new style of communicating. Supervisors can emphasize that it is important for supervisees to make comments with intentionality. Knowing the purpose of an intervention may help beginning therapists communicate in a more therapeutic manner. This may keep beginning therapists from falling into the trap of using a conversational style in their therapeutic work. Hill and O’Brien (1999) discussed helping skills such as attending and listening, restating, using open questions, reflecting feelings, challenging, interpreting, making self-disclosures, using immediacy, imparting information, and providing direct guidance. These atheoretical skills may be helpful for supervisees to learn as they are beginning their work in therapy. These skills are useful in various instances such as building the working alliance or helping the client gain insight into his or her issues and concerns. New supervisees may lack self-efficacy in some helping skills, such as using immediacy and interpreting, and they may keep reusing some basic skills such as reframing and reflecting. In addition, a supervisee’s cultural background may make it difficult to use skills such as challenging the client. Supervisors can explore why a new supervisee may not use certain skills or may overuse others. Supervisors can also help supervisees apply their skills in a more appropriate manner. Yalom (1989) noted that beginning therapists make clinical errors such as interpreting events before discussing the client’s interpretation. He reported that clients’ own interpretations for experiences are much more valuable and pertinent for them. Additionally, some students may be uncomfortable with silence and may feel compelled to speak during these moments. It is important for supervisors to explore student discomfort with silence; they may ask what would happen if they allowed for silence in their sessions. Beginning supervisees may at times be overly judgmental of their clients, as some seem to lack empathic skills. It is important to address this issue, as it may lead to therapists doing harm to their clients. Supervisors may be able to take on a teaching role and illustrate how to use open questions or reflections of feelings that may convey feelings of empathy. It is important for supervisors to notice

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The New Supervisee: Order from Chaos 49 if supervisees are judgmental of their clients and if they are able to build an empathic bond with their clients because this is a key factor in building a working alliance (Bordin, 1979). If a supervisee is having a difficult time being empathic with multiple clients, the supervisor can explore whether the supervisee possesses a skill difficulty or deficit. However, if the absence of empathy persists, the supervisor may need to address character issues and seriously consider if being a therapist is the best route for the individual (Ladany et al., 2005). CULTURAL SKILLS The interaction between the supervisor and supervisee around multicultural issues has implications for the supervisory relationship, trainees’ multicultural competence, and client outcome (Toporek, Ortega-Villalobos, & Pope-Davis, 2004). Supervisors and supervisees must be aware of their own cultural backgrounds, biases, and assumptions in order to work effectively. The failure to examine the impact of societal values and cultural beliefs leads to the continuation of biases and discrimination against those perceived as different (Butler, 2003). It is important that supervisors explore multicultural issues with supervisees and teach interventions and competencies that help supervisees work with diverse populations. These skills include being conscious of language use (e.g., sexual preference vs. sexual orientation), understanding stages of identity development (e.g., racial identity), and understanding the role of different variables such as religion, gender, and socioeconomic status in clients’ experiences. Furthermore, the literature regarding supervisees’ perspectives of multicultural supervision suggests that various problems can arise between supervisor and supervisee, especially if the supervisor lacks awareness and knowledge of certain cultural groups (Daniels, D’Andrea, & Kim, 1999). Additional problems may arise if supervisors provide differential treatment of supervisees based on their cultural background (e.g., race) or if supervisors do not provide direct feedback and establish an interpersonal bond (Gardner, 2002). Interestingly, Duan and Roehlke (2001) discovered that supervisors perceive themselves as making more attempts to address cultural issues than their trainees recognize. Furthermore, Leong and Wagner (1994) warned that the supervisory relationship suffers when the supervisor and supervisee do not discuss cultural issues. When supervisors fail to discuss cultural issues—or worse, dismiss the influence of culture on the supervisory/counseling process—supervisees experience a number of negative consequences including anger, frustration, confusion, loss of trust in the supervisory relationship, dissatisfaction with the supervision process, and poor outcomes in clinical work (Burkard et al., 2006). HELPING SUPERVISEES DEVELOP SKILLS There are a number of ways supervisors can help beginning trainees develop helping skills. For example, role-playing may be a useful tool for beginning supervisees who are unsure or anxious about beginning therapy. Supervisors can practice conducting intakes with their trainees or have trainees practice with one another. Role-playing is a tangible method for students to understand a concept and apply

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it. This tool can help build supervisees’ confidence and may help alleviate their fear of engaging in a challenging task. In addition, it is important for supervisors to review supervisees’ taped sessions in order to identity potential areas for growth. New supervisees may need guidance and direction not only in the beginning of their training year, but throughout the year. This is due to the many stages and changes that can occur during this time. Supervisees may feel they have a handle on initiating treatment, introducing informed consent and ethical issues, and exploring presenting concerns, but they may remain unsure of how to handle termination, which comes later in their training. It is important for supervisors to be conscious and aware of new situations that supervisees may need help with (e.g., conducting intakes, implementing interventions, dealing with termination issues). It may be difficult for a supervisor to remember how he or she felt at different points in training, but having empathy and providing support for supervisees is important as they progress through their training experience and encounter critical incidents in therapy. C O U N T E RT R A N S F E R E N C E : U N F I N I S H E D B U S I N E S S Countertransference is one of many phenomena that illustrate therapists’ and supervisors’ personal reactions to their clients or trainees. These reactions may positively or negatively influence the therapeutic as well as the supervisory relationship. From the psychodynamic perspective, countertransference is generally recognized by a therapist’s emotional reaction to his or her client. Whether in a therapeutic or supervisory relationship, the understanding of clients or trainees is subjective, and one person’s perspectives often influence the understanding of the other person in the relationship (Falender & Shafranske, 2004). Supervision provides trainees with opportunities to explore their emotional reactions toward clients. Identifying countertransference and having better self-understanding as a therapist and a person can be complicated, especially for beginning trainees. However, countertransference may negatively affect the working alliance in the therapeutic and supervisory relationship when it is not identified (Falender & Shafranske, 2004). Furthermore, many trainees as well as supervisors rate their supervision session highly when they recognize and resolve their countertransference issues (Ladany et al., 2005). Thus, regardless of theoretical orientation to supervision, a therapist’s emotional reactions to his or her clients as well as a supervisor’s emotional reaction to his or her trainees are important concepts to understand when striving for the most effective supervision. SUPERVISEE COUNTERTRANSFERENCE The attentive supervisor should notice his or her trainees’ emotional reactions to their clients, which may be expressed verbally or behaviorally (Ladany, Constantine, Miller, Erickson, & Muse-Burke, 2000). This recognition may be crucial for providing effective supervision, as therapists report encountering countertransference in 80% of their clinical experience (Hayes et al., 1998). Behaviors uncharacteristic of trainees, such as being passive, aggressive, or late, could have

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The New Supervisee: Order from Chaos 51 underlying reasons. For example, resistance from a trainee may be a good indicator of countertransference issues (Bernard & Goodyear, 2004). A trainee may be experiencing a strong emotional reaction toward his or her client when the trainee ignores or disagrees with his or her supervisor’s feedback regarding a particular client. Hayes et al. (1998) highlighted therapists’ perspectives on their countertransference experiences. Therapists often experience emotional reactions because of their unresolved family issues, personal needs (e.g., for control, and to help), role as a therapist (e.g., needing to be perfect or feel competent), or cultural issues (e.g., gender and ethnicity). Content presented by clients, the therapist’s comparing himself or herself with others, change in therapy structure or procedures, the therapist’s perceptions of the client, and the emotionality of the client can trigger these emotional reactions. For example, when a therapist perceives his or her client positively, the therapist may feel reluctant to challenge the client. Alternatively, a therapist may perceive his or her client negatively, such as noncompliant, hysterical, passive-aggressive, vacant, or dependent. The client’s appearance can also trigger an emotional reaction in a therapist. Therapists report fluctuations in their emotional distance with clients when they experience countertransference, which can strengthen or weaken the therapeutic relationship. Thus, countertransference can either facilitate or hinder the therapeutic process. One interesting thing to note is that highly experienced and reputable therapists report having countertransference issues (Hayes et al., 1998). It is crucial for supervisors, regardless of training level, to identify and encourage their trainees to explore countertransference issues. ADDRESSING COUNTERTRANSFERENCE IN SUPERVISION Trainees tend to feel more satisfied with supervision when they have opportunities to discuss countertransference issues (Falender & Shafranske, 2004). Identifying countertransference can be achieved through keen observation during supervision. However, addressing and resolving countertransference issues requires skill, sensitivity, and attention to the relationship. It is ideal to establish a positive supervisory relationship before trainees and their supervisors process their countertransference issues. The presence of mutual trust between trainees and their supervisors facilitates resolution of countertransference issues with the least amount of anxiety. Establishing clear boundaries between supervision and psychotherapy may protect the supervisory relationship from deteriorating. Additionally, providing encouragement for self-reflection instead of interpreting or analyzing trainees’ countertransference toward their clients is helpful (Dewald, 1997). This open self-reflection allows trainees to reach insights and obtain a greater learning experience. Exploration of trainees’ feelings when they self-reflect allows them to compare and contrast their previous feelings and reactions toward their clients (Ladany et al., 2005). PROCESSING THE PARALLEL PROCESS In supervision, many trainees may find themselves trapped in the parallel process phenomena. At times, therapists consciously or unconsciously identify themselves with their clients and behave similarly to them while in supervision. When trainees are able to manage the parallel process, their clients tend to exhibit more

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improvement in their treatment (Gelso, Latts, Gomez, & Fassinger, 2002). Although parallel process may relate to supervisors’ countertransference in supervision, many supervisors report lack of sufficient training on supervisor countertransference issues (Ladany et al., 2000). Supervisor countertransference toward supervisees emerges as often as trainee countertransference toward clients. Supervisors may experience “exaggerated, unrealistic, irrational or distorted reactions related to a supervisor’s work with a trainee” (Ladany et al., 2000, p. 111). In many cases, a supervisor’s countertransference starts within a month of starting the supervisory relationship and may last more than 2 months. Supervisors may experience strong emotional reactions to their trainee’s interpersonal style, cues that resemble their own unresolved issues (e.g., family, personal issues, interpersonal style, past experiences with trainees), intern–supervision environment interactions, problematic client–intern interactions, intern–supervisor interactions, and supervisor–supervision environment interactions (Ladany et al., 2000). Supervisors need to consider the potential impact of their countertransference on the supervisory relationship with trainees. It is plausible to think that a supervisor may present different attitudes as their countertransference emerges in supervision. In turn, their trainees may create a greater distance in the supervisory relationship. Thus, supervisor countertransference, if left unaddressed, could potentially cause the supervision experience to deteriorate. Ladany et al. (2000) suggested that supervisors consult with their colleagues when supervisor countertransference emerges during supervision. Direct and open discussions of countertransference may be effective, yet supervisors may need to wait for an appropriate time to discuss supervisor countertransference with their trainees. Furthermore, increasing skills and knowledge about the supervisory relationship (e.g., boundaries), self-reflecting to increase selfawareness, and undergoing personal therapy may help supervisors manage their countertransference issues. CONCLUSION As trainees begin to navigate the often confusing and chaotic new roles and challenges in counseling and supervision, the supervisor is able to assist in the process of gaining a sense of balance and moving toward order and competence. As a supervisor, it may feel daunting to address issues such as early supervisee role conflict and ambiguity, supervisee nondisclosure, skill building, cultural issues, countertransference, and the balance of power in the supervisory relationship. However, the supervisor can have a lasting impact on the professional development of the trainee and strengthen the counseling field by orienting the supervisee to the goals and tasks of supervision, providing a balance between positive and constructive feedback, allowing the supervisee to take ownership of the objectives of supervision, setting clear boundaries around the power inherent in the supervisor role, addressing skill building, encouraging supervisee disclosure through the use of summative and formative feedback, initiating discussion of countertransference issues in the supervision and counseling processes, and attending to growth areas of both parties’ multicultural competence. Again, it is always important for supervisors to keep in mind the confusion and anxiety they experienced during their first training placement as they help supervisees navigate this course.

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The New Supervisee: Order from Chaos 53 REFERENCES Bahrick, A. S., Russell, R. K., & Salmi, S. W. (1991). The effects of role induction on trainees’ perceptions of supervision. Journal of Counseling and Development, 69, 434–438. Bernard, J. M., & Goodyear, R. K. (1998). Fundamentals of clinical supervision (2nd ed.). Boston: Allyn & Bacon. Bernard, J. M., & Goodyear, R. K. (2004). Fundamentals of clinical supervision (3rd ed.) Boston: Pearson Education. Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research and Practice, 16, 252–260. Bordin, E. S. (1983). A working alliance model of supervision. Counseling Psychologist, 11, 35–41. Burkard, A. W., Johnson, A. J., Madson, M. B., Pruitt, N. T., Contreras-Tadych, D. A., Kozlowski, J. M., et al. (2006). Supervisor cultural responsiveness and unresponsiveness in cross-cultural supervision. Journal of Counseling Psychology, 53, 288–301. Butler, S. K. (2003). Multicultural sensitivity and competence in the clinical supervision of school counselors and school psychologists: A context for providing competent services in a multicultural society. Clinical Supervisor, 22, 125–141. Daniels, J., D’Andrea, M., & Kim, B. S. K. (1999). Assessing the barriers and changes of cross-cultural supervision: A case study. Counselor Education and Supervision, 38, 191–204. Daniels, J. A., & Larson, L. M. (2001). The impact of performance feedback on counseling self-efficacy and counselor anxiety. Counselor Education and Supervision, 41, 120–130. Dewald, P. A. (1997). The process of supervision in psychoanalysis. In C. E. Watkins (Ed.), Handbook of psychotherapy research (pp. 31–43). Hoboken, NJ: Wiley. Drejer, A. (2000). Organisational learning and competence development. Learning Organization, 7, 206–220. Duan, C., & Roehlke, H. (2001). A descriptive “snapshot” of cross-racial supervision in university counseling center internship. Journal of Multicultural Counseling Training and Development, 29, 131–146. Ellis, M. V., Krengel, M., & Beck, M. (2002). Testing self-focused attention in clinical supervision: Effects on supervisee anxiety and performance. Journal of Counseling Psychology, 49, 101–116. Falender, C. A., & Shafranske, E. (2004). Clinical supervision: A competency-based approach. Washington, DC: American Psychological Association. Friedlander, M. L., Keller, K. E., Peca-Baker, T. A., & Olk, M. E. (1986). Effects of role conflict on counselor trainees’ self-statements, anxiety level, and performance. Journal of Counseling Psychology, 33, 73–77. Gardner, R. M. D. (2002). Cross cultural perspectives in supervision. Western Journal of Black Studies, 26, 98–106. Gelso, C. J., Latts, M. G., Gomez, M. J., & Fassinger, R. E. (2002). Countertransference management and therapy outcome: An initial evaluation. Journal of Clinical Psychology, 58, 861–867. Gross, S. M. (2005). Student perspectives on clinical and counseling psychology practica. Professional Psychology: Research and Practice, 36, 299–306. Hayes, J. A., McCracken, J. E., McClanahan, M. K., Hill, C., Harp, J. S., & Carozzoni, P. (1998). Therapist perspectives on countertransference: Qualitative data in search of a theory. Journal of Counseling Psychology, 45, 468–482. Hill, C. E., Charles, D., & Reed, K. G. (1981). A longitudinal analysis of change in counseling skills during doctoral training in counseling psychology. Journal of Counseling Psychology, 28, 428–436. Hill, C. E., & O’Brien, K. M. (1999). Helping skills: Facilitating exploration, insight, and action. Washington, DC: American Psychological Association. Hoffman, M. A., Hill, C. E., Holmes, S. E., & Freitas, G. F. (2005). Supervisor perspective on the process and outcome of giving easy, difficult, or no feedback to supervisees. Journal of Counseling Psychology, 52, 3–13. Holloway, E. L. (1984). Outcome evaluation in supervision research. Counseling Psychologist, 12, 167–174. Holloway, E. L. (1992). Supervision: A way of teaching and learning. In S. D. Brown & R. W. Lent (Eds.), Handbook of counseling psychology (pp. 177–214). New York: Wiley. Holloway, E. L. (1995). Clinical supervision: A systems approach. Thousand Oaks, CA: Sage. Howard, E., Inman, A. G., & Altman, A. (2006). Critical incidents among novice counselor trainees. Counselor Education and Supervision, 46, 88–102. Kagan, H., & Kagan, N. I. (1997). Interpersonal process recall: Influencing human interaction. In C. E. Watkins (Ed.), Handbook of psychotherapy research (pp. 296–309). Hoboken, NJ: Wiley. Ladany, N., Constantine, M. G., Miller, K., Erickson, C. D., & Muse-Burke, J. L. (2000). Supervisor countertransference: A qualitative investigation into its identification and description. Journal of Counseling Psychology, 47, 102–115.

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Ladany, N., & Friedlander, M. L. (1995). The relationship between the supervisory working alliance and trainees’ experience of role conflict and role ambiguity. Counselor Education and Supervision, 34, 221–231. Ladany, N., Friedlander, M. L., & Nelson, M. L. (2005). Critical events in psychotherapy supervision: An interpersonal approach. Washington, DC: American Psychological Association. Ladany, N., Hill, C., Corbett, M., & Nutt, E. (1996). Nature, extent, and importance of what psychotherapy trainees do not disclose to their supervisors. Journal of Counseling Psychology, 43, 10–24. Ladany, N., & Lehrman-Waterman, D. E. (1999). The content and frequency of supervisor selfdisclosures and their relationship to supervisor style and the supervisor working alliance. Counselor Education and Supervision, 38, 143–160. Ladany, N., & Walker, J. A. (2003). Supervisor self-disclosure: Balancing the uncontrollable narcissist with the indomitable altruist. Journal of Clinical Psychology, 59, 611–621. Leong, F. T. L., & Wagner, N. M. (1994). Cross-cultural counseling supervision: What do we know? What do we need to know? Counselor Education and Supervision, 34, 117–131. Murphy, M. J., & Wright, D. W. (2005). Supervisees’ perspectives of power and use in supervision. Journal of Marital and Family Therapy, 31, 283–295. Muse-Burke, J. L., Ladany, N., & Deck, M. (2001). The supervisory relationship. In L. J. Bradley & N. Ladany (Eds.), Counselor supervision: Principles, process, and practice (3rd ed., pp. 28–62). Philadelphia: Brunner-Routledge. Nelson, M. L., & Friedlander, M. L. (2001). A close look at conflictual supervisory relationships: The trainee’s perspective. Journal of Counseling Psychology, 48, 384–395. Olk, M. E., & Friedlander, M. L. (1992). Trainees’ experiences of role conflict and role ambiguity in supervisory relationships. Journal of Counseling Psychology, 39, 389–397. Pipher, M. B. (2003). Letters to a young therapist. New York: Basic Books. Pisani, A. (2005). Talk to me: Supervisee disclosure in supervision. Smith College Studies in Social Work, 75, 29–47. Quarto, C. J. (2002). Supervisors’ and supervisees’ perceptions of control and conflict in counseling supervision. Clinical Supervisor, 21, 21–37. Schwitzer, A. M., Gonzalez, T., & Curl, J. (2001). Preparing students for professional roles by simulating work settings in counselor education courses. Counselor Education and Supervision, 40, 308–319. Skovholt, T. M., & Ronnestad, M. H. (1992). Themes in therapist and counselor development. Journal of Counseling and Development, 70, 505–515. Soldz, S., & McCullough, L. (Eds.). (2000). Reconciling empirical knowledge and clinical experience: The art and science of psychotherapy. Washington, DC: American Psychological Association. Stoltenberg, C. D. (2005). Enhancing professional competence through developmental approaches to supervision. American Psychologist, 60, 857–864. Toporek, R. L., Ortega-Villalobos, L., & Pope-Davis, D. B. (2004). Cultural incidents in multicultural supervision: Exploring supervisees’ and supervisor’s experiences. Journal of Multicultural Counseling and Development, 32, 66–83. Van Sell, M., Brief, A. P., & Schuler, R. S. (1981). Role conflict and role ambiguity: Integration of the literature and directions for future research. Human Relations, 34, 43–71. Webb, A., & Wheeler, S. (1998). How honest do counselors dare to be in the supervisory relationship? An exploratory study. British Journal of Guidance and Counselling, 26, 509–524. Worthington, R. L., Tan, J. A., & Poulin, K. (2002). Ethically questionable behaviors among supervisees: An exploratory investigation. Ethics and Behavior, 12, 323–351. Yalom, I. D. (1989). Love’s executioner and other tales of psychotherapy. New York: HarperCollins. Yalom, I. D. (2002). The gift of therapy: An open letter to a new generation of therapists and their patients. New York: HarperCollins. Yerkes, R. M., & Dodson, J. D. (1908). The relationship of strength of stimulus to rapidity of habit formation. Journal of Comparative Neurology and Psychology, 18, 459–482.

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CHAPTER 4

On Being Supervised TANYA H. HESS and ALLEN K. HESS

MOST OF the chapters in this book present supervision from the perspective of seasoned experts. These experts average more than 2 decades of experience conducting supervision. The first author of this chapter has only recently completed her doctoral work. In the process, she accumulated several years of supervision in both cognitive-behavioral and psychodynamic therapy and in both urban training clinics and rural community mental health centers. Using her experiences as background, and in some instances as case material, this chapter provides supervisors with a guide for what the supervisee needs from them. The second author has worked on the other side of the consulting table for several decades, and it is with this expertise that he presents the student and supervisor with suggestions on how to make the most of the experience of supervision. As it has two authors, this chapter also has two audiences and two purposes. The first is to provide students with a guide on how they can maximize the benefits of supervision and avoid creating impasses in their supervision. A list of suggestions for supervisees and supervisors with recommendations for further reading is included. The second goal is to help supervisors to amplify their ability to reach and guide their supervisees. As a result, the second section consists of several vignettes and reaffirms and illustrates some of the guidelines for excellent supervisees and supervisors. This chapter is intended for both supervisors and supervisees; above all, we hope patients are helped by caring, competent, and effective psychotherapists who are educated and sustained by warm and wise supervisors.

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r Take an active role. Find out how the supervisor addresses students (Hess,

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2001). Colleagues can provide a source of information, but you should use that as information only. A veridical collegial report can alert you to ways in which you can best address the supervisor. Of course, the best source is one’s own meeting with the supervisor. Learn what he or she likes and can offer, and use this information to maximally structure your supervisory time. If the supervisor teaches best with audiotapes, with bug-in-the-ear technology, or with process notes, make efforts to learn via the preferred method. Consider the uniformity myth. Can anyone be all things to all people? Thinking “What can I glean from this skilled person?” is the best attitude with which to begin supervision. Graduate school is a highly analytical and critical environment, and some programs have a “gotcha” attitude. Successful students internalize the attitude of “what is wrong with this research” and may transfer that to supervision. Then it becomes as easy to find feet of clay in one’s supervisor as in oneself. A far more beneficial attitude is a benevolent and partnering one, through which both parties take the approach of “How can we both help the student acquire proficiency and develop?” and “How can both of us make supervision rewarding?” Elie Wiesel (1972) said, “Whether a source is blessed or not depends on the person drawing from it.” Seek to learn what the supervisor can offer. Learn about record keeping, fee collection, and other clinic or agency administrative requirements and meet them promptly. Supervision takes an unhappy turn when a supervisor is blamed for the student’s lack of concern for real-world and seemingly mundane responsibilities. Know the cultural, ethical, and legal parameters of your field and of pertinent fields within which you might be working. If you are being supervised by a social worker or psychiatrist, that person might have a different view of a problem than you do. Also, you might be working in court, the police department, a hospital (see Chapter 24), or a prison (see Chapter 21), each of which is its own world and has its own rules, regulations, and practices. Know them. Read the pertinent literature. To learn about an area, make sure you are linking your experiences to the literature in the field. By doing so, you are truly becoming a professional. If you are working with sexual abuse victims or with persons prone to violence, be sure you read the appropriate literature. You and your supervisor ought to incorporate insights from theory, research, and practice into the case at hand. You might suggest trying out a technique you read in the literature or that the supervisor might have mentioned. Given time, ask to shadow the supervisor or an expert and then gradually take a supervised case (e.g., the use of hypnosis in symptom relief) so you can amplify your skill arsenal. Do not be evasive. Test the waters to see how a supervisor responds to a query by you. In most circumstances, you ought to be forthcoming (Hahn, 2001; Ladany,

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Hill, Corbett, & Nutt, 1996; Yourman & Farber, 1996). If you are late or have not kept up the paperwork in a case or there is some other problem, professional courtesy calls for you to bring up the issue. Usually the consequences are not as grave as you might imagine. However, if the supervisor is insecure and the setting is not safe, you might want to hold this advice in abeyance. It is a sign of a good supervision that problems are worked out. If there is some reason you do not feel a problem can be brought to your supervisor, you must find a clinic director or alternative supervisor with whom to raise the issue. r Respect the supervisor’s time. A corollary to the previous suggestion is that things can happen in the moment, such as sessions running over due to emergencies or traffic tie-ups. Inform the supervisor if the session will be delayed. Theses and dissertation work might compromise time during a semester or a month during the semester. Be sure to alert your supervisor when such compromises might occur and offer options, because clinical responsibilities still must be met. Playing “poor me” with the supervisor is acting out. That is, provoking sympathy and manipulating a supervisor into a rescuing role is acting out, even if such tactics might succeed with a vulnerable supervisor. It bodes poorly for the student’s ability to function as a professional. Alternatively, if a clinic is abusive in terms of your time, then a meeting between students and the program’s clinic director might be needed. You must keep such a meeting as nonblaming and emotionally low key as possible. r Respect the supervisory hour. Establish priorities among cases with the supervisor’s guidance (see Case 4.8). Some psychotherapy cases do not receive as much attention as others. But be sure you are not hiding a problematic case by focusing on others so that the failing case is never reviewed. Again, this suggestion is subject to the degree to which the supervisory hour is safe. Out of respect for the supervisor, do not “drop bombs” or present problematic cases at the end of the hour. If you have a patient who drops bombs on you, you might be acting out a parallel process. r Remember that supervision is interpersonal and can be personal, too. Supervisors are keenly aware of the empathic skills of their students: Does the student see a case; can the student set limits on being taken in by client ploys; can the student reflect on interpersonal events and his or her feelings about these events in supervision? As a new student, you are facing a plethora of demands: to be competent, to assess the client, to administer the case properly, to select an intervention and apply it correctly, to adjust the technical and emotional climate of the session. It is pure fantasy to expect all things to go right—to guess correctly on one or two of these questions can be a triumph. The real questions in supervision are “How are errors treated?” and “Can you be open to, and learn from, errors?” Can you see boundary issues, such as when a patient brings in a gift or fails to pay for sessions? Is the client a case or a person? Are you aware of the dynamics of the client session and able to explore in supervision your own emotions toward the client?

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TO THE SUPERVISOR

r Be aware of the role relationship. Be aware that you are in the one-up position.

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Those in the one-down position see the other person as having great power. The one-up person may not see this positional inequity as being nearly as large. Fiske (1993) wrote, “The powerless attend to the powerful who control their outcomes in an effort to enhance prediction and control. . . . The powerful pay less attention, so are more vulnerable to stereotyping” (p. 621). For example, a psychotherapist can mention something to the client that resonates for years, but the psychotherapist may not even remember the event. Prisoners and hospital patients listen to officers and nurses with an acuteness that the latter do not realize. The one-down person sees his or her fate as hinging upon each word the more powerful person utters. The powerful are busy with the ones above them—be they the correctional officer’s chief of security, the nurse’s chief of staff, or the psychotherapy supervisor’s supervisor. It is easy to forget the subordinate’s one-down position. (See Kennard, Stewart, & Gluck, 1987; Ladany & Friedlander, 1995; Mordechai, 1991; and Olk & Friedlander, 1992, for more on the supervisory relationship.) Understand the power of respect, genuineness, and role-modeling. The literature is consistent (Allen, Stollos, & Williams, 1986; Bernard & Goodyear, 2004; Carifio & Hess, 1987; Whitman & Jacobs, 1998) in reporting that the good supervisor treats the student as a person, with respect and with genuineness. You and the supervisee are partners in learning. Your referent power increases as you become a compelling role model. Be knowledgeable. Realize that you have skills to teach; keep your learning refreshed and be delighted by student triumphs. Poor supervisors see their students as rivals and in need of being put down or corrected. As a supervisor, know that two skill areas need attention: your psychotherapy skill area and supervision. As you are reading this, you are attending to the latter skill area. Your initial commitment to this profession impels you to continue to be abreast of the practices in that skill area. Take delight in your proficiencies. Falender and Shafranske (2004) provided an excellent introduction to a competencybased approach to supervision. Be concrete. Students abhor amorphousness. Supervision becomes potent when you provide specific guidance in accordance with student needs. It becomes painfully obvious to the student as well as to yourself if the student fails to develop autonomy. But if you take refuge in never being wrong by not providing some needed structure, you are abandoning the student’s learning needs. Be aware of the student’s learning level and needs. The recognition of the student’s learning needs and competencies follows a spiral omnibus form (see Chapter 10 on Vygotsky’s model). A student can be in touch with both the client’s and his or her own emotions (a higher level of functioning) and be in need of basic skill development in agency responsibilities. Or a student may be proficient in technique and be emotionally unavailable to the client. The devoted supervisor attends to the signals, verbal and nonverbal, of the student.

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r Do not be afraid to show your work. There are two people in the supervision

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session: one skilled and the other not yet skilled. So why show only the work of the unskilled? You may decide to share tapes or transcripts of your work. Supervision can then progress to viewing the student’s work with a shared knowledge of your technique. Be careful not to indoctrinate. If you choose to show your work, be aware that students are quite sensitive to being constrained and indoctrinated. Even with exposure to your work, some may simply not have talents in your area of expertise (Glick-Hughes, 1994). A student may make an excellent clinician and have a great appreciation of your theoretical approach, but he or she may not practice as you would. As long as the student learns what you offer and demonstrates competent performance, even a student who has not “mastered” a new skill set may be able to use what you teach in new and innovative ways. Be aware that you might react to the student seeming to abandon your teachings. Some students are diagnostically skilled but shrink from psychotherapy’s intimacy. Yet graduate programs require psychotherapy training. For example, exposure to psychotherapy may make the trainee’s recommendations in testing reports even more perspicacious because they now know the intricacies of psychotherapy. As a supervisor, your goal should be to help the supervisee develop into the best professional he or she can be. Be cautious not to confuse his or her professional goals with your own. Be present and emotionally available. Students might invite you to explore their emotional life vis-`a-vis a case and may value your insights. This should be done in graduated steps because one of the great failings of supervisors is turning supervision into psychotherapy. Yet emotional work with the student is formative of the genuine, congruent psychotherapy personality. Be sensitive and involved in students’ lives without being therapeutic. A corollary to the previous suggestion is that the ethics admonitions of our day constrain supervision. Involvement in a student’s life ought to be restricted to his or her emotional being as a psychotherapist. Yet if that student is struggling with a failing marriage, it might impact his or her psychotherapy. You must be in tune enough with your supervisee that the two of you can address a personal issue to the extent the personal conflict begins to impact the supervisee’s objectivity. With regard to everyday matters, it is not uncommon for students to meet with supervisors in professional workshops and shared social events (e.g., dinners or religious and family events). You must be aware of boundaries and the supervisee’s sensitivities. Nevertheless, the intimacy of supervision and the growth of the student from a subordinate to a colleague are realities that must be recognized and dealt with sensitively. In small towns, multiple role involvements may be inevitable. In evaluations, let the student lead. Most students are so self-critical that as a supervisor you might find yourself ameliorating most of the student’s selfevaluations. It is so odd to see how many educational efforts are designed to catch the poor student. For each failure, there are dozens of cases of students in want of praise to guide them in their development. The one or two

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psychopathically inclined students will be easily spotted by a failure to selfevaluate. Insight is not their forte. In evaluations, be descriptive. Students occasionally need to be told when they have done something wrong. However, more likely they can tell when things are not going well with a case, and they can benefit from your advice on areas and ways to improve. Take the pulse of supervision sessions. If supervision is work, then something is amiss. That is, if you are exhausted after sessions, be they psychotherapy or supervisory sessions, and there is sparse gratification for such exhaustion, then something is going wrong. And if you feel that way, imagine how the student must feel. Be aware of student shame and humiliation. Students readily feel shame and humiliation (Hahn, 2001). Bad supervision robs our field of potentially excellent psychotherapists and can result in regression, career switching, and lifelong scars or ego breaches. In some students, shaming leads to defensive game playing in supervision. The more competent student can realize he or she needs succor from colleagues or from other supervisors. Imposter feelings predicated on assumption of false selves can ensue if there is no reparative supervisory work. Consider the rewards. Our field does not compensate a majority of supervisions with reduced clinical or teaching loads or with money. So why do supervisors supervise? Ideal supervisors are usually functioning at Erikson’s generative stage. That is, they have a stake in the future and delight in helping a student become a wise clinician who in turn helps generations to come. Students may or may not recognize and appreciate the absence of compensation for you as a supervisor. Regardless, most supervisees can appreciate that supervision might be a gratifying vehicle by which you pass your expertise to the next generation.

PA RT I I : S U P E RV I S E E N E E D S A N D C A S E E X A M P L E S In our experience, good supervisors have a humility and a sensitivity that resonates with the student’s anxieties and uncertainties (Worthen & McNeill, 1996). As previously noted, this chapter has two audiences. The first is composed of supervisors who wish to be refreshed about the stresses, needs, and triumphs of their students. The other audience is composed of students who need to know what sorts of actions they can take to make supervision more productive and less destructive. This section presents case studies from my (Tanya H. Hess) experience as a supervisee.

SET THE SUPERVISORY ENVIRONMENT Above all, the student needs to feel that he or she can be open and honest in supervision. The supervisee needs to know that he or she can bring a problem to the supervisor. The degree to which the student feels he or she is in a safe setting is a good indicator for the supervisor as to whether the conditions the supervisor is providing are working with the student or whether some changes are needed.

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Not every supervisor can work optimally and intimately with every supervisee. Both need to see how they can best work together (Allen et al., 1986; Ladany & Friedlander, 1995). GIVE POSITIVE FEEDBACK Students need positive feedback. Although some students may have experience working in related professions (e.g., as a crisis hotline counselor, as a domestic abuse shelter worker), the psychotherapy relationship carries with it an intensity that students are not likely to have experienced in the past. For example, in therapy the expectations are magnified in contrast to the fairly formulaic and well-rehearsed set of responses that the suicide hotline volunteer uses. This will likely be the first time new therapists feel the responsibility of being the sole individual tasked with a patient’s direct care. New psychotherapists are learning a complex set of skills. Students in graduate school succeed in learning how to work for As, earn undergraduate honors, and even defend honors theses. They are often told that for each student selected into the program, about 100 other applicants are rejected. All of their peers seem peerless and perfect. Within this context, neophyte psychotherapists carry their hopes and years of wishes to learn psychotherapy. Thus, it is not surprising that tension levels are high and the need for affirmation is great. New students need the gold star or red checkmark to let them know they are on the right track. Students are shaped by positive feedback, and they look to their teachers and supervisors for it. It is amazing how one critique or rebuke will resonate with a student for years (and probably even with a reader of this chapter who is a seasoned therapist) and will not be assuaged even by five positive comments (see Frijda’s, 2007, law of asymmetrical hedonism). Punishment or negative reinforcement resonates, whereas positive reinforcement is consumed. DO NOT MAKE EVALUATION THE GOAL OF SUPERVISION Inevitably, and probably rightly so, evaluation may be a component, but the goal of supervision needs to be learning to talk to the patient, learning to better interpret tests, and learning to refine one’s clinical skills. Certainly attentive analysis of students’ work can guide the learning process. But many students who have gotten to this point in their training will have spent a great deal of effort garnering praise, and often good grades. The supervisor, within the programmatic constraints of the department, needs to find a way to ensure that the process is about learning and improving, not saying the right thing every time. When evaluation becomes the goal of supervision, for either the supervisee or the supervisor, the opportunity for the student to come to the supervisor with errors may be sacrificed (Rogers, 1968). ENGAGE IN CASE REVIEW Supervision can be a tricky business. Supervisors take on the responsibility for a process that they are guiding from afar. To gain more information, supervisors

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may ask to review videotapes or audiotapes, to watch through a remote camera or two-way mirror, or to review notes. Some require verbatim transcripts; others prefer transcripts generated from recall or process notes. Still others are more comfortable listening to how the supervisee presents the case from memory or notes. Having been a supervisee who has used most of these techniques, I can say that there are strengths to each. Each provides the student with slightly different information about his or her own therapeutic style. For example, taping provides the opportunity for the supervisor and the supervisee to see the speed of the conversation, the pauses, and the ums.

Case 4.1 I recall one case where I was amazed to watch the little girl I had taped move about the television screen. When I had been sitting in the room with her, I was aware of, shall I say, excess fidgeting; yet the comparison I saw on the tape between my own movements and hers made it look like she had been put on fast forward.

The tape afforded me the opportunity to step back from how it felt being in the room with the patient and to compare that to what I saw on the tape. In supervision we were able to explore the discrepancy and to consider how the emotional storm the patient seemed to create affected those around her.

Case 4.2 In another supervision I had been asked to write the session as I recalled it afterward. This is something I had done many times, often producing about eight pages of transcript text. This patient, however, presented so much detailed information that I found myself looking at the clock after 20 minutes and thinking that I could not possibly retain another word of conversation in my memory. When I later sat down to transcribe the session, I managed to capture themes throughout the entirety of the session, yet with large sections of conversation completely missing.

The process of reviewing the manner in which the patient presented information and my own reaction, in this case as witnessed through my memory gains and lapses, was a valuable way to consider the interactional patterns between the patient and therapist, and to be curious about the interactional patterns between the patient and others. All methods of reviewing case material can have their benefits and limitations. Ideally supervisees will be introduced to a variety of methods throughout their training career as they experience different supervision customs with different supervisors. Regardless of the method, it is important that students be invited to enter into a supervisory relationship in which they can feel free to show their work and to bring up concerns.

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BE RESPONSIVE Supervisors should return supervisees’ calls and e-mails. Supervisees should be told how, when, and under what circumstances to contact supervisors outside of the traditional supervision time. DO NOT YELL AT THE SUPERVISEE This may sound obvious, but unfortunately it has been know to happen. Supervision is a professional activity; the actions of both parties should reflect a professional demeanor. RESPECT THE SUPERVISORY TIME Supervision time should be treated with much the same respect the therapy hour is treated. This is not to say supervision is, nor should it be, therapy. Nevertheless, the supervision hour should be protected. If possible, it should be a regularly scheduled and maintained time. Except in rare emergency situations, supervisors should not answer calls during supervision. The same, of course, should be said for supervisees; the supervision hour is not the time to take a cell phone call.

Case 4.3 One supervisor was known for answering phone calls and knocks on the door during supervision. The supervisor always apologized for the interruption yet never simply let the call go to voice mail or turned off the ringer. The opinion of his supervisees later reflected a split, with some saying they had felt he was trying to show how essential and important he was, and others saying they thought he was simply scattered and disorganized. Many also reflected that they felt he found them and the material they were presenting to be less important than the calls he had taken.

RESPECT BOTH PATIENT AND STUDENT CONFIDENTIALITY It has already been mentioned that yelling at supervisees is ill advised. Along the same lines, supervisors should strive to be as confidential with the trainee as they would of course be with a patient. Supervisors are dealing with a student and with that student’s patient each time they interact with the supervisee. Be respectful of the confidentiality of both the patient and the supervisee. Obviously, the training site creates a shared experience for trainees. Group supervisions, peer supervision, informal case discussions, and formalized case seminars are all sites in which a clinician in training will share his or her work. This is a vital part of the learning process. It is also an exposed position for the trainee to be in. Supervisors should be mindful of this potential vulnerability. Though thankfully rare, there have been instances when supervisors have been known to berate students in clinic hallways. Good clinical and ethical sense should guide such situations. Client and student issues should be handled in an appropriate and discrete manner. Supervisees should be treated with respect and confidentiality.

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BE AWARE OF VERBAL AND NONVERBAL COMMUNICATION Supervisees will likely pay as much or more attention to the details and subtleties of the supervisor’s reactions as the latter will to the supervisees’. Students may imagine what the supervisor’s consulting room may look like, who the supervisor’s spouse may be, whether the supervisor has children, and, especially, what the supervisor thought when he or she made a certain comment in session. As in therapy, the amount to disclose is something each supervisor considers and decides on his or her own. Unlike patients in therapy, supervisees are individuals who will soon be colleagues, may dine at the supervisor’s house, and may attend professional and personal events the supervisor attends.

DO NOT UNDERESTIMATE ONE’S IMPACT AS A SUPERVISOR Depending on the setup of the program in which he or she is supervising, a supervisor may have the luxury of focusing intensively on one or two cases with a supervisee, or he or she may have to manage a large number of cases in the supervisory hour. Regardless, the supervisor must remember that he or she is supervising trainees in order to help them grow into the best clinicians they can be (Fiske, 1993).

Case 4.4 Leonard Handler, a skilled clinician, once supervised me on a particularly complicated child case. He taught me a projective storytelling technique he used in which the child creates and tells a narrative about an animal no one has seen or heard of before. He worked with me to better use, understand, and interpret Winnicott’s (1971) squiggle drawings. He showed me how to incorporate test material into the therapeutic setting. Nevertheless, the case I was working came to a close with unremarkable results.

Luckily, what Handler was teaching me was not just applicable to that case. He taught me the skills for sitting with and connecting to a child. He taught me a way to be creative and spontaneous in session. He helped me reconnect to a playfulness that is as useful with adult as with child cases. When a supervisor works with a supervisee on a case, the case, and in some instances even the outcome of the case, may not be as important to the supervision as the skills the supervisor helps the supervisee acquire and hone.

DEBRIEF THE SUPERVISEE Anyone doing therapy for any period of time is likely, nay, certain to encounter trauma. The supervisor must be aware of the emotional traumas encountered by students and the possible need for debriefing in difficult situations. Of the nearly 300 training cases I have seen thus far, one vividly sticks in my mind specifically because of the trauma the patient encountered and shared with me.

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Case 4.5 A young child, whom I had been seeing for a couple of months, told me one day she had something to tell me. The usually gregarious child, curled up in a ball on my couch, buried her head in her knees and proceeded to describe the details of being “taught” what can be described most kindly as the trade of prostitution, yet more accurately as horrific sexual and emotional abuse. I can vividly remember the events of the day as I navigated the complicated process of securing and reporting on the child’s welfare. All day I was busy consulting, recording, reporting, consulting again, and so on. I was commended by my supervisors on my calm and ability to deal with the difficulties of the case. Hours later I got in my car to make the long drive home from my training site. I had not driven two blocks before I burst into tears.

Supervisees need to be able to discuss and debrief the inevitable traumas they encounter. Although it is a fact of life that trainees cannot, and perhaps should not, be sheltered from the traumas of patients, the supervisor should strive to assist trainees in processing the information, being aware of countertransference, recognizing the schemas that are triggered, and digesting as best they can the information in such a way that the trainees can remain both helpful to the patient and kind to themselves. A trainee need not be traumatized to learn how to deal with trauma, and it is the joint responsibility of the supervisee and the supervisor to help the supervisee learn to process traumatic information provided by the patient in such a way as to keep the supervisee in the position to be helpful to the patient. Thankfully, in the aforementioned case, much supervision was devoted to how to work with this child, and outside consultation offered added insight into the difficulties of managing such a case. HELP THE SUPERVISEE FIND A VOICE Supervisors should not be afraid to offer phrasing (e.g., “Have you considered saying something like . . . to the patient?”). Alternatively, supervisors should make it clear that it is also alright not to say exactly what they have suggested.

Case 4.6 A relatively inexperienced supervisor once insisted that I had to address the transference in the room. Having had a background in cognitive therapy, and being relatively uncertain what I was supposed to be addressing when I addressed the transference, I made several successive attempts to discuss how the patient felt being in the therapy room and talking to me in session. The patient was new to therapy and had expressed concern that therapy might only be “navel gazing,” something he regarded with disdain. He also had a notable history of being avoidant, especially in regard to women, of engaging only in paid sexual relationships, and of remarking on his need to pay in order to talk to me. Acknowledging my own reluctance to openly address my comparison to a prostitute in this metaphor, I also believed directly addressing how he felt about me might be threatening to the patient. He had recently worked hard to process how he felt about a sexual harassment charge at work and had just succeeded in (continued)

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taking steps toward repairing the work relationship. My supervisor insisted I should say “And how do you feel about me?” I felt neither the patient nor I, to be honest, was ready for such an intervention. Nevertheless, the supervisor insisted I must say “And how do you feel about me?” in the next session. Against my better judgment, the next time the patient brought up how he felt dealing with women, I said, “And what about in here? How do you feel about me?” The patient responded, “We’re not going to go there.” He then looked at the clock, said, “Looks like time’s up,” stood up, and walked out of the room. (This patient had a history of looking at the clock when he became uncomfortable and saying playfully, “Isn’t time about up?” However, he had always waited for me to end the session previous to this instance.) For the record, time was not yet up.

Perhaps questioning my patient had been a trainee mistake. Perhaps I should have waited until I was comfortable or worked harder to become comfortable. Maybe I could have timed the intervention better in the session, or not said what I was told to say, instead going with a variation that felt more ego syntonic to me. I know I had (perhaps have) a strong desire to please supervisors. I wonder if I had been in a position to explore my own desires to help the patient, please the supervisor, and simultaneously not hear what I imagined the patient thought of me, might I have been better able to say the “right” thing at the right time. Case 4.6 (Continued) The patient subsequently cancelled a string of appointments, never returning to the therapy. The supervisor viewed the tape and was initially thrilled that I had said exactly what she had asked and had gotten such a marked response. However, she looked visibly crushed in subsequent weeks when the patient did not return, suggesting that perhaps she had given bad advice and that I might want to get “supervision on my supervision.” I found myself in the odd and uncomfortable position of trying to create a holding space in supervision lest my supervisor fall apart. In fact, I did seek additional outside consultation on this case.

CONSIDER SUPERVISION ON SUPERVISION Case 4.6 brings up two concerns: (1) how and when students should seek outside consultation and (2) how and when the developing supervisor should seek supervision. Unfortunately, I cannot fully answer the questions here. What I can say on the first point is that it is important that students be allowed to view a case from alternative perspectives, which additional supervision can offer. The difficulty arises when supervisees must choose which advice to follow. Supervisees should strive to be open about conflicting recommendations. They should be given advice as to who is the primary, and ultimately responsible, supervisor. Supervisees should avoid operating in a rogue capacity and must clearly indicate to their supervisors when they feel they are receiving conflicting advice (whether from a single supervisor or multiple supervisors), lest they be seen as disregarding a supervisor’s suggestion. On the question of supervision of supervision, tackling the role of supervisor, like any new role, requires study and practice. It is an area of training that is too often

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omitted in graduate training and was the impetus for the writing of this book. Some programs now offer coursework in supervision. Others offer the opportunity for students to formally engage in the peer supervision of a less experienced student in the training program. However, many supervisors find themselves being assigned their first supervisee without the benefit of a supervision supervisor or formal supervision training. Generations of supervisors have relied on their own past experience being a supervisee and learning through that experience to master the role of supervisor, and many more will likely do the same. Supervisors need to continue to become skilled in supervision by consulting the literature, attending workshops, consulting with peers, seeking their own supervision, and continuing to practice in the skill areas in which they are providing supervision. To return to the topic of helping the student find his or her voice, I frequently recall the teachings of an object relations professor and supervisor of mine, Jack Barlow. In supervision, Barlow said one thing he did not want his supervisees to think when they were sitting with a patient was “What would Jack say here?” He went on to explain that his goal was for each of us to figure out “What do I say here?” I, as it was I who was sitting in the room with the patient, and it was I who was in the therapy relationship with the patient. Finding one’s voice can be hard for the beginning therapist, as well as for the more advanced trainee. Yet it is essential. The supervisee must be given the tools, the support, and the space to learn what he or she might say, as it is the supervisee who is in the room with the patient. Admittedly, there were times when I found myself thinking, “What would Jack say here?” immediately followed by the image of him saying, “Find your own words!”

BE GENTLE Throughout my training I have been lucky to have had many insightful, supportive, and skilled supervisors. However, with exposure to close to 30 supervisors, I have had a select few who have been less than helpful.

Case 4.7 Early in my training, after a particularly bad supervision ended, I found myself reluctant to engage fully with the next supervisor. I had learned, through aversive experiences with the prior supervisor, to be careful to moderate self-presentation in the previous supervision. Never untruthful to the supervisor, I had learned to present sections of tapes I had thought were benign. I had avoided raising questions of situations in which I thought there might be something better I could have said, as experience had shown me these would be used as examples of how I had messed up and not as learning experiences for how I might say things better the next time.

Self-preservation, though not a bad skill to possess, is not what you want your supervisee to learn from interactions with you. Luckily, my next supervisor, Regina

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Pyke, was an astute, warm, and genuine woman who was aware of the supervision style of my prior supervisor.

Case 4.7 (Continued) When I began the later supervision, I was careful to present cases I thought were going well. After several weeks of supervision, Pyke said, “I noticed we always save Jane* for the end of supervision and never get a chance to really talk about her. Let’s start with her today.” She asked me to put in the audiotape, and she fast-forwarded it to a random point in the session and listened. As we began processing the case material, and as the new supervisor was able to create a safe and open supervision space, I became aware that I did not bring up this patient in supervision for very specific reasons. Jane was a case that I found boring in session and frustrating out of session. Little I or she said seemed to move the therapy forward, and I did not feel that I was doing anything helpful in the treatment. Nothing seemed to me to be happening in the sessions, and I was wondering if it was because I did not know how to make her a “good” case. Pyke, in her gentle way, suggested we continue to focus on this case for several weeks “until we get a handle on it.” As supervision shifted attention to the case, I was amazed to find the patient becoming more engaged in session, and the therapy started moving. * Not

the patient’s real name.

I am reminded of something Herbert Potash once told me: “If you’re bored in session,” he said, “you’d better believe the patient is, too.” Since that time, I have always been careful to note, and discuss in supervision, the patients who get pushed to the end of supervision because “nothing interesting” is happening in session, lest that fact be the clue to change or movement in their treatment. It also highlights, again, the need for the supervisee to feel free to be open or vulnerable in supervision. Therapists need to know they are not failing. There is the occasional harmful or bad student, and for them the supervisor must be alert. However, far more frequent are the scared, insecure, beginning students who need to borrow just enough of the supervisor’s ego and confidence to feel comfortable effectively lending theirs to their patients. Therapy is a noble pursuit. It can also be a frightening one for new therapists. The supervisor is their coach, their teacher, their mentor, their guide. The supervisor may, on occasion, need to be their gatekeeper (Kaslow, Rubin, & Forrest, 2007; Leigh, Smith, & Bebeau, 2007). But I would venture that the supervisor is 100 times more likely to need to be a good object, parental figure, colleague, or friend. That is not to say the relationship should be overly friendly. It should not. Yet supervisees need to know they can come to the supervisor for support, both when they have done well and when they have not. Supervisees will be much more reluctant to tell a supervisor openly of a concern or problem when they have the sense the supervisor will admonish them rather than help them problem solve. One of the most important qualities a supervisor can possess is being wholly present. The supervisor ought to listen to the supervisee in order to encourage him or her to find the right words. Supervision is not therapy. Yet the impact the supervisor can have on changing lives (of both the supervisee and the client) can

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be just as great. A good object (i.e., a supervisor who is a genuine, open, honest, responsive, and informative model for the supervisee) will stay with that person for life. Many supervisors have stayed with me, and I thank them all. REFERENCES Allen, G. J., Stollos, S. J., & Williams, B. E. (1986). Doctoral students’ comparative evaluations of best and worst psychotherapy supervision. Professional Psychology: Research and Practice, 17, 91–99. Bernard, J. M., & Goodyear, R. K. (2004). Fundamentals of clinical supervision. Boston: Allyn & Bacon. Carifio, M. S., & Hess, A. K. (1987). Who is the ideal supervisor? Professional Psychology, 18, 244–250. Falender, C. A., & Shafranske, E. P. (2004). Clinical supervision: A competency-based approach. Washington, DC: American Psychological Association. Fiske, S. T. (1993). Controlling other people: The impact of power on stereotyping. American Psychologist, 48, 621–628. Frijda, N. H. (2007). The laws of emotion. Mahwah, NJ: Erlbaum. Glick-Hughes, C. (1994). Characterological resistances in psychotherapy supervision. Psychotherapy, 31, 58–66. Hahn, W. K. (2001). The experience of shame in psychotherapy supervision. Psychotherapy, 38, 272–281. Hess, A. K. (2001). Learning psychotherapy. In S. Walfish & A. K. Hess (Eds.), Succeeding in graduate school: The career guide for psychology students (pp. 249–261). Mahwah, NJ: Erlbaum. Kaslow, N. J., Rubin, N. J., & Forrest, L. (2007). Recognizing, assessing, and intervening with problems of professional competence. Professional Psychology, 38, 479–492. Kennard, B. D., Stewart, S. M., & Gluck, M. R. (1987). The supervision relationship: Variables contributing to positive versus negative experiences. Professional Psychology: Research and Practice, 18, 172–175. Ladany, N., & Friedlander, M. L. (1995). The relationship between the supervisory working alliance and trainees’ experience of role conflict and role ambiguity. Counselor Education and Supervision, 34, 220–231. Ladany, N., Hill, C. E., Corbett, M. M., & Nutt, E. A. (1996). Nature, extent, and importance of what psychotherapy trainees do not disclose to their supervisors. Journal of Counseling Psychology, 43, 10–24. Leigh, I. W., Smith, I. L., & Bebeau, M. J. (2007). Competency assessment models. Professional Psychology, 38, 463–473. Mordechai, E. M. (1991). A classification of empathic failures for psychotherapists and supervisors. Psychoanalytic Psychology, 8, 251–262. Olk, M., & Friedlander, M. L. (1992). Trainees’ experiences of role conflict and role ambiguity in supervisory relationships. Journal of Counseling Psychology, 39, 389–397. Rogers, C. R. (1968). Graduate education in psychology: A passionate statement. In W. G. Bennis, E. H. Schein, F. I. Steele, & D. E. Berlewe (Eds.), Interpersonal dynamics: Essays and readings in human interaction (pp. 687–703). Homewood, IL: Dorsey Press. (Original work published 1965) Whitman, S. M., & Jacobs, E. G. (1998). Responsibilities of the psychotherapy supervisor. American Journal of Psychotherapy, 52, 166–175. Wiesel, E. (1972). Souls on fire. New York: Random House. Winnicott, D. W. (1971). Therapeutic consultation in child psychiatry. New York: Basic Books. Worthen, V. E., & McNeill, B. W. (1996). A phenomenological investigation of “good” supervision events. Journal of Counseling Psychology, 43, 25–34. Yourman, D. B., & Farber, B. A. (1996). Nondisclosure and distortion in psychotherapy supervision. Psychotherapy, 33, 567–575.

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CHAPTER 5

Supervising International Students in Counseling and Psychology Training JOHANNA E. NILSSON and CHIA-CHIH DC WANG

THE ISSUES and dynamics associated with multicultural supervision have gained increased attention in the past decade. Multicultural supervision refers to situations in which the supervisee, supervisor, and/or clients differ from one another in terms of race, ethnicity, nationality, sexual orientation, or other cultural variables. The dynamics associated with these cultural differences can influence the content, process, and outcome of supervision (e.g., Bernard & Goodyear, 2004; M. T. Brown & Landrum-Brown, 1995; Constantine, 1997; Garrett et al., 2001; Gatmon et al., 2001; Killian, 2001). In the context of multicultural supervision, any member of this triad (supervisor, supervisee, and client) can be foreign born. In situations where U.S. supervisors and supervisees work with international student clients, understanding the impact of language and cultural barriers on academic achievement, adjustment, and psychosocial well-being, as well as the unique culture of each client, is necessary for effective counseling. However, for the purpose of this chapter we focus solely on the international student as a supervisee working with U.S. supervisors and clients; to date, not much literature has been published in this area (e.g., Killian, 2001; Nilsson & Anderson, 2004; Nilsson & Dodds, 2006). Although we touch upon some of the challenges faced by international students, we refer the reader to the general literature on international students for more information regarding counseling this population (e.g., Handbook for Counseling International Students in the United States; Singaravelu & Pope, 2007) International students are foreign-born students who attend U.S. colleges and universities and who are not permanent residents, immigrants, or refugees (Institute of International Education, 2002). Although the experiences of international 70

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students may be similar to those of U.S. students in counseling training and supervision, language barriers and cultural differences often increase the complexity of these training experiences. The goal of this chapter is to provide information about the unique experiences of international students in counseling/clinical supervision and to offer recommendations for U.S. supervisors working with them. We first provide a brief review of demographic and general information about international students in counseling and psychology training programs. We then address different areas of supervision, such as the setting of the stage for supervision, counseling self-efficacy, and the supervisory relationship, in which international students may experience unique challenges. Finally, we conclude the chapter by providing recommendations for supervisors. Given the limited literature on international students in supervision, we also draw from our own experiences as international supervisees in the past and as faculty members and supervisors who work with international supervisees in the present. D E M O G R A P H I C I N F O R M AT I O N There are close to 670,000 international students in the United States, which equates to a little more than 4% of the total enrollment of college students in the nation. The international student body is a diverse group. Based on data from the 2004/2005 school year, about 57% of international students come from countries in Asia, with India and China representing the two largest proportions of students. This is followed by 13% of students from Europe, 12% from Central and South America, 6% from the Middle East, 6% from Africa, and 5% from Canada and Oceania (i.e., principally Australia and New Zealand). Of all international students, about 22% are enrolled in master’s-level degree programs and 18% in doctoral degree programs (Institute of International Education, 2005). Although the number of international students in the United States is substantial, we had difficulty finding out how many students are actually enrolled in counseling and psychology training programs at the graduate level. According to the Institute of International Education (2005), close to 8,000 international students are enrolled in psychology degree programs, although this number includes students at all degree levels. We also contacted the American Counseling Association, the Counsel of Accreditation of Counseling and Related Educational Programs, and the American Psychological Association regarding the number of international students in their training programs, but these organizations were not able to provide us with any specific data. Based on our own experience, we believe that international students enrolled in psychology and counseling training programs are a diverse group representing a large number of countries, different religions, age groups, languages, and cultural backgrounds. International students studying psychology are also increasing in number. This conclusion is supported by a study by Nilsson and Anderson (2004) that surveyed 42 international students enrolled in professional psychology doctoral programs who represented 20 countries. Given this great diversity, it is next to impossible to generalize the experiences of international students. For example, a White international student from England will likely have different experiences from a Black student from Kenya, partly due

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to differences in the degree of language and cultural similarities to U.S. culture. Furthermore, international students who obtained a bachelor’s and/or master’s degree in the United States prior to starting their doctoral training will likely have different experiences, at least initially, than international students who come directly from their native countries to pursue graduate studies in the United States. In Nilsson and Anderson’s (2004) study, 24% of the international students had no previous academic training in the United States. In other words, the international student body in counseling and psychology training programs in the United States is diverse, and each student will have his or her own unique experience. Subsequently, the information provided in this chapter is general; some international students will be able to relate to all of it, others to some, and maybe a few to none. G E N E R A L I N F O R M AT I O N A B O U T I N T E R N AT I O N A L S T U D E N T S Much of the literature on international students has discussed their experiences from a perspective of acculturation, often addressing how language and cultural barriers can cause academic, social, and emotional difficulties (e.g., Chen, 1999; Hamboyan & Bryan, 1995; Hechanova-Alampay, Beehr, Christiansen, & Van Horn, 2002; Mori, 2000; Poyrazli, Arbona, Nora, McPherson, & Pisecco, 2002; Roysircar, 2004; Wang & Mallinckrodt, 2006). Acculturation is defined as the process of adjusting to a new culture (Graves, 1967); it is an individual process dependent on a number of contextual, personal, and psychological factors (Roysircar, 2004). Coming from another country, international students may be unfamiliar with the U.S. educational system and may have to learn to navigate a new system when it comes to grading, choosing courses, attending classes, interacting with faculty, finding an advisor, and learning study skills (e.g., Meyer, 1995; Mori, 2000; Parr, Bradley, & Bingi, 1992; Thomas & Althen, 1989). In addition, international students may need to learn new views and perspectives of mental illness, human dynamics, and treatment. Culture influences how clients present and make meaning of their symptoms, and thus also assessment and treatment (see U.S. Department of Health and Human Services, 2001). Language barriers can result in difficulties understanding lectures, expressing opinions in class discussions, and answering essay questions (e.g., Meyer, 1995; Mori, 2000; Parr et al., 1992; Thomas & Althen, 1989). In addition, international students enrolled in counseling and applied psychology training programs may experience language barriers when working with U.S. clients (Gutierrez, 1982; Lacina, 2002). Paulston (1974) and others (H. D. Brown, 2007; Hymes, 1967, as cited in H. D. Brown, 2007) have differentiated between linguistic and communicative competence. The former refers to knowledge about language forms, and the latter to knowledge of the social rules of language use. International counseling trainees can struggle with the comprehension of English, resulting in difficulties understanding clients and verbally responding effectively to clients. Yet even with a solid proficiency in English, international counseling students may not fully understand or be able to pick up some nuances, subtle cues, or underlying meanings associated with special contexts and social rules and values (H. D. Brown, 2007; Paulston,

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1974). For instance, the expression “cooking up some good stuff” exchanged by clients in a substance abuse counseling group could have multiple meanings. Depending on the context of the discussion, it could refer to normal kitchen work or substance use activities. Furthermore, clients’ nonverbal communications—such as body language, eye contact, interpersonal relationship patterns, and values—are all strongly influenced by culture (Betancourt & Lopez, 1993; H. D. Brown, 2007; Sodowsky, Lai, & Plake, 1991). Not surprisingly, a limited understanding of English and U.S. culture can cause miscommunication and misunderstanding (Garrett et al., 2001) and hence can interfere with effective counseling by international students. Cultural differences and language barriers can also have an impact on the social adjustment and emotional well-being of international students. Newly arrived students may experience culture shock, which is a reaction to experiencing and living in a foreign culture. Reactions due to culture shock vary but can include feelings of helplessness, homesickness, loneliness, mistrust, and ethnocentrism (Hamboyan & Bryan, 1995; Oberg, 1979; Pedersen, 1991). Although many international students in graduate programs in counseling and applied psychology have received previous academic degrees in the United States, which makes them less vulnerable to culture shock in their current training, others come straight to the United States from their native countries. In addition, prejudices held by U.S. students and faculty can directly affect the social adjustment and emotional well-being of international students (Rahman & Rollock, 2004; Surdam & Collins, 1984). Some of the international supervisees interviewed in Killian’s (2001) qualitative study reported times of not fitting in with other students in their training program. Some also reported difficulties with supervisors, an inability to connect with supervisors, and supervisors imposing faulty cultural generalizations on them. Stress is also commonly experienced by international students (Chen, 1999). Students with low proficiency in English and students from certain geographic regions report greater stress due to acculturation (Poyrazli, Kavanaugh, Baker, & Al-Timimi, 2004; Wan, Chapman, & Biggs, 1992; Wang & Mallinckrodt, 2006). Specifically, Poyrazli et al. (2004) found that students from Asia reported more acculturative stress than European students, suggesting that more cultural differences between a student’s native culture and that of the United States may increase stress. Yet it is important to know that for most international students, adjustment improves over time (Hechanova-Alampay et al., 2002), and some international students are even more engaged academically and report greater gains in personal and social growth than U.S. students (Zhao, Kuh, & Carini, 2005). Given the fact that international students receive their counseling and psychology training abroad, many of them also face career-related concerns. Their vocational situations can be complicated by their seeking employment in the United States, in their native country, and in other foreign countries. Those seeking employment in the United States must obtain appropriate work visas (SpencerRodgers, 2000). Those who want to return home must ensure that their training and degree are applicable and marketable in their home countries. In Nilsson and Anderson’s (2004) study, 57% of international students reported that they planned to return to their country of origin upon graduation.

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International and U.S. students alike are often quite excited to begin practicum training and supervision. Yet many may also feel anxious starting this new endeavor: Not only will they have to counsel clients for the first time, but they must also form an effective relationship with their supervisors (Bernard & Goodyear, 2004). For international students, having to manage language barriers and cultural differences in these roles may add to the anxiety. Different cultures hold different expectations with regard to what is considered appropriate when interacting with an authority figure (e.g., a supervisor), and many of the characteristics of an effective supervisory relationship, in our view, are based on Euro-American culture and standards of behavior. International students who enter into supervision for the first time may not be familiar with the process or the culture upon which supervision is founded. For instance, international student supervisees, just like their U.S. counterparts, are expected to be highly engaged and verbally involved in supervision. They need to take the initiative by asking questions and spontaneously expressing their thoughts and feelings about their performance and reactions to clients. Research findings have indicated that U.S. supervisors’ satisfaction with supervision is significantly associated with supervisees’ self-disclosure (Duan & Roehlke, 2001). Yet in other cultures, self-disclosure can be viewed as offensive and inappropriate (Rhinesmith, 1985; Story, 1982). For example, Asian cultures tend to be more collectivistic and stress relational hierarchy, role obligations, and self-discipline (Kim & Omizo, 2005). Supervisors may be perceived and responded to as authority figures, and Asian international students may choose, out of respect, to keep a distance between themselves and their supervisors (Gulgoz, 2001; Killian, 2001). Many Asian international supervisees may attempt to perform well in supervision by adhering to the relational norms of their native cultures (e.g., intentionally withholding questions or expressing their thoughts until invited to do so). This reluctance can put Asian international students in a precarious situation, because they are learning to manage new skills (i.e., counseling clients), which is quite challenging in itself, while not being able to rely on their cultural knowledge of how to work and interact with supervisors. For this reason, international supervisees need to be given enough time to adjust to the U.S. style of supervision (Killian, 2001). Over time, most of them will become acculturated to U.S. culture and will become better equipped at managing differing cultural expectations. Many will also feel more certain and comfortable in their role as a supervisee and gain a better understanding of what their supervisors expect from them (Nilsson & Anderson, 2004).

C O U N S E L I N G S E L F - E F F I C A C Y A N D S U P E RV I S I O N It is generally suggested that for counseling and psychology trainees to feel skilled and secure as clinicians, they need to develop counseling self-efficacy. Counseling self-efficacy has been defined as a professional’s beliefs in his or her capabilities to effectively counsel a client. Clinicians who are more efficacious are better able to integrate and spontaneously apply various counseling skills to

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ever-changing circumstances with clients. Positive levels of counseling self-efficacy are associated with less anxiety and more self-affirming cognition (Larson & Daniels, 1998). Variables that can influence counseling self-efficacy include the quality of the relationship with the supervisor, client characteristics, the amount of clinical experience, and the number of courses taken (Larson, 1998). For international students, it is easy to see how language barriers can interfere with the development of counseling self-efficacy. Counseling is a “talking cure,” and the counseling process relies heavily on counselors’ verbal communication skills (Bankart, 1997). Furthermore, most Asian international students are socialized with beliefs about the virtues of humbleness, emotional restraint, and self-effacement (Ho, 1989; Kim, Atkinson, & Umemoto, 2001). When working with clients in the United States, these students are likely to have difficulty fitting in with the American style of social conversation, which features more direct expression of feelings, assertive expression of opinions, feedback exchange, and expectations of sharing at least some personal information. Thus, international students in practicum training are often juggling two balls at once: developing clinical competence and conducting counseling in a nonnative language. Yet what tends to frustrate international counseling students more is not that they are unable to conceptualize clients’ presenting concerns or select appropriate interventions to facilitate changes, but that the language constraints they experience prevent them from effectively conveying their understanding and implementation of various skills to their own satisfaction. This frustration may lead to feelings of inadequacy or even inferiority compared to their U.S. peers and may affect their counseling self-efficacy. Gutierrez (1982) argued that a lack of proficiency in English may make students seem less skilled in terms of smoothness and clarity of verbal reflections, which in turn can negatively influence their confidence as counselors. Language barriers may also complicate the evaluation process for supervisors, who may be ill equipped for how to distinguish between language barriers and students’ actual counseling skills and abilities. In addition to language barriers, internal cultural conflicts and low levels of acculturation can negatively affect the counseling self-efficacy of international students (Nilsson & Anderson, 2004). Not surprisingly, research findings indicate that international students who do not accept U.S. mainstream culture and experience prejudice also report less counseling self-efficacy (Nilsson & Anderson, 2004). Experiences of prejudice may lead students to distance themselves from U.S. culture, preventing them from forming a bicultural identity that may be needed for successful clinical work in the United States. Such cultural conflicts and identity struggles may be internalized by international students as a failure to adapt to the new environment and may overshadow and even thwart the positive development of counseling self-efficacy. In addition, the evaluative aspect of the supervisory relationship may be not only difficult but also uncomfortable for both supervisees and supervisors (see Bernard & Goodyear, 2004). Role ambiguity, or supervisees’ uncertainty about their role and supervisors’ evaluation criteria and expectations (Olk & Friedlander, 1992), is associated with less counseling self-efficacy and a weaker supervisory working alliance among international supervisees (Nilsson & Anderson, 2004).

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To help reduce the stress associated with evaluation, it is important that the supervisors lay out specific expectations, evaluation criteria, and consequences for poor performance early on in supervision. For international students, the evaluation of supervision may be even more anxiety provoking than for U.S. students, because they may feel that they are being evaluated and judged not only on their clinical competence but also with respect to language proficiency and familiarity with U.S. culture. It is critical to process these concerns and address them via developing clearly defined counseling-related goals and required tasks as well as indicators of achieving these goals, all of which may also strengthen the working alliance. S U P E RV I S O RY W O R K I N G A L L I A N C E A N D M U LT I C U LT U R A L D I S C U S S I O N S Supervisors may play an important part in the development of the clinical competency of all students, but they may be especially important for the professional growth of international students. Not only can supervisors help international supervisees enhance their clinical skills, but they may also serve as mentors when it comes to understanding and navigating U.S. culture. Maybe the most important component of an effective supervisory relationship is the development of the supervisory working alliance (Bordin, 1994; Efstation, Patton, & Kardash, 1990; Larson, 1998; Patton & Kivlighan, 1997). This working alliance consists of several aspects, such as the bond between the supervision partners and the agreement on tasks and goals (Bordin, 1979). For international students, the bond of the supervisory working alliance predicts counseling selfefficacy (Nilsson & Anderson, 2004). To establish a strong alliance with an international trainee, or with any trainee for that matter, supervisors have to gain the supervisee’s trust. Trust can be built in part by creating a sense of safety in supervision through acknowledging the cultural differences between the supervisor and supervisee and explicitly addressing that these differences will not place the supervisee at a disadvantage in evaluation. Another way to build trust is for the supervisor to communicate his or her interest in the supervisee’s cultural background (Duan & Roehlke, 2001). Feelings of trust and safety are needed for a meaningful multicultural discussion to occur (Killian, 2001), as it is only when feeling safe that a supervisee will bring up questions that will allow for an in-depth self-reflection. It is generally agreed that it is the supervisor’s responsibility to bring up cultural issues for discussion in supervision (e.g., Gopaul-McNicol & Brice-Baker, 1998; Harber, 1996; Tyler, Brome, & Williams, 1991). Research findings have shown that such multicultural discussions have ample and positive effects on supervision and training variables. They increase satisfaction with supervision (Duan & Roehlke, 2001; Nilsson & Dodds, 2006), lead to a stronger supervisory working alliance (Gatmon et al., 2001), and result in greater multicultural competence among trainees (Toporek, Ortega-Villalobos, & Pope-Davis, 2004). When multicultural discussions occur in supervision with international students, these supervisees rate their supervisors as more sensitive to diversity issues (Nilsson & Dodds, 2006) and perceive them to be more trustworthy and attractive, as well as experts (Nilsson, 2007).

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An important goal of discussing cultural issues with international supervisees is to deepen their cultural understanding and enhance their ability to understand the subtle nuances expressed by clients through nonverbal messages, slang, or implicit metaphors. However, supervisors need to keep in mind that it takes time to grow knowledge and ability in this area, just as it does to develop language proficiency. Also, it is important for supervisors who work with international supervisees to maintain a delicate balance between enhancing their supervisees’ further learning in subtle cultural issues and promoting a sense of pride of their own cultural heritage. Another goal associated with discussions of cultural issues in supervision, and one that is unfortunately often overlooked, is to facilitate the possible integration of supervisees’ native cultural knowledge/experience into the current counseling process whenever possible. For instance, supervisors may encourage international supervisees to think of some proverbs or brief stories drawn from their own cultures and use them in counseling to facilitate insights and realization from the clients if these examples are appropriate for the presenting concerns. R E C O M M E N D AT I O N S This chapter provides an overview of the possible experiences and difficulties international students may have while involved in counseling training in the United States. We summarize this chapter with five specific recommendations. SUPERVISORY EXPECTATIONS Due to the fact that culture can influence expectations about behaviors and roles (Markus & Kitayama, 1991), it is important for U.S. supervisors at the onset of supervision to explicitly address their expectations for supervision and for the supervisee. If expectations are not clearly addressed, expected supervisee behavior, such as self-disclosure, may not readily happen. Other topics that need to be adequately discussed at the beginning of supervision may include supervisors’ and supervisees’ roles and responsibilities, what it means to be prepared for and engaged in supervision, ethical responsibilities (e.g., client situations about which the supervisee needs to contact the supervisor outside of supervision), evaluation methods and criteria, and consequences of poor performance (Bernard & Goodyear, 2004; Nilsson & Anderson, 2004). To help clarify their expectations and prevent misunderstanding due to language and cultural barriers, supervisors may want to provide supervisees with written information. A supervision contract is an excellent tool for supervisors to spell out their expectations (see Osborn & Davis, 1996, for an example of a supervision contract). In this early dialogue about supervision, it is critical that supervisors acknowledge with their supervisees possible cultural variations when it comes to these expectations and involve supervisees in this discussion. ACCULTURATION ISSUES The level of acculturation of international students may have a significant influence on both their personal well-being and the development of their counseling

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competence. In addition to setting goals related to supervisees’ clinical growth, supervisors may want to spend some time at the beginning of supervision exploring their supervisees’ level of acculturation and encouraging them to set up some clearly defined, achievable learning goals as well as identify possible steps to further advance their knowledge, understanding, and experience of U.S. culture. LEARNING ABOUT THE SUPERVISEE’S CULTURE When working with international supervisees, supervisors want to show genuine interest and curiosity in learning more about supervisees’ native cultures and demonstrate consistent attempts to understand international supervisees’ cultural viewpoints. In addition, supervisors need to make reasonable efforts to increase their knowledge of and sensitivity to supervisees’ cultures by engaging in relevant reading, consulting media resources, or attending workshops or cultural events. These efforts initiated by supervisors not only model being open minded and nonjudgmental but may also help to enhance the development of a positive supervisory alliance and satisfaction with supervision (e.g., Duan & Roehlke, 2001; Killian, 2001; Nilsson, in press; Nilsson & Anderson, 2004). Supervisors who show their openness, curiosity, and struggles in learning about cultures are likely to be better able to connect with their international supervisees (Killian, 2001). Some international graduate students in counseling and applied psychology have received relevant professional training or served as mental health providers in their native countries before coming to the United States. Supervisors could encourage these students to share how the conceptualizations or treatment strategies may be different based on students’ native cultural values or framework. We believe these attempts not only help to strengthen the counseling self-efficacy of international students but also prepare those students wanting to return to their native countries after graduation by integrating Western-based models and theories into their own cultural contexts. More than half of the international students in counseling or applied psychology programs express the desire to return to their native country after the completion of graduate training in the United States (Nilsson & Anderson, 2004). LANGUAGE BARRIERS With regard to language barriers, it is helpful if supervisors openly acknowledge the extra challenge faced by an international student due to language constraints and address how they will evaluate the performance of the student’s counseling work in light of these language limitations. However, when working with an international supervisee, supervisors should not assume that the supervisee possesses knowledge and adequate understanding of the informal or colloquial terms, slang, phrases, short stories, and metaphors with implicit meanings used in the counseling process or between supervisors and the supervisee. We believe it is important for supervisors to check for understanding and to clarify underlying meanings if needed. Furthermore, supervisors may invite international supervisees to share some unique cultural concepts/phenomena of their native cultures in supervision by

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asking them to refer to these terms in their native languages. Supervisors may also want to encourage supervisees to find ways to integrate some of the encouraging stories or philosophical tales from their native cultures into the counseling process. BECOMING A CULTURAL MENTOR Because some international supervisees may still be learning about and adapting to U.S. culture, it may be beneficial for them if their supervisors expand the traditional supervisory relationship, which traditionally tends to be limited to one hour per week in a particular setting (usually the supervisor’s office) and focus on processing clients’ concerns and discussing possible treatment options. Supervision offers international students a unique opportunity to work closely with a U.S. professional, and we suggest that supervisors use this opportunity to serve also as mentors to their international supervisees. In such a mentorship, the supervisors not only respectfully initiate cultural discussion with international supervisees but also become a safe source themselves from whom supervisees feel comfortable seeking input and advice when confusions and difficulties arise. In this role, supervisors may help to further advance supervisees’ personal and cultural growth by referring them to reading resources, movies, local cultural events and festivals, or, if appropriate, inviting them to holiday and social gatherings. CONCLUSION Supervising international students in counseling and applied psychology training programs can be both challenging and rewarding. On the one hand, because of the many extra layers of consideration needed while supervising international trainees, more supervisory time and attention may be required. These additional demands and challenges may cause frustration and dissatisfaction in both supervisees and supervisors. On the other hand, we believe supervising international students is a great opportunity for U.S. supervisors to expand their worldviews and gain more cultural knowledge; if supervisors are open to such a learning opportunity, a great sense of excitement and satisfaction may be obtained. To date, the supervision and counseling literature has given only limited attention to issues and concerns related to supervising international students. In this chapter, we attempted to include information from the available literature and share our thoughts and experiences of working with international supervisees. We hope this initial effort will stimulate more clinical and scholarly discussions in this area. REFERENCES Bankart, C. P. (1997). Talking cures: A history of Western and Eastern psychotherapies. Boston: Brooks/Cole. Bernard, J. M., & Goodyear, R. K. (2004). Fundamentals of clinical supervision (3rd ed). Boston: Pearson. Betancourt, H., & Lopez, S. R. (1993). The study of culture, ethnicity, and race in American psychology. American Psychologist, 48, 629–637. Bordin, E. S. (1979). The generalizability of the psychodynamic concept of the working alliance. Psychotherapy: Theory, Research, and Practice, 16, 252–260. Bordin, E. S. (1994). Theory and research on the therapeutic working alliance: New directions. In A. O. Horvath & L. S. Greenberg (Eds.), The working alliance: Theory, research and practice (pp. 13–37). New York: Wiley.

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Nilsson, J. E., & Anderson, A. Z. (2004). Supervising international students: The role of acculturation, role ambiguity, and multicultural discussions. Professional Psychology: Research and Practice, 35, 306–312. Nilsson, J. E., & Dodds, A. K. (2006). A pilot phase in the development of the International Student Supervision Scale. Journal of Multicultural Counseling and Development, 34, 50–62. Oberg, K. (1979). Culture shock and the problem of adjustment in new cultural environments. In E. C. Smith & L. F. Luce (Eds.), Toward internationalism: Readings in cross-cultural communication. Rowley, MA: Newbury House. Olk, M. E., & Friedlander, M. L. (1992). Trainees’ experiences of role conflict and role ambiguity in supervisory relationships. Journal of Counseling Psychology, 39, 389–397. Osborn, C. J., & Davis, T. E. (1996). The supervision contact: Making it perfectly clear. Clinical Supervisor, 14, 121–134. Parr, G., Bradley, L., & Bingi, R. (1992). Concerns and feelings of international students. Journal of College Student Development, 33, 20–25. Patton, M. J., & Kivlighan, D. M. (1997). Relevance of the supervisory alliance to the counseling alliance and to treatment adherence in counselor training. Journal of Counseling Psychology, 44, 108–115. Paulston, C. B. (1974). Linguistic and communicative competence. TESOL Quarterly, 8, 347–362. Pedersen, P. B. (1991). Counseling international students. Counseling Psychologist, 19, 10–58. Poyrazli, S., Arbona, C., Nora, A., McPherson, R., & Pisecco, S. (2002). Relation between assertiveness, academic self-efficacy, and social adjustment among international graduate students. Journal of College Student Development, 43, 632–641. Poyrazli, S., Kavanaugh, P. R., Baker, A., & Al-Timimi, N. (2004). Social support and demographic correlates of acculturative stress in international students. Journal of College Counseling, 7, 73–82. Rahman, O., & Rollock, D. (2004). Acculturation, competence, and mental health among South Asians in the United States. Journal of Multicultural Counseling and Development, 32, 130–142. Rhinesmith, S. H. (1985). Bring home the world: A management guide for community leaders of international exchange programs. New York: Walker. Roysircar, G. (2004). Counseling and psychotherapy for acculturation and ethnic identity concerns with immigrant and international student clients. In T. B. Smith (Ed.), Practicing multiculturalism: Affirming diversity in counseling and psychology (pp. 248–268). Boston: Allyn & Bacon. Singaravelu, H. D., & Pope, M. (2007). A handbook for counseling international students in the United States. Alexandria, VA: American Counseling Association. Sodowsky, G. R., Lai, E. W. M., & Plake, B. S. (1991). Moderating effects of sociocultural variables on acculturation attitudes of Hispanics and Asian Americans. Journal of Counseling and Development, 70, 194–204. Spencer-Rodgers, J. (2000). The vocational situation and country of orientation of international students. Journal of Multicultural Counseling and Development, 28, 32–49. Story, K. E. (1982). The student development professional and the foreign student: A conflict of values. Journal of College Student Personnel, 23, 66–70. Surdam, J. C., & Collins, J. R. (1984). Adaptation of international students: A cause for concern. Journal of College Student Personnel, 25, 240–245. Thomas, K., & Althen, G. (1989). Counseling foreign students. In P. B. Pedersen, J. C. Draguns, W. J. Lonner, & J. E. Trimble (Eds.), Counseling across cultures (3rd ed, pp. 205–241). Honolulu: University of Hawaii Press. Toporek, R. L., Ortega-Villalobos, L., & Pope-Davis, D. B. (2004). Critical incidents in multicultural supervision: Exploring supervisees’ and supervisors’ experiences. Journal of Multicultural Counseling and Development, 32, 66–83. Tyler, F. B., Brome, D. R., & Williams, J. E. (1991). Ethnic validity, ecology, and psychotherapy: A psychological competence model. New York: Plenum Press. U.S. Department of Health and Human Services. (2001). Mental health: Culture, race, and ethnicity—A supplement to Mental health: A report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services. Wan, T.-Y., Chapman, D. W., & Biggs, D. A. (1992). Academic stress of international students attending U.S. universities. Research in Higher Education, 33, 607–623. Wang, C. D., & Mallinckrodt, B. (2006). Acculturation attachment and psychosocial adjustment of Chinese/Taiwanese international students. Journal of Counseling Psychology, 53, 422–433. Zhao, C.-M., Kuh, G. D., & Carini, R. M. (2005). A comparison of international student and American student engagement in effective educational practices. Journal of Higher Education, 76, 209–231.

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CHAPTER 6

The Transition from Supervisee to Supervisor LINDSEY L. COHEN and CRYSTAL S. LIM

I swear by Apollo the physician, and Aesculapius, and Health, and All-heal, and all the gods and goddesses, that, according to my ability and judgment, I will keep this Oath and this stipulation—to reckon him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it without fee or stipulation; and that by precept, lecture, and every other mode of instruction. —Hippocrates, ca. 400 BCE

AS HIGHLIGHTED in the Hippocratic Oath, the training of the less experienced by the more experienced has important value. The therapy supervisor blends the respected positions of teacher, therapist, consultant, administrator, evaluator, model, and mentor (e.g., Hess, 1980; Holloway, 1995). The Hippocratic Oath indicates a continuity as one develops from supervisee to supervisor. Lastly, as indicated by the Oath, the process of supervision is diverse, including “precept, lecture, and every other mode of instruction.” However, it is not clear how to train supervisees to become supervisors. In fact, a task force of the Association of State and Provincial Psychology Boards (2003) found that given the critical role of supervision in the protection of the public and in the training and practice of psychologists, it is surprising that organized psychology, with few exceptions, has failed to establish a requirement for graduate level training in supervision. Few supervisors report having had formal courses in supervision, and most rely on their own experience as a supervisee. (p. 1)

In fact, data suggest that fewer than 20% of supervisors receive formal supervision instruction (Peake, Nussbaum, & Tindell, 2002). 82

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The Transition from Supervisee to Supervisor 83 C O M P E T E N C I E S I N P S Y C H O L O G Y S U P E RV I S I O N In response to the paucity of formal training supervisors receive and growing recognition that supervision should be considered a psychology core competency area (e.g., Peterson, Peterson, Abrams, & Stricker, 1997), Falender et al. (2004), and Falender and Shafrankse (2007) detailed the competencies of psychology supervision. Awareness of these areas can help the supervisee take a proactive stance toward training and seek out appropriate opportunities and education. There are five superordinate, or overarching, factors that cut across the core competencies. These are recognizing that (1) achieving supervision competencies is a lifelong developmental path, (2) diversity is part of every aspect of supervision and contains its own areas of competence, (3) legal and ethical issues should be considered throughout the supervision process, (4) professional and personal variables can influence and bias supervision, and (5) self- and peer evaluation should always be part of supervision. The 43 competencies identified fall into the areas of knowledge, skills, values, social context, training, and assessment of supervision (Falender et al., 2004; Falender & Shafranske, 2007). Being aware of these competencies and seeking out training in these areas will help the supervisor in training prepare for the demands of serving as a supervisor.

P R E PA R I N G F O R T H E S U P E RV I S O R R O L E Some of the core competencies associated with supervision can be achieved in coursework, practica, supervision, internships, and other areas of training. The role of being a supervisor also shares some commonalities with being a teacher, a therapist, and a researcher, which are common roles for a trainee. Being aware of the overlap in training, as well as how supervision is unique, can help prepare the supervisee for the role of supervisor.

TEACHING Students often teach or serve as teaching assistants during their graduate training, and these experiences can help prepare them to be supervisors. Clearly, an objective of supervision is to teach supervisees how to conduct therapy, and provision of information is the simplest parallel between these two areas. For example, being able to clearly present information that allows students or supervisees to actively learn and use the information is both an art and skill. In addition, recognizing the appropriate quantity of information is common across both entities. Another important characteristic of a teacher is being able to present information at the students’ level. Teachers must be closely aware of when the information and assignments are too difficult or simplistic for students. This skill is critical for supervisors. For example, for a beginning therapist to be assigned a client with significant suicidal ideation might be overwhelming and too challenging for the supervisee, regardless of the amount of supervision provided. In other words, supervisors need to know the developmental level of their trainees in order to match expectations and assignments in supervision.

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Another area that is common to teaching and supervision is awareness of boundaries and professional roles between a supervisor and supervisee, which are not entirely distinct from those of a teacher and student. A supervisee who has taught in a classroom will be able to use this experience. A supervisor should be aware of the power and expertise differential when providing guidance in supervision. For example, there might be interventions that are not difficult for the experienced supervisor but that are challenging and anxiety provoking for the supervisee. A supervisor who is aware of these issues might be better at creating an environment in which the supervisee is comfortable sharing insecurities about competencies. Furthermore, a supervisor typically evaluates the performance and progress of the supervisee, which is not unlike the evaluative role of an instructor. For example, a supervisee who is habitually turning in late notes should be informed that this is poor professional behavior and that there are related liability issues. The supervisor might go further and help the supervisee identify the barriers to completing the notes in a timely fashion, which might include anxiety about the content, poor time management, lack of understanding of the importance of the task, or other issues. In larger classes, it is unlikely that an instructor would provide this level of involvement, but in supervision it is an important part of the teaching process. Instruction and supervision have one distinct difference. Whereas education typically contains a specific curriculum applied across all students, clinical supervision both is tailored to the individual supervisee as well as fluid changes depending on specific clinical cases and circumstances. The supervisee–supervisor relationship as well as the flexibility to adapt to a changing client situation have dual goals of both training the supervisee and simultaneously providing therapeutic services. In other words, the supervisor must be attentive to these two objectives, which are often in concert but at times might be in conflict. For example, there might be times when the supervisor recognizes that his or her own direct involvement with the client is optimal for the client but might undermine the therapeutic relationship between the supervisee therapist and the client. COUNSELING The experience of providing therapeutic services during training will also help prepare the supervisee for the future role of supervisor. Like in counseling or therapy, supervisors might encourage the supervisee to examine his or her own behavior, feelings, and thoughts. In addition, supervisors should work with each supervisee in a manner that is best suited to the particular personality, developmental level, and circumstances of the student. For example, a supervisor might encourage his or her students to develop their own personal styles of therapy rather than trying to emulate that of the supervisor. In so doing, the supervisor will need to help the supervisees develop personal awareness of who they are as therapists. This process is not dissimilar to working with a client to enhance his or her own self-awareness in therapy. Some personal qualities of the supervisee might be pertinent to particular therapy cases. For example, it would be important for a supervisor to encourage a supervisee to explore the latter’s own personal issues if these issues appear to be impacting the supervisee’s work with clients. As an illustration, a supervisee

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The Transition from Supervisee to Supervisor 85 working with an adolescent might enhance rapport by identifying areas of common interests (e.g., sports, television shows); however, sharing more personal information (e.g., drug experimentation, sexual behavior) might prove detrimental to the goals of therapy. Furthermore, the supervisor might explore why the supervisee is sharing this personal information. If it appears that it is being done for the personal enjoyment of the supervisee or because the supervisee wishes to normalize or process the information, it is not appropriate. If the supervisee is sharing personal information with the purpose of helping develop the therapeutic relationship, some sharing is appropriate. However, the supervisor should discuss with the supervisee the consequences of sharing particular information (e.g., normalizing of dangerous behavior might increase rapport at the risk of increasing the likelihood of the client engaging in that behavior). In situations in which the supervisor is feeling that supervision is becoming therapy for the supervisee, the supervisor should consult with seasoned colleagues with the explicit goal of recognizing when supervision is benefiting the training of the student and when the trainee should be referred to an outside therapist. RESEARCH Skills learned via research training can also help the budding supervisor. Training in research encourages objective, systematic formulation and testing of hypotheses. These qualities might also be valuable to the supervisor when helping the supervisee consider various conceptualizations. For example, the supervisor can encourage the supervisee to form hypotheses, develop methods of testing them (e.g., interventions), and measure changes in the client. Research training also helps the student be a critical thinker and consider a variety of variables when answering a question. Thus, a supervisor steeped in research can help a supervisee consider multiple factors that could be at work in a given therapeutic situation. In addition, as the literature base in assessment and therapy grows, it is critical that therapists are able to be critical consumers of the literature. A supervisor with good research training can assist the trainee in being able to competently search the literature and examine the available data that are relevant to specific therapy cases. When taking an evidence-based approach to practice, developing this skill is crucial (American Psychological Association Presidential Task Force on Evidence-Based Practice, 2006). The ethical, legal, and business aspects (e.g., consent, confidentiality, data collection) found in research apply to supervision, too. For example, supervisors are often in the role of training students in obtaining consent for therapy, keeping clear and timely progress notes, handling confidentiality, and other matters. Clearly there are differences between supervision and research. Research typically rejects subjective or intuitive analyses of data, whereas supervision might more readily entertain these approaches. Supervision often involves a flexible and fluid manner of responding to situations as they arise, whereas research is best when it takes an a priori and systematic approach to solving problems. Future supervisors can better prepare for the role by appreciating the commonalities and distinctions in their training as teachers, therapists, and researchers. Important unique characteristics of supervision that are less common in teaching, counseling, or research roles are assessing and managing the internal processes

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of the supervisee, client, and supervisor. In other words, clinical supervisors are responsible for the well-being of the client, the supervisee, and themselves. For new supervisors, balancing these needs can be challenging. For example, new supervisors might feel drawn to enter the therapy room with the goal of helping the client. Although this might potentially benefit the client, it undermines the supervisee therapist and does more harm than good in supervisee training. In contrast, a supervisee wishing to practice additional testing might inquire whether it would be okay to do so with a client. Supervisors will need to balance the trainee’s needs with those of the client, who might resent completing additional measures that are not clearly necessary for therapy. It is common for new supervisors to neglect their own needs by spending too much time thinking about and working to satisfy the needs of the trainee and client. In this situation, supervisors should recognize that modeling a healthy and balanced life will benefit the supervisee. In addition, consulting with more seasoned supervisors should prove helpful to new supervisors facing these challenges. D E V E L O P M E N T O F T H E S U P E RV I S O R As indicated in the core competencies (Falender et al., 2004; Falender & Shafranske, 2007), it is important for the developing supervisor to be aware of theories and models of supervision. There are a number of available theories of supervision dating back at least to Hogan (1964), such as those that are grounded in other theoretical models (e.g., cognitive-behavioral, Henggeler & Schoenwald, 1998; psychodynamic, Alonso, 1983), process-oriented perspectives (e.g., discrimination model; Bernard & Goodyear, 1998), or social role models (e.g., Bernard, 1979; Holloway, 1995). Widely popular and arguably the most relevant to the supervisor in training are the developmental models. Popular developmental models have been proposed by a number of theorists (e.g., Alonso, 1983; Hess, 1986, 1987; Stoltenberg, McNeill, & Delworth, 1998; Watkins, 1990, 1993), and most have the following underlying themes: (a) new supervisors (as well as supervisees) develop and mature over time, (b) there are stages in the developmental process of becoming a supervisor that may not be linear in fashion, (c) new supervisors struggle with issues such as self-identity and feelings of competency, and (d) supervisors should identify supervisees’ developmental levels and match their training and expectations accordingly. There is one commonality cutting across many of the developmental models that is particularly relevant to transitioning from supervisee to supervisor: There is anxiety, self-doubt, and feelings of being overwhelmed when initially assuming the role of supervisor. Whether called role shock, imposter syndrome, or another label, the experience of angst and struggle are common when a supervisee transitions to becoming a supervisor. The new supervisor should find comfort in the awareness that these feelings are not unique and that they will gradually subside over time. In fact, developmental theories suggest that supervisors will transition through phases and eventually feel confident, comfortable, and integrated, similar to the process that supervisees may experience. That being said, new cases, novel situations, and challenges will reignite these feelings in even the most seasoned supervisor; however, the supervisor will likely recognize these emotions as alarms

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The Transition from Supervisee to Supervisor 87 and reminders to consult with others, enhance training, or take other courses of action to provide appropriate supervision. EVIDENCE-BASED PRACTICE According to the American Psychological Association Presidential Task Force on Evidence-Based Practice (2006), “Evidence-based practice in psychology is the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences” (p. 273). As indicated by the definition, evidence-based practice in psychology (EBPP) recognizes the equally weighted value of empirical research, patient characteristics, and clinical expertise across areas of psychological practice. Thus, this framework provides some interesting directions regarding supervision. BEST AVAILABLE RESEARCH In terms of using the best available research, the new supervisor can explore a number of areas. As a start, the new supervisor should examine the empirical evidence regarding supervision models, approaches, and techniques. For conducting literature searches of this sort, new search engines and techniques are being developed in order to help professionals taking an evidence-based practice approach (see Walker & London, 2007). As an example, there are search engines that allow the searcher to find only systematic reviews and meta-analyses rather than individual studies. The supervisor can also explicitly incorporate research evidence into supervision by training and requiring supervisees to conduct literature searches for their cases, including assessment, case conceptualization, and treatment of the specific clients and issues. The supervisor might require that students bring printouts of the searches as well as the specific articles to supervision. That being said, the supervisor should be aware of the ample evidence indicating that common factors (e.g., rapport, therapeutic relationship) are critical to therapy success (e.g., Hubble, Duncan, & Miller, 1999; Weinberger, 1995); as such, a research treatment manual provides only minimal guidance for therapy. The supervisor can assist supervisees by emphasizing ways to conduct evidence-based practice. For example, using the five As (Ask the question, Acquire the evidence, Appraise the quality of the evidence, Apply the results, and Assess the Outcome; Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000; Strauss, Richardson, Glasziou, & Haynes, et al., 2005) is one way to help supervisees systematically incorporate evidence-based practice into their decision making. Furthermore, a supervisor can help supervisees form questions in a way that optimizes the success of finding the appropriate literature. For example, using the PICO (specific Population, Intervention, Comparison group, and study Outcomes) should help in forming appropriate searches for given therapeutic intervention questions (Spring, 2007). PATIENT CHARACTERISTICS, CULTURE, AND PREFERENCES Taking an evidence-based practice approach emphasizes the particular circumstances of the individual. As such, the supervisor will take an idiographic approach

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and appreciate that each supervisee is distinct, with his or her own particular strengths and weaknesses, background, and capacities. Thus, a one-size-fits-all approach to supervision is not warranted. It is incumbent on the supervisor to get to know the unique aspects of the supervisee. For example, the supervisor should be aware of the student’s prior therapeutic work, evaluations of prior performance, personal background that might be relevant to therapy, and goals and preferences for the training experience. This information might be collected in an informal manner, or the supervisor might construct other avenues for obtaining it (e.g., have the student write an autobiographical statement, require typed goals for the practicum training). In addition, the supervisor should train the supervisee to be aware of the patient’s characteristics, values, beliefs, and culture. For example, the supervisor might ask the supervisee how the cultural background of the client is being incorporated into the case conceptualization. Furthermore, a supervisor adopting the EBPP approach will encourage the supervisee to approach therapy as a collaborative endeavor with the client taking part in weighing out treatment options and stating specific preferences about the therapy. The supervisor will encourage a culturally competent approach to therapy, with the trainee learning about and discussing relevant cultural issues for his or her cases. CLINICAL EXPERTISE Finally, clinical expertise involves the establishment of rapport, empathy building and expression, good listening and reflecting, the development of a therapeutic relationship, and other nonspecific or common factors and therapeutic qualities (Weinberger, 1995). The supervisor might also be in the role of training the supervisee in particular areas of expertise, such as administration of diagnostic batteries or performance of particular interventions. Tying in other aspects of the EBPP model, one can see that clinical expertise is needed to be able to synthesize, apply, and modify relevant research findings to the particular characteristics, values, and situations of the client. Whereas some of these areas (e.g., training in test administration) can be straightforward for the new supervisee, others (e.g., how to develop a therapeutic relationship) can be challenging even for the most seasoned supervisor. Although the EBPP framework is relatively new, it is consistent with the views of psychologists who identify as scientist practitioners (Chwalisz, 2003). As such, supervision adhering to EBPP might be seen as a best practices model for incorporating research and clinical expertise into the particular needs and circumstances of the supervisee and clients. S U P E RV I S I O N F O R M AT When assuming the role of a supervisor, one of the first decisions a person faces is what type of supervision to conduct. Common types of supervision utilized in training programs include individual and group supervision. There are strengths and weakness to these alternatives. Individual supervision is considered the gold standard in many clinical training programs, but it has also been identified as the least efficient supervision option (Milne & Oliver, 2000). Group supervision is more

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The Transition from Supervisee to Supervisor 89 time efficient but less tailored to individual trainees. A new supervisor might prefer individual supervision because it might be less intimidating. Specifically, working with a single trainee allows for more of a personal dialogue and discussion of individual issues than the group format, which requires the supervisor to juggle the demands of meeting individual needs without leaving out the other members of the group. A new supervisor using group supervision might actively encourage other members to be engaged in the supervision process by posing specific questions to all members regarding case issues. Another option is to be flexible and use a combination of individual and group supervision. By acknowledging at the outset that supervision will sometimes be done in a group fashion and other times individually, the supervisor has a greater degree of freedom in optimizing supervision. For example, there might be necessary but difficult feedback to provide a supervisee (e.g., the supervisee appears aloof in session) that would be better given in a one-on-one meeting. Similarly, there might be times when a supervisor wishes to praise excellent work by a supervisee without the other students in the group feeling competitive and disheartened about their own abilities. In addition, some difficult and complicated cases require lengthy supervision; in these cases, an individual meeting format might be preferable. Besides different types of supervision, a supervisor can utilize different methods of supervising. These methods may include self-report, process notes, audiotape, videotape, and live observation (Bernard & Goodyear, 2004), with each having its own advantages and disadvantages (Neufeldt, 2003). For example, videotapes provide the richest data, but viewing them is more time consuming for the supervisor than relying on process notes. Although process notes are brief, they require the supervisee to distill, integrate, and summarize the most important parts of the session. As with the format of supervision, again, it might be best for a new supervisor to stay open and flexible with these supervision methods. For example, there might be situations (e.g., new student, difficult therapy session) when the supervisor will want to be on hand watching the session live, and other times when process notes might be sufficient. Although the student supervisee might initially be less comfortable being observed live or via video, this is a time when the supervisor will want to make decisions based on the methods that will allow him or her the essential information. In fact, a student is likely to feel more comfort and even reassurance knowing that the supervisor is behind a two-way mirror and will have another set of eyes on the session. S U P E RV I S O R I N T E R P E R S O N A L C H A R A C T E R I S T I C S Given that new supervisors were recently supervisees, they might possess one quality that is a key component of a good supervisor—empathy for the supervisee. Fortunately, empathy is one of the characteristics found to distinguish high-quality supervisors (Falender & Shafranske, 2004). In other words, supervisors should be able to understand supervisees’ fears and comforts and gently help challenge supervisees to grow as therapists. This might involve seeing clients who are quite different from those seen previously, learning and conducting assessments that are new to the supervisees, or trying novel intervention approaches. In addition to

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having empathy, research suggests that strong supervisors are reliable, trustworthy, intelligent, ethical, committed, genuine, warm, and appropriately self-disclosing and have a sense of humor (Henderson, Cawyer, & Watkins, 1999); this highlights for new supervisors that interpersonal characteristics are valued by supervisees. Research suggests that open communication and two-way feedback are important qualities of supervision, and, hence, supervisors should strive to create an atmosphere that supports supervisor–supervisee dialogue (Henderson et al., 1999). Nelson (1978) found that an interest in supervision was a critical factor and was more important than knowledge and experience. In summary, in addition to keeping in mind a number of technical considerations, supervisees transitioning to supervisor should also respect and value interpersonal qualities in supervision. E VA L U AT I O N The importance of evaluation is recognized in the supervision competencies (Falender et al., 2004; Falender & Shafranske, 2007). Others have stated that evaluation is “a defining aspect of supervision” (Bernard & Goodyear, 2004, p. 19). Therefore, for new supervisors, understanding the evaluation process and how to incorporate it into supervision is important. However, evaluating supervisees can be a difficult task. Specifically, acknowledging that part of therapy is art, it can be challenging to objectively judge the quality of therapy, especially common factors (e.g., development of rapport). When there are no clear criteria of successful and poor therapy performance, supervisors must rely on expertise and experience in providing evaluative comments. However, expertise and experience is typically more limited in new supervisors. One important first step for supervisors is to distinguish between the two types of evaluation—formative and summative (Bernard & Goodyear, 2004)—and decide how to incorporate these different types of evaluation into supervision. Formative evaluations consist of feedback that is given on an ongoing basis to supervisees throughout the supervision experience. This feedback should be used to facilitate skill acquisition and professional growth, and giving it often causes supervisors little to no discomfort (Bernard & Goodyear, 2004). New supervisors might use praise, supportive statements, and constructive feedback in formative evaluations. It is likely that this level of feedback occurs naturally for new supervisors; however, this should not be the only feedback provided. Summative evaluations are formal written evaluations given to trainees by supervisors. These evaluations occur when supervisors decide how supervisees are performing and are usually based on specified criteria (Bernard & Goodyear, 2004). These evaluations most often relate to grades trainees receive for clinical work, as well as their progress as clinicians. Conducting summative evaluations can be stressful for supervisors, especially if evaluation criteria are unclear (Bernard & Goodyear, 2004). Most clinical training programs have their own summative evaluation forms that relate to goals specific to the program and other accrediting bodies (e.g., the American Psychological Association). Bernard and Goodyear (2004) suggested discussing the evaluation process early in the supervisory relationship, utilizing evaluation criteria as teaching and learning objectives, and using feedback based on evaluation criteria throughout supervision in order to create an

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The Transition from Supervisee to Supervisor 91 atmosphere in which evaluation is respected and understood by those involved in supervision. For example, supervisors might present the evaluation criteria at one of the first meetings with the supervisees. Providing specific illustrations of behavior (e.g., lateness on note keeping; difficulty expressing empathy) and tying these directly to evaluative comments would be helpful for students in the evaluation process. One particularly difficult aspect of evaluation for new supervisors is the possibility that a supervisee may be demonstrating problematic behaviors. There is always the possibility that a trainee may fail to meet minimal criteria for continuing in a clinical training program, but the chance of this occurring is not great (i.e., estimates are about one supervisee in every 4 years; Falender & Shafranske, 2004). Some reasons for impairment or incompetence might be substance abuse, interpersonal problems, or personality disorders. New supervisors will want to consult with colleagues at the earliest signs of significant problematic behavior in a supervisee. The consultation should focus on whether remediation is possible. If it does not appear that remediation is in order, dismissal is the likely outcome. If there are opportunities and the supervisee is deemed a good candidate for remediation, identifying specific tasks and milestones is warranted. For example, if the student is repeatedly not able to develop a therapeutic alliance due to interpersonal deficits, engaging in individual therapy, role-playing with the supervisor, and other activities might be in order. Additional supervisors might need to be included in order to provide additional judgment of the impairment and signs of improvement. CONCLUSION New supervisors have a position of importance and value in the field of psychology. Although there is a lack of formal training available to supervisees who will make the transition to being a supervisor, there are resources and training experiences available that may be helpful to beginning supervisors. Recently, supervision competencies (Falender et al., 2004; Falender & Shafranske, 2007) have been delineated that provide transitioning supervisors a gauge by which to conduct self-evaluations. New supervisors should take stock of how prior experiences in teaching, counseling, and research might have provided skills that will prove invaluable when providing supervision. Hopefully heightened confidence in supervision abilities will come from this self-evaluation. Awareness of the developmental process should also help emerging supervisors, especially the notion that insecurities are commonly experienced early on when stepping into the new role. Beginning supervisors should also be knowledgeable about the developmental processes of becoming a supervisor, as well as how developmental processes influence supervisees. Beginning supervisors should understand that there are multiple types and methods of supervision but little data suggesting which particular procedures are superior. Thus, new supervisors should select the format that is most consistent with their goals for supervisees and their interpersonal characteristics. Given that evaluation is an essential part of supervision, new supervisors will want to carefully contemplate when and how evaluation will occur. Fortunately, most clinics have some formalized evaluation systems in place to assist new supervisors.

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In sum, transitioning from supervisee to supervisor can be an overwhelming and intimidating experience, but also an immensely rewarding one.

REFERENCES Alonso, A. (1983). A developmental theory of psychodynamic supervision. Clinical Supervisor, 1, 23–26. American Psychological Association Presidential Task Force on Evidence-Based Practice. (2006). Evidence-based practice in psychology. American Psychologist, 61, 271–285. Association of State and Provincial Psychology Boards. (2003). Supervision guidelines revised 2003 (Final report of the ASPPB Task Force on Supervision Guidelines). Montgomery, AL: Author. Bernard, J. M. (1979). Supervisor training: A discrimination model. Counselor Education and Supervision, 19, 60–68. Bernard, J. M., & Goodyear, R. K. (1998). Fundamentals of clinical supervision (2nd ed.). Boston: Allyn & Bacon. Bernard, J. M., & Goodyear, R. K. (2004). Fundamentals of clinical supervision (3rd ed.). Boston: Allyn & Bacon. Bordin, E. S. (1983). A working alliance model of supervision. Counseling Psychologist, 11, 35–42. Chwalisz, K. (2003). Evidence-based practice: A framework for twenty-first century scientistpractitioner training. Counseling Psychologist, 31, 497–528. Falender, C. A., Cornish, J. A. E., Goodyear, R., Hatcher, R., Kaslow, N. J., Leventhal, G., et al. (2004). Defining competencies in psychology supervision: A consensus statement. Journal of Clinical Psychology, 60, 772–785. Falender, C. A., & Shafranske, E. P. (2004). Clinical supervision: A competence-based approach. Washington, DC: American Psychological Association. Falender, C. A., & Shafranske, E. P. (2007). Competence in competency-based supervision practice: Construct and application. Professional Psychology: Research and Practice, 38, 232–240. Henderson, C. E., Cawyer, C. S., & Watkins, C. E., Jr. (1999). A comparison of student and supervisor perceptions of effective practicum supervision. Clinical Supervisor, 18, 47–74. Henggeler, S. W., & Schoenwald, S. K. (1998). The MST supervisory manual: Promoting quality assurance at the clinical level. Charleston, SC: MST Institute. Hess, A. K. (1980). Training models and the nature of psychotherapy supervision. In A. K. Hess (Ed.), Psychotherapy supervision: Theory, research, and practice (pp. 15–25). New York: Wiley. Hess, A. K. (1986). Growth in supervision: Stages of supervisee and supervisor development. Clinical Supervisor, 4, 51–67. Hess, A. K. (1987). Psychotherapy supervision: Stages, Buber, and a theory of relationship. Professional Psychology: Research and Practice, 18, 251–259. Hogan, R. A. (1964). Issue and approaches in supervision. Psychotherapy: Theory, Research, and Practice, 1, 139–141. Holloway, E. L. (1995). Clinical supervision: A systems approach. Thousand Oaks, CA: Sage. Hubble, M. A., Duncan, B. L., & Miller, S. D. (Eds.). (1999). The heart and soul of change: What works in therapy. New York: Guilford Press. Milne, D., & Oliver, V. (2000). Flexible formats of clinical supervision: Description, evaluation, and implementation. Journal of Mental Health, 9, 291–304. Nelson, G.L. (1978). Psychotherapy supervision from the trainee’s point of view: A survey of preferences. Professional Psychology, 539–550. Neufeldt, S. A. (2003). Becoming a clinical supervisor. In M. J. Prinstein & M. D. Patterson (Eds.), The portable mentor: Expert guide to a successful career in psychology (pp. 209–218). New York: Kluwer Academic/Plenum Press. Peake, T. H., Nussbaum, B. D., & Tindell, S. D. (2002). Clinical and counseling supervision references: Trends and needs. Psychotherapy: Theory, Research, Practice, Training, 38, 114–125. Peterson, R. L., Peterson, D. R., Abrams, J. C., & Stricker, G. (1997). The National Council of Schools and Programs of Professional Psychology education model. Professional Psychology: Research and Practice, 28, 373–386. Sackett, D. L., Straus, S. E., Richardson, W. S., Rosenberg, W., & Haynes, R. B. (Eds.). (2000). Evidence-based medicine: How to practice and teach EBM. Edinburgh, Scotland: Churchill Livingstone. Spring, B. (2007). Evidence-based practice in clinical psychology: What it is, why it matters, what you need to know. Journal of Clinical Psychology, 63, 611–631. Stoltenberg, C. D., McNeill, B. W., & Delworth, U. (1998). IDM supervision: An integrated developmental model for supervising counselors and therapist. San Francisco: Jossey-Bass.

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The Transition from Supervisee to Supervisor 93 Strauss, S. E., Richardson, W. S., Glasziou, P., & Haynes, R. B. (2005). Evidence-based medicine: How to practice and teach EBM (3rd ed.). New York: Elsevier. Walker, B. B., & London, S. (2007). Novel tools and resources for evidence-based practice in psychology. Journal of Clinical Psychology, 63, 633–642. Watkins, C. E., Jr. (1990). Development of the psychotherapy supervisor. Psychotherapy, 27, 553–560. Watkins, C. E., Jr (1993). Development of the psychotherapy supervisor: Concepts, assumptions, and hypotheses of the supervisor complexity model. American Journal of Psychotherapy, 47, 58–74. Weinberger, J. (1995). Common factors aren’t so common: The common factors dilemma. Clinical Psychology: Science and Practice, 2, 45–69.

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CHAPTER 7

Psychoanalytic Supervision MARVIN HYMAN

SOME YEARS ago, at a national conference, I heard a panel presentation in which supervisors and supervisees within two supervisory dyads each described the supervision that had taken place as each of the participants experienced it. In one of the dyads the supervisor and supervisee spoke about a contretemps they experienced in the supervision. The therapist was conducting a psychoanalytic therapy with a 3-times-weekly frequency of meetings. This frequency had been mandated as the minimum necessary for meeting the requirements of the institute in which the therapist was enrolled as a candidate. The treatment was, thus, a part of her supervised analytic work. Accordingly, the supervisee was simultaneously an analyst for the analysand and a student for the institute. The supervisor also wore more than one hat. Not only was he responsible for supervising the technical work of the therapist, but he also wore the hat of institute evaluator of the therapist and the therapist’s performance, and yet a third hat as enforcer of the institute’s standards for the frequency at which an analysis was to be conducted. Thus was the stage set for the supervisory drama that ensued. In anticipation of the coming academic year, the therapist was trying to arrange with her analysand the times of the three weekly meetings that would be held during the coming year. As a student, as a therapist, as a parent, and as an individual, the candidate had a tight schedule and only a limited number of places in her schedule into which to fit the analysand. The analysand, in turn, was beginning a new business enterprise that put severe constraints upon his schedule. In short, they were having a difficult time finding a mutually satisfactory schedule arrangement for the analysis. Complicating the matter further, the therapist, as a candidate, was desperate to meet the 3-times-weekly requirement of the institute. And, as a supervisee, the therapist wanted, with equal desperation, her supervisor’s appreciation of her situation and his approval of her performance as a therapist, as a candidate, and as an individual. 97

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The supervisor viewed the therapist’s inability to get the 3-times-weekly schedule in place as a form of countertransferential acting out—something to be dealt with in the supervision by analysis and interpretation. As an enforcer of institute standards, the supervisor could not conceptualize an analytic therapy that was not defined by the frequency standard of his institute. That standard represented, in his mind, not only a technical requirement for doing psychoanalysis; it also represented the purity of the institute’s training program and the purity of the theories that defined the institute as psychoanalytic. He was, in brief, not pleased with the performance of his supervisee. As I listened to the supervisee and the supervisor describe in detail their several reactions to the situation and to each other, it seemed to me that I was listening to a poignant tale of a supervisory misalliance iatrogenically created by factors unrelated to the essential purpose of the supervision, which was the therapist’s acquiring of additional therapeutic skill and ability. I noted also a kind of parallel between the difficulty between therapist and patient and that between therapist and supervisor.

INTRODUCTION The supervisory vignette just described contains references to some of the myriad factors that are essential elements in psychoanalytic supervision. Indeed, every supervisory interaction contains different configurations of these elements, each of which is unique to the supervisory moment and process. Thus, although it is impossible to elucidate supervisory principles that can be applied to all psychoanalytic supervision, it is one of the goals of this chapter to try to list, describe, and discuss those important factors that can impinge upon the supervisory endeavor.

C O N C E P T U A L I Z AT I O N S O F P S Y C H O A N A LY S I S Throughout its history, psychoanalysis has experienced enduring controversies. Almost from its beginnings, psychoanalysis has been struggling with the implications of unconscious mental life and with its implications for the human experience. Among those implications are such issues as the relation of psychic reality and the so-called actual reality and how they impact upon each other. Another issue concerns the following question: Is psychoanalysis a one-person psychology limited only to the discovery of the analysand’s psychic life, or is it a two-person psychology that studies how that psychic life interrelates with the person’s actual life interactions and with those in the real world about him or her? And where, in this discourse, do the concepts of transference and countertransference fit? Are they only the utilization of the perceptions of analyst and analysand for the exercise of intrapsychic motives, or must we consider the real relationship between analyst and analysand as part of the transference and countertransference? From this issue arises a further question: Is the psychoanalytic situation an interpersonal interaction, the study of which constitutes the essence of the enterprise, or is it an artificial association in which the participants are figments of each other’s perceptions and aspects of their psychic reality, of interest only for the purposes of the analysis?

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I have posed these issues in the form of questions as a means of indicating that they have not yet been resolved. Psychoanalysis, therefore, is in a state of fruitful ferment. Theoretically and technically it cannot be viewed as a unified theory of human psychological function except if one takes a narrowly parochial view in which his own psychoanalysis is the true, correct, and only one and all other conceptualizations are not psychoanalysis! For an excellent depiction and discussion of these issues, which go beyond the scope of this chapter, I refer the reader to Mitchell and Black’s (1995) Freud and Beyond and Greenberg and Mitchell’s (1983) Object Relations in Psychoanalytic Theory. P S Y C H O A N A LY T I C I N S T I T U T E S : E D U C AT I O N AND TRAINING Ekstein and Wallerstein (1972) called attention to the four nodal elements in psychoanalytic education and training: the student, the patient (of the student), the supervisor, and the institute. I try here and within the space allotted to elucidate each of these nodal points and their interactions with one another. Beginning in the 1920s and continuing until the present, psychoanalytic education and training has become increasingly institutionalized. Before the 1920s, psychoanalytic education and training was essentially a function of the master–apprentice model in which the more experienced psychoanalyst (beginning with Freud) taught and mentored the apprentice analyst. The whole process was fundamentally unstructured and informal. The institutional model that replaced the earlier one was believed to bring a degree of uniformity to the development of future psychoanalysts. For the most part, the institutional model rested upon three components: (1) a personal analysis of the student, (2) completion of a psychoanalytic curriculum, and (3) completion of supervised analyses. Students, however, were still strongly influenced by those senior analysts who analyzed, taught, and supervised them. Also, each institute came to embody the theoretical and educational positions of those who governed the institute. As a consequence, the history of the psychoanalytic institute movement is replete with incidents of internecine struggles, splits, and even dissolutions. Coincidentally, the formation of organizations of institutes, for example the American Psychoanalytic Association and the National Association for the Advancement of Psychoanalysis, added still more to the mix of conflicting positions, rules, philosophies, and educational standards. Each of these organizations of institutes accredits each of its member institutes after ascertaining that the institute meets the standards of the larger organization. Because the standards of the larger accrediting organizations differ radically, any one member institute’s accreditation, and the training standards to which it must conform, ensures that the psychoanalytic supervision requirement of that institute (as well as other standards) differs from that of many other institutes. The Detroit experience illustrates the issue. In the 1940s and 1950s, the Detroit Psychoanalytic Institute belonged to and was accredited by the American Psychoanalytic Association. At that time, the American Psychoanalytic Association required that its member institutes train only physicians as psychoanalysts. Richard Sterba, a distinguished Viennese analyst and a founder of the Detroit

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Institute, did not share that position. He, like Freud, persisted in training psychologists, social workers, and other nonphysicians as psychoanalysts. As a consequence, the Detroit Institute lost its accreditation, its students had to find their psychoanalytic education and training in other cities, and the psychoanalytic community suffered a black eye. To add confusion to the psychoanalytic training situation, a large number of free-standing institutes have recently been established, many of them founded by groups of psychologists and social workers who wished to free their psychoanalytic training from the medical orientation of institutes that had been founded earlier. Each of these independent institutes develops its own standards, which may or may not conform to the standards of other training programs or organizations. Also, in some instances institutes are in direct competition with one another for students, for funding, for faculty, and for the promulgation of the particular standards and theoretical positions to which they adhere. Today, most individuals who seek training as a psychoanalyst find that training in one of the ever-proliferating institutes. Often the decision to enter a particular institute for training is a difficult choice that requires a commitment not only to psychoanalysis and a psychoanalytic education but also to a particular organization and community and all that that involves. Participation in the institute activities inevitably immerses students in the organizational standards, philosophies, politics, requirements, rules, and social activities, all of which impact, positively and negatively, the educational experience, even though they are tangential to it at best. Students who enter an institute’s training program have to realize that they will be expected to adopt, espouse, and defend the theories to which the institute subscribes, subordinate themselves to the organization’s needs (e.g., contribute to the institute’s fundraising activities), abide by the institute’s assignments (e.g., to a training analyst and to approved supervisors), and provide accommodation in their personal and professional lives to the several years it takes to complete the training program. T H E O R I E S O F P S Y C H O A N A LY T I C S U P E RV I S I O N Historically and currently, psychoanalytic education and training has encompassed three essential elements: (1) a personal psychoanalysis (once called a didactic or training analysis), (2) a formal psychoanalytic seminar curriculum including theoretical and technical topics, and (3) supervised clinical experience (once called a control analysis that was thought to supplement the training analysis by analyzing the unconscious reactions of the supervisee in the analytic situation). Our concern here is with the first and third of these elements. Psychoanalytic thinking is ever sensitive to the effects of unconscious mental life processes on the course of everyday life, including psychoanalytic training. Thus, in the learning and doing of psychoanalytic therapy, there must, of necessity, be some focus on such unconscious effects making their appearance in the behavior of the analyst as well as the analysand. The question then arises: How does psychoanalytic supervision address this issue? At one end of the spectrum of conceptualizations is the position that the student analyst’s unconscious behavior in the therapy being supervised (and elsewhere) is the responsibility of the student.

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Therefore, beyond calling attention to the phenomenon, the supervisor expects that the student will address the manifestation in the student’s own analysis. (In this view, it is assumed that the student is in analysis.) At the other end of the spectrum is the belief that the analysis that the student conducts is a sphere in which the student’s countertransference (i.e., his or her unconscious reactions to the analysand) will appear. The supervision, therefore, provides an opportunity for the supervisor to focus upon that countertransference and address it psychoanalytically rather than didactically. Indeed, this position equates supervision and the analysis of the student’s countertransference. Between the two conceptual extremes of supervision as education and supervision as analysis of countertransference lies supervision as an admixture of the two, with the supervisor functioning to assist the student analysand in both learning the techniques of analysis and addressing those conscious and unconscious motives that might find expression in the analyzing work of the supervisee. The recommendation that the supervisee be able to analyze such motives while in supervision in the personal (training) analysis or by self-analysis is pertinent here (see Goodman, 1977, p. 37). In some training programs, the supervisor is explicitly charged with the task of evaluating the student as to his or her technical progress and his or her suitability to be in the profession. The supervision, then, is both educational and evaluative in its purpose. Each of these functions impacts the other and can have the unfortunate consequence of making both less effective. The supervisee is less able to function as a therapist when worried about the evaluation that the supervisor might make, and the supervisor’s evaluation of the supervisee might be incorrect because of that worry impacting negatively the supervisee’s therapeutic work. Also, any technical suggestions the supervisor makes can be heard as evaluative criticisms rather than as educational contributions. P S Y C H O A N A LY T I C S U P E RV I S I O N A N D I T S V I C I S S I T U D E S In searching several dictionaries for the definition of supervision, one encounters terms like management, oversight, performance, direction, inspection, critical evaluation, and superintendence. As discussed briefly previously, psychoanalytic supervision can serve one or more of these functions as the participants pursue the educational purpose of the supervision. Even in the word supervision one encounters the idea of a hierarchical relationship between the participants, in that one oversees the other. It cannot be taken for granted, however, that the psychoanalytic supervisory situation is exempt from the consequences of the education process combining with other issues and purposes. I would like to consider some of these at greater length. THE PERSONALITY, PSYCHODYNAMICS, AND CIRCUMSTANCES OF THE SUPERVISEE Individuals who choose to enter psychoanalytic training do not divest themselves of their personal and professional history when they enter the institute. Psychoanalytic education and training, as it is currently and generally formalized, extends over several years and entails considerable expense. Each candidate comes to the training with several years of graduate and professional education and

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experience; often with marital and/or family obligations; sometimes with experience as an analysand; and with expectations, fantasies, hopes, and other conscious and unconscious motives about the psychoanalytic training and its consequences. All of these factors can appear in and interact with the supervisory situation. Thus, for each person in psychoanalytic training, each of the different supervisory situations he or she encounters will be a unique situation. In addition, there is the manner in which each of the person’s supervisors will experience his or her personality and circumstances. A supervisee in a formal training program experiences the additional implicit or explicit demands placed upon him or her as a student in the program. Thus, in addition to meeting the expectations of the supervisor, the student tries to meet the requirements of the program (e.g., get a favorable evaluation, complete a required supervised analysis, or move to the next stage of the program). If the supervisor plays a role in judging if the supervisee succeeds or fails in meeting the requirements of the program, then the supervisor’s ability to advance the supervisee’s proficiency as a therapist can be severely compromised. One of my more intriguing experiences as a supervisor involved supervising a person who possessed vastly more experience than I as an analyst. She was being supervised because of an administrative requirement that had nothing to do with any educational purposes. By mutual consent, we took turns in being the supervisor or the supervisee. In another situation, a supervisee retained me to provide supervision on a private basis. Later, after the supervision ended, I received a request from a prospective employer of the supervisee, from which I discovered that the primary intention of the supervisee in seeking supervision had been to have me provide a favorable endorsement of her application for a position. Because I had not formed such an impression during the supervisory meetings, I conveyed this to the employer. The supervisee—who had not informed me of her intention to provide my name as an endorser, had not asked if I would provide an evaluation, and had not asked for my impression of her as a practitioner—was furious at the evaluation that had been provided to her by the employer. She did not understand that by her not asking if I would provide the recommendation, I was free to write whatever I thought. Although a supervisor may not be required to provide an evaluation of the supervisee to a third party, he or she nonetheless forms evaluative impressions of the clinical work of the supervisee. It is incumbent on the supervisor to convey such impressions to the supervisee tactfully, appropriately, and in accordance with the educational goals of the supervision. The purpose in such communication, although not directly supervision, is to enable the supervisee to gauge his or her progress in developing as a psychoanalytic practitioner. THE PERSONALITY, PSYCHODYNAMICS, AND CIRCUMSTANCES OF THE SUPERVISOR The motives of supervisors are as numerous and varied as the individuals pursuing the activity. In addition to the satisfactions that accompany the furthering of the supervisee’s education and training, motives include status, power, mastery, and identification. Although it may be inevitable that such motives exist, it is a unique hallmark of psychoanalytic supervision that supervisors, by virtue of their

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own education, psychoanalysis, and training, should be alert to and desirous of forestalling the appearance of inappropriate personal motives in the supervision. Usually they do this by analyzing their reactions to the supervisee if they find these reactions noteworthy. Although supervisors seek to deal with their own personalities and psychodynamics as these impinge on the supervision, they have to deal also with many external pressures that result from their position within the professional structures and organizations of which they may be a part. For example, the widespread organizational hierarchy that defines and exists in many, if not most, psychoanalytic institutes requires that supervisors (e.g., training and supervisory analysts) be designated as having special status and skills compared to those in the organization not so designated. Thus, some supervisors feel they are charged by their colleagues and themselves to be responsible for maintaining the technical standards, theoretical position, and educational requirements of the organization of which they are a part. It may be difficult, therefore, for supervisors to be as able to consider neutrally that which they perceive as a technical departure by a supervisee. Also, it is hard for some supervisors to resist the temptation of believing that, because they are supervisors, they know the right way to listen, to formulate, to interpret, and to analyze, and that supervisees, because of their lower status, have to be provided with corrective instruction. I consider it a breach of the technique of psychoanalytic supervision when the emphasis is upon -what the supervisee should or should not do rather than upon why the supervisee does or does not do. I know of instances in which candidates have resigned from institutes because the arrogance implicit in their analyst’s or supervisor’s interaction with them made it impossible for them to continue to participate in the learning experience. It takes considerable psychological strength for students to withstand a supervisor’s efforts to mold them into a particular professional being rather than assist them to realize their potential to be autonomous, albeit well-developed, individuals. Eissler (1953) coined the term parameter to describe certain departures from standard technique that may be indicated in the course of some psychoanalyses. Thereafter, some practitioners developed what their colleagues called parameter phobias and sought to present themselves, in their analytic work, as totally neutral, anonymous, and emotionally abstinent, thus giving rise to the often-parodied psychoanalyst who sits, stone faced, behind the analysand and says only “Hmmm.” Supervisees were, at that time, expected to subscribe to such a model, suppressing all spontaneity lest they introduce a parameter into the analysis. Some supervisors, reciprocally, considered any such spontaneity on the part of their supervisee a serious technical and personal flaw that called into question the supervisee’s potentiality as an analyst. Happily, spontaneity is no longer prohibited, and supervisees can be encouraged to be human beings with their analysands. Freud analyzed his analysands by meeting with them 6 days a week. What Freud did became the standard for all his followers. The justification for this standard was that the frequency served to guarantee the continuity of the analytic process. Over the years, pragmatic considerations (e.g., the 2-day weekend) led to the standard five sessions weekly. Following that, other considerations (e.g., financial exigencies) led to the 4- and then the 3-times-weekly frequency. Notwithstanding that continuity of the psychoanalytic process has not been defined and that such

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continuity is a matter of the perceptions of the analyst and the analysand, the requirement that a certain frequency of meetings be mandatory can be viewed as arbitrary. Yet it is just such arbitrary standards that the supervisor is required, by his organization and/or himself or herself, to enforce. At best, such factors make for a less than ideal supervisory situation, particularly if the supervisor feels impelled to be an enforcer rather than a collaborator of the supervisee. The task of analyzing usually goes better the more frequently the participants are able to work at it. It is for this reason that more frequent meetings are desirable, not because some arbitrary rule requires them. Despite the institute-enforced mandate for more frequent psychoanalytic sessions per week, other situations seek to impose on the psychoanalytic regimen fewer such sessions each week. In some clinics and in treatments where the analysand’s insurance requires minimizing the frequency of therapy sessions, external forces determine the supervisee’s work rather than that which is necessary for the adequacy of the clinical process. In such situations, supervision becomes a challenge to both the supervisor and the supervisee in that they are trying to do the right thing in the wrong way. Sometimes all that a supervisor can do is provide help in learning how to deal with the material of each therapeutic session even though the process of the analysis is severely hampered by the imposed external conditions. THE CONTEXT OF THE SUPERVISION Supervision does not take place in a vacuum. Rather, it takes place against a background of factors that exist as the context within which the supervision is embedded and that have diverse effects upon the process. In some instances, psychoanalytic supervision is a private transaction in which the supervisee retains the supervisor in order to gain access to whatever psychoanalytic skills, knowledge, or abilities the supervisor can provide. Sometimes the supervisor, in such a contract, agrees to provide an evaluation of the supervisee and his or her abilities. An important attribute of such supervision is that both participants are free of external pressures and can utilize the experience in whatever way and in whatever form they decide. In many instances, the supervision is part of and embedded in a formal program of education and training. The supervision, therefore, becomes more than just an exercise in giving and getting technical knowledge and experience. It has the additional burdens of all the expectations and requirements that the training program places upon it regarding the manner in which the analysis or therapy must be conducted, the theoretical viewpoint that the participants must share, and the judgmental (as opposed to instructional) function the supervisor must perform. Thus, the context of supervised psychoanalysis as part of a training program includes much more than just the obvious educational objectives of the activity. T H E P R O C E S S O F P S Y C H O A N A LY T I C S U P E RV I S I O N Psychoanalytic therapy is characterized by a number of axiomatic assumptions: unconscious mental processes, psychic conflict and psychic reality, transference and countertransference, the repetition compulsion, object relations, the analyst’s neutrality, dream interpretation, and the importance of the analysand’s

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associations (Brenner, 1973). Psychoanalytic therapists, in the course of their professional development, have to acquire the skills necessary to recognize these phenomena as they occur in representational form in the analysis, to formulate their significance within the psychodynamics of the analysand, to observe their manifestation within the psychoanalytic relationship, and to include them in the verbal interaction between the analyst and analysand. Because the work of psychoanalysis is a form of artistic creativity, it is learned like all such art. Supervision is a form of master–apprentice mentoring, teaching, and guiding, not of mechanical rules of procedure but of empathic listening, understanding, and responding. Psychoanalytic listening is a semiotic exercise. The analysand’s associations are a coded communication that the analyst has to hear in a decoded fashion. Thus, one of the goals of supervision is to teach the supervisee how to decode and understand the hidden message in the associations and to relate it, conceptually, to psychoanalytic theory and to the theory of psychoanalytic therapy. In addition, the supervisee might want to learn how to invite the analysand’s appreciation of the analytic method and the analysand’s contribution to it. Finally, the supervisee might want to acquire the ability to impart understanding to the analysand in such a way that it impacts the unconscious dynamics. The forms in which such supervisory goals can be met are as varied as the supervisors. Some of them are considered here. THE SUPERVISOR AS MODEL One the more common ways in which psychoanalytic therapy can be taught involves a form of vicarious illustration. The supervisee analyst records the psychoanalytic session in as verbatim a form as possible, recording (preferably after the session rather than during it) the verbalizations and other actions of the analyst and the analysand. The supervisor comments upon this record as though it is an accurate representation of that which transpired between the participants in the analytic session. The supervisor’s comments may include a demonstration of how the supervisor listens to material and understands it and a statement of the psychodynamics of the analysand, the analyst, or both, emerging (as the supervisor perceives them) from the material presented. The comments may consist of a statement of what the supervisor would have said or done had he or she been in the therapy session compared to what the supervisee said or did. The supervisor may inquire about any aspect of the reported session and discuss with the supervisee the theory and/or technique of the analytic work. In this form of supervision, the focus remains on the associative material, its formulation, and its interpretation as the basic data of the analysis. This follows the original conceptualization that what is analyzed in psychoanalysis is the associations of the analysand and that learning the skills of such analyzing is the bedrock of what is to be taught in the education of the psychoanalyst. THE SUPERVISOR AS CONSULTANT Some supervisors prefer to have the supervisee present a general summary of the analytic session focusing on the progression of the therapy from meeting to

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meeting. This mode of supervision places the emphasis on the continuity of psychodynamic process, and supervision focuses on how to study that continuity and understand its meaning, vicissitudes, and implications over time. The assumption is made that the analysand will acquire knowledge and ability within the context of the examination of the dynamic progression. Additionally, this approach assumes that the supervisee possesses the knowledge of what to do and how to do it in the clinical moment.

THE SUPERVISOR AS TROUBLESHOOTER One view of psychoanalytic supervision includes the idea that the analysis progresses satisfactorily unless some problem arises, and that supervision focuses mainly upon such problems that, when resolved, will permit a resumption of the progress and will enable an understanding of the therapeutic work. Implicit in such problem-oriented supervision is the view that the study of difficulties is a useful way to address and enhance the supervisee’s understanding of the psychoanalytic process. Of course, the presentation of difficulties or problems assumes that the supervisor will not view these in an evaluative manner and that the supervisee will feel safe enough to participate in this approach. In some psychoanalytic settings (Moulton, 1984), psychoanalysis is viewed as the investigation of the conscious and unconscious reactions of the participants to each other. What is analyzed is the relationship between the individuals in this interpersonal matrix, and supervision addresses the relationship and its vicissitudes as a means of understanding the dynamics of the analysand. The content of the supervision, therefore, is the reactions of the analyst and the analysand to each other and to the relationship between them as these are reported by the supervisee. One interesting phenomenon that has been noticed in this type of supervision is the duplication of aspects of the relationship between analyst and analysand in the relationship between analyst (supervisee) and supervisor. This so-called parallel process (Caligor, 1984), when studied, can provide useful educational material that is right before the eyes of the student. Studying parallel process, however, should not take the form of analyzing the supervisee. The literature reports various experiments on psychoanalytic supervision. In one such experiment, the supervisor sits in the consulting room with the supervisees and their analysands in order to observe the analytic work. Some supervisors observe their supervisees through a one-way screen. Psychoanalytic sessions have been filmed in order that the supervision have available the actual work of the supervisee. One supervisory arrangement has been described in which the supervisor observed the supervisee’s therapeutic work through a one-way screen and, during the therapy session, communicated with the therapist through an earphone (disguised as a hearing aid) that the therapist wore. In the description of this mode of supervision, the supervisor instructed his supervisee to relax, whereupon the therapist fell out of his chair. Most psychoanalysts would view this experiment as violating the ethical boundaries that are necessary in psychoanalytic therapy in that a third party is intervening in the analysis without the analysand’s knowledge and consent.

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O N T H E E T H I C S O F P S Y C H O A N A LY T I C S U P E RV I S I O N Although not much has been written on the ethics of psychoanalytic supervision, there are few aspects of it that are without ethical implications. Regardless of how the supervisory situation is structured, ethical obligations are assumed by both participants as soon as they enter into the arrangement. Without attempting to be exhaustive, let us consider the following issues. INFORMING THE ANALYSAND Does the analyst in training have an ethical obligation to inform his or her analysand of his or her status as a trainee and supervisee in order that the analysand be able to choose whether to be analyzed by such an individual? In most cases in the psychoanalytic world, the institute that oversees the training also recruits and/or otherwise participates in the selection of the case(s) that the candidate will see. Therefore, from the outset, the analysand is aware that the analyst is being supervised, though the analysand usually does not know the supervisor’s identity. If, however, an analysand is not aware of the supervisory situation, it can be taken for granted that a person entering psychoanalysis is aware that analysts consult others from time to time, whether it be for individual consultation or for a presentation to a group. It is incumbent on the analyst to take all necessary steps to protect the privacy and confidentiality of his or her analysands through the use of appropriate disguises when presenting cases in such consultation. In those situations in which the analysand brings up the matter of the student analyst’s supervision, the analytic approach requires that the motive for such associational material be explored and understood before and if the issue is addressed as one of providing information and reassurance to the analysand. SUPERVISORS’ ETHICAL RESPONSIBILITIES Reciprocally, the supervisor assumes responsibility for protection of the analysand whose case is being supervised. I know of at least one instance in which a supervisor, at a professional meeting, used a vignette from a case he was supervising to illustrate a point he was making. In the course of doing so, he mentioned some specific characteristics of the analysand that not only revealed that person’s identity but also embarrassed the individual, who happened to be in the audience. The point here is not that one should not use case material to illustrate theoretical or technical points; rather, the material from an analysis should be so carefully reviewed that the analysand is unidentifiable. DUAL RELATIONSHIPS It is ethically and technically inadvisable to have a dual relationship with a person whom one is analyzing. The risk inherent in such a situation is that the neutrality of the analyst as observer might be compromised by factors that are not a part of the analysis. Neutrality is part of the technical armamentarium of the analyst; it assists him or her to be as unbiased an observer and listener as possible. Neutrality

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is not the means by which an analyst goes to extraordinary lengths to be totally anonymous, thus becoming a parody of the blank screen. Being neutral does not mean that an analyst cannot be a decent human being in his or her professional demeanor and behavior. If an analyst encounters an analysand in a social situation, it is important that the analyst act in the friendly, open manner that is appropriate to the social situation. What is not advisable is the situation in which the analyst is in continuous association with the analysand, for example by being in a business partnership with the person or by engaging in a sexual relationship. While a supervisor of an analytic candidate assists that candidate in managing the risks of dual relationships in doing analytic work, it is unfortunately the case that the supervisor can find himself or herself in a dual relationship with the supervisee. In many institutes, for example, the supervisor is assigned to the supervisee by the institute. The supervisor is, by definition, not only a consultant to the supervisee but also a representative of the training establishment and, as mentioned earlier, an enforcer of its standards, therefore bringing more than one motive to the supervision (i.e., educating the supervisee about analytic therapy and about the mores and zeitgeist of the institute). In those cases in which the supervisor also serves as a teacher of the supervisee and/or as an administrator responsible for evaluating the supervisee’s status in the overall program, the supervisee is put in the untenable position of risking the educational goals of the supervision (by perhaps fearing an honest presentation of the therapeutic process) in order not to have other aspects of the educational endeavor compromised.

A M O D E L O F P S Y C H O A N A LY T I C S U P E RV I S I O N In this discussion of psychoanalytic supervision I have tried not only to describe the entity but also to comment on some of the myriad circumstances and difficulties that impact the process and the participants. These circumstances are so many and so varied as to make it virtually impossible to illustrate a single, standard, universally accepted procedure that contains the defining and essential elements of the phenomenon. Nonetheless, I am optimistic that there are some attributes of psychoanalytic supervision upon which many can agree, and I offer the following model to illustrate that position.

RESPONSIBILITIES OF ANALYST AND ANALYSAND When individuals enter psychoanalysis they seek to alleviate some subjective distress that they feel helpless to moderate or eliminate. They hope that the analyst will, like a kindly physician, take the responsibility for shouldering their distress and for eradicating it. They do not realize that the analyst can do nothing more than analyze; that the distress is related to the unconscious conflicts they are attempting to resolve; and that with insight into those unconscious motives, defenses, and conflicts they will have the inner resources to effect the relief they seek. The analysands feel they have problems; the analyst recognizes that these problems are solutions. They are the attempts at resolution of unconscious conflicts that all human being make in

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the course of their lives and in their relations with others (see Auld, Hyman, & Rudzinski, 2005). In light of the foregoing, the analyst accords to the analysands the responsibilities that are theirs (viz., living their lives as they choose [consciously or unconsciously] and making apparent the consequences of such choice). Were the analyst to act otherwise he or she would risk imparting to the analysands that they are without the capability of taking responsibility for their lives and that they are in need of caretaking and guardianship service rather than analysis. RESPONSIBILITIES OF CANDIDATES AND STUDENT ANALYSTS In many psychoanalytic institutes that are organized in a hierarchical fashion, the student–candidate–supervisee is at the bottom of a vertical structure in which the supervisor, teachers, training analysts, institute administration, and, indeed, the institute itself are all superior. I believe that such an organization and the activities within it are essentially antipsychoanalytic. In such settings and in regard to supervision in particular, the responsibility for the case, for the supervision, and for the supervisee’s development as a practitioner all rest in the hands of the supervisor and the institute. The student is not accorded primary, or at least equal, responsibility, even though he or she is the consumer (and purchaser) of the educational product. There is a basic inconsistency in that the freedom accorded to the analysand in this model is not accorded to the student candidate. Just as the psychoanalytic practitioner accords responsibility for the analysand’s life to the analysand, so too should a psychoanalytic education program accord responsibility for the progress of the professional development of the self-designated apprentice to that person. When that is not the case, the candidate and supervisee reports feeling infantilized. Indeed, institute faculty can come to share that view. At a meeting in which a candidate’s graduation from the institute program was announced, his graduation was called a sort of a bar mitzvah. Although the program was acknowledging a rite of passage, the analogy chosen was revealing of the status given to the candidate by the faculty. This 40-something professional had finally reached the age of 13 in the eyes of the institute. CHOOSING A SUPERVISOR I present here a model of psychoanalytic supervision that is part of a wider model of education for the would-be analyst. In that model, supervision involves only the supervisee and the supervisor. Presumably, the supervisee chooses the supervisor on the basis that the supervisor possesses some technical ability or skill that the supervisee wants to learn. The supervisor is not assigned to the supervision by some superordinate organization, nor does he or she report to one (except, possibly, at the supervisee’s request). In a like manner, the supervisee is not assigned to the supervisor but is in the supervision as a matter of individual choice and mutual agreement. As part of a contract to which the parties mutually agree, the supervisor undertakes to impart by vicarious demonstration, instruction, and other means, the skills, abilities, and techniques that the supervisee desires to acquire. In other words, the supervisee as customer agrees to buy what the

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supervisor, as merchant, has to sell. The two parties may, should they so desire and agree, engage in evaluation of the supervisee, the supervisor, the supervision, or all three. But the evaluation is not required by some third party intruding into the contract. In this arrangement, each party is free to discontinue the supervision for whatever reason and without repercussions. If the supervisor comes to the conclusion that the supervisee is not competent and should find some other endeavor in which to engage, that opinion can be imparted to the supervisee, who may or may not agree. Of course, the same options are available and open to the supervisee regarding the supervisor. Regardless of the specifics of the supervisory contract and regardless of what constitutes a particular supervisory situation, the essential point is that the supervisor and supervisee are mutually and equally responsible for the enterprise. Any other arrangement implicitly or explicitly derogates one or both parties by assuming in one or both of them a lack of competence to assume the required responsibility. For most of us in the psychoanalytic education world, supervision does not take place within a contextual model such as the one I have just described. Most would not subscribe to the model in the first place because they believe that it places too much responsibility upon the individual supervisee or that it confers too little authority upon the supervisor. Certainly, the model might seem inappropriate in a context in which the supervisor is paid or employed by some third party for the supervision and in which the employer has a different supervisory agenda than does the supervisor. Of course, the supervisor in such a situation is free to cheat the employer and participate in the supervision as though the supervisee were the paying customer. But even if that option is not exercised, both the supervisor and supervisee are free to strive to approximate the model as much as possible. For example, should the context require an evaluation of the supervisee, that evaluation can and should be a product of the collaboration of both individuals rather than a judgment of one upon the other. Psychoanalytic supervision, like all aspects of psychoanalytic professional development, is an enterprise best directed by the professional himself or herself who is seeking such development. It is always possible during the process to collaborate on matters of one’s development with others, such as one’s advisors, analyst, teachers, and supervisors. The ultimate responsibility, however, should rest in the hands of the developing professional. The process of psychoanalytic supervision, as differentiated from the context in which it takes place, is a part of the model. As obvious as it may seem, doing psychoanalytic therapy requires the analyst to analyze, that is to listen to the analysand’s associations and other communications, to formulate from those communications the psychodynamics of the clinical moment (i.e., understanding the nature of the associationally communicated intrapsychic conflict and conflict resolution), and to interpret appropriately to the analysand that which has been formulated. In addition to using the analysand’s associations as data for formulative work, the analyst has available two other sources of data: the analyst’s consciously perceived affects, and the thoughts evoked as part of participating in the therapy and in the supervision of that therapy. The analyst’s experience includes unexpected, untoward, parapraxic manifestations that intrude themselves into the analyst’s

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awareness and even into speech and behavior during the analytic work and during supervision and that signal the existence of unconscious reactions within the analyst (Reik, 1949). It is part of the analyst’s technical function to make use of the data from all of these sources in understanding the analysand’s communications from the unconscious. Sometimes, however, it is difficult for the analyst to do so because some of the data cannot be approached through formulative, ideational activity. Even an analyst’s unconscious cannot be known consciously; it is not available through introspection or through speculative ratiocination. To gain access to such unconscious reactions that manifest themselves during analysis, the analyst first has to analyze his or her own psychopathology of everyday therapeutic life” in order to understand the relation between those unconsciously determined reactions and the analysand’s dynamics. The supervisory process is informed by this conception of what the psychoanalyst does technically. In supervision, the supervisor seeks to maximize what the supervisee gets from all the available data sources. For this reason, the supervisor expects that the supervisee will report, in process form or otherwise, all of the analysand’s associations as these are noted during or after each analytic session. Furthermore, each supervisee analyst has to report his or her affects and thoughts as they occurred during the treatment hour. Finally, the supervisee is expected to report as data unusual and unexpected affects, thoughts, acts of omission and commission, and all other untoward intrusions into the analyst’s experience of the analysis and/or of the supervision. In regard to this last kind of data, the supervisee should be expected to have analyzed these unexpected reactions, as they are a part of understanding the analysand as well as understanding the analyst’s experience of the analysand. The results of this analysis are part of the report of each analytic session being supervised. The analysis of the analyst’s unconsciously motivated reactions in the analysis can be in the form of a self-analysis. Or it could be an analysis deriving from the supervisee’s own therapy. Or, if these avenues of exploration are not available, the supervisor may offer as part of the supervision to listen to the supervisee’s associations to the manifestation needing to be analyzed and to share formulations, derived from those associations, as to the significance of the data for the analysis being supervised. A supervisee’s willingness to accept such an offer, like many of the supervisee’s reactions to the supervision, is related to the supervisee’s feeling of safety in the supervision. The supervisee’s willingness can be enhanced by the degree to which the supervisor adheres to the principles inherent in this model and therefore accords to the supervisee the status of responsible, autonomous collaborator in the supervisory effort. The purpose of the supervisor’s assisting in the analysis of the supervisee’s unconsciously determined reactions is supervisory, not therapeutic. It is done in the hope that the supervisee will come to be able to use all the sources of available data to formulate and to interpret within the analytic situation. It is to that end that the supervisee’s reactions are expected to be a part of the formulations from the data and of the interpretations to the analysand that are reported in the supervision. It is to be hoped that the supervisee in this model of supervision will discover before, during, or after beginning the work that a personal analysis is needed if one is to

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diminish substantially the effects of one’s own psychodynamics upon the analytic work that one is doing. Levenson (1984) discussed the subject of the supervisor as an infallible expert who is perceived by his or her students as omniscient in listening to and understanding an analysand’s unconscious and omnipotent in offering just the right interpretation. All psychoanalysts have had the experience of listening to a presentation of clinical material and noticing that whatever the presenter offers by way of a conclusion, the members of the audience come up with a different take on the situation. It is interesting that, in such a situation, everybody is right. The complexities of unconscious process are such that it is likely that no two individuals will come to the same conclusion about psychodynamic phenomena. However, the more persuasive conclusions will be those that are supported by associations of the analysand. The lesson for supervisors, therefore, is to eschew adopting a supervisory stance of instructing supervisees from an authoritative assertion of superiority and omniscience and instead demonstrate psychoanalytic acumen based on the evidence apparent in the material. CONCLUSION Psychoanalysis is not an arcane rite reserved for an elite of anointed practitioners. Rather, it can be conceptualized as a methodology, art, and discipline involving analyzing one’s analysand and oneself in the service of coming to know unconscious processes and motivations. Thus, anyone can be a student practitioner of psychoanalysis, from the first-year graduate student learning psychodynamic concepts and basic psychoanalytic techniques to the experienced practitioner who seeks consultation regarding a dilemma or difficulty in practice. And anyone can be a supervisor: a peer, as one in a study group or group supervision; a senior professional that one seeks out; or even oneself, as one reviews one’s clinical functioning before, during, and after a day of analyzing work. Supervision, then, from this point of view becomes generally defined as any effort to learn more about being a practitioner by presenting one’s work to someone who knows more and/or who has a different perspective on that work. REFERENCES Auld, B. F., Hyman, M., & Rudzinski, D. (2005). Resolution of inner conflict. Washington, DC: American Psychological Association. Brenner, C. (1973). An elementary textbook of psychoanalysis. New York: International Universities Press. Caligor, L. (1984). Parallel and reciprocal processes in psychoanalytic supervision. In L. Caligor, P. M. Bromberg, & J. D. Meltzer (Eds.), Clinical perspectives on the supervision of psychoanalysis and psychotherapy (pp. 1–44). New York: Plenum Press. Eissler, K. R. (1953). The effect of the structure of the ego on psychoanalytic technique. Journal of the American Psychoanalytic Association, 1, 104–143. Ekstein, R., & Wallerstein, R. S. (1972). The teaching and learning of psychotherapy. New York: International Universities Press. Goodman, S. (Ed.). (1977). Psychoanalytic education and research. New York: International Universities Press. Greenberg, J., & Mitchell, S. A. (1983). Object relations in psychoanalytic theory. Cambridge, MA: Harvard University Press.

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Levenson, E. A. (1984). Follow the fox. In L. Caligor, P. M. Bromberg, & J. D. Meltzer (Eds.), Clinical perspectives on the supervision of psychoanalysis and psychotherapy (pp. 153–167). New York: Plenum Press. Mitchell, S. A., & Black, M. J. (1995). Freud and beyond. New York: Basic Books. Moulton, R. (1984). A Sullivanian approach to supervision. In L. Caligor, P. M. Bromberg, & J. D. Meltzer (Eds.), Clinical perspectives on the supervision of psychoanalysis and psychotherapy (pp. 153–167). New York: Plenum Press. Reik, T. (1949). Listening with the third ear. New York: Farrar, Strauss.

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CHAPTER 8

Supervision of Narrative-Based Psychotherapy JEFFERSON A. SINGER, JENNA BADDELEY, and LISA FRANTSVE

NARRATIVE PSYCHOLOGY has become an important new integrative movement within the field of psychology, one that has spurred and shaped the development of narrative-based psychotherapies. Narrative psychology bridges what Bruner (1986) referred to as the paradigmatic and the narrative modes of thought, both of which are important to a full understanding of human experience. The paradigmatic mode of thought aims at deriving general principles and verifiable truths from observation of the world. Its emphasis on precision and quantification serves as the basis of empirical science. In contrast, the narrative mode of thought aims to construct believable stories about human intentions and their consequences. This mode of thought accounts for particulars rather than aiming to extract abstract generalities, and it is the way that humans seem to talk naturally about and make sense of their experience (Bruner, 1986; Sarbin, 1986). The narrative mode accounts for the traditions of mythology, storytelling, poetry and drama, and hermeneutic or interpretative analysis. As the language of subjective, particular experience, narratives give access to vivid imagery and emotion that other forms of thought do not make as readily accessible. Narratives are also a window into meaning making, giving insight into how individuals construct the world in their own manner. Narratives integrate emotion, cognition, and behavior, which makes them ideal vehicles for conveying the intersection of personality and social influence (Conway, Singer, & Tagini, 2004). Consider the following memory from a woman who had undergone a recent miscarriage:

I was 27 weeks pregnant when I went into labor. When I arrived at the hospital, the nurse could not detect my baby’s heartbeat. He was, in fact, dead. I delivered my son shortly thereafter and shortly after that, went into unexplained heart failure. At least that’s what the doctor says. But I can tell you why—I lost my baby boy and my heart

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Supervision of Narrative-Based Psychotherapy 115 ripped right in two. We spread his ashes on Thanksgiving Day at a mountain lake. My life has never been the same.

Her story makes her emotional experience palpable. Her attribution of her heart failure to her grief and her statement that her life has never been the same give a sense of the subjective enormity of her loss. The narrative hints at other ways that she sees the world. For instance, her story also suggests that there may be a sense of peace for her in the memory of laying her son to rest in the midst of nature—although the hint of peace is certainly not without overtones of terrible pain. In short, the story reveals, albeit incompletely, the phenomenology of her grief.

B A C K G R O U N D O F N A R R AT I V E - B A S E D P S Y C H O T H E R A P I E S We can trace our contemporary emphasis on narrative as a vehicle for treating psychological suffering back to the writings of Freud and Adler. Freud (1900/1953) thought that through interpreting the symbolic or metaphoric content of dreams, memories, and free association, a psychoanalyst could bring to light the patient’s unconscious conflicts. Adler (1930) regarded the manifest content of memories as shaped by and revealing of the rememberer’s current goals and worldview, with the earliest memory having special projective value. Similarly, Rogers’s (1951) client-centered therapy validated the client’s voice and conscious presentation of concerns as opposed to seeing his or her narrated experience as simply a conduit to buried unconscious conflicts. More recently, Bruhn (1990), in the tradition of Adler, proposed that a person’s narrative memories are shaped by his or her current goals and worldview. Bruhn’s cognitive-perceptual theory posits that a person’s attitudes (views of self, others, and the world) provide a framework that shapes memory reconstruction and guides new perceptions to fit with existing memories. In other words, the autobiographical stories that people tell themselves and others have a powerful shaping influence on how they perceive the world. Bruhn developed a method of psychotherapy assessment by which a person’s dominant concerns and interpersonal patterns may be discerned from collection of his or her memories, and his empirical studies demonstrated that the content and structure of early memories correlate with personality differences, diagnostic categories, and varying degrees of psychopathology. Angus and McLeod’s (2004a) handbook highlighted a range of contemporary narrative-based therapies including the most prominent of these approaches, White and Epston’s (1990) narrative therapy. In the remainder of this chapter, we use the term narrative therapy only in reference to the specific type of therapy practiced by White, Epston, and their adherents. We use the term narrative-based psychotherapy to refer to the larger category of therapies that make narrative a central feature of their work. The following paragraphs highlight some, but certainly not all, of the narrative-based therapies currently being practiced.

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CORE CONFLICTUAL RELATIONSHIP THEMES The core conflictual relationship theme mode of psychodynamic therapy is structured to help patients achieve their desired outcomes in interpersonal situations through (a) identifying within their narrative memories sequences of relational events in which they do not act on their wishes because of an imagined (and feared) response from the other person, and (b) analyzing the sources of and disputing the accuracy of the feared response of the other (Book, 2004; Luborsky & Crits-Christoph, 1998). PROCESS EXPERIENTIAL PSYCHOTHERAPY Process experiential psychotherapy (Angus, Lewin, Bowes-Bouffard, & RotondiTrevisan, 2004) aids clients in thinking reflectively about emotionally charged narrative memories in order to coconstruct with the therapist a fuller understanding of life events and their meanings. Clients learn to identify different modes of thought in their narratives and learn to move from more discursive to more analytic ways of engaging with the stories they tell. PERSON-BASED PSYCHOTHERAPY Person-based psychotherapy (Singer, 2005; Singer & Blagov, 2004) integrates the collection of narrative memories with analysis of traits, goals, and defensive styles in order to obtain a comprehensive and holistic assessment of the client’s personality and motivation. Narrative memories are explored as vehicles of self-definition in the context of dialogic relationships with intimate others in the client’s life. In combination with analysis of the client’s characteristic tendencies and long-term strivings, these self-defining memories may be interpreted for insight into interpersonal scripts and the client’s systems of meaning making. NARRATIVE THERAPY Narrative therapy involves the close examination and deconstruction of clients’ stories (Parry & Doan, 1994; White, 2004), with a focus on identifying and disputing dominant cultural assumptions that have shaped and limited clients’ understandings of their lives while opening up possibilities for clients to narrate their lives in ways that are more expansive and liberating. Narrative therapy emphasizes movement away from internalization and self-blaming and toward recognition of community and collective empowerment in resistance to negative and destructive societal messages and practices. COMMON PRINCIPLES OF N A R R AT I V E - B A S E D P S Y C H O T H E R A P I E S These narrative-based psychotherapies, along with others that share similar philosophies, may diverge in terms of the kinds of narratives they explore (some therapies help clients to articulate the social discourses that inform their narratives;

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Supervision of Narrative-Based Psychotherapy 117 other therapies focus on tracking the scripts that clients learned from early childhood experiences). However, according to Angus and McLeod (2004b), all of these psychotherapies share some common tenets, including the following: (a) Narration is a fundamental process of self-construction and self-change; (b) narration is a basic therapeutic process and one that facilitates formation of the therapeutic alliance; (c) narratives contain reconstructive potential, because there is always more than one way to tell any given story; (d) effective therapists are experts in understanding narratives, such that they can identify and help clients capitalize on opportunities for narrative change; and (e) a major goal of narrative-based psychotherapy is the formation of a coherent, accessible, differentiated, and evocative narrative. How might supervisors help their supervisees act on these principles in their therapeutic work? We elaborate in broad terms the kinds of therapeutic practices that these principles call for, and, where possible, we give examples from specific forms of narrative-based therapy. In reviewing past writing on supervision of narrative-based therapy, one should note that most published work up to this point has been contributed from narrative therapists. One of the goals of this chapter is to help expand supervisors’ thinking about how to guide beginning therapists in adopting narrative-based principles that may be broader in orientation and technique than the one modality of narrative therapy.

TEACHING PRINCIPLES OF N A R R AT I V E - B A S E D P S Y C H O T H E R A P Y PRINCIPLE 1: NARRATION IS A FUNDAMENTAL PROCESS OF SELF-CONSTRUCTION AND SELF-CHANGE Dan McAdams (1987, 1999; McAdams & Janis, 2004) has theorized that people construct an identity in the form of an evolving narrative that connects past, present, and future. McAdams (1988) identified four components in his life story theory of identity that are particularly interesting to look at as indicators of how people see the world: ideological settings, imagoes, generativity scripts, and nuclear episodes. The ideological setting is a person’s general sense of whether the world and other people are good or bad, optimistic or pessimistic, just or unjust. An imago is a personal archetype reflected in different characters through the life story. Imagoes capture the repetitive characterizations that a person employs in his or her efforts to understand and engage with others in his or her life. A generativity script reflects a person’s concerns with the ultimate meaning or purpose of his or her life. Generativity scripts reflect a person’s expectations about how typical stories in his or her life will turn out. A nuclear episode is an autobiographical memory that is linked to the individual’s most enduring concerns. It often expresses a turning point, peak, or nadir experience that continues to exert influence over the individual. Because these aspects of life stories reflect and also shape clients’ ongoing experience of the world and of themselves, supervisors might encourage supervisees to read McAdams and other narrative identity researchers (e.g., King, 2001; McAdams & Pals, 2006; Pals, 2006; Pillemer, 1998, 2001; Spence, 1982; Thorne, 2000). In addition to doing this reading, supervisees can follow the protocols for collecting

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life story interviews and self-defining memories (McAdams, 1988; Singer, 2005). Through collecting and analyzing stories and memories, supervisees should become particularly sensitive to how the recurring plots and characters reflect interpersonal scripts and evocative metaphors that might be windows into ongoing relational struggles that clients may be facing. We address how self-defining memories may be used in this manner through a case study later in this chapter. PRINCIPLE 2: NARRATION IS A BASIC THERAPEUTIC PROCESS AND ONE THAT FACILITATES FORMATION OF THE THERAPEUTIC ALLIANCE Angus and McLeod (2004b) proposed that it is inherently healing for clients to be able to tell their stories in a supportive environment and, in so doing, explore and express their stance regarding events in their lives. The quality of therapists’ and other listeners’ presence makes a difference in the quality of the speakers’ recall: In the presence of an attentive listener, speakers recall events in a more detailed and coherent way (Pasupathi, 2001). Supervisors can emphasize to supervisees that empathic attention and feedback is important for the purpose of helping clients to tell their stories in as full and uninhibited a manner as possible (Rogers, 1951). When conducting narrative therapy, a supervisee is encouraged to maintain a compassionate, questioning stance vis-`a-vis the client throughout the therapy and to remain open to new information about the client (Parry & Doan, 1994). The therapist should hold off from quick interpretations or reductive summarizing statements. Through open and empathic listening, the therapist gains a great deal of information about how the client sees the world. Therapist and client also build a sense of working as partners and sharing an experience, and the client builds trust in the therapist. PRINCIPLE 3: NARRATIVES CONTAIN RECONSTRUCTIVE POTENTIAL BECAUSE THERE IS ALWAYS MORE THAN ONE WAY TO TELL ANY GIVEN STORY If, as McAdams and Janis (2004) argued, narrative identity is a key part of personality, then the idea that narratives can be reconstructed in the course of therapy implies that therapy can indeed help people achieve significant personality change. To empower distressed clients to find other ways to tell their stories is to help them to effect significant changes in their lives. The dialogical approach to narrative-based psychotherapy emphasizes the multiplicity of perspectives within the self from which stories might be told. This approach is based on a view of the self as a metaphorical theater of voices, containing multiple characters that relate to one another in any number of possible ways from cooperative to combative (Hermans, 2004, 2006). A therapist using this approach helps the client to identify dominant, problematic characters within the narratives—both internal characters (i.e., parts of the self) and external characters (i.e., other people in the clients’ world)—while also keeping track of the situations in which these characters are prominent. The therapist assists the client in gaining distance from these dominant characters by adopting alternative and more flexible positions to reduce the characters’ impact. In order to assist the client in taking other perspectives, the therapist enters into dialogue with the client’s characters

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Supervision of Narrative-Based Psychotherapy 119 by asking and inviting questions from the client. Additionally, therapist and client develop behavioral experiments to encourage the client to take on and strengthen different positions from his or her repertoire. PRINCIPLE 4: EFFECTIVE THERAPISTS ARE EXPERTS IN UNDERSTANDING NARRATIVES, SUCH THAT THEY CAN IDENTIFY AND HELP CLIENTS CAPITALIZE ON OPPORTUNITIES FOR NARRATIVE CHANGE Research on the different types of narratives that clients tell in psychotherapy has been conducted in studies of process experiential therapy, a therapy in which clients are encouraged to tell significant, emotionally charged stories to induce emotional arousal that clears the way for the therapeutic construction of new meanings for the emotionally charged event (Angus et al., 2004). Angus et al. examined how three narrative processes that clients use in therapy contribute to productive therapy outcomes. These three modes of narrative processing are external, internal, and reflexive. External narrative processing is the mode in which a client describes what happened in a given sequence of actions. In the external mode, a client may articulate important and hitherto forgotten events. Internal narrative processing is the mode in which a client tells how he or she felt in a given situation. The internal mode is important because it helps a client to articulate and differentiate his or her emotional experience. Reflexive narrative processing occurs when a client considers what a given event means to him or her. This can lead to the development of new meanings and perspectives. All modes are valuable in telling complete stories in therapy, and the latter two modes are especially critical for bringing about therapeutic change. It is important, therefore, for supervisees to develop the skills to guide clients to further elaborate on their narratives in the internal and reflexive modes. Also, supervisees should learn when it is useful to guide clients from one mode to another. For example, good-outcome psychotherapy seems to occur when therapists guide clients to the internal narrative mode after clients are already telling stories in the reflexive mode (Angus et al., 2004). Supervisors and supervisees together can review therapy transcripts, videotapes, or process notes from the supervisees’ cases, and supervisors can help supervisees learn to identify points in the narrative at which the supervisee might help the client to sustain narrative processing in a given mode or make a transition to a different mode. PRINCIPLE 5: A MAJOR GOAL OF NARRATIVE-BASED PSYCHOTHERAPY IS THE FORMATION OF A COHERENT, ACCESSIBLE, DIFFERENTIATED, AND EVOCATIVE NARRATIVE McAdams (2006) and Singer and Rexhaj (2006) pointed out that good narratives need to be convincing not only to the self, but also to audiences. To seem lifelike to audiences, as well as to the self, a narrative should be differentiated and evocative; to allow audiences to follow the narrative, it should be comprehensible and not obscure in meaning. Incoherent and fragmented narratives may not only make little sense to audiences, they may even induce discomfort and anxiety in therapists and other listeners (Lysaker & Lysaker, 2006; Salvatore et al., 2006). Supervisors

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should encourage their supervisees to be attuned to their own reactions to clients’ narratives, as these reactions approximate how clients’ narratives are received by others in their lives. Supervisees should be aware that through listening and giving feedback, they inevitably serve as coauthors of clients’ stories (Singer, 2005; Sullivan, 1953). As coauthors, they can suggest connections and linkages across different experiences, which may help the client to see more integration and coherence in the narrative. Also, as is practiced in narrative therapy (e.g., White, 2004), therapists can help clients see how their stories fit within the context of larger cultural narratives. Singer and Rexhaj (2006) also highlighted the value of flexibility and complexity in narratives. As Book (2004) illustrated with his analysis of one client’s core conflictual relationship theme psychotherapy, clients’ narratives become more differentiated and flexible as clients learn to identify and preempt the relational scripts that have previously guided their actions. This increased flexibility may lead to new ways of fulfilling their heretofore frustrated wishes. Supervisees can help clients to increase the flexibility and complexity of their stories through a kind of sustained and empathic attention to the clients’ experience in all its subtlety, including an understanding of the linkages between the clients’ emotion and thought, an attunement to underlying meanings, and dedication to an ongoing process of narrative revision. Supervisors can model these skills of attention and discernment for their supervisees. Having given a broad outline of the principles of narrative-based therapies and how supervisors might encourage their supervisees to implement these principles in their therapeutic work, we now outline more extensively one approach to the supervision of a narrative-based psychotherapy that integrates aspects of cognitive-behavioral, psychodynamic, and humanistic therapies. PERSON-CENTERED APPROACH TO A N A R R AT I V E - B A S E D P S Y C H O T H E R A P Y The fundamental premise of the person-centered approach to therapy (Singer, 2005) is that individuals bring to therapy repetitive self-defeating thoughts and behaviors that take the form of familiar narrative sequences that may be discerned in several domains and specific experiences in their lives. This notion of repetition compulsion is traceable to Freud and other psychoanalytic writings (e.g., Freud, 1950), but a narrative perspective brings the insight that often the repetition of what defeats a person is more than a destructive response to a repressed dreaded impulse; it is rather the imposition on experience of a more elaborate meaning system that is encapsulated by a rigid narrative sequence of interpersonal interactions and corresponding emotions. Only narrative has the capacity to depict the complexity of these interpersonal and intrapersonal dynamics in a format that affords the opportunity for insight to both the individual involved and those others who would hope to understand this person’s enduring conflict. Tomkins’s (1979, 1987) elaboration of Freud’s ideas about repetition into a cognitive-affective theory of scripts anticipated much of the current interest in how individuals process information in narrative terms and how narrative memory may be an anchoring aspect of personality and identity (McAdams & Pals, 2006; Singer,

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Supervision of Narrative-Based Psychotherapy 121 2004, 2005). The key contribution that Tomkins’s script theory offers with regard to the practice of a narrative-based psychotherapy is that the therapist and client working together can identify from the client’s past and current experience certain dominant affective sequences that are schematic expressions of repeated and often unresolved interpersonal conflicts in the client’s life. These experiences or scenes have become linked by their shared affective patterns, for example a sequence of hope followed by disappointment followed by self-disgust and finally withdrawal and depression. Through psychological magnification, these sequences coalesce into a filter through which new affective experiences are processed and understood. Most critically, this filter or script becomes a template not only for making sense of the past but for structuring and rendering coherent, in a rigid sense, new interactions. With the script in place, individuals are all too likely to recreate the patterns of emotional behavior that have brought them previous conflict and frustration. These ideas clearly resonate with those of other important innovators in psychotherapy who emphasized cognitive and interpersonal rigidity (e.g., Beck, 1976; Ellis, 1985; Horney, 1950). Person-based therapy, drawing on the insights of script theory and related cognitive-affective theories, seeks to do the following:

r r r r

Identify enduring conflicts that perpetuate clients’ unhappiness. Identify narrative sequences that encompass these conflicts. Establish clients’ awareness and understanding of these narrative sequences. Help clients overcome these sequences to reduce conflict.

Associated with each of these goals are specific strategies that help clients to make use of their capacity for experiencing the significant emotional struggles of their lives in the language of memories, stories, and metaphors (see Table 8.1). As detailed in Singer (2005) the first step of this approach is to conduct a comprehensive person-based assessment that allows for a thorough examination of clients’ personality characteristics, overarching motivations, defenses, and relational dynamics. IDENTIFYING ENDURING CONFLICTS Drawing on McAdams’s (1995) three-domain framework of personality, the therapist assesses the client’s traits (as measured by the NEO PI-R or other trait inventories), current motivations (as measured by Emmons’s personal striving task, see Emmons, 1986, and Singer, 2005; or other motivation assessment procedures such as the Thematic Apperception Test), and narrative identity (as expressed through collection of a life history, autobiographical writings, and/or self-defining memories, see McAdams, 1987, and Singer & Salovey, 1993). In addition, drawing on the work of contemporary psychoanalysts such as Mitchell (2000) and Ogden (1994), the therapist also strives to assess the quality of the emerging relationship between the client and the therapist, including subtle intersubjective associations and emotions that the two may share (for a detailed account of how to track this intersubjective therapeutic dynamic, see Singer, 2005, chap. 5). In the course of this multitiered assessment, a clear picture of the client’s most enduring and frustrating interpersonal conflicts is likely to emerge.

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PSYCHOTHERAPY ORIENTATIONS Table 8.1 An Outline of a Person-Based Narrative Approach to Psychotherapy

1. Identifying Enduring Themes and Conflicts a. Person-centered assessment i. NEO Personality Inventory—Revised (NEO PI-R) ii. Personal strivings iii. Life history and self-defining memories iv. Observation of relational dynamics in therapy v. Cultural influences 2. Identifying Narrative Sequences That Express These Core Issues a. In current life b. In self-defining memories c. In the therapeutic relationship 3. Aiding Client in Awareness and Insight About Themes and Narrative Sequences a. Learning contexts and triggers b. Developing a narrative language of metaphor and emotional handles for use in therapy and life 4. Changing Narrative Sequences and Overcoming Conflict a. Anticipating and preempting narrative sequences b. Reframing c. Role-playing d. Interpreting transference e. Recognizing and rewarding new endings f. Consolidating and reinforcing empowerment

IDENTIFYING NARRATIVE SEQUENCES The narrative-based therapist then seeks to identify narrative sequences that encompass this conflict in three different modes: 1. Current relational experiences outside the therapy. 2. Specific narrative memories. 3. The current therapeutic relationship. The paramount goal at this point in the therapy is to track and identify the most vivid and compelling narrative examples of how the self-defeating conflict plays out in the client’s life. For example, a client, paralyzed by the prospect of choosing between a husband and a lover, told a compelling memory of her parents’ divorce and how she had locked herself in her bedroom, fearful that she would have to choose one parent over the other. This memory and its affective sequence of confusion, fear of betrayal, and sequestered powerlessness eloquently telescoped the client’s current relational struggle. By doing so, it provided a narrative-based therapy with a rich language of imagery and metaphor that helped the client to articulate her deepest and most subtle fears with regard to the choice she was confronting. This memory of the childhood bedroom and its walled-in terror fit the criteria of a self-defining memory (Singer & Salovey, 1993) in that it was vivid, frequently recalled, emotionally intense, linked to similar memories that shared its affective content, and conveyed an enduring theme or unresolved conflict (in this case a forced choice between two love objects). As therapy progresses, both the therapist and client can increasingly identify the presence of the affective script across diverse current interpersonal situations and past experiences and within the therapeutic transference. As their facility in

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Supervision of Narrative-Based Psychotherapy 123 detecting this pattern intensifies, the therapist and client can take advantage of their shared narrative vocabulary to highlight moments when the affective sequence appears to be unfolding. In the preceding example, the client eventually could say to the therapist “This is a locked door moment,” and the therapist could immediately grasp that the client had gone into a emotional place of confusion and fear. The value of these shared metaphors, or what Leslie Greenberg (2004) called emotional handles, is that they convey affectively intense and complex relational dynamics in a short-hand and efficient fashion. The dyad working together can quickly know the place the client has reached and the risks associated with continuing to remain in that location. In both literature and therapy, metaphors are integrative units of the mind that bring together ideas, feelings, and physical experience within a single trope. In addition to a shared language, the therapist and client can isolate the contexts and triggering circumstances in which the affective sequence is likely to take hold of the individual. Looking specifically at work situations, types of intimate discussions, family gatherings, and peer interactions can help the client find the commonalities, both externally and internally, that serve to energize the activation of narrative sequences. With memories, current experiences, and actual in vivo examples within the therapeutic dynamic to concretize the self-defeating pattern, the client can move from an abstract understanding to vivid and graspable incidences of repetitive and self-defeating conflict.

HELPING CLIENTS OVERCOME SEQUENCES Another advantage of the narrative sequence’s tangibility is that it can become a practical tool for change. Therapist and client are united in an effort to move beyond awareness and institute a change in the self-defeating ending of the repetitive script. Because change in the individual’s interpersonal patterns and selfunderstanding requires alteration in cognition, affect, and behavior, both psychodynamic and cognitive-behavioral strategies come into play. The imposition of the particular affective sequence involves a filtered interpretation of events, what cognitive-behavioral theorists would call a faulty schema. Accordingly, the therapist must help the individual to question assumptions about interpersonal interactions that hold strong similarities to previous experiences that have activated the narrative sequence. A similarity should not determine that the sequence and outcome of the new series of events must be identical to that of the previous ones or that the individuals involved harbor the same feelings or are likely to behave in the same fashion as previous participants in similar scenes have acted. This questioning of automatic assumptions is part of a general strategy of reframing the affective sequence that can include the use of automatic thought journals and the substitution of more constructive self-statements. In combination with reframing efforts, individuals can become more adept at anticipating and preempting the narrative sequence. By knowing the contexts and triggers that are likely to release the sequence, individuals can engage in a variety of emotion regulation tactics (Gross, 1999) to avoid entering into the sequence’s trap. By situation selection, avoidance, and response modulation, to name a few potential strategies, clients can limit their role in taking the potential sequence from spark to conflagration.

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Another practical technique is to allow the client to act out a version of the affective sequence, imagining it unfolding at work or with one’s partner at home. The therapist can play a coworker or the client’s partner, or in a reverse role-play the client can take on the role of the primary other individual involved in the sequence. Reverse role-plays are particularly effective for helping to enlarge the empathetic horizons of the client and negating reductionistic assumptions about the other person whose role he or she has assumed (Singer, 2004). Emphasizing narrative sequences in therapy also leads to real-time interpretations of transference. For example, Singer and Blagov (2004) described a client who returned from a school trip in high school only to find out that his father had wiped out his college savings account (which he had accumulated on his own from years of working a paper route) in order to buy a second car for the family. When the client protested that he would not have enough money for college, the father replied that he could have the car when he graduated high school. The client turned his anger on himself by withdrawing from the family and taking a series of low-paying factory jobs and giving up any ambition for college. This traumatic incident and similar encounters within his most intimate relationships crystallized into a script of distrust and expected betrayal that often caused him both to withdraw from and sabotage his closest bonds. As manifest in the transference, the client would often follow a session of more personal disclosure and deepened therapeutic alliance with disparaging comments about his progress in the previous week or the intervening days between sessions. He would express forgetfulness about the content of the previous session despite its emotional power and extent of insight; his comments and body language verged on indifference or scorn toward the therapist, minimizing the sense of connection and warmth they had achieved. Using the client’s narrative memories that captured this same pattern of intimacy and withdrawal as touchstones, the therapist and client were able to see this script in action and interpret it as a defense against his fear of dependency and betrayal. Linking this relationship pattern in the therapy to the emotional handles of the paper route and the client giving up on himself and his dream of college was a highly effective vehicle for making tangible how damaging his fear and selfdestructive withdrawal could be to his attempts to build a more positive and trusting relationship with another person. Whether one employs reframing, role-playing, or transference interpretations, the goal of a narrative orientation in psychotherapy is to help the client recognize and reward different endings to new situations that share many of the warning signals and triggers that are likely to set off the unfolding of the familiar narrative sequence. Part of what would be defined as a successful therapeutic outcome is the client’s enhanced ability to build a delay into his reactions to situations and to use imagery to imagine where a particular interaction might head before actually engaging in emotional and behavioral responses. When the client is successful in this anticipatory response, the therapist and the client must take the time to acknowledge this victory over the tyranny of the repetition compulsion and enumerate the benefits that accrue from side-stepping this potential trap. In addition to explicit self-reinforcement, the client should clearly see improvement in relationships outside the therapy at home and work. Building on the client’s increased sense of autonomy and flexibility that has emerged from overcoming a previously frustrating narrative sequence, the

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Supervision of Narrative-Based Psychotherapy 125 therapist has a unique opportunity to consolidate and reinforce the client’s more general sense of empowerment. If we might borrow from the language of White’s narrative therapy, clients have learned that by “externalizing a narrative,” they need no longer be controlled by this script or by other “internalized narratives” that are not healthy or liberating for their growth and self-development. The best possible outcome is to see clients willing to question fundamental assumptions about the “oughts,” “musts,” and “shoulds” that too often limit their efforts at risk taking, change, and authenticity in their lives. Whether it is to take the risk of being vulnerable in a love relationship or to pursue an alternative career path or to finally stand up to an authority figure, a sense that one can step back from one’s narrative patterns and direct them rather than simply act in them may be the most powerful offshoot of working with narratives in psychotherapy (see Hermans, 2006). In order to illustrate how one might train and supervise beginning therapists in this application of narrative psychology to psychotherapy, we present the following case study. The first author (Jefferson A. Singer) served as the supervisor of the second author (Jenna Baddeley) for a client referred to her as part of an outpatient psychotherapy service at a Veterans Affairs (VA) hospital. Although therapies in this service are conducted in a cognitive-behavioral framework, the onsite supervisor of the second author (the third author of this chapter, Lisa Frantsve) permitted and assisted with the introduction of the more novel narrative approach in the treatment of this particular client. Once we had agreed to this arrangement, potential candidates for this narrative treatment were considered and this particular client was selected on the basis of his verbal fluency, his openness to participating in a research project, and the interpersonal focus of his presenting concerns. The client provided signed consent to participate in the supervised therapy, which included tape recording, and was aware that the therapy protocol might be further analyzed and written up for scholarly publication. This informed consent did not extend to a discussion of the specific components of narrative therapy or the larger theory behind narrative scripts and person-centered assessment and psychotherapy. Names and identifying details have been changed to protect the confidentiality and anonymity of the client. Case 8.1 Phil, a 54-year-old married White male, was in the military service for 23 years and retired as an E6, after which he went back to college and earned his degree. He now works in the health field in a New England city. He and his wife are happily married and have two adult daughters. He speaks of his wife (and his daughters) with a great deal of fondness. The patient’s father is deceased, and his mother, who is in her 80s, lives in Florida. The patient has been devoting a lot of time and energy to her care. For example, he recently moved her out of her house and into an assisted living facility and is working on sorting out her finances and coordinating in-home care for her. He has experienced his mother as short-tempered, ungrateful, and resistant to his efforts to help her. He had previously sought treatment at a VA hospital for depression and had been diagnosed with Major Depressive Disorder. His current symptoms included dysthymic mood, poor self-image, worry and anxiety, weight gain, lack of exercise, and procrastination at work and home. He started on antidepressant medications (Celexa) at the (continued)

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same time as he began therapy. His therapy was defined as a relatively short-term treatment (in part due to the limited tenure of the therapist at the practicum site) and consisted of 14 sessions of weekly psychotherapy. The therapist (second author) was a second-year master’s student in psychology who was in the midst of a year-long practicum at the VA hospital. As part of the psychology outpatient service, she carried a small caseload (three to four clients) and also cofacilitated group therapies. The general context of her training at the VA hospital was cognitive-behavioral, but her master’s thesis work and related projects with her thesis advisor (the first author) had familiarized her extensively with theory and research in narrative psychology. The supervisor (first author) was a clinical psychologist who served as a professor of psychology at a liberal arts college and also maintained a private practice. With a background in personality research and training in both psychodynamic and cognitive-behavioral therapies, the supervisor in recent years had attempted to articulate a person-based approach to assessment and psychotherapy that highlights the integrative role of narrative psychology (Singer, 2005). The site supervisor (third author) was a clinical psychologist who served as the director of the clinical health psychology section at the VA hospital. Trained in cognitivebehavioral and health psychology, she provided overall guidelines for addressing some of the more specific symptoms of depression but allowed the first two authors latitude to pursue alternative treatment approaches to the more long-standing intrapersonal and interpersonal conflicts that appeared to contribute to the client’s dysthymic presentation. Although the unique circumstances of this collaboration provide an example of an explicit integration of cognitive-behavioral and narrative techniques, the first author in his own practice has found that the weaving together of these two orientations is highly effective, though each approach can certainly stand alone. EARLY WEEKS OF TREATMENT AND SUPERVISION In any cognitive-behavioral treatment, early treatment focuses on problem assessment and goal setting. The therapist pursued these activities with the client, and they agreed to have the client work on an automatic thought log (Persons & Tompkins, 1997) that would chart potential dysfunctional thoughts that exacerbated the client’s depressive tendencies or accelerated stress and anxiety. The therapist understandably wanted to know what a person-based narrative approach would take as its focus in contrast to the cognitive-behavioral approach. Supervision discussions at this early stage highlighted the assessment of Phil as a unique individual rather than as the repository of symptoms or problems. Drawing on McAdams’s (1995) three-domain framework of personality, the supervisor encouraged the therapist to collect data that would reflect Phil’s most characteristic and general disposition (e.g., his particular profile of personality traits as assessed by the NEO PI-R; Costa & McCrae, 1992), his most significant and long-term goals as expressed in the major roles and contexts of his current life (e.g., his personal strivings; Emmons, 1986), and his most vivid self-defining stories that were reflective of his unique sense of identity (e.g., self-defining memories and life story; McAdams, 2001; Singer, 2005). In addition, the supervision emphasized the importance of a fourth domain of relational dynamics that could be monitored by carefully registering the experience of being with Phil and noting the affective quality of the dyadic interactions. The therapist was encouraged to be alive to all sensory, affective, and cognitive responses that Phil evoked in her, as well as to any possible thoughts, sensations, or feelings of countertransference (Singer, 2005). The therapist proceeded to conduct assessments of each domain over the course of these early sessions. For the first domain, not only did the therapist collect Phil’s

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Supervision of Narrative-Based Psychotherapy 127

self-ratings on the NEO PI-R, but his wife supplied her ratings of Phil as well. With a little bit more struggle, Phil was able to provide a set of long-term goals in response to Emmons’s prompt “In my life, I typically strive to . . . .” Within a therapy meeting, he was also able to provide a series of revealing self-defining memories in response to a request for memories that he considered highly important to the dominant concerns and conflicts in his life. He provided additional narrative memories in the course of the ongoing therapy sessions. Finally, the therapist made a special point of recording process notes that highlighted not only Phil’s words but the moment-by-moment interaction between the two. These process notes allowed for open dialogue with her supervisor about the quality of her experience with Phil and the accompanying thoughts and feelings that emerged in her during and after their sessions. These process notes also helped the therapist to look for examples of when Phil deployed defenses in the service of emotion regulation and self-esteem maintenance (another critical dimension of the second domain in McAdams’s framework). Before discussing the results of this assessment, we should call attention to a critical question that the therapist asked of the supervisor—“Why bother with this extensive analysis of his personality? What are our goals in conducting these tests?” This is a question that the client might legitimately raise as well. The answer is that the therapist is looking for the linkage of cognitive schemas, the ways in which the client represents the self and others, to narrative representations of these schemas in past and current relationships. By knowing about traits, strivings, and memories, one is likely to see how the individual connects his or her episodic and semantic understandings of the world or, put in the simplest terms, how he or she makes sense of experience. Gaining insight into how an individual extracts a unique set of meanings from the world and translates those meanings into emblematic memories and stories provides a powerful opportunity for a series of effective interventions. These include the reframing, role-playing, and transference interpretations previously outlined. As one gains access to the touchstone narrative memories that a client describes as selfdefining, knowledge about the client’s characteristic traits and most ardent personal strivings is likely to clarify and confirm the themes that the therapist is able to extract from the memories. The overarching goal, then, of a person-based assessment in psychotherapy is to give therapist and client concrete access to the client’s meaningmaking and emotion-generating dynamic processes, which can then assist the client in gaining greater control over these aspects of his or her personality. One should take note that questions about a client’s overarching personality characteristics or Big Five domains (i.e., introversion vs. extroversion, degree of positive emotionality vs. negative emotionality, flexibility vs. rigidity, other vs. self-orientation, and conscientiousness vs. impulsivity) can be explored without the use of a formal personal inventory. Similarly, the therapist can probe about long-term goals and dominant motives without using a measure of personal strivings. The challenge of a person-based approach is not simply to quantify or record the client’s personality, but to put the presenting concerns and symptoms of the client into the larger context of a complex and dynamic understanding of that particular individual. PHIL’S INITIAL PRESENTATION The therapist described Phil as talkative and eager to please. If not redirected, he was likely to digress into long monologues that reflected his current frustration and anxiety about his aging mother and her noncompliance with his financial and residential recommendations. Despite his stable employment and successful marriage, Phil conveyed a sense of coming up short and not living up to his potential. In responding to supervisory probes about the experience of being with Phil, the therapist stated that she liked his honesty and humor but also noted his discomfort (continued)

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with any positive feedback or praise. He seemed generally dissatisfied with himself and admitted to struggling with his mother’s continued secretiveness regarding her finances, as well as her ongoing criticisms of his attempts to be helpful. On the NEO PI-R, Phil rated himself as average in Neuroticism but did show elevated facet scores in Depression, Self-Consciousness, and Impulsiveness. Supporting the therapist’s perception of Phil’s tendency toward a more negative emotional tone, his wife rated him as very high in Neuroticism and saw him as very high in Depression and Impulsiveness, as well as high in all other facets of this domain, including Anxiety and Angry Hostility. Phil and his wife both saw him as average in Extroversion, though bordering on the higher side of the facet of Warmth. They also agreed that Phil was very high in Openness, particularly in his receptiveness to new activities, ideas, and values. His willingness to participate in this project was a good example of his interest in taking on new opportunities and alternatives. Phil saw himself as a bit more Agreeable than his wife did (high vs. average, respectively), but their biggest discrepancy was in the facet of Straightforwardness. Phil saw himself as high in this dimension, whereas his wife saw him as very low. This gap in their perception suggested that his wife may have seen Phil as not always being able to communicate directly his concerns and resorting to more strategic and muffled forms of expression. Finally, each partner saw Phil as low average in Conscientiousness, emphasizing some occasional difficulty with self-discipline and careful planning and deliberation. Reviewing his personal strivings, we noted that he emphasized his efforts to fulfill his obligations to others at family and work while trying his best to stay positive and optimistic. In light of his NEO PI-R scores, as well as his initial presenting concerns, Phil’s strivings reflected his ongoing tension about meeting these important work and family responsibilities in his life. His depressive cast may have been traced to his awareness that his efforts to stay positive and follow through on his responsibilities often fell short of the mark. EXPRESSION OF DYSTHYMIC THEMES IN NARRATIVE MEMORIES Once our attention turned to Phil’s narrative memories and life story, the outline of his personality sketched out in the previous section came vividly alive in accounts of his lived experiences. Phil depicted his mother as a hard-nosed physical education teacher whose career lasted 35 years. In contrast, Phil was overweight and tended to be a little more emotional. His father was a military man who was scornful of Phil’s displays of feelings. One of Phil’s most defining memories of his mother, to which he returned more than once, was a time when he was gripped by a crab and became upset and tearful. As he tried to shake the crab loose, his mother watched him, laughing. A second linked memory was of a time when his mother promised him a set of tools and then, for some minor infraction, withdrew the offer. He felt this reversal by her as a metaphoric “slap in the face.” A third linked memory was of a time in the service when he rallied his struggling department into shape for a major inspection. He managed to have the only department that passed the inspection, but when commendations were given out, the other departments received recognition and his department received none. In a fourth memory, he recalled winning a race against an arch rival but overhearing the rival’s coach say, “You let that fat bastard beat you and I’ll kill you.” In looking for themes across his larger life story, Phil zeroed in on the fact that he was eligible during his military service for 13 years in row to go up for promotion from E6 to E7 but “never finished that piece out.” Similarly, in his current health services position, he could raise his status by taking an additional accreditation course but had procrastinated from taking action on this coursework.

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When probed about more positive memories from growing up, Phil did recall two positive memories about his mother. One memory was when she reluctantly but ultimately agreed to go riding on a go-cart track. Once inside the cramped vehicle, she actually loosened up and laughed and smiled. A second memory connected to his mother’s strong endorsement of education: One day an encyclopedia salesman came to the door, and, seeing Phil’s interest in the books, she bought the set on the spot. The goal of supervision in working with this narrative material is to encourage the therapist to become a kind of literary detective and critic. What patterns seem to emerge across the memories? Relying on Tomkins’s (1979) concept of affective scripts, the therapist is encouraged to look for the affective sequence of emotions that are magnified across the diverse memories and become a template for organizing current and future experiences. In this case, the therapist was able to define the following pattern: Starting with a sense of shame for emotionality, weight, and disorganization, Phil is able to overcome this negative state, achieving a momentary sense of accomplishment and pride, but an authority figure withholds approval and even mocks his efforts, leading to a sense of humiliation and anger. Such a memory script might be characterized as a “contamination script” (McAdams, Reynolds, Lewis, Patten, & Bowman, 2001), in which the narrative events go from good to bad. These affective sequences are associated with lower subjective well-being and greater susceptibility to depression (McAdams et al., 2001). In contrast, Phil’s positive memories of authority seem to focus on moments in which authority figures acted spontaneously and let go of the control they more typically exercised over him. The supervision then encouraged the therapist to examine these narrative sequences in terms of the other domains of the client’s personality. The therapist made sensible connections between Phil’s elevated facets of Neuroticism and his sense of falling short in areas of Conscientiousness and accomplishment. Similarly, the client’s embracing of spontaneity as a great positive in his memories fit with his elevated scores on Openness. Having used the self-defining memories to extract a narrative sequence that captured Phil’s relational dynamics in an evocative fashion, we then turned to examining manifestations of this pattern in his current interactions with others in his life. TRACKING THE NARRATIVE SEQUENCE IN CURRENT INTERACTIONS Much of Phil’s recapping of his concerns from his previous week as reported in therapy focused on his ongoing frustration with his elderly mother. He returned to this theme repeatedly, and in one of his final sessions he came to an emotional floodgate with regard to his resentment and frustration: I am shouldering a lot of responsibilities for her care, but not getting a word of thanks. She doesn’t appreciate help that she can’t control or dictate. . . . My wife and I had a session of psychoanalysis with each other. . . . We talked about why I’m getting angry and how my mom is not acknowledging me. I just want her to acknowledge that I’m doing work.

The therapist helped Phil put this frustration in the context of his larger pattern of doing for and giving to others but feeling that his contributions or accomplishments are overlooked. Phil admitted that this particular conflict was a repeated trap for him. With a dark humor he pointed out that he had made a printout of his days off in the past 4 years with a record of how each day was spent. He calculated that only 15% of his time off was used for anything recreational or pleasurable for himself. He began to laugh at the absurdity of this time-off record and continued to laugh until his face turned red. The therapist once again linked his current feelings to the larger script from his past of trying hard, succeeding, but not receiving the recognition he craved, especially (continued)

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when his mother was involved. Phil responded by saying, “What I need from you is how to deal with not being appreciated.” In asking this, he mentioned a physical pain in his stomach and his eyes began to water. The therapist mentioned how Phil had taken steps to build up his own self-esteem and feel a self-generated pride. For example, he had been able to follow through with his goal of hiring a personal trainer and keeping weekly appointments over a number of meetings. He could see the results in his weight and health and was justifiably proud of this progress. As the therapist helped Phil to acknowledge this change, Phil recounted another recent episode that beautifully demonstrated how one can give a new ending to a previously troubling narrative sequence: Another thing that has happened is that when I would be at my mother’s building and she would introduce me to her friends in the dining hall, I would not know what to say when they asked what I did. I would mumble something about working in health, but I always felt tongue-tied and inadequate. When I was last down there, I got to thinking about what we have been discussing and I changed how I describe myself. Now I say that I retired from the military after 23 years and have followed that career with one in health services with a focus on managing health benefits and claims at a VA hospital. Now her friends look impressed and go “Oh!” I have felt proud for the first time and like I deserve to hold my head high.

Phil’s story of how he has altered his way of introducing himself highlighted how significant it was for him to make changes in the familiar narrative sequence that had dominated many of his past and current interactions. In subsequent sessions he was able to track this same narrative sequence at work in his relations with his supervisor and coworkers. In all cases his efforts to make the sequence explicit and to discuss it in therapy gave him more flexibility in thinking about his responses to these situations and in opening up the possibility of alternative responses. The supervision zeroed in on these moments from the process notes and highlighted the therapist’s comments and interventions that supported Phil’s efforts to see the linkages across his life domains and to free himself from compulsive repetition of this sequence. TRANSFERENCE MANIFESTATIONS OF THE NARRATIVE SEQUENCE Helping therapists in training to gain the third ear that allows them to track transference and countertransference dynamics in an ongoing therapy is one of the most challenging tasks of supervision. Less experienced therapists are often very task oriented and self-conscious. This makes it difficult for them to pay attention to subtle shifts in the therapy’s relational dynamics and clients’ more muffled expressions of feelings (positive or negative) about the process of therapy itself. For the most part, Phil’s comments about the therapy were much in the vein of seeking to support and please the therapist. Well aware of both the age difference between the therapist and him (roughly 25 years to Phil’s advantage) and the therapist’s relative inexperience, Phil chose to offer encouragement and reassurance, taking on a more parental role at times in the therapeutic interactions. However, he also made several comments in the course of the therapy that conveyed a subtle frustration with himself for not meeting all the goals he had set himself at the beginning of treatment. Some of these comments might also have contained a kernel of discontent with the therapy’s ability to provide him with the nurturance he desired, perhaps a repetition of the feeling of deprivation suffered at the hands of his mother. There were also moments in the therapy when the therapist made supportive and praising observations, which Phil in turn deflected or minimized, reflecting his discomfort with his own success. Given the brevity of the therapy it may have been difficult for the relational dynamics of the therapy to reach enough depth and complexity to give the therapist a powerful real-time instance of the narrative sequence unfolding, but supervision allowed for

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identification of these more minor examples. The supervisor encouraged the therapist to take more opportunities to discuss the therapy process with Phil and to assist him in seeing ways in which his struggles with withheld acknowledgment, unmet nurturance needs, and discomfort with praise were all repeated with variations in the therapeutic relationship. SUPERVISING THERAPIST INTERVENTIONS AROUND NARRATIVE SEQUENCES As the previous sections have demonstrated, much of the intervention in this form of therapy emerges from a teaching process about the role of self-defeating affective sequences in clients’ lives. To make this point with impact and emotional force, the therapist relies on the imagery and metaphors that have emerged from the tracking of the narrative memories and current interactions. The supervisory process is an opportunity to brainstorm with the therapist on the most effective phrasing and timing of these allusive linkages. For example, once Phil’s key phrases or emotional handles had been identified, the therapist helped him to see potential repetitions as instances in which “the crab has got a hold of you again and you are wishing that your mother would do something more than laugh” or “that was a ‘go cart’ moment when your mother could let go of control and just relax” or “this time you could feel like you passed the inspection and others took notice of your accomplishment.” The therapist increasingly gained confidence in developing this shared language with Phil. Phil in turn resonated to these allusions and could immediately experience these emotional linkages. By being able to locate current situations within this more integrated perspective, he could indeed step back and reframe his emotional responses and behaviors, freeing himself from reflexive and often self-diminishing reactions. In addition to an enhanced awareness of patterns, the therapist also displayed an ability to help Phil see ways in which he was able to give new endings to what appeared to be the same old narrative sequence. We saw one example of this in his new style of introducing himself to his mother’s friends. Another instance emerged in the therapist’s and Phil’s discussion of his personal trainer. In the course of trying to praise Phil for using the trainer, the therapist found that Phil was returning to his old pattern of deflecting praise and seeing himself as a passive procrastinator. After all, Phil explained, he was only staying motivated because he had hired someone to motivate him. The therapist adroitly pointed out that Phil was indeed the one who had hired him and the one who was choosing to have him put Phil through the training regime. This reversal of Phil’s self-image from passive to active lifted his spirits, and he was then able to comment on the pleasure he took from the trainer’s positive feedback: Therapist: It strikes me that you’re not only challenged by this guy but also get a lot of support and encouragement. Phil: Bingo! Therapist: It’s like . . . Phil: Euphoria. . . . It’s the kind of thing I’m not getting in a lot of venues.

There are other examples of interventions that we could draw on, but we would like to finish with an illustration of transference interpretation as an intervention. In our supervision discussions, we prepared for termination and the last sessions of the therapy. These supervisory meetings focused on the ways in which the therapeutic relationship had provided a “corrective emotional experience” (Alexander & French, 1946) regarding his pattern of trying to please authorities, having success, and then somehow feeling unacknowledged or sabotaged in his accomplishment. We agreed (continued)

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that it was critical for Phil to see the progress that he had made in the therapy in terms of tangible outcomes (e.g., improved mood, weight-training program, increased assertiveness with mother) and more subtle shifts in his self-understanding (e.g., identifying his self-defeating patterns that thwart his feelings of recognition and positive self-esteem). He had indeed made good use of his treatment and needed to receive the therapist’s acknowledgment of this fact. The last session did indeed achieve this end. As the therapist praised Phil for his work in treatment, Phil began to talk more willingly and openly of the positive accomplishments in his life and how he is slowly realizing that he needed to be more open about them and to celebrate them. Tearing up, he talked about his adult daughters and their continued closeness to him. He talked about the contrast in their upbringing to his own: For his daughters, there had always been an open exchange of feelings between parents and children, unlike in his own childhood. He talked about his pride in his work and recent recognition that he received for his achievements in his department. Most of all, he told the therapist how much she had helped him appreciate his own internal strength. The ultimate goal of this last interaction was to provide Phil with a positive experience that could become an enduring narrative memory with a different ending from his previous set of self-defining memories. In this memory, he could see himself as working in collaboration with a nurturing figure, despite their mutual recognition of her relative youth, who took the time and showed the emotional openness to acknowledge his efforts and achievements. In feeling this validation, he was able to experience a self-validation that he had often denied himself in the past. This constructive and healthy narrative memory of his therapeutic experience could be an antidote to his residual tendencies to impose his old pattern on new experiences that involved questions of recognition and acknowledgment.

CONCLUSION Narrative approaches in psychotherapy highlight the increasing importance of narrative psychology as an integrative perspective across all subdisciplines of psychology. The fundamental concept that human beings struggle to render ongoing experience into a storied form has proven to be useful in understanding phenomena in cognitive, developmental, personality, social, and industrial/organizational psychology. The narratives that individuals tell themselves and others are meaning delivery systems; they convey at both a personal and cultural level how people make sense of the world. The psychotherapist interested in tapping into narrative as a therapeutic resource must learn how to identify, analyze, and interpret the narrative sequences that clients disclose in therapy. Supervision of narrative approaches takes as its task the orientation of the therapist to this fledgling perspective and then the subsequent cultivation of narrative analysis and intervention. Orienting new therapists to narrative psychology means encouraging them to read some of the seminal writings of the originators of this movement. Trainees should go over the work of Alfred Adler (early memories; e.g., 1930), Sylvan Tomkins (script theory; e.g., 1979), Jerome Bruner (narrative vs. paradigmatic thought; e.g., 1986), Donald Spence (narrative vs. historical truth; e.g., 1982), Theodore Sarbin (cultural influences in the construction of moral and emotional discourse; e.g., 1995), Dan McAdams (life story theory of identity; e.g., 1987, 1999), Ruthellen Josselson (use of narrative in qualitative research; e.g., 1995), Kenneth and Mary Gergen (postmodern view of the self; e.g., 1997), Katherine Nelson

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Supervision of Narrative-Based Psychotherapy 133 and Robyn Fivush (development of narrative thought in children; e.g., 2004), among many others. Familiarity with these theoretical and empirical advances in narrative psychology helps therapists in training see memories and stories that clients recount as more than just conduits for the real information or facts. It helps them to recognize that the recounted narratives are themselves critical data for knowing the clients with whom they work. By looking at the narratives as vessels in and of themselves of self-understanding, meaning making, cultural expression, and moral discourse, therapists will listen to these memories and stories with a different level of intensity and acuity. Besides teaching therapists about the profound significance of narrative in human thought and social interaction, supervisors must help trainees to assess and interpret narratives in ways that extract their full potential for therapeutic insight and intervention. The challenge in this regard is to encourage the cultivation of Bruner’s (1986) narrative mode of thought. Most graduate students are well versed in the paradigmatic forms of thought that are based on logico-deductive analysis, categorization, and quantification. In contrast, the narrative mode focuses on good stories, gripping drama, believable (though not necessarily “true”) historical accounts. It deals in human or human-like intention and action and the vicissitudes and consequences that mark their course. It strives to put its timeless miracles into the particulars of experience, and to locate the experience in time and place. (Bruner, 1986, p. 13)

Therapists must come to their clients’ memories, stories, and dreams in the same manner that they would approach a literary text. They must be sensitive to imagery, symbolism, and metaphor; they must enter into the feeling tone and texture of their clients’ narrative. Listening to narratives in this fashion becomes an intersubjective process (Stolorow & Atwood, 1992) in which one’s consciousness accesses and mixes with the narrator’s consciousness (one might consider this a momentary Vulcan mind meld of the type that Mr. Spock used to conduct in the old Star Trek series). In the supervision of the case described in this chapter, the supervisor needed to give continued encouragement to the therapist to take imaginative risks in responding to the client’s narrative material. Narrative truths are not captured in a cut-and-dried manner but through indirection and leaps of fantasy. Bruner drew on the words of the literary scholar Wolfgang Iser to elaborate this point: Fictional texts constitute their own objects and do not copy something already in existence. For this reason they cannot have the full determinancy of real objects, and indeed, it is the element of indeterminancy that evokes the text to “communicate” with the reader, in the sense that they can induce him to participate both in the production and the comprehension of this work’s intention. (Isler, 1978, p. 61, as cited in Bruner, 1986, p. 24)

Clients’ narratives require that therapists perform acts of meaning rather than simply recite the facts of their clients’ lives and words. For supervisors to facilitate this skill in trainees (who might find this challenge quite daunting, given their social science backgrounds), they must send these beginning therapists off to the worlds of literature, art, and music. Reading and discussing poetry, theater, cinema, and music is ironically the best possible mental exercise for enhancing one’s ability to

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make associations across narratives, detect critical metaphors, and track sequences within narratives. Reading literary texts and viewing films and plays may seem intuitively obvious ways to enhance one’s acuity in locating metaphors, dramatic structures, characterizations, and dominant themes, but how might listening to music help as well? All music, but particularly classical and jazz, is based in a theme and variation structure. Listening to chamber music or jazz improvisation will help trainees develop their skills in identifying a sequence of structural and emotional shifts (e.g., an opening theme or melody) followed by the variations and recapitulations of this initial sequence over the course of the work. Even as therapists in training begin to explore this more integrative and creative way of thinking with regard to their clients’ stories, they must also glean from supervision boundaries and restrictions on these imaginative flights. Invariably, therapists must seek additional evidence from the clients’ memories, current experiences, or interactions within the therapy that align with the narrative sequence and metaphoric handles that they have chosen to highlight. The person-based assessment that draws on non-narrative information about the individual offers the opportunity for confirmation and/or revision of inferences drawn from the narrative material. In the spirit of any hermeneutic interpretation, there needs to be plausibility, coherence, and goodness of fit, as well as a sense of consensus between client and therapist, that this particular interpretive frame is accurate and helpful for greater understanding. For Michael White’s narrative therapy approach, the extension of the therapeutic discussion to additional family members, friends, and community members allows the therapeutic formulation to bear the scrutiny of more than the therapist and immediate clients. The supervisor can certainly play a role in the evaluation of coherence and plausibility, but even therapists who no longer partake in regular supervision can still rely on peers to provide consultation about the appropriateness of their interpretive approaches. As demonstrated in this chapter, narrative approaches in psychotherapy ideally integrate theory and techniques from cognitive-behavioral, psychodynamic, and humanistic therapies along with an acute sensitivity to the role that culture, gender, class, and race/ethnicity play in the narratives that people construct. Therapists with previous training in cognitive-behavioral therapy will find many overlaps in the uncovering maladaptive schemas; challenging overgeneralization; and encouraging reframing, role-playing, and more constructive self-statements. Psychodynamically trained therapists will be comfortable with concepts of repetition compulsion, transference analysis and interpretation, and corrective emotional experiences. The true challenge for trainees may be to step out of their comfort zones and allow the integrative aspects of the narrative-based approach to take them in new directions with their therapeutic thinking and practice. In conclusion, narrative approaches in psychotherapy do not represent so much a new orientation in therapy as a shift in focus from more analytic and reductionist to more synthetic and integrative styles of thought. Sympathetic to humanistic perspectives, they certainly emphasize consideration of the whole person rather than a simple problem or set of symptoms. However, in addition to the humanistic stance, these approaches zero in on a unit of human thought—narrative structures created from experience—as a particular focal point in treatment. It is the conviction of those practitioners who employ narrative approaches that from clients’ simple narratives can be woven much larger tales of suffering and redemption.

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Supervision of Narrative-Based Psychotherapy 135 REFERENCES Adler, A. (1930). The neurotic constitution. New York: Dodd, Mead. Alexander, F., & French, T. M. (1946). Psychoanalytic therapy: Principles and application. Oxford, England: Ronald Press. Angus, L. E., Lewin, J., Bowes-Bouffard, B., & Rotondi-Trevisan, D. (2004). “What’s the story?” Working with narrative in experiential psychotherapy. In L. E. Angus & J. McLeod (Eds.), The handbook of narrative and psychotherapy: Practice, theory, and research (pp. 87–102). Thousand Oaks, CA: Sage. Angus, L. E., & McLeod, J. (Eds.). (2004a). The handbook of narrative and psychotherapy: Practice, theory, and research. Thousand Oaks, CA: Sage. Angus, L. E., & McLeod, J. (2004b). Toward an integrative framework for understanding the role of narrative in the psychotherapy process. In L. E. Angus & J. McLeod (Eds.), The handbook of narrative and psychotherapy: Practice, theory, and research (pp. 367–374). Thousand Oaks, CA: Sage. Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York: International Universities Press. Book, H. (2004). The CCRT approach to working with patient narratives in psychodynamic psychotherapy. In L. E. Angus & J. McLeod (Eds.), The handbook of narrative and psychotherapy: Practice, theory, and research (pp. 71–86). Thousand Oaks, CA: Sage. Bruhn, A. R. (1990). Earliest childhood memories: Vol. 1. Theory and application to clinical practice. New York: Praeger. Bruner, J. (1986). Actual minds, possible worlds. Cambridge, MA: Harvard University Press. Conway, M. A., Singer, J. A., & Tagini, A. (2004). The self and autobiographical memory: Correspondence and coherence. Social Cognition, 22, 491–529. Costa, P. T., Jr., & McCrae, R. R. (1992). NEO-PI-R and NEO-FFI: Professional manual. Odessa, FL: Psychological Assessment Resources. Ellis, A. (1985). Overcoming resistance: Rational-emotive therapy with difficult clients. New York: Springer. Emmons, R. A. (1986). Personal strivings: An approach to personality and subjective well-being. Journal of Personality and Social Psychology, 51, 1058–1068. Freud, S. (1950). Beyond the pleasure principle. Oxford, England: Liveright. Freud, S. (1953). The interpretation of dreams. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vols. 4 & 5 pp.1–627). London: Hogarth Press. (Original work published 1900) Gergen, K. J., & Gergen, M. M. (1997). Narratives of the self. In L. P. Hinchman & S. K. Hinchman (Eds.), Memory, identity, community: The idea of narrative in the human sciences (pp. 161–184). Albany: State University of New York Press. Greenberg, L. S. (2004). Emotion-focused therapy. Clinical Psychology and Psychotherapy, 11, 3–16. Gross, J. J. (1999). Emotion and emotion regulation. In L. A. Pervin & O. P. John (Eds.), Handbook of personality: Theory and research (2nd ed., pp. 525–552). New York: Guilford Press. Hermans, H. J. M. (2004). The innovation of self-narratives: A dialogical approach. In L. E. Angus & J. McLeod (Eds.), The handbook of narrative and psychotherapy: Practice, theory, and research (pp. 175–192). Thousand Oaks, CA: Sage. Hermans, H. J. M. (2006). The self as a theater of voices: Disorganization and reorganization of a position repertoire. Journal of Constructivist Psychology, 19, 147–169. Horney, K. (1950). Neurosis and human growth: The struggle toward self realization. New York: Norton. Josselson, R. (1995). Imagining the real: Empathy, narrative, and the dialogic self. In R. Josselson & A. Lieblich (Eds.), The narrative study of lives: Vol. 3. Interpreting experience: The narrative study of lives (pp. 27–44). Thousand Oaks, CA: Sage. King, L. A. (2001). The hard road to the good life: The happy, mature person. Journal of Humanistic Psychology, 41, 51–72. Luborsky, L., & Crits-Christoph, P. (1998). Understanding transference: The core conflictual relationship theme method (2nd ed.). Washington, DC: American Psychological Association. Lysaker, P. H., & Lysaker, J. T. (2006). Psychotherapy and schizophrenia: An analysis of requirements of an individual psychotherapy for persons with profoundly disorganized selves. Journal of Constructivist Psychology, 19, 171–189. McAdams, D. P. (1987). A life story model of identity. In R. Hogan & W. H. Jones (Eds.), Perspectives in personality (Vol. 2, pp. 15–50). Greenwich, CT: JAI Press. McAdams, D. P. (1988). Power, intimacy, and the life story: Personological inquiries into identity. New York: Guilford Press. McAdams, D. P. (1995). What do we know when we know a person? Journal of Personality, 63, 365–396. McAdams, D. P. (1999). Personal narratives and the life story. In L. A. Pervin & O. P. John (Eds.), Handbook of personality: Theory and research (2nd ed., pp. 478–500). New York: Guilford Press. McAdams, D. P. (2001). The psychology of life stories. Review of General Psychology, 5, 100–122.

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McAdams, D. P. (2006). The problem of narrative coherence. Journal of Constructivist Psychology, 19, 109–125. McAdams, D. P., & Janis, L. (2004). Narrative identity and narrative therapy. In L. E. Angus & J. McLeod (Eds.), The handbook of narrative and psychotherapy: Practice, theory, and research (pp. 159–174). Thousand Oaks, CA: Sage. McAdams, D. P., & Pals, J. L. (2006). A new big five: Fundamental principles for an integrative science of personality. American Psychologist, 61, 204–217. McAdams, D. P., Reynolds, J., Lewis, M., Patten, A. H., & Bowman, P. J. (2001). When bad things turn good and good things turn bad: Sequences of redemption and contamination in life narrative and their relation to psychosocial adaptation in midlife adults and in students. Personality and Social Psychology Bulletin, 27, 474–485. Mitchell, S. A. (2000). Relationality: From attachment to intersubjectivity. Hillsdale, NJ: Analytic Press. Nelson, K., & Fivush, R. (2004). The emergence of autobiographical memory: A social cultural developmental theory. Psychological Review, 111, 486–511. Ogden, T. H. (1994). The analytic third: Working with intersubjective clinical facts. International Journal of Psycho-Analysis, 75, 3–19. Pals, J. L. (2006). Constructing the “springboard effect”: Causal connections, self-making, and growth within the life story. In D. P. McAdams, R. Josselson, & A. Lieblich (Eds.), Identity and story: Creating self in narrative (pp. 175–199). Washington, DC: American Psychological Association. Parry, A., & Doan, R. E. (1994). Story revisions: Narrative therapy in the postmodern world. New York: Guilford Press. Pasupathi, M. (2001). The social construction of the personal past and its implications for adult development. Psychological Bulletin, 127, 651–672. Persons, J. B., & Tompkins, M. A. (1997). Cognitive-behavioral case formulation. In T. D. Eells (Ed.), Handbook of psychotherapy case formulation (pp. 314–339). New York: Guilford Press. Pillemer, D. B. (1998). Momentous events, vivid memories. Cambridge, MA: Harvard University Press. Pillemer, D. B. (2001). Momentous events and the life story. Review of General Psychology, 5, 123–134. Rogers, C. R. (1951). Client-centered therapy: Its current practice, implications, and theory. Boston: Houghton Mifflin. Salvatore, G., Conti, L., Fiore, D., Carcione, A., Dimaggio, G., & Semerar, A. (2006). Disorganized narratives: Problems in treatment and therapist intervention hierarchy. Journal of Constructivist Psychology, 19, 191–207. Sarbin, T. R. (1986). The narrative as a root metaphor for psychology. In T. R. Sarbin (Ed.), Narrative psychology: The storied nature of human conduct (pp. 3–21). New York: Praeger. Sarbin, T. R. (1995). Emotional life, rhetoric, and roles. Journal of Narrative and Life History, 5, 213–220. Singer, J. A. (2004). Narrative identity and meaning-making across the adult lifespan: An introduction to a special issue of the Journal of Personality. Journal of Personality, 72, 437–459. Singer, J. A. (2005). Personality and psychotherapy: Treating the whole person. New York: Guilford Press. Singer, J. A., & Blagov, P. (2004). Self-defining memories, narrative identity, and psychotherapy: A conceptual model, empirical investigation, and case report. In L. E. Angus & J. McLeod (Eds.), The handbook of narrative and psychotherapy: Practice, theory, and research (pp. 229–246). Thousand Oaks, CA: Sage. Singer, J. A., & Rexhaj, B. (2006). Narrative coherence and psychotherapy: A commentary. Journal of Constructivist Psychology, 19, 209–217. Singer, J. A., & Salovey, P. (1993). The remembered self: Emotion and memory in personality. New York: Free Press. Spence, D. P. (1982). Narrative truth and historical truth. New York: Norton. Stolorow, R. D., & Atwood, G. E. (1992). Contexts of being: The intersubjective foundations of psychological life. Hillsdale, NJ: Analytic Press. Sullivan, H. S. (1953). The interpersonal theory of psychiatry. New York: Norton. Thorne, A. (2000). Personal memory telling and personality development. Personality and Social Psychology Review, 4, 45–56. Tomkins, S. S. (1979). Script theory: Differential magnification of affects. In H. E. Howe, Jr., & R. A. Dienstbier (Eds.), Nebraska Symposium on Motivation—1978 (Vol. 26, pp. 201–236). Lincoln: University of Nebraska Press. Tomkins, S. S. (1987). Script theory. In J. Aronoff, A. I. Rabin, & R. A. Zucker (Eds.), The emergence of personality (pp. 147–216). New York: Springer. White, M. (2004). Folk psychology and narrative practice. In L. E. Angus & J. McLeod (Eds.), The handbook of narrative and psychotherapy: Practice, theory, and research (pp. 15–52). Thousand Oaks, CA: Sage. White, M., & Epston, D. (1990). Narrative means to therapeutic ends. New York: Norton.

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CHAPTER 9

Supervision and Training of Experiential Psychotherapists ALVIN R. MAHRER

SOME TRAINEES seem to have an experiential way of thinking about human beings, the origins of personality, how and why a person acts and behaves and interacts the way a person does, the kinds of personal worlds the person helps build and live in, how and why a person feels good or bad, how and why change occurs or does not occur, what a person is capable of becoming (Mahrer, 1989). These trainees also seem somewhat knowledgeable about the experiential aims and goals, principles and guidelines, methods and techniques. They have an experiential way of thinking about and doing psychotherapy (Mahrer, 1996/2004), and they are comfortable with strong experiencing in psychotherapy. Many of these trainees are interested in learning how to be skilled experiential psychotherapists. There are two purposes to this chapter. One purpose is to show a somewhat distinctive way of supervising and training these experiential trainees. Some experiential trainees know little about the experiential way of understanding human beings or of doing experiential psychotherapy, but there can be something vaguely appealing about a loose family of experiential, humanistic, gestalt, person-centered, feeling-emotion-centered, existential psychotherapies. However, some of these trainees can be quite interested in exploring and discovering their own inner, deeper, unformulated, relatively hidden notions and ideas about human beings and about psychotherapy. The second purpose of this chapter is to introduce the discovery-oriented approach to supervising and training trainees, especially this second, somewhat loose collection of experiential trainees.

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T R A I N E E S W I T H T H E E X P E R I E N T I A L WAY O F T H I N K I N G ABOUT AND DOING PSYCHOTHERAPY Most of these trainees are in some kind of on-the-job training, such as practicum training, field training, internship, residency, postgraduate or postdoctoral training, or continuing education. Most of these trainees have limited experience actually doing psychotherapy. They are typically beginners, especially in regard to doing experiential psychotherapy. However, the picture can also include seasoned practitioners interested in learning experiential psychotherapy and having regular meetings with an experiential teacher. EXPERIENTIAL TRAINEES HAVE THE EXPERIENTIAL PICTURE OF HUMAN BEINGS When these trainees arrive for on-the-job training, they already have the experiential picture of human beings, or their own pictures and the experiential picture are friendly to one another. They think in terms of the experiential picture of personality structure and of the nature and contents of the inner deeper world; of the meaning and importance of experiencing; of the nature and content of pleasure and pain; of the ways of building and constructing personal worlds; of the meaning and uses of building and constructing personal worlds; of the underlying principles that guide experiencing and move it along; of how and why a person is the way the person is or acts and behaves the way the person acts and behaves; of what accounts for interpersonal, collective, and social change. On-the-job training starts with the mutual understanding that there is a collective sharing of notions and ideas of what human beings are like. These trainees also think in terms that are friendly to the experiential picture in declining most of the truths that are taken for granted in most of the other pictures and theories of what human beings are like (Mahrer, 2004a). In all, there is a refreshing sharing of much the same belief system about human beings. EXPERIENTIAL TRAINEES ARE TO BE FAMILIAR WITH AND WELCOMING TOWARD EXPERIENTIAL PSYCHOTHERAPY Before learning how to do this therapy, it is important that the trainees know the approach, are friends with the approach, and welcome the approach. Either before starting the on-the-job training, or in the initial phases of the training, the trainees learn both about the notions and ideas that underlie and guide the therapy and also about the practical and applied aspects of the therapy. The conceptual notions and ideas are to make sense, the practical and applied aspects are to be appealing, and the trainees are to be welcoming and appreciative toward the therapy. Then on-the-job training can proceed, hopefully without some of the more conspicuous roadblocks. The spirit is that supervision and training are for the supervisor and trainee to be able to do their jobs without having to stop to deal with issues and problems that could and should have been dealt with beforehand. The Goals of an Experiential Session Trainees can understand that each experiential session has two goals, that these are the two goals of every experiential session, and that they are the goals of

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experiential psychotherapy (Mahrer, 1996/2004). Trainees can understand and appreciate that the goals of an experiential session are generally different from, depart significantly from, and have little or nothing in common with the typical aims and purposes of most other psychotherapies. There are two goals, two aims and purposes of each experiential session. Attaining the first goal essentially provides for the second goal, and the second goal requires that the first is achieved. In this sense, the two goals are related, with the first as the key, the critical goal, and the second as the bonus goal. These are the two goals for each experiential session. These are the two goals of experiential psychotherapy. These are the experiential answers to the question, What is psychotherapy for? (Mahrer, 2004b, 2005b, 2007b). The first goal is that the person undergo a wholesale transformation into the person that he or she is capable of becoming. This is a radical shift, a quantum change in who and what the person is; in what and how the person feels, thinks, behaves; in the person’s way of seeing the world; in the kind of world the person helps to fashion, to create. The person who leaves the session is to be a quite different person than the person who entered the session. In the session, the person can discover something quite deep inside, something sealed off and hidden. In the course of the session, that deeper quality can become an integral part of a qualitative new person that the person can become. The aim is for this qualitative new person, this transformed new person, to be the one who leaves the session. The second goal is that the transformed new person be essentially free of whatever may have been so troublesome and painful for the person who entered the session. In the beginning of the session, the person can identify what may be a painful scene of painful feelings that are hurting the person, plaguing the person, making the person feel awful. The aim is that, by the end of the session, the transformed new person is free of that bad feeling in that kind of scene or time when the feeling was so awful. The trainee knows what these goals are, trusts that these are the goals of each session and that they can be achieved in all or most of the sessions, and appreciates that these goals define and distinguish experiential psychotherapy from virtually all other psychotherapies. The Logistics The trainee knows that (a) the therapy room is soundproof; (b) the two chairs are large, facing in the same direction, within a few inches or so of one another; the person can lean back with his or her feet on large foot rests; (c) both the therapist and the other person have their eyes closed throughout the session; (d) the session begins at the agreed-upon time and ends when work is done, usually after 1 12 to 2 hr or so; and (e) at the end of the session, they decide if they want a next session and when it is to be. Most Common Features across Most Therapies Are Respectfully Declined in Experiential Sessions The trainee arrives with a general familiarity that much of what is taken for granted in most therapies has little or no place in experiential sessions, largely because it

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has little or nothing to contribute to achieving the goals of each session, and it can actually puncture the chances of achieving these goals. For example, in experiential sessions, the trainee already knows (a) there is no assessment, evaluation, or diagnosis of the client’s mental disorder or associated symptoms or problems; (b) there is no gathering of standard case material and background information; (c) the two people do not attend mainly to each other in having conversations; (d) how the two people feel about and get along with each other is not a predominant player in achieving the goals of an experiential session; (e) the therapist does not maintain a stream of private thoughts about the patient; (f) the therapist does not have a predetermined, custom-fitted plan for this client in this session; and (g) the therapist does not apply treatment methods or interventions onto the client.

THE MAIN PURPOSES OF TRAINING INCLUDE PROFICIENCY AND PRIDE WELL DONE

IN A JOB

If on-the-job teaching and training go well, the trainee becomes more and more proficient and competent in carrying out an experiential session. The trainee becomes quite skilled, quite competent in knowing and in using and achieving the steps and methods of an experiential session as given in the accompanying Table 9.1.

Table 9.1 Steps in Each Session of Experiential Psychotherapy Step 1 Discover the deeper potential for experiencing Get into state of readiness for change Find scene of strong feeling Live and be in scene of strong feeling Discover deeper potential for experiencing in moment of peak feeling Step 2 Welcome and accept the deeper potential for experiencing Name and describe deeper potential Give positive and negative reactions to deeper potential for experiencing Use other methods of welcoming and accepting deeper potential Step 3 Be the deeper potential for experiencing in past scenes Find past scenes Be deeper potential for experiencing in past scenes Step 4 Be the qualitatively new person in the qualitatively new world Find and create unrealistic postsession scenes Be qualitatively new person in unrealistic postsession scenes, including initial painful scene Find and create realistic postsession scenes Be qualitatively new person in realistic postsession scenes Modify and rehearse being qualitatively new person in postsession scenes Be ready and committed to being qualitatively new person in qualitatively new world Be qualitatively new person in qualitatively new world

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In addition, the trainee takes increasing pride and pleasure in carrying out an experiential session, in a job well done. These are the aims and goals of the trainee. These are what the trainee wants. In addition, these are also the aims and goals of the teacher, the trainer. The Purpose Is That the Trainee Knows What to Do Next in the Session The trainee is essentially programmed to know the steps of the session. The steps are so seared into the trainee’s mind that the trainee can and will go through the steps automatically and mechanically, without thinking. The trainee will first help the person discover the deeper potential for experiencing (Step 1; see Table 9.1) and then welcome and accept the deeper potential for experiencing (Step 2). Next the trainee will move on to helping the person be the deeper potential for experiencing in past scenes (Step 3) and finally to helping the person be the qualitatively new person in the qualitatively new world (Step 4). Knowing what to do next also applies to the substeps. For example, in the first step of the session, the trainee learns that after the person is in a state of readiness for change (see Table 9.1), what is next for the person is finding a scene of strong feeling, then living and being in the scene, then discovering the actual moment of peak feeling in the scene, and finally using the methods for discovering the deeper potential for experiencing in the moment of peak feeling. That completes the first step, and the trainee knows to move on to the second step. The Purpose Is That the Trainee Knows the Methods Training teaches the trainee not only what to do next, but how to do it. For example, staying with Step 1, the trainee learns how both the trainee and the person can get into a state of readiness for change. Once the person is in a state of readiness for change, the trainee is to show the person how to find a scene of strong feeling. What are some useful methods? What are the actual working methods of then discovering a moment of peak feeling in the scene of strong feeling? Finally, if the precise moment of peak feeling is discovered, what methods can then be used to discover the deeper potential for experiencing? These methods are essential, but the trainee has to know what they are. The Purpose Is That the Trainee Becomes Increasingly Proficient in Doing the Methods, Achieves Mastery in the Methods It is one thing for the trainee to be able to name the methods, to know what method might well be used in a particular instance, and to be able to talk about the methods. It is one thing for the trainee to do the method in a way that is conspicuously rudimentary, shamelessly inadequate, but at least a beginning. However, the purpose is for the trainee to gain increasing proficiency and competency in the methods, to become good at the methods. The trainee is to practice the methods, to learn them, to get better and better at doing them. The aim is increasing mastery in a spirit of practice, practice, practice. At this point in the beginning of a session, it is time to find a scene of strong feeling. The trainee knows the simple idea. At first, the trainee has little or no proficiency, and the session has big trouble moving along. Later, the trainee is

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quite skilled in doing this method, and the session moves along well. That is the purpose. The Purpose Is That the Trainee Has a Sense of Pride in Carrying Out an Experiential Session For most trainees, before most sessions, the purpose is for the trainee to be able to enjoy a sense of excited readiness and anticipation, of looking forward to the session, to what can happen. In the course of the session, the purpose is for the trainee to ride on a wave of buoyant enthusiasm and pleasure in moving from step to step along with the person and to share in undergoing what an experiential session can achieve. When most sessions are completed, the aim is for the trainee to be able to enjoy a sense of pride in a job well done, in a worthy accomplishment, in having participated in some magnificent changes, in having participated in a session that can invite study (Mahrer, 2004b), in having enabled this person to become much more of what this person can become. It is a sense of pride in work that can be fulfilling, intoxicating, exhilarating.

WHAT ARE SOME WAYS OF TEACHING EXPERIENTIAL TRAINEES HOW TO CARRY OUT AN EXPERIENTIAL SESSION? Some of the ways of teaching experiential trainees are probably similar to ways of teaching Adlerian trainees, cognitive behavioral trainees, and trainees of other approaches. Some of the ways of teaching experiential trainees are likely to be conspicuously different. Consider the Logistics I am familiar with a format of one teacher and either one trainee or a small group of trainees. I am also familiar with a teacher alone in the room with a cassette from a trainee or a practitioner who lives far away. One can also picture the teacher and the cassette in a room with one or more trainees who listen to the cassette or who see and hear the video recording. Picture a small group of trainees who come for an intensive 2 to 3 days of training, or a small group of trainees who meet once a week as part of a larger program of internship or residency or on-the-job training. Play a Recording of the Session The training session revolves around a recording of the session. Either an audio recording or video recording will do. I am most familiar with audio recordings because they are usually easier to get and because both the therapist and the other person have their eyes closed throughout the session. The recording is played from the beginning because the session rests on steps, and the trainee can move on to the next step if the present step is carried out well enough. This means the teacher and the trainee may not get through the whole session in a single training session.

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Emphasize Increasing Proficiency, Even When Drawn toward Conceptual Issues These trainees mainly want to learn how to do experiential psychotherapy. They are in a training program designed to produce reasonably competent practitioners. They are in a program of on-the-job training, and their job includes people they work with, they have experiential sessions with. In the course of their work, conceptual issues will come up. For example, trainees will be drawn to issues such as whether there are limits to how much a person can change, why a person has such awful feelings, how one person can truly understand what another person is undergoing, when and how a person became the kind of person he or she is. In the training session, the teacher can go into these conceptual matters, especially if the conceptual talk ends with a consideration of the implications for in-session work with this particular person. The teacher can recommend sources for the trainee to read on that conceptual matter. If the conceptual issue is still front and center, is still percolating, the teacher can dedicate one or more sessions to an in-depth examination of the conceptual issue. However, sooner or later, the teacher and the trainee or trainees can return to the matter of how all this conceptual talk bears upon the initial in-session work that led to the conceptual issue in the first place. In other words, how can all this conceptual talk help make the trainee more proficient in the experiential session? Teach the Steps in Order In the beginning of training, the aim is for the trainee to be able to carry through an experiential session. The trainee should be good enough, proficient enough, to get through an entire experiential session. The trainee will have a hard time getting to Step 2 unless the trainee has achieved Step 1, so it is important for the trainee to learn how to achieve Step 1. The trainee does not have to become a master at achieving Step 1, just proficient enough to achieve it. Usually this means playing the recording from the beginning and seeing if the trainee was good enough on what comes first so that the trainee can move on to what comes next. In other words, the session starts with the trainee inviting the other person to lean back, put his or her feet on the large foot rest, close the eyes, and keep them closed the whole session. If the trainee did this well enough, then the next thing is for trainee and person to get into a state of readiness for change. If the trainee did not do this especially well, that is the focus of training. If the trainee did this well enough, then move on to seeing if the trainee was able to show the person how to find the scene of strong feeling. Picture the trainee sufficiently skilled so that he or she and a young woman, in the initial session, selected a recent scene in which the woman, once again, was hurt, gloomy, fearful as her boyfriend, this time, was assessing her poor performance entertaining his friend who was visiting for a few days. The discovered instant of peak feeling is when the friend pokes his head into the room, the boyfriend notices and is obviously delighted in displaying his analysis to the new audience—”To continue with my dissection . . .” In this instant the peak feeling is a sudden freezing as her whole torso clenches up.

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Using the proper methods in this instant of peak feeling, Step 1 ends with the discovery of an altogether newly felt deeper potential for experiencing sheer freedom, absolute liberation, a peaceful letting pass by. Throughout Step 2, the woman is able to befriend this new experiencing, to welcome and embrace it, to love it and play with it. In Step 3, she undergoes the radical and wholesale shift into actually being the altogether new, qualitatively new, transformed new person who is the live embodiment of exuberant freedom, open liberation, and peaceful letting pass by, all in the context of playful unreality in scenes from the recent and remote past. In the final Step 4, with this potential for experiencing being an integral part of the whole new person, the qualitatively new woman continues being alive and well in made-up scenes from after the session in a context of silliness and whimsical playfulness. When the context takes on a quality of reality, she rehearses and arrives at a readiness to be this new person in forthcoming scenes with her supervisor at work and her boyfriend. In scenes in the beginning of the next session, she and her boyfriend have moved on; he has moved out; and she radiates a sense of exuberant freedom, open liberation, and a serene letting it pass by. Once the trainee is good enough to go through a session, even in a bare-bones, rudimentary way, with barely adequate skill, then training can move on to other matters, such as the importance of the therapist’s picture of how very much can be accomplished in a session, or expanding the methods the trainee can use in Step 2. However, the first aim is for the trainee to be able to go through an entire session, and that usually means learning the skills one at a time, in the order in which they occur so that the trainee can achieve Step 1 and then can move on to Step 2 and so on. Show the Trainee How to Keep Getting Better and Better at Each Skill in Sequence Suppose that the trainee does reasonably well throughout Steps 1 and 2 and is able to find past scenes in Step 3. But he or she does not know the Step 3 skill of enabling the person to be deeper potential for experiencing in past scenes, or the trainee and the teacher agree that this particular skill can use some work. In teaching the trainee to do this substep, or to do it better and better, the teacher can do the following: 1. Play the recording and stop at the point where the therapist could have carried out this substep or did, but poorly. 2. Explain the substep to the trainee. Here is where the trainee may take 10 to 15 min to read about this particular substep. 3. Play the recording, stop at the right point, and model the skill for the trainee. Say what the trainee might say to enable the person to be the deeper potential for experiencing in past scenes. Model it a few times. 4. Record the trainee trying it out a few times. 5. Go over the recording with the trainee. 6. When the trainee is ready, record the trainee doing it better and better. The spirit is that in each training session the trainee is to practice, practice, practice, and to get better, better, and better on the selected skill.

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Give Homework for the Trainee to Practice the Skill on His or Her Own The training session found a skill that the trainee needed to learn, or to learn better, and gave the trainee a chance to practice the skill. The homework is to practice that skill outside of the training session on one’s own. The trainee has the recording of the actual session with the person and can stop the recording at a point where the trainee can practice what could and should have been done at this point. The trainee can also have a recording of the teacher modeling the skill. By himself or herself, the trainee can practice the skill. Over and over, the trainee tries out the actual skill, varies it somewhat, improves the performance. The practice is done over and over again until doing it, under the right conditions, becomes automatic and natural, something the trainee does easily and well, with real proficiency. Send Recordings from Far Away Teaching can be done with trainees who are far away, and this can include trainees who are just beginning and trainees who are advanced. These trainees send a recording of a session. The recording is the essential element, although many trainees like to say something about the session itself or the person they were working with in the session. The teacher listens to the tape, finds the first place where he or she believes the trainee can use some skill training. The teacher typically explains what the trainee might have done, or done better, and invites the trainee to practice that particular skill. As with face-to-face training sessions, the emphasis is on the particular skill that the teacher notices first in the sequence of steps across the session. It is this emphasis on skill identification and skill learning that makes it attractive and fun to teach trainees who are far away. WHAT IS MINIMIZED IN TRAINING FOR EXPERIENTIAL PSYCHOTHERAPY? There can be some glaring differences between teaching experiential trainees and supervising trainees of most other approaches. The reasons for these differences seem to have little to do with some sort of value system. Perhaps the reasons have more to do with the teacher being more in the role of teacher than supervisor or the emphasis being on skill training (i.e., on what is genuinely useful in gaining the skills of carrying out an experiential session). Whatever the reasons, here are some things that are minimized in on-the-job teaching of experiential trainees. The Supervisor–Supervisee Relationship In general, little of what the experiential teacher does includes talking about how the teacher and the trainee are getting along with each other, or what kind of role they are putting each other in. The experiential teacher has few thoughts about stages in the supervisor–supervisee relationship or how this relationship relates to the trainee–client relationship. The picture is that the relationship does not seem to be an important component as far as most experiential teachers or psychotherapists are concerned, although this can be exceedingly hard to accept by most supervisors who take the relationship

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for granted as a major component of both supervision and psychotherapy (Mahrer, 2005a, 2007b. The Trainee’s Personal Problems In general, experiential teachers seem to spend little or no time on the experiential trainee’s personal problems. Teachers don’t seem to look for them, bring them to the trainee’s attention, assess and evaluate them, judge them, see how they affect the trainee’s work, help the trainee cope with them. It may be that the learning of experiential skills has a complex relationship with the particular personal problems of the particular trainee. In any case, teaching and learning the skills seem to leave little or no room for doing something about the trainee’s personal problems. Passing or Failing the Trainee The experiential teacher seems to decline the role of grading the trainee, wielding the power of passing or failing the trainee. In many programs, someone likely has the understandable responsibility of passing or failing the trainee, but the experiential teacher typically declines participating in the role. One of the reasons may be that most experiential teachers see such a role as being unfriendly and unhelpful to the role of simply teaching experiential skills. Passing or failing a trainee can be almost alien to being an experiential teacher. Another reason may be that the entire training session is characterized by both teacher and trainee judging, assessing, grading how well or how poorly the trainee is carrying out the skills. Grading the learning of this particular skill is a main ingredient of training and is almost a continuous job of both trainee and teacher. FIRST ACHIEVE MASTERY, THEN MAKE EXPERIENTIAL PSYCHOTHERAPY BETTER The aim of training is for the trainee to be able to carry out an experiential session with proficiency. If the training program could talk, it would likely say that when the trainee is competent at carrying out an experiential session, when the trainee has achieved mastery, there can be more to do: (a) The trainee can make the therapy better by, for example, revising and improving the steps and by adding new and better methods, or (b) the trainee can customize the approach to better achieve what the trainee wants to achieve in her or his particular work. The trainee must first learn the approach, then make it better, either in general or for his or her own particular uses and aims. ADVANCED TRAINEES CAN LEARN HOW TO HAVE THEIR OWN EXPERIENTIAL SESSIONS Many advanced experiential trainees seem to turn to the idea of having their own experiential sessions, of going through the four steps on their own with no therapist. At least three routes seem to culminate in their mentioning the possibility of having their own sessions by themselves. I tend to introduce this possibility when trainees have reached the stage of being quite proficient at the steps and methods of an experiential session. A second route is when trainees seem to come up with the idea on their own: “If patients get so much out of these sessions, why can’t I do

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it too? They just seem to come back for more and more sessions. I think I would like to have my own sessions!” A third route seems to dawn rather slowly: “Lots of my patients know what to do. I teach them and they learn what to do, so if I can teach them, why can’t I have sessions by myself? If patients can learn what to do, I can too, right?” Not all advanced trainees are interested in having their own sessions by themselves, but many are. They study a volume on how to have one’s own experiential sessions (Mahrer, 2002), and training includes a separate stream of people, including trainees, who are interested in learning and having their own experiential sessions by themselves. As with regular training of experiential trainees, this type of training highlights careful listening to recordings of sessions. The training sessions are remarkably similar, except that the patient is the trainee himself or herself. T R A I N E E S I N T E R E S T E D I N D I S C O V E R I N G T H E I R O W N WAY OF THINKING ABOUT AND DOING PSYCHOTHERAPY Some trainees have a mindset that is cordial to an experiential way of thinking, and these trainees want to learn how to do experiential psychotherapy. There often are other trainees, usually drawn toward what may be called a loose humanisticexistential-experiential family, and some of these have a keen interest in discovering their own way of thinking about and doing psychotherapy. Teaching these trainees can call for some novel and distinctive methods. They are introduced next. SOME TRAINEES WANT TO LEARN AN EXPLICIT THERAPY IN THE HUMANISTIC-EXISTENTIAL-EXPERIENTIAL FAMILY When these trainees arrive for on-the-job training, they already have their eyes on an explicit approach such as person-centered therapy; logotherapy; focusing therapy; gestalt therapy; or some explicit existential therapy, emotion-centered or feeling-centered therapy, or humanistic therapy. Furthermore, these trainees are already somewhat familiar with the literature on the approach, on the picture of what human beings are like, on what the therapy is like and how it works. I rarely if ever teach and train these trainees, in large measure because (a) I much prefer teaching and training my experiential psychotherapy, (b) I know far too little about the approach and have no experience doing the approach, and (c) the trainee would be unfairly deprived of a teacher with proper knowledge and experience in the trainee’s selected approach. Accordingly, I usually try my best to point these trainees toward proper teachers for the approach they want to learn. MANY TRAINEES ARE SIMPLY DRAWN TOWARD HUMANISTIC-EXISTENTIAL-EXPERIENTIAL IDEAS Many trainees are drawn toward some humanistic or existential or experiential ideas, although they have rarely thought carefully about these ideas, would have a hard time separating humanistic from existential from experiential, and are not

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especially clear about what these therapists actually do in their in-session work. Yet there is something appealing about humanistic-existential-experiential ideas, whatever precisely they are. In addition to the ideas, many of these trainees have favorite humanistic techniques, existential methods, experiential tools. They may be drawn toward parts of some particular humanistic-existential-experiential psychotherapy. They arrive with appealing preferences, especially about the general ideas. ARE TRAINEES GENUINELY INTERESTED IN DISCOVERING THEIR OWN DEEPER IDEAS ABOUT PSYCHOTHERAPY? This is the important question. If the answer is no, we do not work together. The trainee is free to sit in with the group, but the no answer is respected. If the answer is yes, we can work together. Trainees often believe they ought to be able to recite the therapy’s basic principles, dictums, canons, propositions. If trainees are merely drawn toward the humanistic-existential-experiential family, and if they cannot pronounce their basic beliefs about psychotherapy or their own deeper ideas about what psychotherapy is and how it works, how could they pass themselves off as psychotherapists? In general, most trainees do not publicly announce enthusiasm for discovering their own deeper ideas, largely because they truly believe they already should be known. Their ideas about psychotherapy should be displayed on the wall for all to see. What Is a Meaning of “Deeper Ideas about Psychotherapy”? Ideas about psychotherapy can include ideas about what psychotherapy can and cannot achieve; how and why a person feels bad or has bad feelings; how much and how far a person can change; what pieces and parts make up what is called personality; how a person got to be the way he or she is, the origins of personality; what a person is like deep inside, fundamentally, at the bottom; what determines the way the person acts and behaves, relates and interacts; the kind of personal world that one creates, builds, fashions, lives in; how and why change can occur on the outside and in the inside; what accounts for a person feeling good, happy, exhilarated; what a person can become, the optimal state; whether change can occur gradually or in quantum leaps. Ideas about psychotherapy can be said to be deeper when the trainee does not seem to know they are there and is unable to put them into words, to say what they are. Ideas are deeper when they seem to be relatively diffuse, undifferentiated, cloudy, unclear, undeveloped. Ideas can be said to be deeper when one arrives at them by inner exploration, by penetrating down inside one’s own thoughts and notions, by an active inner search of one’s own beliefs and of the foundations of those beliefs. Ordinary Training Seems to Have Little or No Place for Discovering the Trainee’s Deeper Ideas about Psychotherapy Both classroom teaching and applied on-the-job training have plenty of knowledge to pass on to trainees. There is plenty to teach and plenty to learn.

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Occasionally a training program can ask what the trainee thinks, but this is almost always an invitation to voice the trainee’s on-the-surface notions and ideas rather than to probe down into the dark undercurrents of the trainee’s manifest thoughts. Furthermore, what the trainee thinks is typically some version of what the profession believes. If the trainee departs too far, without a sufficient number of safety-ensuring references, the trainee can be in big trouble. With almost no exceptions, training programs are not especially dedicated to helping trainees explore their inner notions and ideas, do not work with trainees to discover the trainees’ own deeper ideas about psychotherapy, and do not stake their crowning glory on finding and developing their trainees’ own deeper ideas about psychotherapy (Mahrer, 2007b). WHAT ARE THE ORIGINS OF THE DISCOVERY-ORIENTED APPROACH SUPERVISION?

TO

The origins lay in my conspicuously dismal track record of trying to get trainees to do my experiential psychotherapy. For the one trainee whose eyes lit up with this therapy, about 50 to 60 seemed to be personally violated by the actual in-session methods and the underlying, supporting notions and ideas. Many of these trainees argued against experiential psychotherapy by reciting the truths of client-centered therapy or gestalt therapy or cognitive behavioral therapy, and that was that. However, some of the trainees defended themselves against experiential psychotherapy by looking for their own personal notions and ideas, beliefs that were there long before the trainees studied psychotherapy. These were the beliefs that were violated, and these were the beliefs that were awakened and voiced. The origins of the discovery-oriented approach to supervision lay in the trainees who said, “Could supervision help us to discover our own notions and ideas about psychotherapy? We know what we are taught, and that is important, but how can you help us find our own deeper ideas about psychotherapy?” With the help of these trainees, I tried to find ways of training and supervising trainees to help discover their own intrinsic, deeper ideas about psychotherapy. We were certain that the supervision literature would show us how to do this. We were surprised. We were wrong. Except for occasional hints, the literature was surprisingly silent about helping trainees discover their own notions and ideas about psychotherapy. We were surprised. Not only did the literature fail to show us how to supervise this way, the literature can be said to have nothing to say about the topic at all. We must be wrong; there was nothing? Except for one paragraph in a chapter by Carl Rogers (1957, p. 87): I believe that the goal of training in the therapeutic process is that the student should develop his own orientation to psychotherapy out of his own experience. In my estimation, every effective therapist has built his own orientation within himself and out of his own experience with his clients or patients. It is quite true this orientation as finally developed may be that it closely resembles that of others, or closely resembles the orientation to which he was exposed.

This paragraph seemed to stand out in at least three ways: (1) Unusual as this seemed to be, as a program and purpose of supervision, it seemed to have

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impressive goodness of fit with the same spirit that fueled Rogers’s client-centered therapy. To ones who know his therapy, it would seem to make sense that here was what he wanted to achieve in supervision. (2) Neither Rogers nor other client-centered therapists apparently wrote anything more about this kind of supervision. (3) That single paragraph captured the spirit of what I was trying to do in supervision. Following Rogers’s lead, I tried to find whatever methods seemed to help trainees discover their own notions and ideas about how and why to do psychotherapy. Working closely with some highly interested trainees, I was able to arrive at the following methods that make up the discovery-oriented approach to supervision (Mahrer, 2005a).

METHOD 1: IDENTIFY AND USE THE PART OF THE RECORDING THE TRAINEE SELECTED TO STUDY Trainees are to record all or most of their sessions. In preparation for supervision, trainees are to select one of their own recordings or some other recorded sessions, including those of exemplary therapists. On their own, before supervision, the trainee is to listen to the recording and to find some concretely explicit parts that stand out in one of two ways: (1) The trainee is pleased with what happened, is proud of that part, truly enjoys that part, is genuinely impressed with that part, could play that part over and over again because it is so appealing; or (2) the trainee is genuinely troubled and bothered by what happened in that part, frets and worries about that part, sees that part as bad or awful, wished that part had never happened. Once the trainee plays that part, the trainee and the supervisor try to identify what makes it stand out: “He’s always depressed, practically dead. But here he’s laughing. This guy is happy! He’s giggling! ‘Course it only lasts about 30 seconds, but what a switch!” Or, “So she wants to know if I think this therapy’s working. I’m scared of her! I don’t like her! I don’t like anything about her! I wish she would just go away and leave me the hell alone!” By working together with the trainee, and by carefully studying these parts of the recording, here are some ways of discovering the trainee’s own personal approach to psychotherapy.

Find the Trainee’s Personal List of Valued In-Session Changes These are valued in-session changes discovered by studying the parts the trainee picks out. There may be 5 to 10 or so such valued in-session changes. After studying a number of sessions, what typically emerges is a relatively stable set that cuts across clients but is characteristic of this particular trainee, even though the content is usually somewhat surprising to the trainee, in regard to both what is and what is not on the list. Here are two examples from studying recordings of a trainee: (1) The client spontaneously says how much better things are; and (2) the client welcomes the therapist’s homework assignments.

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Find the Trainee’s Personal Sequences of Valued In-Session Changes First the trainee values this in-session change, then it is followed by that in-session change. Especially by examining an ample number of recordings, even across a number of clients, the teacher and the trainee can usually find one or more characteristic sequences of valued in-session changes. The sequences may cover single sessions or a series of sessions, yet they typically are rather surprising to the trainee: “I didn’t realize, but yes, I like that sequence. It’s important to me.” Discover How the Therapist Helped Bring about the In-Session Changes That Are Pleasing and That Are Displeasing By studying what actually seemed to happen before the occurrence of the pleasing or displeasing in-session change, the trainee can see how the therapist helped contribute to the occurrence of both kinds of in-session changes. Such careful study generally leads to a principle along these lines: When the client does this, or is in this explicit state, and the therapist does this or that, for a shorter or a longer period, then the typical consequence seems to be the occurrence of this pleasing or displeasing in-session change. Furthermore, with this principle spelled out, the trainee can be in a position to improve helping to bring about the pleasing in-session change or to prevent the occurrence of the displeasing in-session change. Discover Ways of Using the Valued In-Session Change Whether the recording is of the trainee or some other therapist, take a careful look at what happens after the occurrence of the valued in-session change. Often the therapist may seem to overlook the in-session change. However, there are times when the therapist uses the in-session change in ways that are surprising, seem new and different, and can be impressively effective, especially when studying truly gifted therapists. It pays to study if and how the trainee or therapist seems to use the valued in-session change. METHOD 2: DETERMINE HOW AND WHY THIS PART IS PLEASING, DISPLEASING, OR INEXPLICABLE It is important that the premium be on honesty in the trainee’s saying how and why this selected part is so pleasing and precious, or displeasing and bothersome, or downright inexplicable. In this method, honesty trumps professionally approved correct answers, even though honesty can be embarrassing: “Right here he just looked at me and I was just plain aroused. He is drop-dead gorgeous. It was really safe sex. In a bar that guy wouldn’t even see me, but here, with that look, I am so close to that gorgeous guy! Highlight of my week!” Or, “It’s the fourth session and I have no idea what her problem is! She comes in and tells story after story. Right here I just wanted to slap her, but instead I got this big booming headache.” Discover the Trainee’s Favorite Therapist Role Starting with the selected parts that are accompanied with feelings that are special, wonderful, the highlights of the session, the teacher and trainee can try to discover

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the therapist role the trainee is drawn toward playing, the role that helps the trainee bring about and have these special wonderful feelings. Here are some relatively common therapist roles:

r I provide valued closeness and intimacy, caring and concern, valued understanding and empathy.

r I am your hero, your model, the mature and psychologically sound exemplar of the kind of person you can become.

r I am the old wise sage, the font of wisdom about the world. I can tell you parables about the age-old truths.

r I am the one who is on your side, your trusty defender, your ally who knows your side of things.

r When you are fragmented and crumbling, I am your rock. When things are falling apart, I am your solid anchor to reality.

r I am the grand healer. I can make things all better. I can take away the pain and hurt and make you into the wonderful person you really are. There are many therapist roles. Once the trainee’s favorite therapist roles are identified, the trainee can accept or decline them, can improve and modify them, can replace them with more pleasing ones. Discover the Trainee’s Inner Deeper Framework Work can start from the trainee’s answer to how and why this particular part is pleasing, displeasing, or compellingly inexplicable. The answer can be used to probe further and further into the trainee’s own deeper, usually hidden, unformulated notions and ideas about psychotherapy (Mahrer, 2007a). For example, here are three somewhat surprising discovered parts of a trainee’s own inner deeper framework: (1) There is an almost universal need for belongingness; (2) in initial sessions, most clients can be in a heightened state of vulnerability; (3) some symptoms may be inexplicably weird and bizarre without necessarily being symptoms of psychosis.

METHOD 3: WHAT DOES THE THERAPIST SEEM TO BE TRYING TO ACCOMPLISH IN THE SELECTED PART? Whether the selected part is pleasing or displeasing, whether the recording is the trainee’s or some other therapist’s, it can almost always be examined to get some idea of what the therapist seems to be trying to accomplish, the direction the therapist seems to be heading. Usually the answer is somewhat sensitive, touchy, embarrassing, or novel and innovative. The answer may nicely fit in with or gratingly depart from the trainee’s own surface beliefs. Here are two examples of answers that were somewhat embarrassing to the trainee: (1) In a somewhat indirect way, the therapist is trying to build a case against the client’s explicit desire to stay with her husband. (2) The therapist is trying to steer the client away from what the client wants to continue talking about and toward what the therapist prefers the client talk about.

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Identify Working Principles That Can Guide the Trainee’s In-Session Practices Once the teacher and the trainee arrive at what the therapist seems to be trying to accomplish in the selected part, they can consider some working principles that can be used to guide the trainee’s in-session practices. For example, here are two working principles that might be used: (1) The therapist’s concrete wants and preferences for how the client is to be can be put on the table and openly discussed by both client and therapist. (2) The therapist generally has the main hand in determining what the client is to talk about and in explaining the reasons for the therapist’s choice. It is now the trainee who can have a choice. The identified working principles can be declined by the trainee, or they can be welcomed and incorporated as parts of the trainee’s own discovered and developing way of thinking about and doing psychotherapy.

METHOD 4: FIND OUT THE TRAINEE’S ANSWERS TO “BASIC QUESTIONS” The parts of the recording that the trainee selects can almost always be examined for the underlying basic question. These are the deeper questions, some of which were there long before there was such a thing as psychotherapy, some of which helped give rise to the field of psychotherapy. These are the basic questions that underlie and help determine the therapist’s way of thinking about and doing psychotherapy, that cut across virtually all conceptual systems and approaches. They are truly the foundational issues underlying the art and science of psychotherapy (Mahrer, 2004a). The teacher and the trainee listen to the tape, trying to be open and receptive to the basic questions the trainee is close enough to touch or to be touched by. Here are a few of the basic questions: What kinds of psychotherapeutic data are trusted as hard, objective, and real? Are there basic, general causes of the way a person acts, behaves, relates? What are the criteria for determining which explanation is better than or superior to rival explanations? How and why does a person have feelings that are good and pleasant or bad and unpleasant? What are the limits and restrictions on how much and how quickly a person can change? What can be so special about actual in-session work is that the trainee can easily come face to face with basic questions that are immediate, directly challenging, and concrete—basic questions that the trainee would otherwise rarely come up against, see, or think about, especially in such a real and immediate way. The method depends in large part on the teacher having some idea of what the basic questions are. Most supervisors do not have much of a need to know. Discovery-oriented teachers do have a healthy need to know the basic questions. The teacher is to know when the trainee is in close vicinity to a basic question. The teacher is to know which basic question the trainee is facing right here and now in this selected part. The teacher is to be able to work together with the trainee to arrive at and to put into words the trainee’s own personal answer to the basic question. The trainee’s answers to basic questions are powerful determinants of

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the trainee’s own foundational way of thinking about and doing psychotherapy. Here are a few more of these basic questions:

r Where does personality come from in the first place? r How can a therapist know what another person is thinking, feeling, undergor r r r r r

ing? What are the parts of what is called personality? What events from the past are important? How and why are they important? How can dreams be used to enable a person to undergo change? What can a person become? What accounts for substantial change in who and what a person is? How can a person be free of painful feelings?

Once the trainee’s own personal answer to the basic question is put into words and is welcomed, the teacher can work together with the trainee to use the answer in bigger and broader ways. For example, if this is where personality comes from in the first place, the answer can go a long way in determining where psychotherapy goes in looking for causes. The teacher can work with the trainee to appreciate how the trainee’s answer compares and contrasts with other, perhaps generally accepted, answers to the basic question. The teacher can also work with the trainee to look for more or less direct implications for what the trainee does in actual in-session therapeutic work. For example, if this is the trainee’s favored answer to the basic question of how to be free of painful feelings, that answer may well go a long way in determining what the therapist does in actual in-session work. METHOD 5: ASSIGN HOMEWORK Training sessions ordinarily end with a homework assignment. In an important sense, the training sessions really end when the homework assignment is carried out. Add to the Notebook of the Trainee’s Deeper Framework for Psychotherapy The trainee keeps a notebook of his or her own developing deeper framework for psychotherapy. The notebook contains thoughts and ideas, principles and speculations, statements of truth and practice guidelines. The notebook may be organized or disorganized, systematic or jumbled, and it may consist of carefully worded or fragments of ideas. In any case, the training session comes up with some notion or idea, and the assignment is to add this to the trainee’s developing deeper framework for psychotherapy. Often the assignment includes studying particular readings that relate to that likely addition to the trainee’s deeper framework for psychotherapy. Spell Out the Trainee’s Creative New Idea Suppose that the training session brings the trainee to a creative new idea; either a creative new idea for the trainee or perhaps even for the field as a whole (Mahrer, 2006). The homework assignment is to think further about this new idea; to engage in free speculation; to follow the implications, both big and little; and to write

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anywhere from a few paragraphs to a number of pages. The teacher’s job is to encourage the creatively thinking trainee, to invite any kinds of thoughts and ideas, to be available as someone to talk with, and to suggest a reading or two for the trainee to study. Spell Out the Trainee’s Answer to the Basic Question Suppose that the trainee came face to face with a basic question in the training session: Why does a person have feelings that are painful and hurtful? Suppose that the training session saw the trainee move closer to his or her own emerging answer to the basic question. Building on these rudimentary fragments, the homework assignment is to spell out more about the trainee’s own personal answer to the basic question. In whatever way seems fitting and inviting, the teacher can help the trainee figure out more about the trainee’s position on the basic question. The teacher can help by suggesting a relevant reading or two and, if the trainee wants, reading and responding to what the trainee writes or wants to discuss about his or her emerging answer. The Trainee Is to Practice This Particular Skill Most of the teaching sessions arrive at a defined skill that the trainee could or should have carried out in the part that the trainee selected to study. Studying that part of the session can lead the trainee and the teacher to suggest that the trainee’s own deeper framework points toward some defined skill such as inviting the patient to engage in this kind of role-playing with the therapist; or playfully arguing with the patient; or telling the patient to say all that again, but this time say the words to his or her mother, and with much stronger feelings. The aim is for the trainee to try out this skill, to see how it feels to actually carry it out, to become increasingly proficient in this skill, to engage in proficiencydeveloping practice of this skill. The trainee can practice this skill by himself or herself or with a training partner. If a recording is available of that skill being carried out by a master, that can help. In any case, the trainee can stop the recording of the session at just the right point and practice inserting the new skill, trying it out again and again as the trainee becomes increasingly proficient at using this particular skill under these particular in-session conditions. These are some of the methods a teacher can use in helping humanisticexistential-experiential trainees discover, develop, and use their deeper ideas about psychotherapy. These methods can be appealing and useful for teachers drawn toward the discovery-oriented approach to psychotherapy teaching and supervision. However, these methods do not seem to have much of a track record in finding trainees whose mindsets suit them for my experiential psychotherapy.

REFERENCES Mahrer, A. R. (1989). Experiencing: A humanistic theory of psychology and psychiatry. Montreal, Quebec, Canada: Gontovrick. Mahrer, A. R. (1996/2004). The complete guide to experiential psychotherapy. Boulder, CO: Bull. Mahrer, A. R. (2002). Becoming the person you can become: The complete guide to self-transformation. Boulder, CO: Bull.

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Mahrer, A. R. (2004a). Theories of truth, models of usefulness: Toward a revolution in the field of psychotherapy. London: Whurr/Wiley. Mahrer, A. R. (2004b). Why do research in psychotherapy? Introduction to a revolution. London: Whurr/Wiley. Mahrer, A. R. (2005a). Supervision of psychotherapists: The discovery-oriented approach. London: Whurr/Wiley. Mahrer, A. R. (2005b). What is psychotherapy for? A plausible alternative to empirically supported therapies, therapy relationships, and practice guidelines. Journal of Contemporary Psychotherapy, 35, 99–115. Mahrer, A. R. (2006). The creation of new ideas in psychotherapy: A guidebook. Ross-on-Wye, England: PCCS Books. Mahrer, A. R. (2007a). The other deeper you. Ottawa, Ontario, Canada: University of Ottawa Press. Mahrer, A. R. (2007b). How psychotherapy can become a science. Montreal, Quebec, Canada: Gontovrick. Rogers, C. R. (1957). Training individuals to engage in the therapeutic process. In C. R. Strother (Ed.), Psychology and mental health (pp. 76–92). Washington, DC: American Psychological Association.

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C H A P T E R 10

Interpersonal Approaches to Psychotherapy Supervision: A Vygotskiian Perspective ALLEN K. HESS, CLARA E. HESS, and JOEL H. HESS

In every hour the human race begins. —Buber (1965, p. 83)

IN 1997, Hess wrote that comprehensive psychotherapy texts and handbooks would be criticized if they omitted a chapter on psychodynamic, cognitivebehavioral, or humanistic approaches but that the omission of a chapter on interpersonal theory would not be noticed. On the one hand, nothing much has changed, as can be seen, for example, in the most widely used text on psychotherapy (Corsini & Wedding, 2005). On the other hand, significant developments have shown that both psychodynamic and behavioral approaches have insinuated the interpersonal approach to psychotherapy into their practice and theory. This chapter first traces the incorporation of the interpersonal approach into two dominant theories of psychotherapy: psychodynamic and behavioral. This incorporation has, in effect, changed the nature of these theories into de facto and largely unacknowledged interpersonal approaches. Then we examine the essential nature of psychotherapy supervision as interpersonal. This is followed by an explication of the main principles of the interpersonal approach. The balance of the chapter shows how the work of a theorist from the first three decades of the twentieth century, only recently (re)discovered, provides a schema that is the most fitting for the roles of educator and eductor (or one who draws out the talents of the student; see Chapter 1) that compose the essence of supervision.

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PSYCHOTHERAPY ORIENTATIONS TWO DOMINANT APPROACHES: PSYCHODYNAMIC A N D B E H AV I O R A L

PSYCHODYNAMIC APPROACH One of the major contributions of psychodynamic theory to the understanding of people is its recognition of the inner or psychic world of the individual. Part of this contribution includes the symbolizing of external events into mental representations that result in internal structures. People experience their lives and symbolize events in their own ways, so the same event affects two different people distinctly. That is, the structures within each person will metabolize the events into their idiosyncratic schema resulting in individualized patterns of thoughts and feelings. Symbols crystallize our experiences in such forms as dreams, free associations, and waking reverie. Different interpretations by different people of the same stimuli, as in Rorschach perception or in common social interactions, illustrate the individuality of experience. These symbols are both unique to the person’s experience and, as Jung informed, common to the culture and to the species as in archetypes. Psychoanalytic theory and practice dwells on understanding this subjective world of the patient. Yet even as psychodynamic theory developed, both Freud (Blanton, 1971) and dissident theorists understood that there is an external reality, that a patient’s life is replete with struggles beyond the intrapsychic and includes real people. Adler recognized that defense mechanisms are more pointedly distancing mechanisms (Monte & Sollad, 2003). Defenses are subjective internal reactions that shield a person from anxiety provoked by the external stimuli that incite recalling of past painful experiences. But when the defenses are expressed through eye glances, facial expressions, hostile retorts, slips of the tongue, body postures, aggressive responses, or failures to respond (passive-aggressive nonresponding), these objective behaviors are off-putting to others in the relationship. They distance the person from others. Yet people often crave the relationship with others they so effectively repel, creating the conflict that relationships are both painful and healing. This movement to the interpersonal perspective can be seen among more contemporary psychodynamic theorists, too. The interpersonal notion that there are both subjective and externally real aspects to human interaction or that objects or cognitive structures represent real significant others in the patient’s environment penetrates psychoanalytic thinking in the works of Mitchell (2000) and Stolorow and Atwood (Stolorow, 1993; Stolorow, Atwood, & Brandchaft, 1994; Stolorow, Brandchaft, & Atwood, 1987). In these works, the authors argue that people truly reflect external realities that might provoke responses within patients, responses that may augment or sabotage treatment and the patient’s well-being. The term intersubjective, now frequently seen in psychoanalytic journals, refers to the interpersonal. BEHAVIORAL APPROACH At the same time psychodynamic theories were showing conceptual growth toward the intersubjective approach, the cognitive-behavioral approach was replacing radical operant behaviorism. This ascendance of cognitive-behavioral approaches was fueled by the advent of cognitive psychology (Neisser, 1976) coupled

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Interpersonal Approaches to Psychotherapy Supervision: A Vygotskiian Perspective 159 with the realization that the older paradigm had become brittle and was unable to account for mental processes. The new cognitive behaviorism recognized internal events such as object and self-representation though the ideas of social and cognitive schema. Social cognition emerged as a fertile research and applied area and practitioners joined in the efforts of cognitive, social, and developmental psychologists in investigating such topics as perinatal and postnatal facial and emotional recognition and how stable cognitions form in children. Behavioral clinicians became cognitive behaviorists, allowing them to operate on covert or cognitive processes, or, dare we say, imagination mental imagery, terms that brought opprobrium during the halcyon days of behaviorism. Clinicians such as Arnold Lazarus (cf. his dialogue quoted in Chapter 1), Donald Meichenbaum, and Donald Peterson (1968) led in the liberalization of cognitive behaviorism. This less behaviorally orthodox umbrella allowed the incorporation of Albert Ellis (whose theory gravitated from rational-emotive therapy to cognitive-emotive therapy) and Aaron Beck’s cognitive therapy into the fold and greatly enhanced the behavioral approach. These figures were a major factor in keeping the behavioral approach from becoming so narrow as to lead to its obsolescence. Instead, this more interpersonally oriented behaviorism remains a dominant force, though the construct of clinical skills remains unrepresented in behavioral theories. That is, the major factor in effective psychotherapy is often termed nonspecific therapist factors. This refers to those abilities and clinical skills that engage the patient, that build a therapeutic alliance, and that guide the psychotherapist’s strategies in judging the type and dosage of intervention most fitting the patient at this particular point in psychotherapy. Yet these qualities appear nowhere in the theories of cognitive behaviorism. So the times are more favorable for interpersonal approaches, particularly in psychotherapy supervision. What then are the reasons for the goodness of fit or isomorphism between the interpersonal approach and psychotherapy supervision? T H E S T R U C T U R E O F P S Y C H O T H E R A P Y S U P E RV I S I O N A N D T H E I N T E R P E R S O N A L R O O T M E TA P H O R If any area is quintessentially interpersonal, it is psychotherapy supervision. Supervision refers to the examination of the work of a person in relationship with a patient, be the patient an individual, a couple, a family, or a group. The root metaphor1 for interpersonal theory is the person in relationship, in contrast to the behavioral metaphor of a water- or food-deprived organism, or the psychoanalytic metaphor of the organism in search of tension reduction. (Certainly these metaphors become more varied with more complex implications than these succinct summaries indicate, but delineating this is beyond the scope of this chapter.) Examining supervision as a relationship, we see that supervision often involves an agency and even an education committee that monitors the supervision and that can vote on the student’s fitness for the profession. When the patient and the treatment occurs in an offsite placement that reports to the student’s university or internship base, an even more complicated layer of relationships arises. 1 See

Pepper (1942) for an excellent treatment of root metaphor theory and Lakoff and Johnson (1980) for a plethora of examples about how we conceptualize, communicate, and live by metaphor.

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Intrapsychic models such as that of Ekstein and Wallerstein (1972) recognize in their clinical rhombus this complicated web. These authors outlined the relationship between four parties—agency, supervisor, therapist, and client. Holloway (1995) expanded the rhombus by recognizing that there are multiple parties to the supervision, even if only two are physically present during a session. In sum, the descriptions of supervision by authors from across all theoretical perspectives involves the very root metaphor of the interpersonal approach, that of the person in relationship. And the layering of one relationship (that of the supervisor and supervisee) upon another (that of the patient and psychotherapist), compounded by unseen but potent third parties (licensing boards, agency policies, insurance agencies, and reporting requirements such as the Tarasoff rule and child abuse reporting laws), imposes another layer upon the already-layered structure. Certain propositions follow from adapting a root metaphor. Let us examine how this works generically and for supervision specifically. ROOT METAPHOR “You are right on target,” “He is a drip,” and “She lifted his spirits” are commonly understood expressions. Underlying all thought are metaphors or graphic representations of ideas. An idea is expressed analogically (think of the “tick-tock” of the pendulum on a grandfather clock as signifying inevitability vs. the “tick-tick-ticktick. . .” of a second hand rushing time by us). Ideas are embodied or corporealized. Thus the first metaphor in this paragraph refers to “you” as an archer and the second metaphor symbolizes feebleness as dripping rather than forceful water. No one can question the spirit that was lifted in the third example—he is happier because “up is good,” and “bad feelings are heavy” are two of the underlying metaphors invoked in describing affect. Although someone can “be in the black” in terms of accounting, which is good, usually “dark days” and “Black Bart” refer to a dismal future and a villain. As these last two examples indicate, one must be aware that metaphors entail assumptions, some of which can be harmful and wrong. With this in mind, we need to examine what sort of assumptions the person in relationship brings with it. ASSUMPTIONS OF THE INTERPERSONAL APPROACH Hess (1997) discussed foundational precepts of the interpersonal approach. We succinctly recapitulate them next. Both Physical and Psychological Realities Exist Salmon Rushdie said, “The sound is truer than the echo.” Over time such realities as running through one’s bank account or failing to take care of human relations do have a reckoning day. Ignoring deadlines has consequences. Working on a project to which one has made commitments can bring tangible rewards in addition to the intrinsic reward of self-satisfaction. Our contemporary age is a psychological one. We view perception as reality. Certainly someone’s perception is a reality that must be taken into account, whether that person is a voter, a consumer, or a patient. Each bases his or her actions on

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Interpersonal Approaches to Psychotherapy Supervision: A Vygotskiian Perspective 161 the view of the world he or she holds. Through reframing or cognitive reappraisal, views and actions are modified. But only in relationships does human growth occur, as Buber indicated in the epigraphs that begin and end this chapter. Each moment the psychotherapist can relate to the patient in an I-Thou fashion rather than to a case, each moment when the supervisor can relate to the student as a human, a spark of confidence and competence can be ignited. All Human Experience Is Textured by Emotions and Cognitions That, in Turn, Have Drive Properties Emotions are fundamental to the human experience. Without hedonic tone or the seeking of pleasure and avoidance of pain, life is not assured. One could say that anhedonia is the common problem of two of the three major psychoses, schizophrenia and affective psychoses. Parkinson and Totterdell (1999) studied how undergraduate, office worker, and consumer participants used various strategies to regulate their emotional states or hedonic tones. Cluster analyses revealed a variety of maneuvers ranging from more primitive to quite sophisticated strategies. Waterman (1993) showed how happiness is not merely hedonic enjoyment but that eudaimonia, or personal expressiveness usually via accomplishments, provides meaning to our lives. Avoiding pain, seeking pleasure, and experiencing the need for accomplishment and meaning probably account for most human motivation (Oatley & Jenkins, 1996). Effective supervision entails not just ensuring competence in meeting minimum standards but actualizing the student’s talents that lead to effective psychotherapy and an actualizing therapeutic identity. Our Experiences Have Two Modalities: One Is Analogic and the Other Is Digital The inner life is much as Freud initially proposed as primary process but Vygotsky reconceived inner life as egocentric thought (primary process) and inner speech. The latter is a product of social speech or interactions with others that is then processed with spontaneous mental activity (addressed later). Typically, outer or social speech is digitalized, as are the written notes of a melody. When we listen to the melody, we experience the tune and might allow our reverie to lead to feelings, thoughts, and judgments. This reverie can lead to an understanding of the melody’s author, or an I-Thou relationship with the author or the melody, even if the author has been dead for decades. The internal interplay of the three speeches or languages may have evoked images and unleashed creative processes for Vygotsky. For Buber (1970), a meaningful human relationship was one that occurred between an I and a Thou. A formal transaction occurs between an I and an It. The latter occurs in much of our lives, such as when a bureaucrat is processing our case, whereas the former occurs when we are truly communing with another, whether or not the other is present. I-Thou occurs when I is sharing an experience with another in which one can finish the other’s thoughts and knows the other’s feelings. Modalities Are Based on a Rational (It and Digital) and a Psychological (Thou and Analogic) Logic The whole field of consumer psychology explores how people make economic decisions based on nonrational causes. Unconscious processes refers not only to

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events being unattended to but to the ongoing processing of this information and the effects of this processing on a person’s actions. These emotions, perhaps subceived and processed unconsciously, nonetheless participate in ongoing and future behaviors, thoughts, and feelings (Westen, 1999). Often they are unaffected by cognition but these processes affect cognition and decisions in ways the person may not realize. People Are More or Less Aware of Their Psychological Processes We can examine another’s body language, but then we might fail to attend to that person’s vocal tone. Or we can attend to both the body and vocal features, but our cognitive processing of the message may suffer. Simply put, our ability to attend is limited, and some features of the world are missed. Sometimes we recall these unprocessed materials and invoke the unconscious. And these unconscious percepts might influence us in ways we know not. As we are made aware of more of our experience, we have the potential to live richer lives. This awareness must be accomplished within the bounds of our ability to tolerate the experience. This relates directly to (a) the necessity for defense mechanisms, (b) Baumiester’s (Baumeister, Bratslavasky, Muraven, & Tice, 1998) idea that people do experience ego depletion or limitations on what he termed the active self when they suffer performance decrements in the face of ego assaults, and (c) Vygotsky’s idea of the zone of proximal development—the degree to which a person can metabolize incoming material. Human Productions Are Repetitive Our behavior, body postures, and thoughts tend to repeat and characterize us. This allows for a sensible continuity or sense of self, as William James (1890, as cited in Sahakian, 1968) describes making change a challenge. This precept leads to an important fact for both the supervisor and the psychotherapist. If either observes an important interaction but is startled and does not respond, the interaction will resurface at a time when the supervisor or psychotherapist is more able to intervene. (Note that certain actions may require intervention for the patient’s safety or for ethical and legal concerns before the event recurs.) This is particularly necessary information for the supervisor to impart to the student who might feel as if he or she failed when surprised by the patient during the course of a psychotherapy session and left without a therapeutic response. Golden opportunities may be missed, but if the moment is central to a patient’s problems, more such opportunities will arise. Successful supervision encourages the student and rehearses how the student might turn the next opportunity presented by the patient into a corrective emotional experience for the patient. Human Experience Is Contagious When one mentions an idea, the listener is hard pressed not to process the idea. When one person is anxious or suspicious, it is difficult for others not to become anxious or at least solicitous of the anxious person or wary of the suspicious person. In supervision, anxiety is the major feature characterizing the supervisee as he or she grapples with becoming competent in technique and secure in forming a psychotherapist identity. Similarly, teaching the student to intuit a client’s areas of

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Interpersonal Approaches to Psychotherapy Supervision: A Vygotskiian Perspective 163 concern is not mystical but is rather a matter of disciplining observational powers (i.e., teaching the student how to use his or her abilities to listen to the client through a variety of senses and modalities). Sensing the response a patient incites in a psychotherapist may be essential for understanding a case. If a patient behaves toward the psychotherapist as if the psychotherapist were angry, but the psychotherapist feels no anger, then the psychotherapist has invaluable information about this patient’s personality largely uncontaminated by countertransference. Perhaps the patient projects his or her distancing maneuvers or bristling anger onto others, unwarranted by them. Now the psychotherapist’s experience allows him or her to relate to the experience of others in helping the patient see his or her effect on others. One Cannot Not Behave Even if the patient can govern his or her eye glance, vocal tone, choice of words, and the rest of the flow of communication, the person is under a heavy emotional load that will cause hesitancies, slips of the tongue, and disjunctions between gestures and words. Just recall President Bill Clinton’s denial (“I did not have sexual relations with that woman”) while his head nodded up and down. Even silence or failure to show for an appointment is interpretable in supervision, in psychotherapy, and in the rest of life (Haley, 1963). How we, as psychologists, respond to these communications involves an option unavailable to most others in society. It involves the ability to respond asocially (Beier, 1966). Intervention Involves Asociality “Do you have the time?” “I am really feeling sad,” and “Should I marry him?” are compelling prompts. The customary, usual, and social response is to tell the time, to try to soothe, and to provide information or an opinion, respectively. In contrast, the psychotherapist and the supervisor are able and obliged not to respond. Our roles allow for us to be asocial; not asocial in the sense of a psychopath’s uncaring asociality, but asocial in the sense of expressing care and concern through one’s attentiveness but not providing answers to questions the person might simply be wanting to express. The effective consulting room is one in which the patient and student have found it safe to express their needs and worries with little concern for how they may appear in a social sense. The astute reader at once sees the impending conflict with the evaluative function of many supervisions, wherein it is not safe to look weak in any regard. The Crux of Change Is Authentic Communication Within the safety of the consulting room, the patient can explore his or her feelings without the sense of being sanctioned. This is why Freud invented psychoanalytic incognito, or the blank screen upon which the patient can project feelings, thoughts, and expectations upon the unrevealing other. Similarly, with the major exception of the evaluative function in many supervision settings, the student functions best when feeling safe enough to review errors; raise doubts; and express the baser feelings he or she may have about a patient, his or her progress through graduate school, or even his or her career choice without a sense of the impending doom from professional or personal sanctions. Only after a supervisory alliance is established

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can the supervisor indulge in asociality. Only then can the student bring forth those matters that elude many supervisions. In this context of a supervisory alliance the student can risk self-revelation and the supervisor can respond authentically. That is what most humans crave: authenticity within a caring and safe context. Not a demand for change or any competency benchmarks to meet, but the ability to receive honest communication untainted by the other person’s needs or an agency’s requirements. This communication has drive properties toward change all its own, needing no hammer or sword, no grade or threat of not sending a positive letter of support for licensure, to compel change. The nonevaluative stance seemingly runs counter to contemporary practice and even to the whole competence movement. The thrust of the competence movement is to establish important dimensions and functions, then to evaluate them. Although this is wholly rational, it encourages students to feel shame (Hahn, 2001), to cover their mistakes (Yourman & Farber, 1996), and to appear fault free. This dynamic of other- and self-evaluation and the related problem of supervisor (in)competence lead to a duality of experience in supervision. Although many supervisions are affirming, Olk and Friedlander (1992) found that role conflict and role ambiguity in the supervisory relationship to lead to unsatisfactory trainee experiences. Most troubling is the supervisor who is not invested in supervision. The senior author recalls vividly his supervisor answering phone calls regarding his real estate business, sometimes lasting a half hour each, during supervision. When the student confronted the supervisor and asked for compensatory time, the supervisor blithely answered, “People who sign up for my supervision know their session is interrupted by my calls, that is just part of what they signed up for.” Poor alliances, noninvestment by supervisors, and supervisor anger (Nelson & Friedlander, 2001) are crushing experiences for neophyte psychotherapists. When supervision allows the student to reflect upon psychotherapy sessions in a safe environment, the student can internalize the best of our profession and be of lifelong help to others. The relationship, the relationship, the relationship—it is everything in supervision, in psychotherapy, and in life. The interpersonal approach stems from the work of Sullivan and Buber. A model of supervision based on Buber’s thinking appears in Hess (1987), and one on Sullivan’s appears in Hess (1997). As fitting as both of these models are for supervision, during the past 2 decades the work of Vygotsky has appeared after being censored in the Soviet Union for the better part of the past century. Vygotsky’s range of interests and specificity of recommended practices is stunning. The fit with supervision as a form of education that involves the whole of the teacher and the student in an active process seems as though it was formed with supervision in mind. What follows is a primer on the fundamentals of Vygotsky’s thinking with applications to supervision. V Y G O T S K Y A N D A N E D U C AT I O N A L P R O C E S S M O D E L O F P S Y C H O T H E R A P Y S U P E RV I S I O N Lev Semeonovich Vygotsky (Vigotskii, 1896–1934) earned his doctorate at the age of 20 with an analysis of Shakespeare’s Hamlet, illustrative of his background in linguistics. With his background in the philosophy of humanities and drama, he was

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Interpersonal Approaches to Psychotherapy Supervision: A Vygotskiian Perspective 165 drawn to epistemological problems in psychology. The behaviorism of Behktehrov, Pavlov, and Sechinov were too narrow for him, though he acknowledged the power of association learning. Just when his laboratory was generating a plethora of research on how children learn language and concepts, his writings were held to be anti-Soviet and the Lenin and Stalinist regimes censored much of his work. He was open minded and cited the writings of Sherrington, Cannon and Bard, William James, Freud, Piaget, and Kohler, among others. Appreciating Freud’s psychodynamics, Vygotsky felt it told a good deal about depth psychology but preferred to work also in what he termed acme psychology, foreshadowing the growth or Third Force psychology, or what we now find popularized as positive psychology. Blundin, (1997), Daniels (1996), and Kozulin (1990) are excellent sources for the reader interested in Vygotsky’s life and work. Cole and Maltzman (1969) illustrated the pervasive influence of Vygotsky on Soviet psychology. His influence is felt in current education theory as well as in neuropsychology and some cognitive psychology circles. In fact, the handbook Contemporary Soviet Psychology (Cole & Maltzman, 1969) cited him in a number of chapters even before the rediscovery of his work provoked translations into English. Vygotsky died at 34 years of age from familial tuberculosis, leaving a young wife and two daughters. His work is isomorphic to psychotherapy supervision, as we discuss here. If supervision is educative, then it makes sense to feature an educational process model. Vygotsky’s work features an empirically grounded, theoretically sophisticated model of conceptual development centered on the teaching–learning relationship. Having read through the filters of translated accounts of his work, we distill nine principles and concepts on which to base effective supervision. ALL LEARNING IS HISTORICAL Students do not come to us de novo. They bring many experiences, both from their extensive education and from life experience. As the previous sections illustrate, psychotherapy and its supervision has a lengthy past filled with the contributions of many gifted clinicians and theoreticians. It is important to understand we are conveyers of social values. The whole of psychotherapy occurs while embedded within a specific matrix of values. Decisions about the duration of psychotherapy are heavily influenced by insurance reimbursements, and patient needs might play a lesser role. The whole of our profession’s ethical concerns are heavily weighted toward risk aversion, as one author in psychotherapy supervision advises supervisors to be friendly but not familiar. Basing supervision on this as a preeminent value is troubling. It shaves behaviors so fine that the attention given to these boundaries may well take up more energy than the matters more central to supervision. All choices are predicated on values. For example, what part of a tape to play, when the therapist intervenes with a patient or a supervisor in a student’s narration—or even when a supervisor intrudes into the psychotherapy—are choices, and choices are predicated on values. The values of a system must be understood, and the values of the institute, the supervisor’s supervisor or program, the student, and the patient must be considered, as unknown values will manifest in decisions that seem to beg for rationale. Whereas these values ought to be discussed at the initiation of

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supervision, many issues emerge during the supervision are also based on values. Differences in values allow the supervisor and supervisee to reflect upon these decisions. In this way, both parties ought to find supervision growth enhancing, not merely checking off items on a competence checklist and avoiding risks. Being independent versus merging into the common masses has been an antimony in psychology for ages. Andras Angyl (autonomy vs. homonomy) and David Bakan (agency vs. communality) are two preeminent authors who articulated this well, as did Watkins (1997), who applied the notions of individuation to supervision. Buber’s (1965) essay on education (pp. 83–103) seems to extricate the supervisor and supervisee from the dilemma of whether the supervision creates a clone of the supervisor, or the degree to which a student does his or her own thing. Simply put, Buber’s creativity (origination instinct) meets socializing influences not in the sense of conformity, but in the sense of true meeting, by which each party—the student in creating a psychotherapist and the supervisor in creating in himself or herself a true supervisor—allows the generative instinct to flourish Through honest dialogue they are able to build each other using the power of being-in-relationship with a sense-of-the-other (Hess, in press). ALL LEARNING IS SOCIAL As can be seen in the preceding paragraph, supervision is relational. Rather than see language as initially internal and then becoming social, Vygotsky saw three types of language: egocentric, external, and internal. The egocentric or idiosyncratic meets the social or external language, the latter being necessary for survival. Vygotsky’s ideas about language and meaning converged with Sullivan’s notion of consensual validation between the child and the outside world. Both Sullivan and Vygotsky read Edward Sapir and George Herbert Mead on the shaping influence that society has on language and thought. Internal language lets the child engage in what Vygotsky termed science or reasoning. Computing a math problem in one’s head or anticipating a response from another to one’s utterance are examples of science in Vygotsky’s terms, or the education of relations in Sullivan’s terms (Carson, 1969). ALL LEARNING IS EMOTIONAL Wechsler (1943; Matarazzo, 1972) recognized the “nonintellective” aspects of intelligence and its testing. He engineered a measured amount of failure into the Wechsler scales (i.e., discontinue criteria). For example, a person produces five wrong responses to discontinue the Vocabulary subtest (unless the person’s ceiling level is not reached), and then the assessor can see how the person responds to the next subtest, given the set number of failures and presumably frustrating experiences. Does the person give up? Does the person keep trying? Does he or she learn from mistakes? Use blame or humor to bolster sinking self-esteem? What spontaneous comments does the person make? Does he or she blame himself or herself? The instrument? The assessor? Currently, student teachers are advised to use any ink but red ink in correcting students’ papers. People feel success and failure when they finish or fail at Sudoku, the crossword puzzle, and other tasks that have nothing other than self-esteem hinging upon the outcome. And this is much more so the case in psychotherapy. A

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Interpersonal Approaches to Psychotherapy Supervision: A Vygotskiian Perspective 167 person’s chosen profession hinges on the outcome of student-learning experiences. The patient, and even more so the supervisor, can determine the emotional state of the student. It is interesting that a senior clinician uses ridicule to teach the student to use silence. He puts his right hand upon his left hand, then, using the bottom of his palms as a hinge, he imitates a duck’s bill, opening and closing his hands, yelling out “Quack, quack, quack,” letting the student infer that he is calling the student a quack. Or maybe not. The ambiguity itself is punishing. The senior clinician delights in catching a student’s mistakes. No doubt he may be right in terms of the student’s technique, but the humiliation he heaps upon the student is damaging, as other students report to their colleagues after sessions with him. Separating cognitive learning from emotions is artifactual. It does not carve nature to join, or let theory and reality meet. Posing puzzles for the student to solve, as we see below in the “Pivots” section, engages the student’s motivational system in the learning process. There is no separating the joys and frustrations of learning from the learning itself. ALL LEARNING OUGHT TO BE LEARNER INITIATED Texts on Vygotsky regarding teaching young students are replete with advice to engage the student in setting goals (cf. Wink & Putney, 2002). How much more so is this important in graduate education. Yet it seems the professor knows best. Supervision ought to start with the student letting the supervisor know what he or she has learned, how he or she has benefited from previous supervisions, and what alienating events he or she has experienced in psychotherapy and its supervision. Without this exploration, the supervisor simply has no idea how his or her offerings, interpretations, and interventions will be received—how effective and affective they might be. Certainly the learning goals of the organization are important, for that is why the student entered the program, presumably. And disjunctions between the student’s goals and the university’s or agency’s goals need to be explored. It is folly to assume the agency’s goals are the student’s goals or that the student must blindly obey agency rules.

Case 10.1 G was placed in a long-term state hospital to learn inpatient group psychotherapy as cotherapist with an esteemed clinical forensic psychologist. During a session, a schizophrenic woman shrieked that she recalled killing her 1-year-old child. Suddenly the psychologist said he had to leave the room to check with the district attorney. G went with him to the door and asked him whether he was violating the patient’s privilege and whether this was something to explore as a feeling rather than a fact. The psychologist scolded her for being impertinent. G consulted with a faculty member who was credentialed in clinical and forensic psychology, asking about the ethics of this situation. The consultant affirmed G’s thinking, to the latter’s great relief, that even if there had been a real death, several factors weighed against the session’s interruption and the breaching of privilege, as it existed in group treatment. Any attorney would consider a number of factors such as the privilege under which the information was (continued)

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gained, the sort of credence the psychologist was placing in a schizophrenic’s oral report, and what sort of disposition would result even if a prosecution were successfully pursued—the woman’s landing back in the long-term forensic unit of the mental health institute! A clinician might consider what breach of trust would be communicated to the other patients in the hospital. And what this was, was a schizophrenic woman’s attempt at communication through the fog of medications, the feelings of loss of a child, or even loss of her childhood, not necessarily her literal child, to psychologists she trusted with this information.

Students are not necessarily driven only by their better angels. What follows is a case that confronts a student’s seemingly fraudulent application to an internship.

Case 10.2 The student went to the training director, saying he was skilled in existentialism and neither needed nor wanted the cognitive-behavioral supervisor and rotation he was assigned. His goal was to be an existentialist, and that was the only satisfactory supervision for his career goals. The director was stymied. The director asked a consultant for advice. They role-played. The “director” (played by the consultant) told the “student” (played by the director) that he was glad the student was forthright enough to come for a meeting about the placements. He then asked whether the student knew from the advertised literature and his own application indicating the need to amplify his skills that the internship prided itself on offering expertise in several skill areas. The student admitted that he had wanted to go to the internship for its location and status. Then the director asked the student how he thought Dr. A, the cognitive-behavioral supervisor, was feeling. The student looked puzzled, as if cognitive-behavioralists did not feel. The director continued that if the student communicated to Dr. A the type of feelings he communicated in this meeting with his frowning demeanor, then Dr. A must feel unskilled and frustrated, angry and alienated. Furthermore, the director asked whether the trauma patients were the type the student might reasonably expect to treat in his subsequent postings in this national service that treats military casualties. Did the student not think it a good exercise to see how an existentialist can learn and incorporate cognitive-behavioral skills? Did he know Victor Frankl’s (1984) cognitive-behavioral ways of reframing events? Was he secure enough in his existentialism that he could benefit from the rotation and supervisor? The director told the student to think about these questions and return after the weekend to see whether he could be flexible enough to explore with Dr. A the learning possibilities on that rotation. And he asked the student to consider whether a truly adept existentialist would have simply not considered Dr. A’s experiences of the student and the student’s worth as a learner.

Whatever the student’s game in this case, he needed to confront it but not be pounded. He was given the task of suggesting to the director an appropriate set of learning goals and corresponding placements that took advantage of the internship and was consistent with fulfilling the internship’s service commitments. Similarly, the student and supervisor in any supervision ought to negotiate what is on the learning agenda. To be successful, the student must be able to learn from anyone, not just reputedly gifted teachers. That is the art of learning. The teacher must assess where the student is and what the student’s trajectory or learning arc may be. This notion is more fully explored in the next section.

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Interpersonal Approaches to Psychotherapy Supervision: A Vygotskiian Perspective 169 ZONES OF PROXIMAL DEVELOPMENT BECOME APPARENT AND CENTRAL CONSTRUCTING STUDENT LEARNING

IN

Vygotsky wrote about two students with 10-year mental ages. One would think them similar, but when faced with a teacher who exposed them to 11-, 12-, and 13-year-level tasks, one student could master the 11-year-level but not the other two age-level tasks, whereas the second student could master all three. The second had a greater zone of proximal development. Vygotsky wrote extensively about animal learning compared to human learning. At first, both animals and humans seem to learn similarly, with the advantage to the animals on motor and most perceptual skills. Yet the animal reaches its species learning constraints and has a limited learning arc or trajectory (Bitterman, 1965). Even orangutans taught several hundred words are limited in further learning and in ways to use language. The zone of proximal development is “the distance between the actual developmental level as determined by independent problem solving and the level of potential development as determined through problem solving under adult guidance or in collaboration with more capable peers” (Vygotsky, 1978, as cited in Wink & Putney, 2002, p. 86). The psychotherapist might face regressed patients for whom there is a limited zone of proximal development. The good teacher, the good supervisor, and the good psychotherapist understand the level of the student and the student’s optimal ability to extend himself or herself. The student psychotherapist learns to assess the patient’s zone of proximal development or ability to try a new behavior, cope with an interpretation, or confront a fearful feeling.

Case 10.3 The agency was the end of the line for most of the patients. They were 17- to 21-yearold inner city youth who were adjudicated “mad” and “bad,” having committed criminal acts resulting from horrid life circumstances culminating in severe mental illnesses. The 48-bed unit housed a dozen youth who were too disturbed to go on day passes, even under medication and with almost a 1-to-1 patient-to-chaperone ratio. The youth paced the ward in eerie silence, virtually equidistant from one another, hour after hour, up and down the hallway counterclockwise. The psychologist decided they ought not be warehoused, and so he began a socialization group. Even if they just sat in the day room looking at one another, it was better than the death march they were on. An echolalic 20-year-old seemed unable to stay quiet. When anyone spoke, she would echo what they had said, disrupting the group that was already struggling for some semblance of social order. Several members of the group started rumblings about her being ousted from the group. The psychologist thought how bad it would be for someone struggling to participate, who had a history of rejection, now to be excluded from a group that might be thought of as a last resort. He asked the young lady to sit with him and hold his hand. Each time she felt the need to repeat something someone had said, he asked her to squeeze his hand. And if the impulse was strong, to squeeze harder. If she had something to contribute to the discussion, she was to shake the hand and the group would listen. She beamed. She had never been given a way to participate before. After the session, the psychologist and some patients congratulated her on her participation and her new-found control (albeit perhaps limited to the setting). (continued)

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The interpersonal approach examines how even a severe and biologically driven disorder takes on meaning from the social matrix within which it is embedded. Certainly the zone of proximal development was limited, but the patient’s sense of effectance and expression of joy seemed boundless. For the first time fellow patients smiled at her rather than saw her as an annoyance.

Psychotherapy requires a number of skills. For example, some essential skills include the ability to listen, a conceptual network that allows the recognition of phenomena such as a client’s readiness for interpretation, the ability to monitor one’s emotional tone and to monitor one’s client’s emotions, the ability to plan, and the ability to modify plans extemporaneously. No two people come with equally developed skill sets. Supervision entails both the supervisee and the supervisor taking stock of the skill sets and then determining the zone of proximal development the student shows for the various skills. That is, the supervisor might find one student remarkably undefensive, relinquishing control to the expert in psychotherapy, whereas another student wrestles with supervisor interpretations of the client sessions. Yet the second student might be much more intellectually adept and may play with concepts mentioned in supervision. The supervision goes smoothly when the supervisor realizes different students have different zones of proximal development and abandons a one-size-fits-all approach. In classroom teaching it is clear that certain students “get it” and may even anticipate the teacher’s lesson, whereas others may need repetition. Again, we see how emotions may be triggered in the learning process as the teacher wonders why some students do not get it, and the students feel frustration and distancing from the teacher’s emotional reaction, even if that reaction is covert.

SCAFFOLDING: INTERNALIZING LEARNING STRUCTURES Scaffolding is a useful term in the sense that the teacher gradually withdraws assistance as the learning structure (or practical and then scientific learning) is internalized. Practical learning refers to more applied problem solving, whereas scientific learning connotes a meta-learning, learning set, or, in Vygotsky’s terms, that an understanding of the principles underlying the solution has been internalized. In psychotherapy, and with learning in general, a variety of techniques are subsumed within scaffolding. These include modeling; using algorithms; backward chaining; priming; building confidence; validating the person’s efforts; breaking a task into components and subcomponents; engaging in cotherapy; and listening to or watching tapes of sessions, with the student gradually assuming more activity in going over the parts of the tapes he or she senses are in need of processing.

SPIRAL OMNIBUS Binet developed the intelligence test as a battery of a number of skills. These ranged from aesthetics to bead counting to vocabulary to social judgment. As a person progresses through the battery, he or she might be tested on a skill such as

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Interpersonal Approaches to Psychotherapy Supervision: A Vygotskiian Perspective 171 counting, then word meanings or perceptual-organizational ability, and then back to counting or higher mathematics. In this way a spiral could be formed, with the omnibus structured by the different skill sets being assessed and developed. Effective psychotherapy supervision takes on this form. That is, the student may have learned excellent listening skills and empathic understanding when serving as an undergraduate volunteer for a suicide hotline. But the student may have few skills in recognizing defense mechanisms. The student may have experience working with depressed clients but little exposure to the severely mentally ill, children, or the aged. In effect then, an approach combining Vygotsky with the spiral omnibus schemata suggests that the student and supervisor set an agenda together. This agenda will shift as the student has a greater or lesser zone of proximal development within each area. A variety of theories agree that the zones might increase as the student’s confidence and ego involvement increases, threat sensitivity decreases, and sense of validation increases (Bandura, 1989; Klein & Schoenfeld, 1941). As an area is mastered the supervision ought to take a free-flowing nature whereby there is spontaneity as shown by the student’s (or the supervisor’s) suggesting that they work on another facet of the student’s psychotherapy skills. The growth takes on an upwardly spiraling form, buttressed by the scaffolding and resulting in increased confidence and autonomy experienced by the learner, and sharing in the supervision. Contrast this attitude with the notion that there are agency-determined prescriptions, not so much in skills to be mastered as in Case 10.2 but in attitudes and feelings, as found in this admonition in a graduate student handbook: “Lack of openness to supervision also constitutes unprofessional behavior. Students who cannot properly and consistently utilize and implement feedback from a supervisor is [sic] at risk of being terminated from their practicum.” This confronting approach, given its awesome demand, will stultify and chill the student who comes filled with hopes of learning psychotherapy and fears of adequacy. The whole of the work-as-play or identity- and growth-oriented aspects of work are bleached out. As a child at play seems to work at building a block tower and sees it topple, only to rebuild the tower, an engaged learner will work arduously and joyfully. The demand to “be open or else” will beget anxiety and guardedness. PIVOTS As the child builds the tower, an adult might engage the child. The language of the adult may serve as a pivot. Vygotsky saw the pivot as a useful tool in scaffold building. It shows the developmental stage of the child at play or the student in supervision. A pivot is a tool such as a broomstick with a horse’s head that the child might ride as if on a horse, or a blanket wrapped around a ball that the child pretends to care for as a baby. The pivot allows the internal language to be acted upon. It ascends to a level of thought that becomes scientific. Although the play horse cannot be fed as a real horse can, the child can recognize the practical aspects of the real horse and the practical aspects of the play horse as toy. This allows the child to begin to use scientific thoughts about what is real in both worlds, what is conceptually linked between the two horses, and what is purely hypothetical that can also be tested with other sticks as animals.

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Case 10.4 A student was eager to help patients with his insights and to show the supervisor how bright and caring he was. The student realized that he was failing to allow a patient to explore. The student needed to develop the ability to listen to the patient without interfering. Moreover, rather than the eager person he was, he was appearing arrogant to his supervisor, and probably to the patient as well. Realizing this, he decided that he needed a method to help him listen, process, and reflect. Listening to tapes and reading tomes helped but did not solve the problem. The student remembered seeing a picture of Freud and hearing of the 20-a-day cigar habit Freud incurred and realized that some prosthesis like a cigar might help. But cigars were not appropriate, and a pipe seemed so trite. He remembered a favored supervisor who would grip his right knee with his right hand when he wanted to say something to the supervisee but thought the supervisee would be better served by working out the problem himself. With these two models, the student created his own pivot, similar to Freud’s cigar and the supervisor’s knee. The student fondled a favored pen, then placed it between his lips and solved the problem. This pivot allowed him the moments to delay and use the cognitive structure, another pivot, as to whether his input would really serve the patient or his own gratification. The supervisor noted how much better the student seemed to be at hearing his patients and focusing on their core issues.

Seeing psychotherapy supervision as a pivot then allows us to see parallel process in an entirely new light. Parallel process traditionally reveals a problem the student is having with a patient that is replicated or acted out in supervision. In parallel process, if a patient misses or is tardy for appointments, the supervisee may miss or be tardy for supervisory sessions. The concept traditionally and seemingly universally is viewed as acting out and is indicative somehow of a student flaw. In Vygotsky’s work, the activity of the student would not be pointed out with the “gotcha” attitude. Instead, it would serve as a pivot or learning opportunity. What is being acted is the student’s problem, and the student needs to see how the supervisor handles it (either between the student and supervisor) or how the supervisor suggests the student act in the patient’s sessions. This makes the problem a learning opportunity rather than a pathology. The student can then manage the patient’s actions from a far more advantageous perspective, one that unfreezes the attitudes of both the student and the patient. Say, for example, that the patient is having a problem with some aspect of his or her life that is being expressed motorically or even somatically and is not being put into language or digitalized. The parallel process occurs when, in the supervisory and in the psychotherapy sessions, scenarios are acted out or analogized. In fact, the patient may even confront the issue in relating to the psychotherapist a problem he or she is having with an employee who is tardy. The patient might be tardy or miss sessions rather than ask the psychotherapist about the problem, in effect acting out the dilemma. In turn, the student might echo this problem of how to bring up the unverbalized with his or her supervisor, creating echoes in the supervision. In almost all cases, identifying the parallel process by name to the supervisee chills the supervision. Instead, supervision works better when the supervisor demonstrates how to determine the student’s zone of proximal development regarding the issue at hand. The student will understand how the supervisor is addressing the problem. If the

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Interpersonal Approaches to Psychotherapy Supervision: A Vygotskiian Perspective 173 supervisor identifies the process to the student, then one of two things will occur: The student will accept or reject the diagnosis. But no course of action follows. If the supervisor asks whether the time is good or whether they might switch if the student has trouble with that time, the responsibility to make supervision work falls more on the student’s shoulders, and the student learns about options to use with the patient. The pivot is a transitional linguistic device bridging the space between a person’s accumulating meaning structures and an activity. It is language objectified. But for Vygotsky, language took on several aspects. LANGUAGE Language is central to Vygotsky’s ideas. He saw egocentric thought not as something to be replaced but as an autistic, eidetic, or experiential language that endures. This mode of experience is the individual’s graphic representation of the world undifferentiated as to what is external and what is driven by wishes and needs. It works through analogy, originates preverbally, and is often inadequately symbolized in words. External speech allows us to affect the environment; internal speech allows us to connect that which we learn from the outside to our inner experience and to process these experiences, perhaps forming insights. What we learn scientifically and externally can be internalized. When specific life events or spontaneous learning can be metabolized into hierarchical and systematic thinking, scientific discourse is accomplished. All of this is well and good, but what does it have to do with psychotherapy and its supervision? This system is a process model that shows how both molecular and molar learning occurs. It fits well the type of learning that psychotherapy requires. For example, we grow up with hyper-real concepts of what type a person a psychologist or a psychotherapist is. Kubrick’s A Clockwork Orange, Vance Packard’s Hidden Persuaders, and John Frankenheimer’s The Manchurian Candidate were society’s ways of expressing fears about behavior modification, subliminal persuasion, and brainwashing, respectively. How do we learn our concepts of psychology or of psychotherapy but through societal images, be they real or fantasy? How did we acquire our images of psychotherapy but through television’s Frasier or the Sopranos’ Dr. Malfi? An older generation learned through Bob Newhart, or even Montgomery Clift’s portrayal of Freud, what a psychotherapist looks like, how he thinks, and how he behaves. The first task of a supervisor might be to learn students’ spontaneous or autistic thoughts. Regarding assessment, Schaefer (1954) described four rather unconscious roles students bring to the testing session: voyeur, oracle, autocrat, and saint or savior. As Wood (1987) described, students can wish to become psychotherapists to help heal parts of themselves, particularly the parts they project onto others they see as damaged and in need of healing. This is not necessarily negative, but these egocentric thoughts can lead to blindness in the psychotherapist. These analogic images need to be processed so students can become psychotherapists with the patient’s welfare uppermost in mind. The psychotherapist’s identity, discussed in the previous models, can be conceptualized as a dialogue between the three speeches: his or her internal speech

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that exchanges with external speech and is fortified by egocentric speech. This approach calls for an entirely different role for the supervisor—one that is more enriching, fun, and personally enhancing. By sensitively participating in how the student structures psychotherapy and supervision sessions, and by seeing what responses the student elicits in both the patient and the supervisor, the supervisor makes possible a special type of learning. We rarely have a chance to learn how we impact others—what our stimulus value is. TO A LOUSE ON SEEING ONE ON A LADY’S BONNET AT CHURCH O would some Power, the gift to give us, To see ourselves as others see us! It would from many a blunder free us, And, foolish notion: What airs of dress and bearing would leave us, And even pridefullness! —Robert Burns (1759–1796)2

Within a safe, caring, and authentic supervision, a student can learn how he or she impacts others. This is an uncommon opportunity, as the effective supervisor ought not to have an ax to grind, no personal gain in mind, nor any sadism to express. Instead, the supervisor’s dominant goal ought to be the realization of the student’s abilities to effectively engage in interpersonal and intrapersonal relationships. The latter refers to continued introspection and improvement after the termination of supervision. With Vygotsky’s approach, the supervisor can explore his or her own images, ranging from egocentric to external (the strictures of our profession and its ethics code as well as local agency strictures) to internal (literature findings as well as our understanding of our experiences and the subsequent processing of these into an internal system of psychotherapy and system of supervision). For those who have done little to no prior supervision, the process of discovery is thrilling. For those who have some experience, learning how this particular student in training construes his or her clients is new learning that is a wellspring for the supervisor. Jaded supervisors are anomalies for this Vygotskiian method; that is, it seems endlessly fascinating to be involved in understanding this multilayered system of learning the client’s and the student’s language systems and their matches and mismatches. There are two forms, indispensable to the building of true human life, to which the originative instinct, left to itself, does not lead and cannot lead: to sharing an undertaking and to entering into mutuality. (Buber, 1965, p. 87) Compulsion in education means disunion, it means humiliation and rebelliousness. . . . Freedom in education is the possibility of communion: it cannot be dispensed with

2 Selected and transliterated by the first author and available from www.mikeseigelczc.com/oldubbArchives/archive-000002/HTML/20000819-20-000002html.posed12/20/2001, edited by snorrithor3July2000.

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Interpersonal Approaches to Psychotherapy Supervision: A Vygotskiian Perspective 175 and it cannot be made use of in itself: without it nothing succeeds, but neither does anything succeed by means of it: it is the run before the jump, the tuning of the violin, the confirmation of that primal and mighty potentiality which it cannot even begin to actualize. (Buber, 1965, p. 91)

REFERENCES Bandura, A. (1989). Human agency in social cognitive theory. American Psychologist, 44, 1175–1184. Baumeister, R. F., Bratslavasky, E., Muraven, M., & Tice, D. M. (1998). Ego depletion: Is the active self a limited resource? Journal of Personality and Social Psychology, 74, 1252–1265. Beier, E. G. (1966). The silent language of psychotherapy: Social reinforcement of unconscious processes. Chicago: Aldine. Bitterman, M. E. (1965). Phylogenetic differences in learning. American Psychologist, 20, 386–410. Blanton, S. (1971). Diary of my analysis with Sigmund Freud. New York: Hawthorn Books. Blundin, A. (1997). Vigotsky and the dialectical method [Vigotsky archives]. Retrieved July 31, 2007, from www.marxists.org/archive/vygotsky/works/comment/vygotsk1.html. Buber, M. (1965). Between man and man. New York: Macmillan. Buber, M. (1970). I and thou. New York: Scribner. Carson, R. C. (1969). Interaction concepts of personality. Chicago: Aldine. Cole, M., & Maltzman, I. (Eds.). (1969). Contemporary Soviet psychology. New York: Basic Books. Corsini, R. J., & Wedding, D. (2005). Current psychotherapies (7th ed.). Belmont, CA: Brooks/Cole. Daniels, H. (Ed.). (1996). An introduction to Vigotsky. London: Routledge. Ekstein, R., & Wallerstein, R. (1972). The teaching and learning of psychotherapy (2nd ed.). New York: International Universities Press. Frankl, V. E. (1984). Man’s search for meaning. New York: Washington Square Press. Hahn, W. K. (2001). The experience of shame in psychotherapy supervision. Psychotherapy, 38, 272–282. Haley, J. (1963). Strategies of psychotherapy. New York: Grune & Stratton. Hess, A. K. (1987). Psychotherapy supervision: Stages, Buber and a theory of relationship. Professional Psychology, 18, 251–259. Hess, A. K. (1997). The interpersonal approach to the supervision of psychotherapy. In C. E. Watkins, Jr. (Ed.), The handbook of psychotherapy supervision (pp. 63–83). New York: Wiley. Hess, A. K. (in press). The sense-of-the-other: At the core of interpersonal theory and practice. Journal of Contemporary Psychotherapy. Holloway, E. (1995). Clinical supervision: A systems approach. Thousand Oaks, CA: Sage. Klein, G. S., & Schoenfeld, N. (1941). The influence of ego-involvement on confidence. Journal of Abnormal and Social Psychology, 36, 249–258. Kozulin, A. (1990). Vygotsky’s psychology. Cambridge, MA: Harvard University Press. Lakoff, G., & Johnson, M. (1980). Metaphors we live by. Chicago: University of Chicago Press. Matarazzo, J. D. (1972). Wechsler’s measurement and appraisal of adult intelligence. Baltimore: Williams & Wilkins. Mitchell, S. A. (2000). Relationality: From attachment to intersubjectivity. Hillsdale, NJ: Analytic Press. Monte, C. F., & Sollad, R. N. (2003). Beneath the mask: An introduction to theories of personality (7th. ed.). Hoboken, NJ: Wiley. Neisser, U. (1976). Cognition and reality: Principles and implications for cognitive psychology. San Francisco: Freeman. Nelson, M. L., & Friedlander, M. L. (2001). A close look at conflictual supervisory relationship: The trainee’s perspective. Journal of Counseling Psychology, 48, 384–395. Oatley, K., & Jenkins, J. M. (1996). Understanding emotions. Oxford, England: Blackwell. Olk, M. E., & Friedlander, M. L. (1992). Trainees’ experiences of role conflict and role ambiguity in supervisory relationships. Journal of Counseling Psychology, 39, 389–397. Parkinson, B., & Totterdell, P. (1999). Classifying affect-regulation strategies. Cognition and Emotion, 13, 277–303. Pepper, S. C. (1942). World hypotheses. Berkeley: University of California Press. Peterson, D. R. (1968). The clinical study of social behavior. New York: Appleton-Century-Crofts. Sahakian, W. S. (1968). History of psychology; A sourcebook in systematic psychology. Itasca, IL: Peacock. Schaefer, R. (1954). Psychoanalytic interpretation in Rorschach testing. New York: Grune & Stratton. Stolorow, R. D. (1993). An intersubjective view of the therapeutic process. Bulletin of the Menninger Clinic, 57, 450–457.

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Stolorow, R. D., Atwood, G. E., & Brandchaft, B. (Eds.). (1994). The intersubjective perspective. Northvale, NJ: Aronson. Stolorow, R. D., Brandchaft, B., & Atwood, G. E. (1987). Psychoanalytic treatment: An intersubjective approach. Hillsdale, NJ: Analytic Press. Waterman, A. S. (1993). Two conceptions of happiness: Contrasts of personal expressiveness (eudaimonia) and hedonic enjoyment. Journal of Personality and Social Psychology, 64, 678–691. Watkins, C. E., Jr. (Ed.). (1997). The handbook of psychotherapy supervision. New York: Wiley. Wechsler, D. (1943). Non-intellective factors in general intelligence. Journal of Abnormal and Personality, 38, 101–103. Westen, D. (1999). The scientific status of unconscious processes: Is Freud really dead? Journal of the American Psychoanalytic Association, 47, 1061–1106. Wink, J., & Putney, L. G. (2002). A vision of Vygotsky. Boston: Allyn & Bacon. Wood, B. L. (1987). Children of alcoholism: The struggle for self and intimacy in adult life. New York: New York University Press. Yourman, D. B., & Farber, B. A. (1996). Nondisclosure and distortion in psychotherapy supervision. Psychotherapy, 33, 567–575.

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PART FOUR

SPECIAL MODALITIES

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C H A P T E R 11

Supervision of Couples and Family Therapy LYN E. STYCZYNSKI and LEONARD GREENBERG

THE SUPERVISION of couples and family therapy is embedded in a theoretical tradition of appreciating the power of multiple realities and contexts. From this philosophy, a number of approaches to couples and family therapy have evolved. Each of the different approaches emphasizes a different philosophy and different skill base in the therapeutic work. However, a central commonality of systemically based family and couples therapy has been a therapeutic stance emphasizing active interventions. Supervision of couples and family therapy likewise tends to be particularly active but occurs within a wide range of philosophies and techniques. In writing this chapter, we were immediately struck by the problem of characterizing supervision of the variety of models of family and couples therapy in a single chapter. The problem of writing about family therapy supervision mirrors the problem of providing that supervision. As family therapists for 30 years, we have trained in a variety of therapeutic models—structural, strategic, systemic, Bowenian, solution-focused, narrative, and, to a lesser extent, Nagyian, psychodynamic, structural analytic, and behavioral. Because of the plethora of approaches, it is difficult to write a chapter that adequately characterizes the variations in our own supervisory approach. And it is clearly not possible to contain within these pages a complete description of the variation that exists in the field of couples and family therapy supervision. This chapter represents a summary of the commonalities among couples and family therapy approaches and the ways in which they are unique. In addition, given the constraints of a single chapter, we have chosen to focus on the challenges and techniques that are common to systemic approaches to therapy, both for couples and families. Thus, when we refer to family therapy supervision, it is to be understood as couples therapy as well. The wide variety of conceptual approaches in family and couples therapy also underscores one of the fundamental problems in supervising family therapy. As 179

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family practitioners, we tend to think that the theoretical, didactic background necessary to do competent family therapy is at least as extensive as that which is necessary to do proficient individual therapy. However, the training provided in academic programs rarely reflects this. Most graduate programs in social work, psychology, counseling, and psychiatry provide only a single course in family treatment. (The more exceptional programs may provide a two-course sequence.) This means that in family therapy supervision, the task of the supervisor is often broader, in that the trainee is struggling both with understanding the concepts and theory as well as with performing the mechanics of the treatment. RESEARCH Although family and couples therapy has traditionally placed a strong emphasis on supervision, the available empirical research in the field of family and couples therapy is quite limited. Recent research suggests that key dimensions that distinguish positive and negative family therapy supervision experiences include creating an open supervisory environment, communicating, providing encouragement, attending to personal growth, and providing conceptual and technical guidance and direction (S. A. Anderson, Schlossberg, & Rigazio-DiGilio, 2000). Supervisor multicultural competence was demonstrated to be positively associated with supervisory working alliance and perceived supervision satisfaction (Inman, 2006). Using a 40-item Family Therapy Skill Evaluation, Doty (1985) found that both trainees and supervisors reported increased skill over time in family therapy supervision, with trainees evaluating their own skill levels higher than their supervisors. Research focused on the family therapy supervision process (Ratliff, Wampler, & Morris, 2000) found that, when there was a lack of consensus between trainee and supervisor, supervisor responses were characterized as influence and evaluation; trainee responses as cooperation and deference; and the supervisor–trainee interaction as negotiation and cooperation, in which the supervisor offered requests in a subtle manner that appeared open to modification, and the supervisor cooperated with the trainee in creating a competent and cooperative image. In a qualitative study (Murphy & Wright, 2005) of the use of power in family therapy supervision, trainees perceived supervisors as (a) using power to empower trainees, promote an atmosphere of safety, collaborate with supervisees, and impose style or orientation; and (b) misusing power (e.g., to violate confidentiality). Power use themes for trainees included supervisee–peer power, supervisee as consumer, and withholding information. In examining the live supervision process, Moorhouse and Carr (1999) found that less frequent phone-ins were associated with greater client cooperation, greater supervisor collaboration, and less therapist collaboration with clients. When the gender of supervisor/trainee pairs in live supervision was examined by these same researchers (Moorhouse & Carr, 2002), the highest quality supervisor collaborative behavior was found in male supervisor/male trainee systems and the lowest quality in male supervisor/female trainee teams. In female supervisor/male trainee pairings, the trainee engaged in more frequent collaborative and supportive behavior with clients and less frequent teaching. Morgan and Sprenkle (2007) used a meta-analysis of supervision literature to produce an initial list of 283 supervision activities. Based on this data they proposed a

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Supervision of Couples and Family Therapy 181 three-dimensional model of supervision with three continua (emphasis, specificity, and relationship) and four supervision roles (mentor, coach, teacher, and administrator). In summary, most previous research has focused on specific questions in relation to family therapy supervision, but the recent literature has begun to take a more integrative approach.

S K I L L S T H AT M U S T B E L E A R N E D TAKING AN ACTIVE STANCE In family therapy the problems within the family usually become apparent within the sessions as the work progresses and family interactions occur. This is different from individual therapy, in which the patient might tell of problems occurring elsewhere but can more easily avoid or defer showing his or her problems in the treatment setting. In contrast, family problems are readily displayed during family sessions. The family therapy trainee must be able to attend to a variety of problems as they materialize in the session, and he or she must have an active approach to keep the session from getting out of hand and provide the family with a different interactional experience. The trainee typically looks to the supervision to get the large knowledge base needed to actively manage sessions as well as the conceptual training to support this. Thus, the supervision task, especially with beginning family therapists, can seem daunting for all involved. By virtue of his or her active involvement in families, the therapist must be able to understand the nature of the problems that he or she is seeing and must have the social skills to work with them effectively. Though the therapist may bring many of these social skills from other social situations, some of them are unique to family therapy. The therapist must be able to be both central and peripheral to the conversation. When central, the therapist manages the conversation so that it is directed at the therapist. When peripheral, the therapist must be able to politely direct the clients to speak to each other, while observing their interactions. Leading a conversation is an active process, and the family therapist makes a series of decisions about when and how to direct the interactions. The therapist must be able to cut off people who are running on without insulting them, recognizing that this is a context in which individuals are often hypersensitive to criticism. Likewise, he or she must be able to draw out more reserved family members. Additional challenges occur when individual family members attempt to get the therapist to take sides with them against other family members. The therapist must be able to remain joined with a family member while rejecting the invitation to take his or her side.

CONCEPTUALIZING DIFFERENTLY To become competent in doing family therapy one must master a substantial array of theoretical knowledge. A therapist working with families needs to accept the notion that a family is not simply a group of individuals but is an entity unto itself, with emergent properties that are larger than individuals. This requires that the therapist see the family members’ actions in context and recognize that the

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context is a significant force in determining the actions. Because this approach to conceptualizing therapeutic problems is particular to family and couples treatment, the trainee must learn to forgo previous ways of thinking and doing to learn this modality. We find the notion of multiple subjective realities particularly useful in working with families. This contrasts with the belief in a single correct explanation for a problem that tends to imply a correct way of addressing the problem. We believe that families can become stuck by tenaciously adhering to a particular explanation or belief system. An important task in supervision is often helping the supervisee see that there are multiple explanations for what goes on in a particular family and that he or she may choose to use the explanation that provides the greatest utility or most productive opportunity for change. Often considering the idea of homeostasis (the force within a system to maintain sameness) is useful because this idea implies that the task of therapy is to create movement, not to induce a specific change. Subjective reality and homeostasis are particularly useful concepts for supervising work with families. Supervisees often have ideas about what is good for a family. Selling a particular solution to families is often more difficult than simply persuading them to try something different. Nevertheless, it is often hard for supervisees to abandon their own sense of how they would like families to do things and settle for getting the family to abandon the problematic status quo. This can be especially difficult for supervisees whose desire to do good may exceed their knowledge of their limitations in the therapeutic role. Another conceptual task that is sometimes difficult for family therapy trainees is attending to organizational aspects of the family as a system rather than just treating it as a collection of individuals. Because most therapists do not train first in family therapy, not fully understanding the ways that family therapy differs from individual therapy may create problems for supervisees. For new therapists, the problem is often that they have only recently learned to do individual therapy and now they must suspend much of what they have just learned in order to assume a new model. For experienced therapists, learning family therapy often involves undoing ingrained habits from individual therapy; this too can be challenging. For trainees accustomed to a pathology-focused approach to therapy, an additional shift is that many family therapy models put considerable emphasis on activating family strengths to enhance the family’s problem-solving abilities and using positive connotation to further change the family’s experience. There are conceptual challenges, not unique to family therapy, but still especially important within this modality. A trainee must be knowledgeable of norms for both individual development and family development. The supervisee is expected to be sensitive to issues surrounding gender, race, and sexual orientation. One must be aware of the cultural norms affecting the family with which one is working while avoiding excessive stereotyping based on those norms. USING AFFECTIVE TONE A family therapy supervisee should learn to recognize that in joining with a family, he or she accommodates not just to the family’s perspective but to its affective tone as well—volatile, avoidant, jovial, suspicious, placating, hopeless. The

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Supervision of Couples and Family Therapy 183 supervisee must know how to create a new affective tone within the family. This may include an ability to create play in serious situations, to inculcate concern when the family is nonchalant, and to activate warmth when presented with anger and hostility. Affective tone can seem such a fundamental characteristic of the family that it is sometimes difficult to recognize that it can be a target for intervention. This is often the place where a supervisee’s emotional reaction to the family is most relevant. Helping the supervisee identify his or her reaction to the family and then utilize it effectively is often an important supervisory task. In contrast to one doing individual therapy, the therapist working with families does not use emotional reactions as just a diagnostic tool. Instead, the family therapist ideally energizes his or her interventions with those reactions. The challenge of being not merely an observer but a participant in the family’s drama requires one to be acutely aware of one’s personal investment in the intervention. It is important to be sure that interventions reflect the needs of the family, not the personal needs of the therapist. The supervisor of family therapy must balance the knowledge that effective family therapists uses themselves personally in their interventions with an awareness that supervisees are rarely without significant blind spots about what they bring to their therapeutic work. Supervisors must use their own clinical judgment about the personal resources and stage of professional development in supervisees to determine how much to encourage the use of self in treatment. This dilemma can be further exacerbated by the extent to which the supervisor has other tasks as well. The need to impart specific knowledge about cultural norms, techniques of intervention, and alternative ways of conceptualizing the family often takes precedence over specific explorations of supervisees’ personal experiences. WORKING WITH CONFLICT Working with conflict can be particularly unsettling, especially for those new to family therapy. Family members do not always behave well toward each other in family sessions. Although some exceptionally negative behavior can never be tolerated in family sessions, there are times when it is tactically inappropriate to critique family members for behavior that is unpleasant for the therapist to observe. In working actively with family conflicts in a therapeutic setting, a therapist usually does not immediately disrupt family disputes. A new family therapist must often learn to live with the discomfort associated with not intervening precipitously in those situations. A supervisee particularly prone to providing comfort to distressed clients often finds tolerating family conflict particularly challenging. The supervisee must learn not to intrude so aggressively into family conflicts that he or she impedes the family’s learning to manage the conflicts better themselves. Not only must the therapist be able to tolerate family conflict, but he or she must be able operate effectively in its presence. Learning how to be in control when the family is not can be an important skill for the new family therapist to develop. The family therapist must be able to wrest control from controlling family members as well as facilitate risk taking by the meek. The therapist must be able to both deflect conflict and facilitate conflict as well as know when to do each. At times,

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the therapist should be willing to support one side of an argument and not another based on strategic considerations, not simply which side is most consistent with his or her own values. The flexibility to support individuals regardless of one’s own opinions does not come naturally to many trainees. Several things can help cultivate this flexibility. In particular, a worldview that supports the perspective that there is more than one way to see things and more than one correct solution to problems is central to family work. Supervision around this stance may involve some exploration of supervisees’ own values and may challenge the tenacity with which they are held. USING A RANGE OF INTERVENTIONS The supervisor of individual therapy can usually assume that his or her supervisee already possesses most or all of the theoretical knowledge necessary to plan and implement a therapeutic intervention; supervision then serves to facilitate the implementation of those ideas. In contrast, the family therapy supervisor can anticipate that his or her supervisee may need to learn a range of interventions during the supervision so as to accommodate to the particular needs of the family with which he or she is working. Part of the reason for this difference derives from the expectation that much of the work in individual therapy centers around acquiring a more subtle understanding of the client. Although diagnostic work in family therapy is also important, often the biggest tactical challenges are not in understanding families but in finding ways to utilize this understanding to create effective change. Individual therapists most frequently have sessions in which the clients report problems that occur in their day-to-day lives; it is possible for the therapist to listen to them, consider them, discuss them with their supervisor, and then attend to them in the next session. In contrast, most often the family therapist is confronted with problems occurring immediately in the session. Optimally, the new therapist would be knowledgeable in a wide range of interventions, but in reality this is frequently not the case. Under the best of circumstances, the experienced supervisor may be able to anticipate likely challenges based on his or her experience with similar families. In actuality, the family therapy supervisor is frequently confronted with the problem that a supervisee has unsuccessfully met the challenges that the client families present and now needs to recover. Perhaps the best way for the supervisor to accommodate this problem is to expect that it is a natural process for families to trap, bind, and otherwise co-opt the therapist into undesirable positions or stances. The supervisor can assume that joining with the family frequently results in suboptimal positioning by the therapist, that it is a basic therapeutic task to extricate oneself from such undesirable commitments or positioning, and that it is the supervisor’s task to facilitate this. CONSIDERING SOCIAL SKILLS AND BAD HABITS A family therapist cannot lead simply by assuming the role of expert about how therapy should proceed, nor can he or she be the arbiter of what is right or best for the family. Rather, the family therapist tends to minimize the extent of his or

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Supervision of Couples and Family Therapy 185 her knowledge so as to emphasize the family’s own resources. A family therapist often derives a sense of expertise from the role of facilitator rather than expert. Helping supervisees become comfortable with their role as facilitator rather than purveyor of expert knowledge is sometimes an important task in supervision. A frequent challenge in learning the role of expert facilitator is learning how to be “one down.” In being one down, the therapist must be willing to say, “I don’t know; please explain to me.” For new supervisees, the ability to say “I don’t know” as a means of showing self-confidence and as a therapeutic strategy may be novel, but it is an essential skill in activating competence or knowledge in families. Often in working with the new family therapists, the supervisor must contend with styles of leadership that are excessively formal or otherwise stilted. These bad habits may include needing to announce what one is going to do before one does it or using a therapeutic voice that has an artificial tone. It is desirable to learn how to lead without sounding bossy or excessively authoritarian. One must learn how to say “I don’t know” in such a way that it enhances one’s authority and how to introduce new ideas in ways that are easy for a family to make those ideas their own. E N G A G I N G I N S U P E RV I S I O N : I S S U E S I N S TA RT I N G O U T In some ways, the process of engaging in family therapy supervision is not different from that of engaging in individual supervision. Most often there is an initial discussion or engagement period in which the supervisor and supervisee become acquainted and agree about the focus of supervision. However, because family therapy has many models and approaches, the initial negotiations will often involve discussion of the models the supervisee wants to learn in relation to the models in which the supervisor feels he or she is most proficient. Frequently compromises are necessary. As in the supervision of other treatment modalities, the supervisor and supervisee must agree on the extent to which they will regularly cover all of the supervisee’s work versus focusing on specific problems, cases, or issues. There should be some understanding as to whether the supervision will be primarily supportive and problem solving in nature or whether it will focus on development of the supervisee’s style and technique. The clearer the understanding of these and similar issues, the more likely both parties will be to consider the supervision successful. Family therapy generally makes the assumption that therapists intervene actively and, in doing so, present a visible style and personality in their sessions. The development of a therapeutic persona that is natural and effective, yet does not prioritize the therapist’s needs over those of his or her clients, can be an important task in supervision. It is often useful for a supervisee to see and understand how a supervisor does this in the latter’s own therapeutic work. For this reason the supervisor may offer the trainee an opportunity to watch the supervisor in a therapy or consultation interview, see videotapes of the supervisor’s work, or have the supervisor role-play therapeutic interventions. This can help the supervisee visualize how the supervisor might execute interventions that are described to the supervisee, although clearly supervision must focus on helping the supervisee develop his or her own style.

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Many models of supervision make the assumption that the supervisee has all or most of the skills necessary to intervene effectively; supervision then focuses on identifying appropriate opportunities at which to intervene. One thing that may set family therapy apart is the expectation that mastering the mechanics of implementing an effective intervention is most often a greater challenge than knowing when to intervene. It is useful for a supervisee to have the awareness that supervision will focus not just on when to intervene but also on how to intervene. In developing the supervision relationship, the supervisee may wish to see family therapy as not so different from individual therapy. However, both the style of leadership and the nature of interventions are qualitatively different in family therapy. For supervisees to make effective use of family therapy supervision it is easiest if they do not immediately take it for granted that they can import learning from other modalities. Only as they gain experience doing family therapy will they be able to discriminate which aspects of family therapy are similar to individual therapy and therefore justify carrying over their knowledge and experience from those approaches. Homeostasis is a central concept in family therapy. Families who come to treatment tend to have achieved an equilibrium such that minor initiatives for change eventually lead to self-correcting forces that return the family to its habitual way of doing things. Homeostasis implies that families often have a strong impulse to avoid change and that they can be skillful in inducting the therapist into a nochange position. Induction occurs when the therapist is drawn into abiding by the family system’s implicit rules. An understanding of homeostasis and induction can be valuable to the new family therapist in that it clarifies that a therapist may expect to be seduced into unproductive ways of relating to families because of homeostatic forces. Thus, it is a therapist’s job not to avoid being inducted but rather to find ways out once he or she has become inducted. The concepts of homeostasis and the family’s inductive potential are especially useful to new therapists because they invite the notion of identifying ways in which the therapist is being ineffective without the expectation that it is due to some failure on the therapist’s part. It is particularly valuable to introduce these concepts to supervisees early in supervision so that challenging some of the ways in which the trainee is being inducted can be relatively nonpejorative. Early in the supervisory process it is also likely that the supervisor will begin to become conscious of the interpersonal range within which his or her supervisee tends to operate. The supervisor will begin to track the extent to which a supervisee uses drama or intellectualization. The supervisor may also track other aspects of style, such as the ease with which the supervisee provides support or initiates challenges. Taking this assessment of the supervisee’s range is important in order to judge both which interventions a supervisee can successfully execute and which they cannot. This helps a supervisor suggest interventions that the supervisee is most likely to use effectively in treatment. It is useful to recognize the type of interventions that are near the boundary of the supervisee’s abilities. This enables the supervisor to successfully offer interventions that broaden the range within which the supervisee ordinarily operates. It is also important for the supervisor to track the current level of development of supervisees in performing family therapy. Supervision of beginning family

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Supervision of Couples and Family Therapy 187 therapists will require a greater emphasis on education in the mechanics of doing family therapy. New therapists of course have the advantage that they are especially excited by what they are learning. Often their enthusiasm can be a force that makes things happen that might otherwise not occur. The experienced therapist, in contrast, is less likely to be overwhelmed by pathology and crises. He or she may be more committed to a way of doing things, and although an experienced therapist may have the time and energy to focus on range and style, he or she may be settled in a way of approaching things and less likely to incorporate new ideas or a broader range in his or her interpersonal style. Being conscious of the supervisee’s stage of development clearly has an impact on both the style and emphasis of supervision. PRIMARY MODELS OF SUPERVISION Throughout its history, family therapy has embraced diverse models of supervision. In particular, family therapy has placed great emphasis on supervision using videotape and live supervision from behind a one-way mirror. It may be that the nature of family therapy as a more public event makes it easier to execute more public forms of supervision. It may also be that the emphasis on interpersonal skills as a requirement for effective family therapy necessitates models of supervision that facilitate the observation and coaching of interpersonal skills relevant to therapeutic interventions. Or it may be that family therapy developed at a time and in contexts when the technology for live supervision and video supervision were more available. Family therapy supervision is also provided in a didactic format based on the verbal report to the supervisor of what the supervisee remembers and sees as relevant. Didactic Supervision The most common kind of family therapy supervision takes place in a one-to-one meeting between supervisor and trainee in an office with the discussion focused on the trainee’s cases (Lee, Nichols, Nichols, & Odum, 2004). This is most efficient, allowing for the addressing of several different cases in a single supervision hour. It also increases the opportunity to focus on the trainee’s formulation of the case and internal process in relation to what is occurring in the sessions. However, the supervisor is dependent on the reporting of the trainee to understand what is occurring in a therapy with highly complex interactions. Didactic supervision works best when the supervisor is helping the trainee use his or her existing skills on behalf of families for whom there is a good working formulation of the case and problem. The supervisor must assess what biases the trainee may have in process reporting and include this in supervisory decisions. Expanding the trainee’s repertoire of technical skill is more challenging within this supervisory context, especially if the proposed new technique requires a significant shift from the trainee’s preferred therapeutic stance. Role-playing, reading, and watching videotape examples of new techniques can provide additional perspectives for the trainee along with a clear discussion of the rationale behind the technique so that the trainee sees it as an opportunity for both the family and himself or herself. A major tool in this type of supervision is the supervisory relationship.

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The supervisor can choose to increase or decrease the trainee’s arousal, direct the focus in a particular case, challenge in a playful or dramatic way, or take a more collaborative or directive stance to ensure that the supervision continues to improve and expand the trainee’s skill. Videotape Supervision Videotaping sessions for supervision offers some unique advantages and disadvantages and particular technical challenges. Video recording, especially if done routinely, is notably less intrusive into the therapy process than live supervision and easily disappears from the consciousness of both family and trainee as the session unfolds. Interactions that can be observed on video might be missed in the trainee’s awareness and process recording or might not be a focus in a live supervision session when the primary goal is to cocreate a successful session for the family and the trainee. In supervision, watching videotapes provide the opportunity to stop action in the flow of the session. The trainee or the supervisor can review the tape and select segments on which to focus, or the supervisor can pause the tape to discuss what has been observed. It is thus possible to address what occurs in the session on more of a microlevel. Accomplishing this productively, however, is labor intensive. Reviewing an entire taped session during supervision (with time to pause it to discuss) is seldom possible. For the supervisor or trainee to review the tape and select segments before supervision also requires considerable time and energy often not available in professional schedules. In selecting segments, the trainee and supervisor should have an understanding of why particular segments are being chosen. The selected segments must be put in the context of the rest of the session and the therapy. In addition, the supervisor must recognize that the trainee’s response in a particularly challenging portion of a session has been taken out of context and does not necessarily represent his or her stance at other times in therapy (either at different points during the particular session or in other treatments). Finally, several significant dimensions are notably diminished by video recording—the nature of the affect present during the session, the events that are occurring off camera, and the trainee’s internal process. All of this must be taken into account in the supervision process. Useful guidelines for video supervision have been proposed (Breunlin, Karrer, McGuire, & Cimmarusti, 1988). These include (a) focusing videotape supervision by setting goals, (b) relating internal process across contexts, (c) selecting tape segments that focus on remedial performance, (d) using supervisor comments to create a moderate evaluation of performance, (e) refining goals moderately, and (f) maintaining a moderate level of arousal. These guidelines clearly recognize the vulnerability of trainees in the video supervision process and the tendency they may have to judge themselves harshly when observing themselves on video. According to these guidelines, it is the supervisor’s responsibility to manage the supervision process to maintain moderation in evaluation feedback, goal setting, and level of arousal so as to optimize learning. Live Supervision Family therapy supervision has traditionally included the possibility for the family and trainee to meet in front of a one-way mirror while the supervisor and other

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Supervision of Couples and Family Therapy 189 trainees observe from behind the mirror. During this live supervision session, the supervisor may call the trainee with suggestions during the session, or the trainee may leave the session to have short supervision conferences. The supervisor is able to observe dimensions of the trainee’s work that are not possible to convey in a report on a session. And the trainee can be given suggestions as the session unfolds to allow him or her to interact and intervene in ways that he or she might not otherwise do. The supervisee might not have previously had an intervention in his or her repertoire, might not have the courage to try to execute the intervention without live support, or might typically choose a different direction for the session than the one he or she develops with the supervisor in the live context. The live supervision context allows the supervisor to expand his or her understanding of the trainee as a therapist; the trainee is able to expand his or her range as a therapist, try new things, and experience new possibilities with the immediate support of the supervisor. Although it is time intensive, live supervision allows for a level of supervision not otherwise possible and, when done as a team, allows multiple trainees to learn from one another’s experiences. Live supervision begins with helping the supervisee to become comfortable with the context. Optimally, the trainee will experience live supervision as a team effort in which he or she and the supervisor are collaborating within different roles. It is the supervisor’s task to provide feedback that matches the trainee’s therapeutic style and the needs of the family. It should be made clear that the success of the session is the supervisor’s responsibility. Observing other live supervision done by the supervisor is often useful for the trainee. When the first anxiety-laden live supervision session goes well, the trainee usually experiences subsequent live supervision as supportive and expanding. Clearly the development of a comfortable and trusting relationship between supervisee and supervisor is crucial to smooth teamwork in this modality. It has been our experience that, in negotiating with a family about participating in a live supervision experience, the more comfortable the trainee is with the context and the more he or she is convinced of the benefit to the family, the easier this negotiation proceeds. In preparing the family, the student may need help in striking the right balance in openly providing information about how the live supervision session will be different. The goal is to allow the trainee and family to work together in optimally effective ways, with the supervisor remaining as much in the background of the family’s awareness as possible. In deciding which families are appropriate to bring to live supervision, the supervisor–supervisee team should be aware that some families (e.g., those who are suspicious) may find the context difficult. Before the session begins, the supervisor and trainee must create a game plan. This usually includes the trainee’s goals for the session (both for himself or herself and for the family) and a plan for how the trainee will begin the session. It may also include a tentative plan for the rest of the session, with an understanding that this may be revised based on what and how the family presents, and the judgment of either the therapist or supervisor. It can be useful to have an agreement that the therapist may step out for a conference with the supervisor if there is a major change in the game plan, to ensure that therapist and supervisor are collaborating toward the same goals with the same plan.

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Live supervision requires the supervisor to develop additional supervision skills. With an intercom phone system or bug in the ear, timing the phone-in so that it occurs at a point in the session when the therapist can stop the flow of the session long enough to receive the suggestion is often challenging. The supervisor must be sensitive to creating patterns (e.g., always interrupting after a particular family member speaks) yet call in a sufficiently timely way to guide the development of the session. The feedback must be short, clear, and constructive. Live supervisors must adapt their feedback style to the learning or receiving style of the therapist in the room. Some trainees like being given specific instructions as a way to jumpstart a new direction (e.g., “Ask each member of the couple if they still love each other”), whereas others prefer to be told which direction to go (e.g., “Can you find a way for the father to be more involved?”). Supervision in which the trainee leaves the room for a conference likewise requires the supervisor to be succinct and sensitive to the trainee’s level of anxiety, receiving style, and current range as a family therapist. The conference approach is more disruptive to the session but allows the trainee to clarify or disagree if necessary. It is often especially useful toward the end of a session when the goal is for the final stage of the session to be dramatic or summarizing. For the supervisor and supervisee to coordinate smoothly can take several live supervision sessions. However, the process will clearly be facilitated by the supervisee having a chance to observe more experienced trainees in live supervision, and engaging in conversations before the session in relation to what the trainee knows about his or her own style of receiving verbal information. When there are other trainees behind the one-way mirror, it is important to create the best learning environment possible. It is the supervisor’s responsibility to orient those behind the mirror and establish norms: that team feedback must be constructive and positive; that the supervisor determines when team feedback is indicated and when this needs to wait while the supervisor works with the therapist; and that the other trainees may operate as consultants in a variety of ways, but ultimate responsibility for the session rests with the supervisor and trainee. Sometimes the supervisor may want to use the team to provide feedback to the trainee that is more effectively received from peers. Whether it is providing specific positive feedback or encouraging the trainee to consider useful alternatives, it should always be done in a supportive tone. It is important to recognize that a live supervision session creates a distinct context for the trainee and the family. The interactions of both are likely to be influenced by the strangeness of the situation and the audience in not entirely predictable ways. Often the nature and level of affective intensity in the therapy room is muted by the observation glass, so the supervisor may need to actively check with the trainee about how it feels in the room. When possible, it is useful to observe other live sessions or to role-play a live supervision session in advance to allow the supervisee to become accustomed to orienting the family to the room and situation, incorporating phone-ins to the flow of a session, and giving feedback after a conference with the supervisor and team; and to help the supervisor and trainee operate smoothly during consultations. In summary, live supervision is a teaching technique particularly suited for the learning of couples and family therapy. Family interactions are complex, and an additional experienced observer can usually see more patterns and possibilities.

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Supervision of Couples and Family Therapy 191 The therapeutic stance is more active and planful, which lends itself to supervisor suggestions as the session unfolds. The supervisor is able to observe those dimensions of the trainee’s work that might not be apparent in other supervision modes. And it is the easiest way for the trainee to try on new therapeutic techniques or stances with the live support of the supervisor. Liddle and Schwartz (1983) also provided extensive recommendations for live supervision. SPECIAL SUPERVISION TECHNIQUES FOR FAMILY THERAPY Family therapy tends to be a relatively public therapy. There are more people in the room, and it often occurs in front of a one-way mirror or video camera. It is also a therapy that emphasizes active techniques that may be difficult to execute. Just as family and couples therapy as a field tends to include an emphasis on technique and be more directive in its stance, supervision in this field has developed special techniques that can be useful around particular supervision tasks (Mazza, 1988). Perhaps because of the challenging nature of this model and the diminished sensitivity about privacy, family therapists have created a variety of special supervision techniques. Rather than coaching from the sidelines, many of these techniques involve the supervisor (or supervisory team) taking a more active and exposed position in the therapy (i.e., the supervisor might at times actively intervene with the family in order to facilitate the supervisee’s work). This derives from the theoretical assumption that it is most important to get someone doing something different—that the experience of doing something differently (whether it’s riding a bicycle or interacting with a family) is much more important than how the person gets there. In this approach to supervision, the experience itself is the most important aspect in getting a new behavior to occur for the trainee, not the process leading up to it. Most of the succeeding interventions are designed to help the supervisee engage with families in a different manner, on the assumption that having gotten there once through the intervention of the supervisor or team, it will subsequently be easier to get there on his or her own. Most of the techniques are specific to live supervision but are occasionally utilized in a more traditional supervisory context. Some were developed by the family therapists we mention; some were inspired by others but are techniques we have developed as supervisors. The Consultation Interview Perhaps the simplest technique is for the supervisor to do a consultation interview with the family in the presence of the supervisee. As family therapists, we tend to believe that families will present themselves differently depending on the context the therapist creates. The therapist who creates a structured organized session is likely to see a more organized functional family. The therapist who gives relatively few cues about what is expected is likely to see a less organized family and, quite frequently, a more complex one. Other aspects of the therapist’s style may similarly bias the way the family operates in therapy. In a supervisory interview, not only does the supervisor get the opportunity to demonstrate technique, he or she also may succeed in getting the therapist to have a different experience of the family with whom that therapist is working (i.e., by interviewing the family differently than the supervisee does, the supervisor may allow the family to show aspects of

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themselves not previously apparent to the supervisee). It is hoped that once the supervisee experiences the family in a new way, a way that he or she may not have known was characteristic of that family, the supervisee will then feel encouraged to activate the observed aspect of the family in future sessions. Clearly it is important to set up the consultation in such a way that the supervisee feels collaborative around the goals for the consultation interview, even though it is often agreed the supervisee will take a passive role during the particular session. Entering the Room during Live Supervision An intervention similar to that of the consultation interview is the supervisor entering the therapy room during live supervision (Calopinto, 1988). This is used most often by supervisors either to help supervisees move beyond an impasse, to demonstrate a particular maneuver, or to give the supervisee a different experience of the family (as in the previous example). This supervisory strategy must be executed with considerable care, as the possibilities for making the supervisee feel undermined are quite significant. If this intervention is used, the supervisor should also be particularly mindful of how such a move will be experienced by the family and how it will affect the therapist’s relationship with the family. Usually this intervention should be planned in advance, with the supervisor requesting and getting the supervisee’s permission to intervene in this manner. Although this intervention can be quite effective, it should be used judiciously given the potential risk that it could adversely affect the therapist–family relationship and the therapist’s budding and vulnerable self-regard. Therapeutic Splits Therapeutic splits, most often used by systemic therapists (Boscolo, Cecchin, Hoffman, & Penn, 1987), is a live supervision intervention in which the therapist offers two conflicting points of view to his or her clients, one held by the clients and one held by the team behind the mirror. For instance, the therapist might offer an optimistic appraisal of the family’s ability to accomplish some particular task while reporting that the supervisor or team behind the mirror does not believe that they will succeed. Although clinically the intervention may have a variety of uses, it is particularly interesting in its effect on the relationship between the therapist and the client. By presenting an apparent conflict between the therapist and the supervisory team, the intervention pushes for an alliance between the family and the therapist. This intervention frequently reduces the emotional distance between the supervisee and the family and may be used by the supervisor for its clinical impact and in order to facilitate a different relationship between the supervisee and the family. The Bet This intervention is a variation on therapeutic splits. The therapist brings up a particular behavioral goal that has been a focus of treatment and is not yet resolved. The therapist then represents that the team or supervisor has offered the therapist a bet that the family is not going to change on a particular dimension (e.g., the father will not be able to stop drinking, the couple will not find a way to stop bickering). The therapist then asks the family if he or she should accept the bet on behalf of

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Supervision of Couples and Family Therapy 193 the family’s ability to succeed at the particular task at hand. This is done in a way to optimize the family’s likelihood for telling the therapist that indeed they will be successful in achieving their goal and the therapist should bet on them, and with the therapist playfully wanting to be sure this is a winning bet. To add to the energy, the trainee may explain that the supervisor is experienced and smart but the therapist believes the team or supervisor does not know the family as the trainee does and is underestimating them. As is apparent, this intervention externalizes both the desire for change and the reluctance to do so. Although seemingly manipulative, it puts an issue front and center and facilitates a playful relationship between the family and the therapist while allowing the therapist to push in a benign, nonauthoritative fashion. By playing with the role of the therapist, the supervisor can challenge some of the formality with which a therapist normally interacts with families. By presenting an intervention that is not typical of more straight-laced therapeutic behavior, a supervisor may facilitate a looser yet still therapeutic role for the supervisee. Reflecting Teams A reflecting team is a group of people who, after observing the family behind a oneway mirror, switch places with a family, going in front of the mirror and speaking with each other while the family observes them (T. Anderson, 1991). Usually the reflecting team presents many different points of view about the dilemmas facing the family and the family’s response to them. These points of view are often in conflict with one another; the team does not take it upon itself to resolve the differences that the different points of view represent. There are many reasons why the use of reflecting teams may be a useful therapeutic intervention; this technique also has particular value in supervision. The use of reflecting teams can be useful with a supervisee who has trouble seeing a family from multiple perspectives. The multiple perspectives presented by a reflecting team often enable the supervisee to understand that there is more than one way to see a family and that families do not necessarily expect resolution of multiple conflicting perspectives on their dilemmas. Strategic Reflecting Team We have found that when a trainee is having difficulty introducing alternative possibilities into a family, engaging the trainee in more actively planning the perspectives of the reflecting team can be a useful clinical and supervision technique. Specifically, when this intervention is planned, the trainee, with the help of the supervisor, develops a number of positions or perspectives (often contradictory) that they would like introduced into the family session. Team members each select a position that they feel they can comfortably represent; the family and trainee meet in front of the mirror for a limited period of time; and the trainee and family then go behind the mirror while the team goes in front of the mirror to discuss the family using the positions they have planned, often with a planned dramatic punctuation (e.g., the team members voting on the family’s chances for success from their particular positions). The trainee is able to observe the family’s reaction to the various positions offered, and the family is put in a position of not being able to respond or argue as they just observe the different positions being taken.

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Finally, the family and trainee exchange places once again with the team, and the family is given the chance to respond to what they have heard while the trainee facilitates the family attending to each of the different perspectives via his or her questions (e.g., “What did you think about the person who said it was a problem of courage versus fear?”). Clearly this strategy helps the family to broaden their perspective and develop a more complex map of their problems. However, it also offers the trainee the opportunity to consider how to shift and add perspective and energy, especially in the middle stages of therapy when the trainee and family may have developed their own rut. The trainee is able to experience the family’s response to the expanded perspectives and to consider how to sustain the new possibilities with the particular family. Narrative Interview Narrative therapy (see Chapter 8) introduced a supervisory intervention in which the supervisor joins the therapist in the room with the family; the supervisor then proceeds to interview the therapist in the presence of the clients. We believe that a supervisee’s emotional response to the family, when used effectively, can be powerful in creating effective movement in therapy. Some supervisees seem to relate to their clients in an impersonal and excessively formal manner. These supervisees often report reactions to their clients in supervision but are unable to utilize their emotional responses to the client during sessions. Interviewing the therapist in the session can be a means of facilitating a more genuine way of working. We have used this intervention with great caution with our supervisees for several reasons. Some supervisees experience the process as threatening to their sense of authority; others are concerned that their clients will feel demeaned by the process. The supervisor must be careful not to interview in such a way that supervisees’ hierarchical relationships with their clients are threatened. One must be mindful that both clients and supervisees can feel out of control when someone new suddenly becomes a part of the therapy. Careful discussion and planning is necessary prior to executing this intervention to keep it from being excessively threatening. Considerations that can ameliorate this jarring effect include ensuring that the family is informed of the training nature of the treatment and sees as cutting edge this modeling by the therapist of emotional comfort and openness. Role-Playing Any list of supervisory techniques in family therapy would be incomplete without the mention of role-playing. A supervisor can expect, at times, to need to present a therapeutic intervention by demonstrating it. Role-plays can be used as a means of demonstrating how to execute a particular maneuver with a particular family. They may also be valuable as a means of enhancing empathy between a supervisee and his or her client. By asking a supervisee to take the role of the client in a role-play, a supervisor may facilitate greater understanding of why the client behaves the way he or she does. Finally, role-plays can provide the trainee with an opportunity to practice and refine a technique before using it with a family or couple.

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Supervision of Couples and Family Therapy 195 SPECIAL PROBLEMS IN THE SUPERVISION OF FAMILY THERAPY Supervisor–Supervisee Mismatch Learning family therapy usually includes simultaneous learning on a number of dimensions including a conceptual shift in formulating cases, selecting the particular family therapy models within which to work and understanding their assumptions, being sensitive to the culture and gender of a particular family, and developing skills both in managing sessions and intervening. Due to the broad range of teaching and learning tasks, there is probably a substantial risk of mismatch along one or more dimension between the supervisor and the trainee in family therapy. Potential mismatches can occur when the supervisor and trainee are each strongly committed to different family therapy approaches, when the supervisor’s teaching style does not match the trainee’s learning style either in relation to formulating cases or developing skills, or when the supervisor and trainee deal with cultural or gender sensitivity in significantly different ways. Over the course of supervision there are a number of ways in which this imperfect match plays out. Often the supervisor may try to seduce the supervisee into working in ways that are consistent with the supervisor’s preferred approach. When successful, these supervisory forays can be an exciting and productive aspect of supervision. There is always, however, the potential for a poorly functioning supervisory relationship if the tensions around supervisory models are too great. Then criticism or challenges from the supervisor will often be seen by the supervisee as lack of understanding or respect for his or her preferred models. Thus, sometimes it is possible to identify the mismatch in a way that the supervisor and supervisee can find common ground on which to build a stimulating positive learning experience with some compromises on each side. However, maximizing the match when supervisory assignments are made is probably especially important within family therapy to minimize the additional challenges to the supervision process that occur with mismatches and reduce the potential for a failed supervision experience. Supervisees with Insufficient Social Skills The effectiveness of a family therapist is dependent in part on the range and flexibility of his or her social skills, because the therapist must be active, often using interpersonal positioning to facilitate interventions. Although these qualities are useful in other therapeutic modalities, they are essential to doing family and couples therapy. However, such skills are not always inherent in the trainee who chooses to learn family therapy. When the supervisee does not have a wide range or flexibility in social skills, the supervisor has several options. Occasionally the supervisee has more flexibility available than he or she is presenting, and it is a matter of changing the supervisee’s understanding of the therapist’s role to include more of the various aspects of his or her interpersonal range. Sometimes it is possible to find a niche in which the trainee can be successful working in a particular approach or a particular kind of problem. However, it may also be necessary to recommend that the trainee focus on a different modality in his or her professional work.

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DECIDING WHETHER FAMILY AND COUPLES THERAPY IS APPROPRIATE In general, the decision about whether family or couples therapy is appropriate is closely related to the levels of comfort the trainee and supervisor have with these modalities. When a trainee dislikes or is intimidated by a particular family member, it can be tempting to choose a treatment modality that does not require the therapist to work with that person. Likewise, if the interactional style of the family or couple makes the trainee uncomfortable, it is tempting to opt for a different modality. Occasionally the supervisor must decide whether the level of skill required to work with a particular couple or family is truly beyond the trainee and another modality must be selected. The more the trainee trusts that he or she has the capacity to work with a family or couple, either alone or in collaboration with the supervisor, the more likely the trainee is to believe that family therapy is appropriate.

CULTURAL COMPETENCE Inevitably, the cultural competence of the trainee and the supervisor will be an important dimension of family therapy supervision. Culture includes dimensions of ethnicity, race, religion, social class, sexual orientation, language, immigration process, and sometimes region of the country. Recent research indicates, not surprisingly, that supervisor multicultural competence is positively associated with supervisory working alliance and perceived supervision satisfaction (Inman, 2006). In a therapy in which the trainee is observing and actively influencing patterns in intimate relationships, an awareness of his or her own cultural biases and the cultural norms of the family is crucial in setting appropriate goals, making intervention choices, and shaping the nature of the therapist’s position. A supervisee must be able to take a one-down position in learning about cultures that are not his or her own and be sensitive to the ways in which the family’s problems do or do not relate to their culture. The supervisor’s task is to help the trainee to have sufficient awareness of the trainee’s own cultural assumptions and to learn enough about the family’s culture to have a starting point in learning from the family. The supervisor and trainee can then plan a treatment that will create an effective interface between the particular trainee and the family within their cultural contexts. Family therapy has a strong tradition of recognizing the importance of culture in treatment, so there is a substantial literature available to be recommended to supervisees (Boyd-Franklin, 2003; Falicov, 1998; McGoldrick, Giordano, & Garcia-Preto, 2005). Cultural differences between trainee and supervisor pose additional challenges for the supervisor. Because family therapists often use themselves in the family sessions as a tool for shifting interactions, when the trainee is different from the supervisor in cultural background, the supervisor must consider how the trainee’s cultural identity should be factored into both the supervision process and treatment planning. The potential combinations of complexities in the domain of cultural competence (e.g., when the trainee is from the same culture as the family but the supervisor is not) make it a rich domain in the supervision process. Especially in this area, it is crucial that supervisor and trainee be comfortable acknowledging

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Supervision of Couples and Family Therapy 197 what they do not know, recognize personal biases, and be aware of the challenge of balancing cultural sensitivity with universal principles and goals both in therapy and in supervision.

OPTIMAL LEVEL OF AROUSAL IN SUPERVISION As family therapy training is likely to include live sessions in front of the one-way mirror or videotaping of sessions, the trainee is in many ways more exposed and, in these contexts, has less control over what is revealed to the supervisor. Even when supervision is didactic, it is likely to require that the trainee report on the active intervention he or she selected, how the or she executed it, and whether it was successful with the family. And the supervisee is expected to sustain active learning simultaneously on a conceptual and skill level while attending to the use of personal style and responses in the therapy. Thus, the family therapy supervisor must be particularly conscious of maintaining optimal levels of support and challenge to sustain the trainee’s learning experience. Although research suggests that a moderate level of arousal is optimal (Deffenbacher, 1978), what this means will clearly vary for each individual and the particular mode of supervision. Generally, the more exposed the supervisee is, the more sensitive the supervisor must be around challenging feedback.

SUPERVISION FOR DIFFERENT LEVELS OF TRAINEE EXPERTISE Research suggests that the level of experience of the supervisee may not affect the qualities identified as desirable in a family therapy supervisor, the supervision needs identified by supervisees, or the supervisory behaviors identified as helpful (Fisher, 1989; Wark, 1995). Although good supervision may not differ significantly for supervisees with different levels of experience, this does not preclude different levels of developmental tasks at different stages of trainees’ development. Typically, beginning trainees require help with surviving a session, learning basic skills unique to couples and family therapy, and applying the concepts of family therapy to their particular families. With more advanced students, one can focus on refining technique, expanding their range of intervention options, and considering choices of alternative ways to formulate a case.

BALANCING THE TRAINING NEEDS OF THE SUPERVISEE WITH THOSE FAMILY

OF THE

With the increased likelihood that the supervisor will directly observe the trainee, either in front of the mirror, on video, or in a role-play, it is also likely the supervisor will have clear ideas about the training needs of the supervisee, the types of interventions he or she needs to experience, or areas of therapeutic flexibility that need work. The trainee may also have clear agendas about the particular skills he or she wants to learn. These do not always match the needs of the families with whom the trainee is working. It is the supervisor’s responsibility to prioritize the needs of the family first and help the trainee appreciate these, and then carefully look for

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opportunities for the trainee to expand his or her expertise in ways commensurate with the family’s needs and, if possible, the training goals.

CONCLUSION Within the diverse field of family and couples therapy, there are common themes that distinguish it from supervision of other psychotherapy modalities. The process of supervision, the techniques, and the particular challenges of supervision of family and couples therapy are all somewhat distinct. Just as systemic treatment approaches require flexibility in formulating, active positioning, a technical base, interpersonal skills, and substantial self-awareness, these qualities all come into play for effective couples and family supervision. Family therapy and couples therapy have always prioritized interventions that reflect the culture and context in which they occur. We anticipate that the supervision of family and couples therapy will likewise continue to evolve to reflect changes both in the current culture and in the field of family and couples therapy.

REFERENCES Anderson, S. A., Schlossberg, M., & Rigazio-DiGilio, S. (2000). Family therapy trainees’ evaluations of their best and worst supervision experiences. Journal of Marital and Family Therapy, 26, 79–91. Anderson, T. (1991). The reflecting team: Dialogues and dialogues about dialogues. New York: Norton. Boscolo, L., Cecchin, G., Hoffman, L., & Penn, P. (1987). Milan systemic family therapy. New York: Basic Books. Boyd-Franklin, N. (2003). Black families in therapy: Understanding the African-American experience. New York: Guilford Press. Breunlin, D. C., Karrer, B. M., McGuire, D. E., & Cimmarusti, R. A. (1988). Cybernetics of videotape supervision. In H. A. Liddle, D. C. Breunlin, & R. C. Schwartz (Eds.), Handbook of family therapy and supervision (pp. 194–206). New York: Guilford Press. Calopinto, J. (1988). Teaching the structural way. In H. A. Liddle, D. C. Breunlin, & R. C. Schwartz (Eds.), Handbook of family therapy and supervision (pp. 17–37). New York: Guilford Press. Deffenbacher, J. L. (1978). Worry, emotionality and task generated interference in test anxiety: An empirical test of attentional theory. Journal of Educational Psychology, 70, 248–254. Doty, D. R. (1985). Family therapy supervision: Assessment of skill attainment by trainee and supervisor. Unpublished master’s thesis, Oklahoma State University, Stillwater. Falicov, C. J. (1998). Latino families in therapy: A guide to multicultural practice. New York: Guilford Press. Fisher, B. L. (1989). Differences between supervision of beginning and advanced therapists: Hogan’s hypothesis empirically revisited. Clinical Supervisor, 7 (1), 57–74. Inman, A. G. (2006). Supervisor multicultural competence and its relation to supervisory process and outcome. Journal of Marital and Family Therapy, 32, 73–85. Lee, R. E., Nichols, D. P., Nichols, W. C., & Odum, T. (2004). Trends in family therapy supervision: The past 25 years and into the future. Journal of Marital and Family Therapy, 30, 61–69. Liddle, H. A., & Schwartz, R. C. (1983). Live supervision/consultation: Conceptual and pragmatic guidelines for family therapy training. Family Process, 22, 477–490. Mazza, J. (1988). Training strategic therapists: The use of indirect techniques. In H. A. Liddle, D. C. Breunlin, & R. C. Schwartz (Eds.), Handbook of family therapy training and supervision (pp. 93–109). New York: Guilford Press. McGoldrick, M., Giordano, J., & Garcia-Preto, N. (2005). Ethnicity and family therapy. New York: Guilford Press. Moorhouse, A., & Carr, A. (1999). The correlates of phone-in frequency, duration and the number of suggestions made in live supervision. Journal of Family Therapy, 21, 407–418. Moorhouse, A., & Carr, A. (2002). Gender and conversational behavior in family therapy and live supervision. Journal of Family Therapy, 24, 46–56.

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Supervision of Couples and Family Therapy 199 Morgan, M. M., & Sprenkle, D. H. (2007). Toward a common-factors approach to supervision. Journal of Marital and Family Therapy, 33, 1–17. Murphy, M. J., & Wright, D. W. (2005). Supervisees’ perspectives of power use in supervision. Journal of Marital and Family Therapy, 31, 283–295. Ratliff, D. A., Wampler, K. S., & Morris, G. H. (2000). Lack of consensus in supervision. Journal of Marital and Family Therapy, 26, 373–384. Wark, L. (1995). Live supervision in family therapy: Qualitative interviews of supervision events as perceived by supervisors and supervisees. American Journal of Family Therapy, 23, 25–36.

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C H A P T E R 12

Supervision in Therapeutic and Collaborative Assessment LEONARD HANDLER

BEFORE I begin a discussion of supervision in therapeutic and collaborative assessment approaches it is important to define and describe these techniques in some detail. This description identifies and highlights important areas that supervisors must explore with their supervisees in order to be fully effective with them. DEFINITIONS OF THERAPEUTIC ASSESSMENT AND C O L L A B O R AT I V E A S S E S S M E N T Therapeutic Assessment (TA) is an approach to assessment in which the assessment process itself is considered to be a therapy-like intervention that is transformative for the client. That is, the TA process provides experiences that allow clients to alter their self-view. In a sense TA is a treatment experience in microcosm, one that enhances self-awareness and often leads to life changes (Finn, 1996, 2007; Finn & Martin, 1996; Finn & Tonsager, 1992, 1997; Handler, 2007). Although the literature contains various examples of situations in which assessments have proven to be therapeutic for clients (see Finn & Tonsager, 1997), it was Stephen Finn (2007; Finn & Tonsager, 1997, 2002) who devised the first systematic therapeutic assessment approach. He called this Therapeutic Assessment (uppercase; TA) to distinguish it from other assessment techniques, less systematic but nevertheless effective, called therapeutic assessment (lowercase; ta). Collaborative assessment techniques have primarily been developed by Connie Fischer and are

Many clinicians who do TA, ta, or collaborative assessment use the term client rather than the term patient. They make good arguments for using client, as do those who use patient. Therefore, I have decided to use both terms interchangeably in this chapter. I thank Steve Finn who read and commented on an earlier draft of this chapter.

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Supervision in Therapeutic and Collaborative Assessment 201 described in her book Individualizing Psychological Assessment (1985/1994), in Fischer (1998), and by Handler (1996, 1998a, 1998c, 1999, 2002, 2005a, 2005b, 2007; Handler & Hilsenroth, 1994, 1998). I view my approach as a combination of TA and collaborative assessment (see Handler, 1997, 2000, 2004, 2006; Mutchnick & Handler, 2002). Finn (2007) views collaborative assessment as “a subset of therapeutic assessment (lower case ta)” (p. 5). He views, correctly in my opinion, my approach and that of Fischer as “loosely structured” collaborative assessment “because there is [italics added] a systematic method to their work—but it is not spelled out as explicitly as in TA” (p. 5). He points out that collaborative assessment and ta are more difficult to teach compared with TA, primarily because TA is a more organized approach, which helps to guide assessors. Now that the therapeutic assessment terms are defined, I next describe each approach so that the reader can get a good idea of how it differs from the traditional assessment approach. Whereas traditional assessment has its roots in psychometric theory and ego psychology, TA and ta have their roots primarily in humanistic theory and interpersonal theory (Sullivan, 1953, 1954). Both Finn’s and my approaches have also been enriched by intersubjective theory (Atwood & Stolorow, 1984, 1996; Buirski & Haglund, 2001a, 2001b; Orange, Atwood, & Stolorow, 1997; Stolorow, Atwood, & Brandchaft, 1994; Stolorow, Brandchaft, & Atwood, 1987) and narrative theory (McAdams, 1985, 1993; McLeod, 1997). Fischer’s collaborative assessment approach has its roots in human science psychology and is grounded in the European existential phenomenology philosophy of science and in humanistic psychology (Fischer, 1985/1994). Despite the fact that Finn, Fischer, and I have been influenced by somewhat different theorists, there is a great deal of overlap in the ways in which we approach and interact with clients. In addition, we have learned from one another by sharing examples that have enriched our own assessment practices. In a landmark paper, Finn and Tonsager (1997) made a cogent comparison of TA and traditional assessment and highlighted the marked difference between the two approaches. The goals of assessment are quite different. The goal of traditional assessment is primarily to diagnose, plan treatment, evaluate treatment, understand a patient better, or to monitor the progress of treatment. The focus is on communication about the patient. A document (the report) is produced, primarily for use by another professional (usually the referral source), and the report is traditionally written using technical terminology, often with abstract and impersonal language. In sharp contrast, the goal of TA is to help clients learn, experientially, aspects of their personality functioning that impair personal and interpersonal functioning during various steps in the assessment process itself. Finn and Tonsager (1997) stated: The major goal is for clients to leave their assessments having had new experiences or gained new information about themselves that subsequently helps them make changes in their lives. The assessor’s primary task is to be sensitive, attentive, and responsive to clients’ needs and to foster opportunities for self-discovery and growth throughout the assessment process. (p. 378)

In contrast to the traditional approach in which a report is written, in TA this summary is done as a letter written for the client rather than for another

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professional. It is written in clear, personal language to summarize the assessment and therapeutic work accomplished in the TA process and to summarize the client’s experience of the assessment. Concerning the view of tests by the assessor, Finn and Tonsager noted that in the traditional assessment approach tests are usually seen as methods used to provide standardized scores reflecting client behavior. These scores are used to make nomothetic comparisons that reflect or predict behavior outside of the assessment setting (in the real world, so to speak). Emphasis is placed on the reliability and validity of the tests. Although TA models also consider the reliability and validity of the tests important, tests are viewed in a more expanded and comprehensive manner. Specifically, Finn and Tonsager (1997) emphasized that a test is considered useful if it also provides an opportunity for the client and the assessor to have a dialogue concerning “characteristic ways of responding to usual problem situations and tools for enhancing assessors’ empathy about clients’ subjective experiences” (p. 378). Notice that the emphasis here is on mutual learning by the assessor and client. The procedures for conducting a traditional or information-gathering assessment were described by Finn and Tonsager (1997) as “data collection; deductive, unilateral interpretation of [the] assessment data; and recommendations” (p. 378). In contrast, the TA paradigm emphasizes the development and maintenance of an empathic connection with clients, “working collaboratively with clients to define individualized assessment goals, and sharing and exploring assessment results with clients” (p. 378). The focus of attention in the traditional information-gathering approach typically includes a diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders, but ordinarily it does not include the assessor’s thoughts and feelings while doing the assessment or the client’s subjective experience of the assessor and the assessment process. Whereas in the traditional assessment approach some attention is paid to the establishment of rapport, this is mainly valued because it facilitates the collection of reliable and valid data. I agree with Fischer’s (1985/1994) complaint about rapport as it is described in traditional assessment. She wrote: Most test manuals and assessment courses include early sections on “establishing rapport.” However, psychology’s historical effort to model itself after the physical sciences too often has resulted in a scientized transformation of rapport’s meaning. When psychologists have strived for laboratory-like objectivity, thereby presumably removing themselves from the complexity and ambiguity of everyday mutuality, they have curtailed rapport. When this process occurs, rapport becomes a unilaterally established condition, monitored and manipulated by the professional. This so-called rapport has been established to serve the assessor’s ends of which the client is largely uninformed and for which he or she is merely the source of data. (pp. 296–297)

Despite the emphasis on rapport, the assessor’s role in the traditional model is to adopt a neutral stance with the client/patient—not entering the process of data collection except to record responses, and being a conceptually invisible presence in merely managing the client’s responses. In contrast, in the TA model the assessor is a participant observer who, along with the client, plays an active role in shaping the

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Supervision in Therapeutic and Collaborative Assessment 203 assessment process. The assessor’s personality, appearance, past experiences, and theoretical framework are viewed here as potent factors that can either facilitate or hinder the assessment process. Such factors influence how the client and the assessor relate to one another and often determine what information is shared, how the assessment data are understood or contextualized by the assessor, and whether or not clients experience significant learning or change during the assessment. It should be noted that in the TA model “the assessor is required to be a skilled and sensitive facilitator of change, who is knowledgeable about tests, personality, and psychopathology and who has a high degree of interpersonal skill” (Finn & Tonsager, 1997, p. 379). In a section of her book titled “A Return to Rapport as a Relationship,” Fischer (1985/1994) reconceptualized rapport from a collaborative assessment point of view: I propose that rapport be regarded as a relationship in which client and assessor have found that they share certain understandings that serve as common ground for joint, give-and-take exploration of the client’s situations and opinions. This exploration is carried out through mutual respect for the limits, openings, and ambiguities posed by each other’s perspectives. (p. 300, italics in the original)

Finn and Tonsager (1997) also discussed what defines success in TA compared with traditional assessment. In the traditional approach success is determined by how cooperative a client is in following instructions and generating responses to the tests in an uneventful manner. Also considered here is whether the diagnoses and recommendations are clearly evident and if the referring agent is satisfied and puts the report to good use. Success in TA is defined by whether the assessor understands the client and whether the client has had experiences in the assessment process that are transformative. In other words, a successful assessment in TA is determined by whether the client feels that he or she was understood, valued, and respected by the assessor, and whether the answers to the client’s questions produced some meaningful change for the better. Success is also determined by whether the client feels more empowered and capable of maintaining the positive changes in the future. T H E R A P E U T I C A S S E S S M E N T ( TA ) P R O C E D U R E S I now outline the steps of TA described by Finn (2007) so that you can get a sense of the skills involved in the process. Similar skills are required in ta and in collaborative assessment. THE INITIAL SESSION(S) The initial session consists of an interview of one or more sessions focused on establishing a working relationship with the client and setting the stage for what will take place in later sessions. Also in this interview process the client and assessor collaborate to produce one or more meaningful questions about life issues, personality issues, or relationship problems that concern the client (e.g., “I can’t

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concentrate; do I have ADD [Attention Deficit Disorder]?” “Why do people always get angry with me?” “Why do I get frightened when someone challenges me?”). The assessor also focuses on relevant family-of-origin information, occupational information, and a host of other information that might help the assessor and client understand each other better. Finn (2007) described what goes on in this first phase: “By focusing psychological assessments on clients’ personal agendas, we [make] the whole assessment process much more client-centered, which [seems] to lower clients’ anxiety, enlist them in the assessment in an active way, and engage their curiosity” (p. 11). In picturesque language Finn added, “By assisting clients in forming questions, we invite them to ‘climb up’ with us, if you will, on an ‘observation deck’ overlooking their lives where we may begin to look jointly for answers” (p. 11). STANDARDIZED TESTING SESSIONS Tests are selected by attempting to determine which measures might best illuminate the client’s problems. Finn indicated that he selects some tests that might have face validity for the client. For example, if a client’s questions concern ADD, he will begin with a test purported to measure Attention-Deficit/Hyperactivity Disorder, rather than a projective test, to be followed by cognitive tests of attention and memory. Most of the time the tests chosen are administered in the traditional manner, usually over two or more sessions of 1 12 to 2 hr each, and they are initially interpreted using normative data. This procedure is preferable to giving the tests in a single session because in the latter situation there is not enough time for the assessor to discuss with the client the client’s experience of each test and for the assessor to share some initial observations he or she noted about the testing process with the client. Perhaps this is one reason why Finn’s clients so readily accept many of his interpretations at the end of the assessment process in the feedback session. In making these initial observations the client is being gently and gradually prepared for the final feedback. Indeed, Finn (2007) noted that this procedure prepares clients well for the final feedback and that the procedure of providing partial feedback little by little is definitely more effective than giving feedback all at once at the end of the process. What is different in TA compared with traditional assessment, is the importance of the interaction with the patient before and after each test and the relationship established during and throughout the testing process. Therefore, the assessor should take ample time to process each test. I ordinarily take time to ask clients to discuss how they felt about the test, what they liked or disliked about it, and whether they learned anything about themselves from taking it. I also share with them a bit of what I noticed about their approach to the test. For example, on the Rorschach I might say something like, “I noticed you were having some discomfort with the colored [or in another case, the darkly colored] cards. What do you think was going on there for you?” This often leads to a discussion of problems with emotional regulation or issues surrounding depression. If the client is interested in further discussion about these problem areas, I might go further and discuss the fact that, for example, he or she had some problems seeing positive (or perhaps reality-based) percepts on these cards. Therefore, it would not be a surprise

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Supervision in Therapeutic and Collaborative Assessment 205 to the client at feedback time for me, looking back to the initial observation, to then say something like, “It seems like your thinking gets confused or unclear when you’re emotionally stimulated.” I often ask questions about specific projective test responses as well because I have found the responses to my questions are great empathy magnifiers (see Handler, 1998b, 1999, 2005a, 2005b). Finn (2007) made an important point about the dialogue between clients and the assessor between tests, stating that “it provides opportunities for clients and assessors to gradually ‘coedit’ the clients’ existing stories [about themselves] rather than trying to make big changes all at once [during the feedback or summary session(s) at the end of the assessment]” (p. 13). I also find that the dialogue between tests enhances the relationship. ASSESSMENT INTERVENTION SESSION OR SESSIONS These sessions are devoted to producing test-related patterns that clearly illustrate the client’s problems. These interventions are especially useful in helping a client understand issues that he or she does not consciously recognize. Concrete and obvious test findings in this phase are often quite convincing where mere discussion, without examples, might not make the interpretation clear or meaningful to the client. Finn (2007) described this process as “[bringing] into the room those problems-in-living of a client that are the focus of the assessment, where they may be observed, explored, and addressed with various therapeutic interventions” (p. 14). This process is quite difficult to learn because it requires flexibility and creative thinking—thinking outside of the box. When a client’s problems are illustrated by the creative use of the test materials, the assessor typically spends time processing the meaning of these findings with the client and assists the client in responding in healthier ways. In addition, the client does not have to wait for psychotherapy weeks or months in the future. For example, an adult male patient of above average intelligence believed he had ADD. He rushed through the Bender-Gestalt copy phase, in which he was instructed to “copy these figures as best you can.” He provided poorly executed designs, saying, “I just can’t do these; they’re way too hard!” I asked him to compare his copy with the stimuli, and he recognized that there was little accuracy in his designs. His impulsivity and agitation were clear to me but not at all clear to him. I spent a significant amount of time soothing him and helping him focus on our mutual task. Then I asked him to copy the figures again, emphasizing that he needed to copy them as well as he could. He surprised himself by producing an excellent rendition of each card. We spent a great deal of time discussing the two copies of the test and the differences between them. The client soon became aware of how his inability to soothe himself and modulate his anxiety and impulsivity produced poor results in many other phases of his life. He recognized how much he needed soothing and structuring and decided to enter therapy to deal with these issues. In another TA the supervisee and I noted the client had a number of Rorschach minus form responses and special scores, primarily on Cards II and III, suggesting that she had become disregulated by the color. I suggested to the student that he readminister the two cards, but this time he should cover the red areas. The result

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was that she gave excellent responses, with good form level and with no special scores. The client was startled when the student then uncovered the red areas. She immediately understood that when she was emotionally aroused, it was difficult for her to think clearly and logically, which then led to an understanding of why she was having so much trouble getting along with family members and with colleagues at work. In a similar case I had I copied the two problem cards on a black and white copier and compared the patient’s responses on the regular cards with those of the altered cards. SUMMARY DISCUSSION SESSION OR SESSIONS The next step in TA is the feedback session or sessions. Supervisees have a great deal of difficulty in conceptualizing and carrying out the feedback process. They literally do not know where to begin. I can remember, as a relatively new graduate student, giving feedback to a patient by reading to him selected sections of my report. Throughout my training in assessment, supervision was focused entirely on test interpretation, with no attention to feedback. I quickly learned that reading my report to patients or discussing my report with them was not at all adequate. After one such session I asked the patient what he felt he had learned from the feedback; he was unable to formulate a response to that question. I became keenly aware that when I used my approach, patients went away confused, often feeling they had not been helped. It was at that point that I made a vow to myself that I would find a better way to give feedback to my patients. Part of the problem for most students is that they fear hurting patients’ feelings and being the deliverer of bad news. I feel certain that supervision concerning feedback to clients is quite limited in doctoral programs. That is one reason Finn’s discussion of feedback is so important; it is the highlight of the TA process for me, because, if done correctly, it gives the patient important answers about his or her problems, allowing a therapeutic effect to occur. Giving feedback should be an active process of discussing the assessment findings in light of the client’s thoughts and feelings and the questions he or she initially posed. Therefore, the term feedback does not accurately describe the process. It should be an interactive process, beginning with information the client already knows about himself or herself. Finn calls this Level 1 feedback. He used the example of telling a self-labeled extrovert that “his very low score on Scale 0 of the [Minnesota Multiphasic Personality Inventory–2] suggests that he enjoys meeting new people, is comfortable in large groups, and would not do well in a job where he works mainly on his own” (Finn, 2007, p. 8). As the feedback continues and all is going well, the assessor introduces Level 2 findings “in which the assessor reframes or amplifies clients’ usual ways of thinking about themselves”(Finn, 2007, p. 8). Level 2 findings are those that, although not unconscious, are nevertheless not openly acknowledged. However, the client is somehow aware of these issues but has not verbalized them to himself or herself. Finn gave the example of telling a client “who is concerned about lethargy, lack of motivation, and poor focus that his Rorschach D score of –4 suggests he is extremely overwhelmed, rather than just ‘lazy’ as he fears” (p. x).

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Supervision in Therapeutic and Collaborative Assessment 207 Level 3 findings are not close to clients’ consciousness, and it is these findings that “conflict in some major way with their usual conceptions of themselves” (Finn, 2007, p. x). For example, a person who comes for assessment and firmly believes he or she has ADD might be quite surprised to discover that he or she is significantly depressed and that that is the reason for his or her poor ability to attend and concentrate. WRITTEN FEEDBACK Written feedback consists of letters written to the client by the assessor rather than a formal, technical report. It addresses the questions posed jointly by the client and the assessor. The letter also includes the client’s input during the assessment sessions. A client can also comment on the letter or modify drafts of it, an approach first developed by Fischer (1985/1994). FOLLOW-UP SESSIONS Finn added one or more follow-up sessions to his model, initially because his clients often asked for them. Clients are now told that it would be useful to meet again in 2 to 3 months to discuss the assessment and to discuss questions or new developments. C O L L A B O R AT I V E A S S E S S M E N T This section is much shorter than the TA section because there is significant overlap between TA and collaborative assessment. For example, Finn (2007) stated that he adopted some of Fischer’s practices for assessment intervention and for feedback approaches. In collaborative assessment the clinician intervenes either during the data collection process or soon after completing a specific test or test battery. The intervention is done to help a patient see any problems and/or strengths in his or her performance and generalize them to similar aspects of everyday life. The assessor also helps to provide or illuminate for the client answers concerning the problem issues brought to the assessment. Fischer’s approach to teaching and supervising focuses on engaging the client as a co-assessor. This approach begins at the initial interview and goes throughout the entire assessment process. Taking a specific pattern of findings on a test, for example, a specific detailed interpretation may be made to the client. However, if the client does not agree with the assessor’s observations or conclusions, the assessor changes his or her formulations. In this collaborative interaction interpretations are refined and recast by both the client and the assessor. Reports are written in clear, nontechnical language. Fischer (1998) offered the following example of the absence of technical terms in her reports: Instead of reporting that the F-% and low P [on the Rorschach] indicate that this person has poor reality testing [or even saying the client has poor reality testing] we might say, “Joe acknowledged that just as he doesn’t pay attention to what most people notice on the inkblots. . . he often has found himself trying to find something pleasant even when he knows his family and coworkers don’t share his Pollyannish view.” (p. 355)

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I find that in rare cases, interventions are not planned but occur spontaneously. One example of an intervention that took place during a test is that of a man who later proved to be bipolar. I was in the process of administering a Rorschach to him, and during the Inquiry he gradually became more and more annoyed with me, especially when I continued to ask, “What about the blot made it look like. . .?” Somewhere during the Inquiry on Card VII he became openly angry with me. I stopped, looked at him, and said, “I think we need to stop for awhile so we can examine what’s going on here between us.” I was quite surprised when he responded, perceptively, “Dr. Handler, I think what just happened between us will be the most important thing we’ll discover in this testing”—and he was correct! We spent a great deal of time at that point discussing his everyday problems with emotional regulation and with his family and employees. Earlier, on Card VI, the patient had given the following response: “A butterfly coming out of this iceberg.” When the Rorschach was completed I casually asked, “What’s that butterfly doing coming out of that iceberg?” The patient smiled and said, “I guess that doesn’t make sense; it’s a butterfly here [pointing to one area of the blot], and over here [pointing to another part of the blot] is an iceberg.” We later discussed the response, which I used to explain the patient’s problems in logical thinking and the kind of assistance he needed to deal with his problem. Fischer’s book Individualizing Psychological Assessment (1985/1994) is a goldmine of excellent ideas in collaborative assessment. I include here two examples of her work so the reader can get an idea of her interactions with clients.

Case 12.1 The first case is of an 18-year-old college freshman, female, self-referred for academic problems: ASSESSOR: I noticed just now [on the Bender-Gestalt] that you started out very carefully—checking the card several times, making small drawings. Then toward the end you only glanced at the cards, and the drawings became bigger and somewhat more casual. Do you recognize that as something you’ve done before? CLIENT: I’ve never done this before [the Bender]. ASSESSOR: I mean have you done other things in the same way? For example, if you’re cooking with a recipe, do you start out double-checking the instructions, and then toward the end just trust your inclinations? CLIENT: [Laughs] That’s exactly what I do! Unless it’s a recipe I’ve done several times. Then I just review it once. ASSESSOR: What was it like while you were doing the drawings? How did it become different when you began to draw them on your own? Somehow you looked both more confident and more impatient at this juncture [pointing to the Bender-Gestalt reproductions]. CLIENT: I wouldn’t say “confident.” I just decided it was pretty silly to take something so simple so seriously. ASSESSOR: Okay. Is that what happened on your English term papers? Maybe your instructor was partly right—perhaps you don’t follow the instructions carefully, especially if you’ve already done other papers. And I’ll bet since you did study the instructions very carefully at first, you assumed you remembered them. CLIENT: Oh my! (p. 90)

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Supervision in Therapeutic and Collaborative Assessment 209

Case 12.2 The second vignette is that of a 16-year-old high school junior, female, referred for declining grades: CLIENT: This is horrid [Draw A Person Test, DAP]. I can’t draw. This didn’t come out right at all. ASSESSOR: Okay. If you were an artist what would it look like? CLIENT: Like an artist’s drawing! You know, no erasures, confident lines, perfect rendition of an elegant woman. ASSESSOR: Uh-huh [both laugh]. So here we are again, with you comparing yourself to perfection! That sure is a rough thing to be doing to yourself so often. CLIENT: Yeah, and the worst part is that I don’t know when I’m doing it. ASSESSOR: There’s hope! You knew you’d done it this time! But I’d like to pursue something else here. If you could draw well, this drawing would have been of an elegant woman? [Client blushes, nods hesitantly.] Let’s draw it with words. What about the arms—what effect were you after? CLIENT: This arm should be gesturing emphatically but gracefully. This one should fall easily to her side. [Client illustrates.] ASSESSOR: Yes! Look at you! You’re doing it. Granted, you’re not standing, and it was just a quick gesture, but it was certainly more “elegant” than this woman [DAP]. Kind of symbolic, isn’t it? Instead of trying out, practicing being elegant, you and she [DAP] hide your hands behind your back? [Client and assessor chuckle.] Like a lot of young women you’re not sure whether or not to hide the fact that your breasts have developed? [Assessor points to erasures of lines indicating sizes of breasts. Client nods; after further discussion, assessor asks client to draw her elegant woman, even though it won’t be perfect.] (pp. 101–102).

Note that in each case Fischer focused on the client’s test behavior and generalized it to the referral problem or issue. I have included throughout this chapter several vignettes to illustrate my approach. One example concerns a suspicious man I tested a long time ago with the Wechsler Adult Intelligence Scale (WAIS). When I came to the Similarities subtest and I asked him how an orange and a banana were alike, he responded, “They’re not alike.” To my surprise he did the same for the next five or six items. I finally stopped him at that point and assured him the test questions were not trick questions, but that there really was a way in which these pairs of items were alike. I began the testing again and he earned a superior score on that subtest. We discussed our interaction after we completed the WAIS and I said something like this to him: “I noted that you were suspicious that those questions were trick questions, but you were able to trust me when I reassured you they were not trick questions. That tells me you can relax your suspiciousness in everyday situations if you get just a little bit of reassurance.” He agreed with my statement and continued by giving me several examples to illustrate what I had just told him. Ordinarily, however, I wait until a test is completed before I intervene with a variety of questions about the test the patient just took, to help illuminate various test responses. T H E S U P E RV I S I O N P R O C E S S In this and subsequent sections I use the italic term ta to encompass TA, ta, and collaborative assessment. What is primary to communicate to students learning ta

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is the importance of developing a sense of the client’s or patient’s experience of the assessment process. Concerning the role of a supervisor, Paul Lerner (1998) said the following: As a teacher and supervisor, both in words and in actions, I attempt to impart to beginning students and beginning psychologists an approach to assessment based on a humanistic-clinical attitude. By humanistic I am referring to the humanness of the assessor as expressed in his or her compassion, concern, and therapeutic intent toward the patient. This involves the continuous awareness that the individuals who seek our help are in pain and are suffering, and that our task is to understand the nature of their difficulties and to assist them to get well. Students ought to know that regardless of how provocative, obnoxious, or alienating a patient behaves, or how repulsive we experience their past behavior, as a professional psychologist one attempts to maintain a concern for the patient’s self-esteem, self-regard, and dignity. (p. 112)

LEARNING OBSTACLES It is obvious, I hope, from the definitions provided previously, the description of the steps of TA, and the examples of collaborative assessment that these approaches to assessment are difficult to learn. New students are just getting experience in administering and scoring various tests, and they often feel overwhelmed with the volume of material they must now master. Often their focus of attention in doing assessments concerns getting enough responses, recording verbatim, and trying to make sense of what is going on between them and their clients. At this stage in their development they literally often do not have the ability to attend to the nuances of their interactions with their clients, let alone think about such issues as formulating therapeutic questions, choosing appropriate tests, or designing intervention procedures. With good supervision, through discussion, and by demonstration, it becomes evident to students that the exploration of symbolic and narrative understanding requires a certain sensitivity on part of the interpreter, “intimate contact with the internal life that makes the assessor the same as his or her patients” (Handler, 1998a, 1998b; Handler, Fowler & Hilsenroth, 1998, p. 440). Although I do not doubt the intellectual ability of supervisees in learning difficult material, ta nevertheless requires the type of thinking that is quite different from the scientific approach to education stressed in many or most doctoral programs, in which experiential learning is not emphasized. The approaches described require a great deal of flexibility and creative thinking, along with the ability for empathic attunement to the patient. Although students show a great deal of eagerness to learn ta, they also believe that whereas experts can do this kind of assessment, it would be impossible for them, mere beginners, to master these approaches. An important goal for the supervisor is to convince students, by discussion, demonstration, reassurance, and support, that they, too, can learn to use themselves flexibly and creatively. This task requires a great deal of energy and emotional investment on the part of the supervisor to energize students and deal with their anxieties about assessing their patients. NOT ONLY BY THE BOOK The practice of assessment psychology has been heavily steeped in psychometric theory, with its traditional emphasis on standardization and the use of normative

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Supervision in Therapeutic and Collaborative Assessment 211 data, sometimes as ends in themselves. In ta, this emphasis is only a small part of the assessment process. In order to make the assessment meaningful to the client, much more is required of the assessor. Although many students are well schooled in this psychometric tradition, they are much less schooled in ways in which to engage a client in a collaborative and therapeutic approach. They often adhere to these rules tenaciously, perhaps as a way of reducing anxiety, because it is difficult to standardize methods employed to establish and maintain a relationship with a client. STUDENTS’ ANXIETY Many students have told me that they are more anxious about doing assessments than they are about doing psychotherapy because in therapy, if one makes an error with the client/patient, one can most often repair it in future sessions, whereas in assessment there is typically not that opportunity. When I describe approaches in ta, students can see that there are numerous opportunities to correct mistakes in ta. Students are also fearful that an interpretation written after spending just a limited time with a patient could result in harm to the patient when written in a report. Here again, the supervisor can emphasize that the collaborative procedures inherent in ta obviate this problem. Another problem encountered by many supervisors is that students do not feel qualified in their initial attempts at interpretation of the tests they are learning to administer, and they feel even less competent in writing reports, where they must put down on paper their possibly unfounded conclusions. They are also afraid to hurt their patients by giving them negative feedback rather than positive feedback. They often believe that their reports, which they feel are based “just” on their interpretations, could do immeasurable harm to their patients—or as one student feared, “My report could ruin their lives!” Here again, when supervisors describe the ta procedures, it becomes clear to supervisees that in these collaborative approaches, such fears are unfounded. In fact, the letters to clients and the reports are more accurate, comprehensive, and useful for referral sources (because the patient helps correct the assessor’s impressions) and more meaningful for patients. However, there is a great deal more a student must be aware of in ta compared with traditional assessment. In the latter procedure, the standardized approach is to give the tests in a neutral manner, referring all or most questions to the end of the assessment when all tests are completed. In ta the emphasis is on the development of a therapeutic relationship. Here, the client’s subtle and not-so-subtle interactions are quite important throughout the process. Thus, the assessor enters into the process rather than attempting to blend into the background, as suggested in the traditional approach to assessment. Although one can probably agree that there is no such thing as neutrality from the client’s point of view, the traditional approach that highlights the tests themselves is certainly easier to learn than an approach based on mutual interaction between the client and assessor. The assessor in ta should constantly be monitoring the interactive process between himself or herself and the client, whereas a student learning traditional assessment often waits until the testing is over to begin conceptualizing the material. A student attempting to master ta methods needs to learn the importance

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of being a participant observer (Sullivan, 1954). However, it is an art to develop the ability to participate actively while observing the client. Supervisors should be sensitive to this difficulty and should perhaps ask students to spend less time, initially, giving many tests and more time learning to understand and appreciate the client. I often ask students not to give any tests during the first meeting with the client and perhaps only one test in the next session, in order to lighten the test-taking pressure on both the client and the student. Supervisors should spend time in the first supervision session concerning a client asking the student to describe the process developed and helping the student initially conceptualize the patient’s life issues. Following this, the supervisor should help the student decide on a suitable test battery for this particular client. Meeting supervisees in a group setting, in addition to individual supervision, is quite effective in stimulating questions and presenting problems. The group setting is also an effective environment for discussing the differences between traditional assessment and ta. The supervisor can also use the group setting to model and/or rehearse interviewing and testing details. It often takes a great deal of encouragement to help students switch from emphasizing their book knowledge to emphasizing their ability to establish a therapeutic relationship with a client. Students find this change quite difficult and anxiety producing, and therefore they need time and encouragement in order to learn optimally. Given the descriptions of ta, I hope the reader can appreciate that these procedures are often difficult to teach and to supervise, because they rely upon trusting the creative skills of the assessor. In addition, the flexibility and empathic attunement to the client that are necessary are definitely not standardized. Often, students (especially new students) are quite wary of modifying standardized measures, even though these modifications are done after the test is administered. Students are often taught that the assessor should approach the client in a neutral manner, following only those procedures outlined in the test manual. Students prefer this approach to a more flexible one because by using it they feel they are safer rather than flying by the seats of their pants, with no script in hand. Supervisors should be aware that students must be gradually introduced to unscripted approaches and that the their role is, in part, to help students trust themselves in the assessment process and gradually develop the ability to attune themselves to their clients/patients. Finn (2007) highlighted the importance of this process in the title of his book In Our Clients’ Shoes. Students have many problems and anxious moments when learning to do various forms of ta. One anxiety-generating issue is their concern that they will be unable to answer therapeutic questions posed by a client, which will therefore undermine their ability to provide adequate feedback. Another problem supervisees have is the concern that the client will not be able to formulate therapeutic questions and then they will feel stuck and will not know how to proceed. A new clinician is often intimidated by referrals for assessment that are too vague or incomplete. These referrals often come from other mental health professionals who are unfamiliar with various ta approaches. One student in a reportwriting seminar I conducted told the group that she recently got a one-word referral question—”dynamics.” Supervisors can be most helpful in this situation in teaching the student or intern how to contact referral sources to get them to be

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Supervision in Therapeutic and Collaborative Assessment 213 more revealing and more specific. In an optimal setting the assessor might even explore the possibility of discussing the ta approaches with referral sources, perhaps assisted by the supervisor. Another student in that same report-writing seminar asked how some form of ta can be used when the supervisee is required to test the patient and have the report ready by the end of the same day. This is a typical procedure in some hospitals where patients are kept for short periods. Naturally, an extensive evaluation cannot be done because of the severe time limitation. The supervisor is important here in being readily available to the student for quick consultations. The supervisor can help the supervisee in choosing a shorter battery of tests, and, if necessary, a shorter interview might be conducted. The types of therapeutic questions asked unfortunately must be limited. Finally, the supervisor must be more active in helping the student integrate the data and provide feedback to the patient. This would probably necessitate several brief intermittent consultations with the supervisor. What is needed is a great deal of support and encouragement so the student will feel more secure about venturing outside his or her area of expertise with the tests and the therapeutic procedure. Such active techniques as role-playing are quite effective in reducing a student’s anxiety, as are discussions concerning “What is the worst thing that could happen and how can you recover from such an event and do a good job?” In this approach the supervisor might take on the role of the client, and the roles could later be reversed, so the student plays the role of the client. For example, a supervisee elected to do a TA on a patient who appeared to be quite disturbed (Peters, Handler, White, & Winkel, 2007). Immediately upon meeting the student the patient sized up the young clinician and said, “I want Freud,” meaning he wanted to be seen by someone with more experience. This interaction temporarily destabilized the student until he regained his composure by getting in touch with the client’s sense of inadequacy and his underlying feeling of helplessness. Among the therapeutic questions the client and assessor formulated were “Am I as sick as I think or am I ‘frauding’ everybody?” and “Am I crazy, doc?” Throughout the testing the patient was provocative and arrogant but also openly admitted feelings of emptiness and inadequacy. The student remembered our previous discussion of how disorienting it could be to be evaluated, and he was able to successfully put himself in his patient’s shoes. During the administration of the Rorschach the patient showed significant cognitive confusion, affective instability, and an overall sense of inner fragmentation. The student empathized with the patient’s experience of falling apart. He reported that the room became hot, and he felt suddenly dizzy as he sat with the patient’s profound regression. He felt an intense pressure to help the patient and seemed to be drifting away into a despondent state of anxious helplessness. The student did indeed recover, and I discuss just how he did toward the end of this chapter. Having recovered, he remembered that we had discussed in our group an assessment intervention that I felt would be effective if the Rorschach showed significant pathology. So the student said, “I want you to look at the cards again, but this time tell me what you think most people see in each card.” The client gave significantly improved responses without any signs

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of regression or decompensation; this structure was effective in stemming the regression. The student became apprehensive when feedback time came. He wondered and worried whether discussing the client’s fragmented and disorganized thinking would precipitate a frank psychosis. Again, we discussed this important issue in a group session, and I emphasized to the student that the patient was ready to hear that information, and that the patient would devalue the assessment unless he was told about his disorganized thinking. I also told the student that conveying accurate understanding would have a positive effect on the patient because he already had a sense that his thinking was disordered. Avoiding such essential feedback was akin to “not seeing” and “not understanding” the patient, therefore invalidating the assessment process in his eyes. As the student gave the patient feedback, he eventually came to discuss the patient’s disordered thinking. He explained that under emotional pressure the patient displayed significant problems with his thinking, to which the patient responded, “I think that’s right on; the emotions just become so overwhelming!” He went on to give the student several examples of this problem. It is helpful if the supervisor shares his or her own work, and if the supervisor helps students build psychological pictures of their clients. I often tell students about a patient I assessed when I worked as a trainee in a Veterans Affairs neuropsychiatric hospital. I assessed a man who was accused of locking his wife in the basement of their home during an explosive confrontation. The man was charming, and he put forth a great deal of effort attempting to convince me that he was falsely accused and that he never got angry. He had almost convinced me, but in processing a test I had given him I noted some flicker of anger in his eyes. I said something like, “I wonder why you just got angry.” Suddenly he pounded the table with his fist and shouted at me, in a voice filled with rage, “I’m not angry!” It took me a few minutes to regain some semblance of composure, but we were able, at that point, to discuss this explosive experience more openly. Another problem for supervisees just beginning to learn these assessment approaches is that they are anxious about not being able to design an effective intervention to illustrate to the client their problem(s), because there is no standardized way of accomplishing this task. Students need assurance that the TA model, in which each test is discussed before and after the client takes it, will yield clues for such an intervention. They also need reassurance that they can work out and rehearse their interventions with their supervisor. In the example of TA with the very disturbed man, a great deal of support and reassurance for the student helped to make the case a success. T H E G O O D S U P E RV I S O R I N ta One of the most important functions of a good supervisor in ta is his or her ability to empathize with the supervisee rather than the supervisee’s client. S. Finn (personal communication, June 12, 2007) emphasized that if one focuses mainly on the client’s experience, it is very easy to become frustrated with the supervisee and protective of the supervisee’s client, because the supervisee did not handle the client optimally. In contrast, if the supervisor focuses on the student, who is typically

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Supervision in Therapeutic and Collaborative Assessment 215 struggling to learn, it becomes quite easy to be more patient and understanding of the supervisee’s struggle to learn. Finn stated, “Whereas TA is client-centered, TA supervision is supervisee-centered” (S. Finn, personal communication, June 12, 2007). Buirski and Haglund (2001b), intersubjective theorists, noted that the supervisory setting, itself an indissoluble intersubjective field, must facilitate learning by being ‘pro-supervisee. They recommend that the supervisor adopt a nonjudgmental stance whereby the supervisor is sensitive to the affective experience of the supervisee. The more accepting and nonjudgmental the supervisor is, the more a supervisee will take a similar stance with his or her client. Very often a supervisee has trouble seeing how his or her own feelings and actions might be an important part of the intersubjective field of the assessment. S. Finn (personal communication, June 12, 2007) stated, “For example, a student comes away after a Rorschach administration feeling incompetent, not noticing that there were things the client did that helped him feel that way, or realizing that his feeling represents how the client feels all the time.” In such circumstances the supervisor’s role as supportive and yet inquisitive will gradually help the supervisee see and understand this complex interaction. Given the complexity of such interactions, and because ta deals with issues related both to assessment and psychotherapy, an effective supervisor should have assessment and therapy skills and experience. Optimally the supervisor should also have some experience in doing and teaching these methods. However, I write this preceding sentence with somewhat less conviction than I would have recently. It seems that a student who was learning to do TA in my assessment class also decided to try this approach in her clinical placement, a community mental health center. Her supervisor had no knowledge of or experience with TA, but she was open to learning this process from the student. What the supervisor provided was the freedom to try something new, along with encouragement. Apparently, this support and freedom were enough, because the experience appeared to be positive for the patient, the student, and the supervisor. In ta supervision the best results are obtained if the supervisor and student can establish a relationship that is trusting, one in which the student feels safe discussing his or her thoughts and feelings about clients and about himself or herself in reference to these clients. Therefore, any deviation from this open relationship would be important to study and discuss. I am referring here to the issue of parallel process (Berant, Saroff, Reicher-Atir, & Zim, 2005; Ekstein & Wallerstein, 1958/1971), in which the student and the supervisor come to interact with each other in the same manner in which the client and the student interact in the assessment process. The study of this changed relationship between the supervisor and student could then illustrate for the student the effect the client had on him or her. In the analysis of this changed relationship or attitude between supervisor and student, the student can come to understand the effect the client had on him or her and its implications for both client and student, in this case and perhaps in others as well. For example, a supervisee was assessing a man who interacted with her as if to indicate how emotionally fragile he was. The supervisee became protective of him and in supervision protected the man from the supervisor by withholding from him certain important information. In addition, the supervisee, ordinarily

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a strong, open, and direct individual, acted weak and timid with the supervisor while discussing this case (a manner that was unusual for her). In supervision, the supervisor spent time discussing the student’s impressions of the client and eventually the hidden material was discussed. In a patient and nonconfrontational manner the supervisor helped the student understand that parallel process was at work here. She was able to see how she had been caught up in protecting the client. The parallel process was somewhat complicated in that the student recognized her propensity to protect someone who appeared fragile because she had, as a youngster, learned to protect her younger sister from their angry father. An important next step was to help the student intervene with this client now that she was more aware of her protective stance. This material could then be useful in helping the client deal with his fragile stance. In addition, the supervisor should optimally help the student work out ways of avoiding being stuck in future similar situations with clients. Good things happened when the student helped the client to act in a less fragile manner and when the student could prevent herself from acting fragile in her future supervision. Thus, the supervisor helped the supervisee deal with her relationship problem, just as the supervisee helped the client deal with his relationship problem, by helping him learn that presenting himself as fragile is a problematic way of dealing with problems. It is important to note here that supervision is not psychotherapy, but often highly personal issues are brought up that could easily turn it into psychotherapy. Although it is the supervisor’s responsibility to deal with personal issues as they impinge on the case at hand, the supervisor should suggest a student seek therapy if the problem exists in other phases of the student’s work. It is important in supervision to help the student become aware that in doing an assessment, as in doing psychotherapy, there is a real relationship formed between the client and the assessor. Although the student may believe that he or she is neutral in the assessment procedure, the patient may or may not experience the examiner in that way. It is not unusual for a patient to view the neutral approach of the examiner as the assessor’s indifference, disapproval, disinterest, or, worse, dislike. No patient who takes such a view of the assessor can come away from the assessment feeling he or she has been helped. A supervisor can be quite effective in helping students become aware of their impact on the patient. This learning can sometimes be accomplished through roleplaying, either in a group or in a one-to-one setting. Another method I employ at times is to ask students what they think the patient is experiencing at certain times during the assessment. This approach is facilitated by watching a videotape of the assessment. In the training program at the University of Tennessee, students videotape all interactions with patients. I usually watch the initial session and then selected parts of other sessions (depending upon how problem free the initial session appeared) in addition to obtaining feedback from the students about how they felt about the relationship. One of the more difficult parts of TA for students is the identification and clarification of therapeutic questions—those questions clients identify, typically in collaboration with the assessor. This process is often a problem because students’ interview skills may not be refined at this stage in their development. Therefore students sometimes have trouble helping patients identify therapeutic questions.

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Supervision in Therapeutic and Collaborative Assessment 217 A supervisor is effective when he or she demonstrates how these questions arise as part of the interview process. Although it is not a bad idea to ask clients directly about what they wish to learn about themselves in this process, some clients are unable to come up with questions. It is better to have questions arise from the interaction in the interview (e.g., “So you are saying that you’ve been wondering why you can’t concentrate?”). Sometimes clients pose questions that are not answerable from the ta process; students need help in identifying questions that are possible to answer from the assessment. The supervisor has an important role in helping students, in supervision, to pose questions they might have for their clients and then to choose test batteries that will be effective in helping to provide answers to the questions posed by the students, the clients, and the referral source. The merits of each test can be discussed, and a final test battery can be outlined. The supervisor can often help in suggesting various techniques to employ with patients to help amplify their experience with the tests, which often leads to information concerning the therapeutic questions previously posed. Students are often reluctant to use these examples, perhaps because they are not standardized parts of the tests. I often suggest to supervisees, for example, that they ask patients about their experience of each test and their reactions to the various stimuli in each test. For example, I almost always ask patients which Rorschach cards they liked and which they disliked, and the reasons they felt they liked or disliked each card. One patient disliked Cards IV and V because they were dark and made him feel depressed, whereas he liked Cards VIII, IX, and X because they were full of color and made him feel more cheerful. This feedback helped to give the assessor the idea, later proven correct, that the patient avoided life issues that put him in touch with underlying depression and provided part of an answer to his question of why he felt his interactions with others were so difficult. Giving feedback is often difficult for a student, especially one who sees it as giving the client bad news. However, remember the example of giving feedback to the disturbed patient: He was relieved that he finally had an answer to questions that had been plaguing him for years. It is important to work with students in supervision to make certain that the feedback is not a one-way process, going from assessor to patient. Instead, effective feedback is a dialogue between the assessor and patient. It is sometimes helpful to begin the feedback with a question, such as asking the patient/client to speculate about what the assessor found. This procedure helps to identify what area(s) are Level 1 areas, defined as those areas about which the patient is already aware. Supervisees need particular help in working with clients who have little motivation to self-reflect or self-analyze aspects of their life issues. It is true that clients who are sent for assessment (e.g., custody and other forensic evaluations) rather than come of their own accord are often unable or unwilling to generate therapeutic questions. A supervisor can help students understand the self-protective defensive approach many of these clients adopt. It is necessary to understand just how frightened and cautious these clients are about their interactions with a psychologist. For example, Ben-Porath, Graham, Nagayama Hall, Hirschman, and Zaragoza (1995) found that elevated Minnesota Multiphasic Personality Inventory–2 K scores are typically found in custody assessments. Often students see this defensiveness as a

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personality trait of the clients rather than as a self-protective adaptation to the situation. The supervisor can help students focus on the clients rather than focusing on themselves and their frustration because the clients will not cooperate fully with them. Students tend to disparage these clients rather than becoming aware of the clients’ previous experience with people who want to decide their fate. Finn (2007) offered many valuable suggestions about working productively with defensive clients. In this regard, the supervisor should keep a list of reading materials about ta that can be of assistance for students dealing with difficult clients. Supervisors should be able to help students differentiate whether the problems encountered in the assessment stem from life issues and expectancies of the testing situation, or whether the students’ contribution to the establishment of the relationship was problematic for the client. Students often need assistance in learning to be flexible and creative in the interview process. Supervisors can assist by discussing some of their cases and by sensitizing students to the feelings of the client. Students need help putting themselves in the place of the client, which is sometimes a difficult task when they are anxious about their own performance. This is an important issue because a lack of empathic attunement can put the entire TA process in jeopardy. Open recognition of students’ anxiety or concern is the first step in dealing with the problem. This should be followed by support, clarification, and encouragement, which are quite effective in helping students provide the same for their client. That is, supervisors model the approach taken in helping students, and students, in turn, do the same with their client. I often make it a point with students to tell them directly to do with the client what we have done with each other in supervision. Supervisors should discuss with new students the subtle and at times not-sosubtle opportunities to slowly begin the interpretive process during the testing period. All too often students are primarily focused on getting test responses, and they miss the opportunity to begin some interpretation before the testing is completed. Although I typically wait until a test is completed before I do such interpretation, in Fischer’s collaborative assessment approach she interrupts the client during the assessment in order to highlight an important issue. ta W I T H C H I L D R E N , A D O L E S C E N T S , A N D C O U P L E S Although I have focused on ta with individual adults, it is important to note that these methods are quite effective with other populations (e.g., children, adolescents, and couples). Although procedures vary depending upon the population, the basic philosophy of ta remains the same. A description and discussion of the methods as employed for children and adolescents are available in the work of Finn (2007) and Handler (2007). Supervision of ta with children and adolescents requires additional skills compared with the assessment of single adults. For example, many supervisees have had no experience with children or with the assessment of children. They have little knowledge of test norms for these groups or understanding of children’s developmental and physical milestones. Supervisees therefore require careful and close supervision in all phases of TA and collaborative assessment with children and adolescents. They would also benefit from opportunities to do therapy with

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Supervision in Therapeutic and Collaborative Assessment 219 children and adolescents or, if that is not possible, to observe more experienced students working with them. In addition, supervisees need exposure to family systems theory so that they are aware of family dynamics issues with regard to children and their families. Over the years I have become more and more aware that sometimes families identify a scapegoat, focusing family problems on a child client. It is also possible that children become negatively affected by parents’ critical comments and responses. Supervisees need training to identify these maladaptive family systems where they exist and to learn how to intervene to support the entire family. TA and collaborative assessment with couples involves the use of assessment tasks to “bring the problem into the room,” to borrow one of Finn’s phrases. One popular approach is to use the Consensus Rorschach (Finn, 2007; Handler, 1997). In this procedure both partners are tested individually and are then asked to take the test again. However, this time the partners are asked to work together to produce and report only responses upon which they both agree. Supervision of TA or collaborative assessment with couples calls for experience with dyadic relationships. Students must be aware of two individuals rather than just one person and need to be able to focus on the mutuality of the persons’ responses to each other. Students sometimes find that they become disoriented in trying to track two people rather than one, and they sometimes miss the subtle and not-so-subtle interactions. Almost any test or task may be used in a consensus manner, especially the Wechsler tests. I have used the Vocabulary, Similarities, and Comprehension subtests in the same manner as outlined for the Consensus Rorschach. Many years ago a student and I did a study with couples who rated their marriage as unsatisfactory and couples who rated their marriage as satisfactory (Handler & Sheinbein, 1987). The couples were tested individually with the WAIS Similarities and Vocabulary subtests, and then they were brought together to take the tests again, this time generating one answer between them for each item. The satisfied couples significantly raised their individual scores when they worked collaboratively: Often one partner gave up his or her 0 response to take his or her spouse’s 2-point answer. When the dissatisfied couples worked together, their collaborative scores went down significantly. They scored significantly lower when working together than they did while working individually. In this case, partners often gave up perfectly good 2-point answers and agreed on a 0 answer instead. Students need to become familiar with these methods of bringing these interaction problems into the room so the problems may be pointed out to the partners and so that the supervisees can learn ways in which to help the partners be more effective in their relationships. CONCLUSION The last but perhaps the most important issue concerning good supervision of ta concerns the development of a supervisee’s identity as a clinician and the internalization of the supervisor’s skills, values, and ideals. Concerning this issue Paul Lerner (1998) wrote the following: Meaningful learning takes place in an interpersonal context. As teachers and supervisors, beyond issues of course content and dispersing information, we need to attend

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to our relationships with our students and supervisees. Students identify with and internalize far more than our knowledge and our skills. They internalize our entire being; they embrace our values, our ideals, our passions, and our attitude toward them. Therefore, as supervisors prepare to encounter their supervisees they should ask themselves “what is it I want students to take in from me and to take away from our encounters?” (pp. 110–111)

Lerner believed that a mutually shared goal of supervision involves the student’s eventual sense of greater autonomy, “where students are increasingly able to do for themselves those functions they originally looked to their supervisors to perform” (p. 111). Such facilitative supervision should eventually become collaboration and should accompany positive shifts in the supervisee’s sense of self, his or her progression toward a professional identity, and “greater awareness and sensitivity in experiencing and relating to another” (p. 111). In my opinion, the internalization process is the most important aspect of good supervision. Earlier I promised the reader that I would discuss how the student who assessed the disturbed client reestablished a sense of equilibrium. The process is well illustrated by the following quote from a paper written by the student (Peters et al., in press). The reader will remember that the student became temporarily destabilized when his disturbed client, Mr. G., gave a significantly disturbed Rorschach: As had been my tendency throughout the assessment, I began actively wondering how my mentor might respond to this situation. By evoking images of us sitting together in class where collaboration was the standard, I began to reorient myself with a renewed sense of compassion, minus any feelings of being taunted or belittled by Mr. G. By calling upon a person whose skills and integrity I idealize, I provided myself access to a much needed calming selfobject function. In this way I was able to avoid a regressive preoccupation with “messing up” the test administration and as a result was able to stay open to Mr. G’s own need for a calming idealized selfobject function.

As I have said elsewhere (Handler, 2006), my goal as a supervisor is to facilitate such identification as mentioned by Lerner, to facilitate increased independence, and to share my knowledge with students and supervisees so that they may pass on their knowledge and values, modified and improved, to their supervisees, and on and on, ad infinitum. REFERENCES Atwood, G., & Stolorow, R. (1984). Structures of subjectivity: Explorations in psychoanalytic phenomenology. Hillsdale, NJ: Analytic Press. Atwood, G., & Stolorow, R. (1996). Faces in a cloud: Intersubjectivity in personality theory. London: Aronson. Ben-Porath, Y. S., Graham, J. R., Nagayama Hall, G. C., Hirschman, R., & Zaragoza, M. (Eds.). (1995). Forensic applications of the MMPI-2. Thousand Oaks, CA: Sage. Berant, E., Saroff, A., Reicher-Atir, R., & Zim, S. (2005). Supervising personality assessment: The integration of intersubjective and psychodynamic elements in the supervisory process. Journal of Personality Assessment, 84, 205–212. Buirski, P., & Haglund, P. (Eds.). (2001a). Foreword. In P. Buirski & P. Haglund (Eds.), Making sense together. Northville, NJ: Aronson. Buirski, P., & Haglund, P. (2001b). Making sense together. Northvale, NJ: Aronson.

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Supervision in Therapeutic and Collaborative Assessment 221 Ekstein, P., & Wallerstein, P. (1971). The teaching and learning of psychotherapy. Madison, CT: International Universities Press. (Original work published 1958) Finn, S. (1996). Assessment feedback integrating MMPI-2 and Rorschach findings. Journal of Personality Assessment, 67, 543–557. Finn, S. (2007). In our clients’ shoes: Theory and techniques of therapeutic assessment. Hillsdale, NJ: Erlbaum. Finn, S., & Martin, H. (1996). Therapeutic assessment with the MMPI-2 in managed health care. In J. Butcher (Ed.), Objective psychological assessment in managed health care: A practitioner’s guide (pp. 131–152). New York: Oxford University Press. Finn, S., & Tonsager, M. (1992). Therapeutic effects of providing MMPI-2 test feedback to college students awaiting therapy. Psychological Assessment, 4, 278–287. Finn, S., & Tonsager, M. (1997). Information-gathering and therapeutic models of assessment: Complementary paradigms. Psychological Assessment, 9, 374–385. Fischer, C. (1994). Individualizing psychological assessment. Mahwah, NJ: Erlbaum. (Original work published 1985) Fischer, C. (1998). The Rorschach and the life world: Exploratory exercises. In L. Handler & M. Hilsenroth (Eds.), Teaching and learning personality assessment (pp. 347–358). Mahwah, NJ: Erlbaum. Handler, L. (1988, March). The use of inquiry and testing of the limits in WISC and WAIS interpretation. Paper presented at the annual meeting of the Society for Personality Assessment, New York. Handler, L. (1996, March). Single projective test responses which illuminate therapeutic issues. Paper presented at the annual meeting of the Society for Personality Assessment, Denver, CO. Handler, L. (1997). He says, she says, they say: The Consensus Rorschach. In R. Meloy, M. Acklin, C. Gacono, J. Murray, & C. Peterson (Eds.), Contemporary Rorschach interpretation (pp. 499–533). Mahwah, NJ: Erlbaum. Handler, L. (1998a). Schachtel and teaching: What color is the couch? (Invited special series, Rorschach Contributions of Ernest Schachtel). Journal of Personality Assessment, 71, 172–181. Handler, L. (1998b). Teaching and learning the interpretation of the Wechsler Intelligence Tests as personality instruments. In L. Handler & M. Hilsenroth (Eds.), Teaching and learning personality assessment (pp. 295–324). Mahwah, NJ: Erlbaum. Handler, L. (1999). The assessment of playfulness: Herman Rorschach meets D. W. Winnicott (Invited special series, The Assessment of Psychological Health). Journal of Personality Assessment, 72, 208–217. Handler, L. (2000, March). How Harry Stack Sullivan taught me therapeutic assessment. Symposium conducted at the annual meeting of the Society for Personality Assessment, Albuquerque, NM. Handler, L. (2002, July). Non-traditional approaches to the administration and interpretation of projective techniques. Paper presented at the 17th International Congress of Rorschach and Other Projective Methods, Rome, Italy. Handler, L. (2004, August). A changing paradigm in personality assessment. Paper presented at the annual meeting of the European Rorschach Society, Stockholm, Sweden. Handler, L. (2005a, July). The administration and interpretation of the Rorschach in light of changes in psychoanalytic theory. Paper presented at the 18th International Congress of Rorschach and Other Projective Methods, Barcelona, Spain. Handler, L. (2005b, July). A Rorschach assessment amplified, using play in testing of the limits. Paper presented at the 18th International Congress of Rorschach and Other Projective Methods, Barcelona, Spain. Handler, L. (2006, March). Oh you must remember the Marx brothers: My past is not your present. Symposium presented at the annual meeting of the Society for Personality Assessment, San Diego, CA. Handler, L. (2007). Therapeutic assessment with children and adolescents. In S. Smith & L. Handler (Eds.), Clinical assessment of children and adolescents: A practitioner’s handbook (pp. 53–72). Mahwah, NJ: Erlbaum. Handler, L., Fowler, C., & Hilsenroth, M. (1998). Teaching and learning an advanced course in personality assessment. In L. Handler & M. Hilsenroth (Eds.), Teaching and learning personality assessment (pp. 431–452). Mahwah, NJ: Erlbaum. Handler, L., & Hilsenroth, M. (1994, April). The use of a fantasy animal drawing and storytelling technique in assessment and psychotherapy. Paper presented at the annual meeting of the Society for Personality Assessment, Chicago, IL. Handler, L., & Hilsenroth, M. (Eds.). (1998). Teaching and learning personality assessment. Mahwah, NJ: Erlbaum. Handler, L., & Sheinbein, M. (1987, March). Decision making patterns in couples satisfied with their marriage and couples dissatisfied with their marriage. Paper presented at the annual meeting of the Society for Personality Assessment, San Francisco, CA.

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Lerner, P. (1998). Training in assessment: Internalization and identity. In L. Handler & M. Hilsenroth (Eds.), Teaching and learning personality assessment (pp. 107–118). Mahwah, NJ: Erlbaum. McAdams, D. (1985). Power, intimacy, and the life story: Personological inquiries into identity. New York: Guilford Press. McAdams, D. (1993). The stories we live by: Personal myths and the making of the self. New York: Morrow. McLeod, J. (1997). Narrative and psychotherapy. London: Sage. Mutchnick, M., & Handler, L. (2002). Once upon a time . . .: Therapeutic interactive stories. Humanistic Psychologist, 20, 75–84. Orange, D., Atwood, G., & Stolorow, R. (1997). Working intersubjectively: Contextualism in psychoanalytic practice. Hillsdale, NJ: Analytic Press. Peters, E., Handler, L., White, K., & Winkel, J. (in press). Am I going crazy doc? A self psychology-based approach to therapeutic assessment. Manuscript submitted for publication. Stolorow, R., Atwood, G., & Brandchaft, B. (Eds.). (1994). The intersubjective perspective. London: Aronson. Stolorow, R., Brandchaft, B., & Atwood, G. (2000). Psychoanalytic treatment: An intersubjective approach. Hillsdale, NJ: Analytic Press. Sullivan, H. (1953). The interpersonal theory of psychiatry. New York: Norton. Sullivan, H. (1954). The psychiatric interview. New York: Norton.

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C H A P T E R 13

Hypnotherapy Supervision C. ALEXANDER SIMPKINS and ANNELLEN M. SIMPKINS

HYPNOSIS HAS long been known to be a powerful and effective tool. For hundreds of years, psychologists, medical doctors, and researchers have devoted their careers to deepening the understanding of the phenomenon. Today, after centuries of empirical research, hypnosis has been shown to be both an effective stand-alone treatment (Simpkins & Simpkins, 2008; Yapko, 2003) as well as a useful adjunct to many currently accepted methods (Allison & Faith, 1996; Bryant, Moulds, Guthrie, & Nixon, 2005; Habermuller & Revenstorf, 2006; Hornyak & Green, 2000; Kirsch, Montgomery, & Sapirstein, G 1995; Kroger, 1977; Schoenberger, 2000). Practitioners of all forms of psychotherapy will find many benefits to incorporating hypnosis into their practice. This chapter begins by showing how hypnosis can be used therapeutically. Next we introduce some primary theories, past and present. Supervisors are then given ways to conduct a supervisory session, with answers to commonly asked questions and instructions for how to enter hypnosis. The student can learn strategies for guiding the application of hypnosis to some conditions for which it is most commonly used: relaxation, habit control (e.g., smoking and weight), pain management, anxiety, anger problems, stress reduction, and mild depression. Relevant research findings are presented throughout, showing how the long history of hypnosis has found firm scientific footing as an effective method for the twentyfirst-century practitioner. Case histories illustrate the varied applications of hypnotherapy. THE THERAPEUTIC USE OF SUGGESTION AND TRANCE Hypnosis offers specific techniques to help people with a wide range of problems. Researchers have tested specific applications of hypnosis. For example, hypnosis is effective for pain control. This is useful for a number of different fields including medicine, dentistry, and athletics. In one study, Miller and Bowers (1986) found 223

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that highly hypnotizable subjects had significant reduction of pain when hypnosis was used as a stand-alone method. Anxiety is another area that has been well researched regarding the use of hypnosis. Schoenberger (2000) found that many forms of therapy, including cognitive-behavioral therapy, could be enhanced using hypnosis, even when subjects scored low on hypnotizability scales (Benson et al., 1978). These findings are encouraging because they demonstrate that most people can use hypnosis for anxiety management. Mild to moderate depression can also be helped using hypnosis. But hypnosis is not recommended for cases of severe depression (Yapko, 2001). Hypnosis can be used to facilitate behavioral methods of treatment (Kroger, 1977). One specific application is with desensitization therapy. The originator of systematic desensitization, Joseph Wolpe (1915–1997), used hypnosis as part of his method (Wolpe, 1990). Hypnosis can make desensitization techniques more efficacious in several ways, by permitting quicker relaxation response, facilitating retrieval of traumatic material without the usual corresponding anxiety and distress, and enhancing conditioning and learning.

ALTERING SYMPTOMS Hypnosis and suggestion can be applied when the symptoms are so disabling as to block all psychotherapeutic efforts. Although medication may be one choice to alleviate symptoms, hypnosis allows the client to gain mastery, confidence, and relief to face treatment gracefully and courageously. Hypnotic work may open new doors of possibility for the client by giving vivid, new experiences for creative transformations. Additional positive resources can be developed along the way through skillful facilitation. The therapist can initiate new possibilities through analogy. The problem can either be intensified or diminished with the help of hypnosis. In the following case, the client intensified and redirected her tension, thus mastering the situation.

Case 13.1 A ballet dancer suffered from chronic anxiety and shyness and had been unsuccessfully under medical treatment with anti-anxiety medication for 2 years. She sought hypnotherapy for her anxiety during performances and competitions. She worked out hard when practicing and could perform her dance routines well when alone. But whenever she performed in front of the class, she felt extreme discomfort with audience attention focused on her. Her anxiety was so great that she would shake all over, which was extremely embarrassing, causing her to blush. She could not imagine ever being less nervous. She learned to relax completely and feel calm in hypnosis. She always felt relief from her symptoms during and following trance. She learned to move a finger, a hand, or an arm with hand levitation. We realized that her learning process could begin there. We decided together on an acceptable alternative to shaking all over. She could direct her anxiety into her little finger, which could shake intensely during her performances. Of course, others might not notice, but she would know. The rest of her body was free to perform well, and she could enjoy her secret. Her anxiety was subtly hidden in her little finger. This thought amused her.

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After her next dance performance, the client reported that she found herself dancing well, and she smiled to herself about her little secret. She was the only one who noticed the trembling little finger. To the judges she merely appeared to be enjoying her performance, fully at ease, which added to her high score. This permitted her to develop further possibilities for herself, both as an artistic performer and, later in life, as a performer of work. As her confidence grew, she frequently “forgot” to take her medication. Eventually she lost the bottle and never bothered to refill the prescription. She continued hypnotherapy until she was free from anxiety in all of the significant aspects of her life.

ACTIVATING AND INCREASING NONSPECIFIC FACTORS Many of the nonspecific factors of effective therapy are activated with hypnosis. A meta-analysis of a number of studies (Kirsch, Montgomery, & Sapirstein, 1995) found that hypnosis measurably increases effectiveness when combined with one of the most commonly used modern psychological treatments, cognitivebehavioral therapy. All forms of therapy are enhanced by demonstrating the influence the mind has over the body. Hypnotic phenomena, brought about by the skillful use of suggestion in trance, offer tangible experiences of this mind–body link. Clients can be led to experience many interesting phenomena such as anesthesia of a hand, paralysis of an arm, a vivid image, or a hallucinated sound. These experiences help clients to understand by analogy how symptoms may be created by suggestions they give to themselves (Ritterman, 2005). Such learning lets them disentangle from neurotic patterns, bringing about experiences of mastery (Frank & Frank, 1993). Suggestion can be an ally for change. In fact, suggestion can be considered a nonspecific factor in psychotherapy (J. D. Frank, personal interview, Baltimore, MD, September 1978).

Case 13.2 In this case of anger management, the client learned through hypnosis that things could be different. A lawyer underwent hypnosis to learn to control his temper, which was interfering with his professional and personal lives. Before the trance, we discussed hand levitation as one hypnotic phenomenon he could learn from. He said he was curious about it but thought it would be difficult to actually do. He developed a comfortable trance and even smiled as he entered trance. Hand levitation was suggested. His hands moved barely, if at all, but his face became flushed and a few beads of sweat appeared on his brow. Upon awakening he recounted what he referred to as a “marvelous experience.” He said that the levitation was so powerful that he was embarrassed that he was doing jumping jacks! The experience was that vivid for him. He felt tired afterward, as if he had exerted tremendous energy. We reassured him that he had barely moved at all. He was extremely pleased to realize that he could have such an intense experience in his imagination and remain in control of himself. Similarly, he could feel emotionally aroused with anger but not have to express it in action. Subsequently he was able to moderate his temper.

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IMPROVING COGNITIVE ABILITIES Researchers have found that many cognitive abilities increase under hypnosis: more focused attention, more effective processing of information, faster reaction times, and better access to imagination and imagery. Experts can pinpoint activation and inhibition of different parts of the brain through different forms of improved efficiency in brain activity (Ray, Blai, Aikins, Coyle, & Bjick, 1998).

Case 13.3 A young man in his 20s, teeming with excess energy, came for hypnotherapy. He had lost his job and decided to start his own business tuning and repairing machinery. He spoke quickly, often paced during the sessions, and described himself as “hyper.” He complained that sometimes in his new business he would miss a small detail, which caused him to have to return to the job site to redo the work. All profit was lost, and at times it even cost him money to complete the job. He was inattentive to important details of his work but overly attentive to unimportant details. He learned to go into trance and found himself enjoying the calm and relaxation he felt. During trance, we suggested that he imagine a place where he felt very comfortable. He thought of the woods near where he had grown up. He recalled every detail: the wood noises, the smell of the leaves and plants, the colors of the sun shining through the trees. He searched back in his memory to carefully recall many details, focusing all his energy on sensitizing himself to the experience. The week after this trance, he reported that he was surprised to discover something new. Seemingly automatically, he found himself listening intently, looking carefully, and noticing exact details in the machinery he was fixing. He reported hearing minute sounds indicating where the malfunction had occurred. His exacting attentiveness resulted in a week with no callbacks and no errors. We asked him to focus on his body, to feel his calves; notice how long his arms were, his legs; and feel his breathing. This evolved his learning further. He learned to become so sensitive that he could feel a whisper of a breeze or a minute touch to his arm. He gained greater skill with tools. He applied hyperesthesia, suggested in trance, in useful ways in his life, overcoming a long-standing problematic adjustment.

Memory can be enhanced in hypnosis, making this technique an effective tool for recovering helpful material from the past to be used for insight in the present. However, always consider recovered hypnotic memories as subjective material rather than objective facts: Expectancy and bias can affect client material, leading to false memories (Battino & South, 2005). Finally, hypnosis helps to strengthen the therapeutic relationship. Hypnosis can be performed with either a directive or nondirective approach. The individuality of the client is primary in deciding which approach to use. For some, a strong authoritative prescription for change through suggestion is powerful in bringing about positive outcome. A client who wishes to participate more actively may prefer suggestions that are presented in such a way that he or she can choose to accept the helpful ones and reject those that are not helpful. Indirect suggestions, as Erickson so expertly demonstrated (Simpkins & Simpkins, 2000), give a client the opportunity to make his or her own meaningful associations and links.

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SELECTIONS FROM THE THEORIES OF HYPNOSIS Hypnosis has always been an elusive phenomenon. Many plausible theories have been formulated to account for it. Consider a rock from multiple perspectives: The chemist analyzes its inner molecular structure, the geologist places it into an external category, and the structural engineer considers its density and resistive force. All perspectives have merit for an outer understanding of the rock. But no amount of scientific measurement, dissection, or categorization reveals its true nature. Only through art can it be shown and its inner essence of truth revealed. Similarly, hypnosis has been looked at from many perspectives. With new technology, people are learning more about hypnosis. Although one definitive, unifying, grand theory has not been agreed on, the true nature of hypnotherapy is revealed through the art of practice. For the most improvement, science and art can be melded together. As practitioners and supervisors, we are well aware of the value of formulating a clear theory to build the foundation for practice. Arthur Combs (1989), a founding father in counseling, explained how theories can help: “To assure [sic] that clients receive effective help, counselors need trustworthy theories, capable of providing reliable guidelines for thinking and planning about counseling in general or for the moment to moment decisions of professional practice” (p. 11). The hypnosis supervisor may need to familiarize the supervisee with various hypnotic theories to offer this possibility. Supervisors can integrate methods from traditional and modern hypnosis theories with contemporary psychotherapy, encouraging supervisees to use theories as resources to enhance creative use of hypnosis in conducting therapy. We hope that the theories presented here will help the new practitioner discover his or her own artistry in the sensitive practice of effective hypnotherapy. Some of the best historical accounts of hypnosis are found in Janet (1925), Tinterow (1970), James (1896), and Bramwell (1903). We suggest reading original sources of theory and practice whenever possible, such as Braid (1960) and Bernheim (1973). We have also included a history of hypnosis in our books (Simpkins & Simpkins, 2000, 2004).

VITALISM In one form or another, hypnosis has been in use since the beginning of human history. But Franz Anton Mesmer (1734–1815) is often credited as a pivotal founding figure in modern hypnosis. His approach became known as Mesmerism. It grew in popularity, developing into a highly influential force. Today, the dictionary includes mesmerize as a verb that means to fascinate somebody or absorb all of the person’s attention, as well as refers to the use of mesmeric methods of hypnosis. Mesmer’s method was guided by a theory that resonated with a dominant theory of the time: vitalism. He believed that matter, at the ultimate level, was made up of a powerful subtle fluid that filled the universe, interpenetrating and surrounding everything. He called this animal magnetism. If properly channeled so that the patient was guided into harmonious rapport, this fluid could positively affect healing. Mesmer’s approach relied upon a strong intersubjective relationship and a

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deeply absorbing trance experience in which the active influence of the magnetizer directed the fluid in the subject. Animal magnetism was explored and developed by Alfred Binet and Charles F´er´e (1888). Binet is best known for publishing the first usable intelligence test, but he also had a strong interest in hypnosis. FIXATION OF ATTENTION James Braid (1795–1860), the man who coined the term hypnosis, demonstrated that by using monotony to fixate attention onto one thing, the hypnotist could produce deep trances and hypnotic phenomena. Braid theorized that hypnosis was based in changes in the brain of the subject due to attention focused on one idea. Many are familiar with this approach to hypnosis, in which the subject is instructed to look at a swinging object or watch a turning spiral. Later developments showed that hypnosis could be induced without such devices by simply turning the subject’s attention inward. Braid was also one of the early theorists to move away from Mesmer’s idea that subjects were under the power of the operator. Braid wrote that the effects of hypnosis were not due to the active influence of the hypnotist. Instead, effects took place in the mind of the subject. Modern self-hypnosis evolved from these formulations of Braid. Even though he thought that hypnosis was based in physiological events and changes in the brain, somewhat similar to sleep, he recognized that the hypnotic effects took place through the imagination and concentrated attention of the subject. Crawford (1994) supported Braid’s view. She found that highly hypnotizable subjects have the ability to focus and sustain their attention better. They are also better at ignoring irrelevant stimuli in the environment. She proposed that hypnosis is a state of enhanced attention that activates interplay between cortical and subcortical brain dynamics during hypnotic phenomena, suggesting that these attentional differences are reflected in underlying neurophysiological differences in the far fronto-limbic attentional system. PARTIAL SLEEP The sleep theory of hypnosis reaches back to the early Greeks. The cult of Asclepius, which flourished around 300 BC, healed patients as they slept. Patients came to special centers to undergo therapeutic sleep (called incubation) under the guidance of a healer (“Sleep Temple,” 2006). Over the centuries, the idea of hypnosis as resembling sleep was an important theory. One of the proponents who led the way scientifically was Ivan Pavlov (1849–1936). All modern psychologists are familiar with Pavlov’s experiments in conditioned response with animals and his discoveries about the effect of the cerebral cortex. But what is less well known is that hypnosis was important in Pavlov’s theory of cortical excitation and inhibition (Platinov, 1959). Pavlov (1960) defined hypnosis as a state of partial, scattered sleep. Sleep is a state of generalized inhibition in the cortex, and waking is a state of generalized excitation. Hypnosis is a transitional period between waking excitation and sleep inhibition: “In hypnosis we are not dealing with complete sleep but only with partial sleep. This is the difference between hypnosis and natural sleep” (p. 336).

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People feel relaxed in trance, like in sleep, while also being alert and receptive, similar to when they are awake. Early EEG studies in the 1940s compared hypnosis with normal sleeping. Gordon (1949) found that EEG sleep patterns differed from EEG hypnosis patterns. A contemporary researcher who has done extensive EEG studies with hypnosis confirmed that even though people feel relaxed in hypnosis, almost like when they are sleeping, their brains are active (Crawford, 2001). De Pascalis’s (1998) research on the hemispheres showed that as people first enter hypnosis, the left hemisphere is more active. But when they enter more deeply, the left hemisphere is inhibited. CONDITIONED RESPONSE Pavlov also developed a theory of suggestion. He believed that the cerebral cortex closely coordinates the inner and outer environments of the organism. His research led him to believe that people and animals are subject to the action of the cerebral cortex, which he called the first signal system. But humans have a second signal system that arises from work, social activity, and language. Words become symbolic signals, abstractions from reality that stimulate the organism just as concrete experiences do. Words act suggestively when they become a conditioned stimulus by combining with an actual experience such as eating a delicious dessert paired with its name, apple pie. Eventually just the words apple pie can activate the brain to elicit hunger. Words combine as complex conditioners that lead to a broad range of experiences. This discovery of the influence of words on the brain offered a deeper understanding of how physiological responses are stimulated by suggestions. During hypnosis, the conditioned link between mind and body is utilized and developed. This natural mind–body connection is known as the ideomotor response. Described early on by William James (1896), this natural mind–body link includes more than just a physical response but also, in combination with sensory and emotional experiences, an ideodynamic response. The hypnotherapist can utilize natural, automatic, conditioned responses to give the client corrective experiences to help move therapy in the right direction. So, in a sense, rather than fighting against the current, the sensitive hypnotherapist goes with the natural flow, gently guiding it toward health. SUGGESTIBILITY Hypnosis was associated with suggestion from its formative movements in nineteenth-century France, leading to an important theory of hypnosis as suggestion. Hippolyte Bernheim (1840–1919), the founder of the famous Nancy School in France, clarified the idea that suggestion was the underlying force in hypnosis. Hypnosis makes people more responsive to suggestion. Bernheim defined suggestion as influence exerted by a suggested idea and received by the mind through the imagination. So when an idea is introduced to the mind, it gives rise to a corresponding sensation in the body. Once in trance, suggestions are transformed into action, sensations, movement, or images. This theory helped lead to the ideomotor concept.

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Clark Hull (1884–1952), who opened one of the first hypnosis laboratories, believed that hypersuggestibility distinguished hypnosis. His experiments showed that under hypnosis people become more responsive to suggestions. The change in suggestibility was a measurable verification of hypnosis (Hull, 1968). Andre Weitzenhoffer (1921–2005) wrote several comprehensive books and clinical teaching manuals on hypnosis, carefully detailing mechanisms of suggestion with applications. He postulated that the differences between hypnotic and waking phenomena are essentially qualitative, not quantitative (Weitzenhoffer, 1957). Neurological imaging research combining EEG and positron emission tomographic scans distinguished distinct cerebral changes between (a) relaxation, (b) hypnosis alone, and (c) hypnosis combined with suggestion (Rainville et al., 1999). The researchers found that cerebral activation patters differed in all three groups, leading them to conclude that not only does trance activate unique brain patterns, but suggestion does as well. NEO-DISSOCIATION Hypnotism can also be defined as a momentary transformation of the mental state that brings about dissociations of personal memories. Ernest Hilgard (1904–2001), the eminent Stanford University professor and researcher, explored and developed the dissociation theory into a neo-dissociation theory of hypnosis. Hilgard (1977) believed that all people naturally are conscious of more than one thing at a time. In hypnosis, this capacity is exaggerated. Hypnosis allows people to temporarily dissociate from normal consciousness to develop a separate, new state of consciousness. Hypnotic dissociation has continued to play an important role in pain control, in which it can be a valuable tool. Hilgard, along with his wife Josephine, made many important contributions to hypnosis. The Hilgards firmly believed that by exploring hypnosis, researchers could deepen understanding of the workings of attention, memory, perception, creativity, and imagination. The Hilgards did much to help hypnosis find a respected place within the scientific community. They devoted many years of productive professional life to further knowledge about hypnosis at the Stanford University hypnosis laboratory (Hilgard & Hilgard, 1975). The Stanford Susceptibility Scale is one of the Hilgards’ many achievements in advancing the understanding of hypnosis. SOCIAL-PSYCHOLOGY VIEW Theodore R. Sarbin (1911–2005) was one of the early practitioners to propose that hypnosis could be better understood as a social phenomenon rather than a phenomenon of consciousness; T. X. Barber (1927–2005) followed in this thinking (Barber, 2000). The social role enactment theory of hypnosis views the phenomenon from an external perspective. Hypnosis is defined as a social interaction. The hypnotized individual takes on a social role based in a broader theory of role-playing drawn from social psychology. According to social role theory, we as people can conceptualize about our lives in terms drawn from acting and role-playing on a stage. We all have multiple roles in the drama of life. For example, we act as a parent to our own children, but paradoxically we play the role of child

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when we interact with our parents. And we engage in our roles with varying levels of involvement. The role of a hypnotic subject represents a high level of role-taking involvement wherein the subject is personally engaged with a high degree of imagination and goal-directedness. Hypnotic role enactment is characterized as earnest and sincere, not sham behavior. Proponents of this view all shared in a social–psychological interpretative perspective (Barber, Spanos, & Chaves, 1974; Sarbin, 1950). STATE THEORY Hypnosis has been defined as a unique state, a shift in consciousness that activates unconscious processing with less interference from conscious cognition and rational reasoning. This theory of hypnosis opens up vast potentials for working with trance as an altered state to bring about changes in normal functioning. Generally, brain researchers express the view that hypnosis can be clearly distinguished from normal waking through real, consistent, and distinct changes that take place in the brain. Such findings support the theory that hypnosis is a psychological state with distinct neural correlates (Crawford, 1994, 2001; De Pascalis, 1998). Milton H. Erickson (1901–1980) was a strong proponent of the theory that hypnosis is an altered state. Erickson’s theory was based in a firm belief that the unconscious mind is a reservoir of positive potential and that the hypnotic state activates unconscious intelligence. People think that they function best by being completely rational and consciously aware, but Erickson believed that a large part of intelligence comes from the unconscious. In fact, the conscious mind often holds a person back due to learned limitations concerning what one can and cannot do (Simpkins & Simpkins 2001). The issue of unconscious intelligence has been tested extensively (e.g., Bowers, 1984; Kihlstrom, 1987; Kihlstrom, Barnhardt, & Tataryn, 1992; Lewicki, Hill, & Czyzewska, 1992). These studies show that people have an unconscious sense of coherence and understanding that takes place with little or no conscious intervention. This view holds that many abilities are already present in the unconscious mind, just waiting to be mobilized to help people learn and grow. Hypnosis enlists the unconscious to break through barriers and discover new possibilities (Erickson, 1964a). By going into trance, people get access to their untapped possibilities. Erickson used trance in creative ways to help people get around the barriers that held them back. Then they could make positive use of the vast potentials for change and growth that were just waiting to be enlisted for their benefit (Erickson & Rossi, 1980). The therapeutic principle of utilizing personal experiences evolved into what has become known as the utilization method of facilitating every aspect of the hypnotherapy process. The Ericksonian approach helps people utilize what they are already doing, thinking, perceiving, or remembering, even if it seems to be only a form of resistance, to bring about therapeutic change (Erickson, 1959). Erickson’s definition of suggestion incorporates utilization theory: Suggestion is the ability of the mind to respond to an idea. The unconscious mind responds best when suggestions are open ended, leaving room for the unconscious to respond in its own way and time. This form of suggestion is known as indirect suggestion.

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Erickson developed a complex lexicon of indirect suggestions to help stimulate the unconscious mind to respond. Suggestibility studies on attribution of meaning to ambiguous figures corroborate Erickson’s view (Marucci & Meo, 2000). NEUROSCIENCE VIEW A dialogue between hypnosis and neuroscience is evolving, whereby each field is hoping to shed new light on the other. In a recent cross-talk between clinical and cognitive researchers, Raz and Shapiro (2002) stated, “Neural-imaging techniques offer new opportunities to use hypnosis and posthypnotic suggestion as probes into brain mechanisms and, reciprocally, provide a means of studying hypnosis itself” (p. 88). Rossi (2002) postulated a new theory of the connection between mental enrichment through hypnosis and gene expression. Rossi drew parallels between Erickson’s extensive use of implication through indirect suggestion, and neurobiological findings on implicit processing of memory, learning, and behavior. Rossi’s theory builds a bridge from the recent findings of the Human Genome Project to the helping community. Rossi cited a growing body of empirical evidence for accepting the belief many practitioners have intuited for centuries: Nature and nurture are one. What people think, feel, and experience has real and immediate effects on their physical reality through gene expression. Gene response is activated by novel experiences, creativity, dreams, and hypnosis. Rossi presented a new theory for hypnotherapy as a four-stage creative cycle that utilizes trance to provide the underlying mechanism for positive neurogenesis and gene expression. This theory shifts away from the traditional psychopathological orientation toward a positive psychology emphasis on optimal performance, happiness, creativity, and human potential. The proponents of this theory are optimistic about the potentials of the mind to heal the body, and the body to affect mental well-being. Hypnotic trance can activate this process to influence health in positive directions. S T R U C T U R I N G T H E F I R S T H Y P N O S I S S U P E RV I S I O N S E S S I O N When clients begin hypnotherapy, they usually have questions. The hypnotherapist often needs to address clients’ concerns before proceeding. This section answers some commonly asked questions about hypnosis. The supervisor should go over these and other relevant topics with the supervisee to make sure that the student has an appropriate understanding based on fact, not fiction. Then the supervisee, in turn, can release clients from the inhibiting influence of misunderstandings and myths about hypnosis. CAN I BE HYPNOTIZED? Anyone who genuinely wants to experience hypnosis can be hypnotized (Bramwell, 1903; Hilgard, 1965). In hypnosis, people are exercising their natural capacity to be responsive. Hypnosis teaches people how to develop a cooperative relationship with their own unconscious mind. All people have this ability if they choose to develop it.

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People vary in how easily they enter trance and experience hypnotic phenomena. Proponents of standardization claim that this characteristic remains constant, like personality traits. But any motivated person can make an excellent hypnotic subject. Apparent differences are due to interactions between the hypnotist, the subject, and time. For example, some people immediately are good subjects, whereas others take longer to develop trance and to learn to experience hypnotic phenomena. But this does not mean those who need more time cannot experience hypnosis, nor that they are less capable of developing trance. We have found this to be true in our own practice. This is an important point: Be sure to take whatever time is needed for the client to develop trance. Even though modern research has shown that some people seem more readily susceptible, the largest hypnosis study ever attempted was in 1892. This study determined that 75% of people are moderately to highly capable of entering hypnosis (Bramwell, 1903). This finding was based on 8,705 hypnotized subjects from 15 different countries. The study also recorded factors that influence how people respond. They noted no influence of race or sex across the 15 participating countries. Researchers did find an age difference, because children found it easier to go into trance than adults. Intelligent, imaginative subjects were better subjects than duller, unimaginative ones. People who were mentally passive with poor concentration abilities were not as capable as subjects who could more freely focus and direct their attention (Simpkins & Simpkins 2004). One of the factors that influences whether someone is able to experience hypnosis in a particular situation is motivation. When people have a good reason to use hypnosis to help them make a positive change in their life, they can usually experience some level of trance. So the skilled hypnotherapist should be able to use hypnosis with most clients who are motivated by problems ranging from sleep disorders to pain to anxiety disorders. Many people can experience hypnosis, but not all experiences will be the same. Some people will feel a light trance, whereas others will have a deep trance. If clients sincerely want to use hypnosis and are willing to take the time needed, each will be able to find his or her workable individual level of trance. Another difference involves the type of phenomena clients can most easily develop in hypnosis. Some will experience certain phenomena more easily than others. People are spontaneously capable of doing certain trance phenomena and not others due to how they naturally orient, using a preferred perceptual mode. For example, people who get lost in music or daydreaming might use rhythms or imagery, respectively, to enhance trance involvement. Most people find themselves naturally adding new skills with well-directed practice.

WILL I COME OUT OF HYPNOSIS? People worry about being able to wake up from hypnosis. The answer to this question involves the theory of hypnosis being similar to sleep. Subjects always awaken from hypnosis just as they inevitably awaken from sleep. Some people, at first, take longer than others to come out of trance. But transitions in and out of hypnosis become quicker and easier with practice.

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WILL I LOSE AWARENESS? Clients wonder if they will know what is happening to them in hypnosis. Some people like to keep a close conscious watch over themselves and would not want to let go of their awareness. Others like to experience altered states of consciousness and so enjoy letting go and not noticing every detail. Hypnosis develops sensitivity, so clients come to know what they need more clearly. Some clients will follow the entire process with full awareness if this is their preference. For example, we have offered an option to people who worry about losing awareness to let the body go into trance while the head remains awake and watching. Then mistrustful or hesitant clients can gain confidence and trust in the process. As a by-product of hypnosis, clients become more trusting of unconscious processing in general, which can be helpful for clinical work.

DOES HYPNOSIS MAKE SUBJECTS WEAK OR SUBMISSIVE? Sometimes clients ask if hypnosis will make them submissive or follow suggestions without any intelligent thought. The reason for these concerns is the result of a fallacy: People often confuse unconscious, out-of-awareness responses with low intelligence and weakness. But numerous research projects have found the opposite: The unconscious mind is intelligent and can understand the meaning of situations intuitively. For example, Groeger (1984) flashed words on a screen for a group of subjects to view. Half the subjects received the words faster than they could consciously perceive them, registering them unconsciously. The second group received the words a little slower so that they saw the words consciously. Unconscious perceivers could match meanings, whereas conscious perceivers only found similar sounding words. Researchers have investigated subject compliance to try to understand how far hypnotic influence can go. In one experiment, Erickson (1980, p. 505) suggested, in an unrealistic way, that an ordinary box was a hot stove and told subjects to sit on it. Subjects did sit on the box and squirmed as if they felt excessive heat. But when Erickson gave realistic suggestions that another box was a hot stove, subjects refused to sit there. This experiment shows that in a trance, people are able to make subtle distinctions from how realistic the suggestion seems that allow them to decide whether they want to comply. When people are hypnotized they are themselves with an unusually clear sense of their standards for behavior. Clients will have a direct, literal sense of what they want and feel, sometimes even more so than when they are fully awake.

CAN HYPNOSIS MAKE ME DO SOMETHING I WOULD NOT WANT TO DO? Clients may fear that under hypnosis they can be made to do something against their will. The media have played upon this common misconception for the sake of drama. To test these fears of hypnosis, researchers have tried in many experiments to induce such actions as telling lies, intruding into other people’s property, doing something that would cause pain, or committing theft. The results showed clearly that during hypnosis people could not be made to do anything that they did not

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want to do. Subjects were either unwilling to perform these acts or else did them in such a way that the action became harmless (Erickson, 1980, pp. 523–524): Instead of blind, submissive, automatic, unthinking obedience and acquiescence to the hypnotist and the acceptance of carefully given suggestions and commands, the subjects demonstrated a full capacity and ability for self-protection, ready and complete understanding with critical judgment, avoidance, evasion, or complete rejection of commands. (Erickson, 1980, p. 529)

EXPERIENTIAL TRAINING Theory is helpful only to a point. Anyone who wishes to use hypnosis ought to experience hypnosis first hand. The student should learn to enter trance under competent professional guidance and experiment with the usual phenomena of trance and suggestion. Supervisors should, of course, have extensive personal experience with trance as well as a great deal of clinical experience using hypnotherapy. If you are supervising a group of students, begin by picking a volunteer and demonstrating a simple relaxing trance (see instructions below). This offers supervisees an opportunity to observe the hypnosis process and begin to feel comfortable with the process in a nonthreatening way. Observers may incidentally go into trance as well. The group setting also offers an excellent setting for teaching students how to hypnotize and be hypnotized all at once. Following the demonstration, divide the students into groups of three: One person becomes the hypnotist, the second is the subject, and the third acts as the observer. Allot approximately 15 minutes to the first induction. Shift roles in 15-minute increments to allow all participants to experience being hypnotist, subject, and observer. INSTRUCTIONS FOR TRANCE INDUCTION Begin with the subject’s natural tendencies, and the person will find his or her way into trance naturally. There are inclinations to favor one perceptual mode over another. Everyone uses all of these ways at times but tend to rely on one more than others. The following script can help a subject recognize his or her preferred perceptual mode: Close your eyes and think about when you first arrived at the supervision session. How do you remember your arrival? Do you see an image of yourself walking through the door? Do you remember the physical sensations of walking to the entrance and opening the door? Or maybe you recall the sound of the door opening and closing? Another possibility is that you might tie your experience to a feeling or thought you were having as you opened the door, such as, “I was feeling tired,” or “I was looking forward to my supervision session,” or “I was thinking about what I did last night.” Ask the subject to feel free to express himself or herself without conscious awareness when necessary, by nodding or using another signal such as lifting

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a finger or hand. This will encourage the client to remain in touch with the hypnotist. HYPNOTIC INDUCTION Hypnosis is an inwardly focused experience. Instruct the subject to choose his or her most natural way of imagining something, as in the preceding exercise. We offer a simple hypnotic induction for each way. Begin with the appropriate perceptual mode: Body sensations: Sit comfortably in a chair with your feet flat on the floor. Place the palms of your hands on your knees, resting gently. Close your eyes and notice the sensations in one of your hands. Ask yourself: Does my hand feel light or heavy? Wait for a sensation to happen that will give you your answer. Do you immediately feel that your hand is distinctively light or heavy? Or do you feel a mild sensation? You might feel something else, such as a sensation of warmth, coolness, tingling, or other possible sensations. Imagery: Sit or lie down comfortably. Imagine a place where you felt very relaxed and comfortable. Perhaps it is a beautiful place where you vacationed, the beach, the woods, a favorite restaurant, a museum, or even somewhere in your own home. Picture this calm scene. Notice as many details as you can: the objects, colors, textures, lighting, and so on. While you enjoy the experience, let yourself relax for a few moments. Sound: Close your eyes and suggest to yourself that you can hear a song playing, perhaps some music that you especially like. Begin by remembering a line of the song and then allow it to continue of itself. Can you hear the melody and enjoy listening to it? As you listen, let yourself become more relaxed. Scent: Imagine your favorite perfume, a fragrant flower, and the smell of pine or fresh salty sea air. With each breath in, increase the fragrance. Draw on past experience if helpful. Feeling: Recall a time when you were completely relaxed with a feeling. Perhaps you were soaking in the tub or enjoying a relaxed walk with a friend. Let yourself remember the feeling as vividly as possible. Thought: Think about hypnosis. What do you think it would be like? Would you feel comfortable? Do you think your muscles would be relaxed? Do you think your thoughts might slow down or center on relaxing ideas? While you think along these lines, let yourself experience what it might be like for you. For all perceptual modes: If a different sensation from the sensation you suggested happens, accept it instead. You may find there are alternative ways that your unconscious expresses itself, and these variations can be useful as well, not just the responses that you consciously thought of. A few people may feel nothing at first. If this is your response, try to pay close attention to how this nothing feels, and let it develop. You can learn to build on whatever your unconscious processes present, even if the experience seems minimal. Accept what you are given, follow it attentively, and enlarge on it as an expression of your unique responsiveness. Then other experiences become possible.

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DEEPENING THE TRANCE After the subject begins to feel some response, even if it is minimal, you should guide him or her to deepen the experience, as you have learned to with yourself. Here is an example of a typical narrative: As you sit quietly and allow yourself to focus, you can become very relaxed. When working with hypnosis you are engaging in a subtle communication between your conscious and unconscious mind. Your conscious has an idea; for example, I want to be relaxed. But the unconscious cannot be ordered what to do. Instead, just imagine what you would like to bring about. Then wait, allowing your unconscious freedom to discover the best way to bring this about. You don’t really know just how your unconscious would like to relax, but you can be confident that it will find a way.

DEEPENING RELAXATION THROUGH A RELAXING MEMORY I wonder whether you can recall a memory of a time when you were feeling completely relaxed and at ease. Don’t try to remember, just invite your unconscious to come up with a nice memory, and then sit back and wait. You may be surprised by the memory your unconscious provides. Be aware of even the subtlest part of a memory. You may remember vividly or only vaguely, in pieces. Be patient. As you wait, your breathing rate can become slower, more relaxed, as your muscles settle and your thoughts slow down. Enjoy the memory and let yourself relax very deeply as you think about and then reexperience the memory.

TRANSITIONING OUT OF TRANCE There are many different ways to come out of trance. Here is a commonly used method for bringing someone out of trance. Use your own variations. Counting Now it is time to come out of trance. I will count backwards from five to one. Five—You are beginning to become more alert and aware. Four—Sensations are beginning to return to normal. Three—You are becoming more alert. Two—All sensations are coming back to normal. One—Now you are completely awake and fully alert.

From time to time, people are reluctant to come out of trance. Give them a moment or two, and if you do not observe any efforts to wake up, speak slowly and repeat the count from 3, 2, and then 1. Students should follow scripts at first, but as they become more accustomed to working with hypnosis, they will develop their own individualized way that is attuned to the client, open ended, and permissive. TRANCE RATIFICATION The subject may have a definite experience of the first trance or may not be able to notice any difference. Trance may be immediately deep; or it might be subtle, hardly noticeable. Trance ratification helps the subject to recognize that something

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has happened. It also opens the door for later communication with the client while in trance. If you don’t notice a distinctive difference, close your eyes again and let your hands rest comfortably on your legs. Ask if you could have some small indication of trance. It could be a slight alteration in a sensation in your hand, an all-over feeling of relaxation again, or something else. Wait for some sign from your unconscious. And then when you are ready, open your eyes alert and refreshed.

TRANCE PHENOMENA There are many trance phenomena. Each gives a unique experience that can stimulate learning and development. Hypnotic phenomena do not always correlate with what they seem to be. An experience can become an analogy to lead to something new, or it can serve as an inspiration for learning. The case examples at the end of the chapter illustrate how this occurs. Here are a few examples of some classic trance phenomena. The reader will find more possibilities in Simpkins and Simpkins (2000, 2004). SENSORY ALTERATIONS Sensations of warmth and coolness, heaviness and lightness, and body size can be readily altered. This is often a good place to begin, saying, for example: “Which hand feels warmer?” or “Your eyelids may begin to feel heavy and want to close.” Many people will spontaneously experience changes in body sensations, and you can follow up by enhancing and increasing the response with your suggestions. HAND LEVITATION Lightness and movement developing in a finger, hand, or arm are components of a classic hypnotic phenomenon called hand levitation. The finger, hand, or arm feels as if it is moving by itself. People who tend to use the kinesthetic mode may find this easier to experience, but most can learn to experience levitations with practice. Hand levitation can be initiated by suggesting a slight tingling in a fingertip, and then gradually increasing this sensation until the finger wants to move. Watch for a slight spontaneous movement in a finger. Hand levitation gathers momentum from suggestions that follow each successful action in sequence. VISUAL IMAGERY AND HALLUCINATION Visual images in trance are natural phenomena of hypnosis. Most people can learn to see visual imagery, even though it might be easier for some than for others. Vividness in mental imagery is a natural talent but can be developed further with correct practice. Hallucinations can be positive (seeing something that is not there) or negative (not seeing something that is there). A classic method for entering trance is by looking at something. The hypnosis subject is encouraged to look at an object that can fascinate, like a crystal, a lit

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candle, or a turning spiral. We have often used abstract paintings hanging in the office. Use whatever interests the client. Ultimately, direct the client’s attention inward. So if you begin with an outer focus on an object, lead the client to close his or her eyes and picture the object within. Encourage minor alterations: “Can you allow your object to change in size or color?” or “Or perhaps it becomes something else.” Base your suggestions on experiences that are meaningful to the client. ANESTHESIA AND HYPERESTHESIA Anesthesia is a well-documented hypnotic phenomenon. Hypnosis has been used in surgery as the sole anesthetic. Classically, anesthesia has been produced by direct suggestion, relying upon the subject’s suggestibility. But mobilizing motivation through the use of indirect suggestion can enhance the ability to produce anesthesia. Hypnosis can also enhance sensations, known as hyperesthesia. TIME DISTORTION Another natural ability of the unconscious is time distortion. Time distortion occurs when the seeming duration of a time interval is different from the clock time of that interval. Time can appear to be either shorter or longer, depending upon the experience. Both forms of distortion are natural and can be utilized for creative and therapeutic applications. Everyone has felt the minutes ticking slowly when waiting in line, sitting through a dull lecture, or enduring a boring dinner party. Conversely, there are times when the hours pass too quickly, and one wonders what happened to the day. These are both examples of the mind’s natural ability to alter the experience of time. Erickson and Cooper (1982) did extensive research on this phenomenon. S P E C I A L C O N S I D E R AT I O N S I N T H E U S E A N D S U P E RV I S I O N O F H Y P N O S I S HOW TO DEAL WITH RESISTANCE IN CLIENTS What if the client says he or she did not go into trance? The hypnotherapist uses every response, even resistant ones, as responsiveness. Build on “no response” or “feeling nothing”: What does this feel like? Do you feel nothing on one side more than the other? How could you increase this nothing? Trance may be subtle at first. So tune in to even the tiniest cues such as slowed breathing, slight change in muscle tonus, slowed movements, even twitches. Take a positive attitude and accept the client’s resistance as you would work with, for example, silence from the client. Some clients have such a rigid perspective that they do not recognize an alteration even when they have one. In such cases the therapist may want to introduce some flexibility exercises drawn from creativity enhancement to guide the client into more accepting, open thinking (Erickson & Rossi, 1992; Simpkins & Simpkins, 2000, pp. 139–155).

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Another concern is that a client may come out with bizarre or negative associations. Use every disclosure as an opportunity for the client to learn. Do not judge seemingly odd images and thoughts. Instead, reassure the client that you will work cooperatively together. Sometimes unconscious meaning shows itself to the conscious mind in a partial understanding or an exaggeration, not quite formulated rationally. Encourage trust in the process. It is also helpful to reassure a client, when appropriate, that he or she does not have to reveal anything he or she does not want to. Then the client will disclose only when ready and can feel more trusting of trance. You may also need to protect the client from his or her own understandings. For example, we have had clients who worked material through unconsciously and did not want to consciously know what they revealed in trance. And we never told them. Therapeutic learning took place through the clients’ unconscious, and insight was not needed. The hypnotherapist develops skill and sensitivity by attuning to subtle cues and respecting the process. HOW TO DEAL WITH PROBLEMS IN SUPERVISEES Someone learning to use hypnosis as a therapeutic tool may need to discuss his or her own attitudes about hypnosis. As a supervisor, you should have a frank discussion about the supervisee’s beliefs and attitudes regarding the realistic use of hypnosis, clearing up the common misconceptions described previously. But occasionally, a student may continue to have fears or reservations about the use of hypnosis, even though he or she is familiar with the scopes and limits. Sometimes an individual will be skeptical about hypnosis having any efficacy whatsoever. You can address these concerns when you are training the supervisee in how to do hypnosis as we have instructed previously. Observe your supervisees as they learn how to experience trance for themselves, keeping in mind that people vary in their spontaneous comfort with altered states of consciousness. If one supervisee is skeptical or fearful at first, does he or she become more comfortable with the process over time? Hypnosis can be a new experience for some and so may take repeated practice. Most people find it natural as they become familiar with the feeling. Occasionally you will observe that a student cannot experience hypnosis at all. Sometimes fear gets in the way. An overly cynical attitude may also prevent trance from developing. If your supervisee continues to feel discomfort about hypnosis after education and direct experience, hypnosis might not be a suitable tool for him or her to use. A cautionary note: If many of your supervisees are feeling uncomfortable and unable to experience hypnosis, examine your own approach. In the successful hypnosis supervisory session, the atmosphere should be exploratory, positive, and enjoyable. Perhaps you are being too controlling, or perhaps you are not respecting students’ privacy with inner experience. At the other end of the spectrum are the supervisees who are overenthusiastic about the method and make unrealistic promises. As therapists, we try to radiate positive expectancy, but always within the scope of realistic possibilities. Supervisees who hold unrealistic expectations should be given reading materials cited here to help educate them as to the well-researched therapeutic uses of hypnosis.

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TRAINING IN HYPNOSIS Anyone who intends to use hypnosis therapeutically will benefit from formal training beyond what you provide as a supervisor. There are several organizations offering quality professional training. We recommend the Milton H. Erickson Foundation located in Phoenix, Arizona (www.erickson-foundation.org). The Foundation holds a yearly conference as well as regular seminars where master’s-level and doctoral-level students as well as professionals can take a series of workshops to learn the most up-to-date techniques. The Society for Clinical and Experimental Hypnosis (www.asch.net) and the American Society of Clinical Hypnosis also offer professional training (www.sceh.us/). A D D I T I O N A L A P P L I C AT I O N S Applying hypnotherapy involves putting the client into a trance at each session. The first few sessions are spent training the client to develop a deep trance and experimenting with trance phenomena. The clinician learns to use language in metaphors, ambiguity, stories, and implication to suggest possibilities in an open-ended way that stimulates the client’s personal associations and responses. Always try to draw from the client’s interests and concerns, not your own. Then both you and the client will discover the rewarding experience of facilitating solutions in new and creative ways. Here are some additional case examples from our own practice to illustrate the use of hypnosis for problems commonly presented to the hypnotherapist. The supervisor can observe the supervisee or listen to audio- or videotapes to help guide the supervisee in crafting suggestions that facilitate the client. Sometimes a novice will become lost in his or her own associations, losing touch with the client. Keep bringing the supervisee back to the meaningful world of the client.

Case 13.4 Pain Management Trance offers an opportunity to alter painful memories, opening up the potential for a pain-free future. A woman requested hypnosis to help her prepare for the birth of her second child. Nine years had passed since her first, painful delivery. She felt extremely apprehensive about the second. She began weekly sessions during her seventh month of pregnancy. She entered a deep trance and then imagined a cabin in the mountains by means of vivid hallucination. She felt as if she were actually in the cabin as well as in the room with us. Whenever she thought of snow for the purpose of therapy, she entered a deep trance. Finally, during one of her sessions she returned to the experience of her first birth. She watched the entire process as a little mouse in the corner of the room. She noticed many decorative details, such as the color and pattern of the wallpaper and the sound of the doctor’s voice. Although she could see herself lying on the bed in pain, she also noticed herself experiencing the wonder and beauty of the birth experience. Upon awakening, the client remembered everything. Now she realized she had had many positive feelings during her first childbirth. Before, she only remembered the pain. Now she discovered a new, more creative and positive interpretation of childbirth. She was grateful for her new perspective. (continued)

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Her second experience was not painful. Whenever she felt pain from a contraction she thought “snow” and was able to delight in the birth process while feeling relaxed at her little cabin in the mountains.

Case 13.5 Smoking Cessation Smoking and other unhealthy habits can be associated with something different. A negative experience associated with a habit can facilitate a client’s letting go of it or changing it. The client may not make an association for all time, but you show the client that new directions are possible. A client wanted to quit smoking but believed she would have difficulty doing it. She knew a great deal about quitting smoking. She had done it hundreds of times! She always gave in to the craving. Before the session, we led her to a beautiful area at the ocean. She got out of her car and followed us, with a puzzled look on her face. We demonstrated taking a number of deep breaths of fresh ocean air. She did the same. Then we asked her to throw her entire package of cigarettes into the smelliest, dirtiest garbage can we could find, one filled with dog manure and rotten food. She said, “I might return to get them.” We gestured toward the can and said, “Would you?” She answered, “I had better dump my ashtray, too, because I might try to smoke the butts.” We urged her to memorize the smell and appearance of that disgusting garbage can and to remember it whenever she felt tempted to smoke. Then we went to the office and began the session. She experienced a deep trance. She quit that day, never to return to cigarettes. She came in for one more session about a week later. She told us that she was surprised that she had lost her craving to smoke. She realized that the function of cigarettes was important. Without her cigarettes, she needed to find a new way to relax. She learned to do so with one more session of hypnosis that taught her how to relax by instructing her in self-hypnosis.

Case 13.6 Fears Consciously reexperiencing a trauma without trance does not automatically lead to change. Trance work can bridge the gap between thought and action for a corrective experience, often without conscious insight, to bring freedom from the grip of fear. Sometimes the client may need to unconsciously relive a traumatic memory, but often developing positive inner resources allows for change. A middle-aged woman requested hypnosis as an adjunct to her ongoing psychoanalysis to help with her phobia of driving. Whenever she got on the interstate, she was stricken with an intense feeling of panic and anxiety. The feelings were so overwhelming that she felt forced to pull over to the side of the road. She needed to overcome this fear because her new job required that she drive on the superhighway. She wanted to be able to work at this job, but her fear was interfering. During her hypnotherapy sessions, we taught her how to feel enjoyment during trance. General suggestions were given to stimulate her own ability to develop a deep sense of inner confidence, with no specific suggestions about her fears. Following the third session, she reported a strange experience. She had been driving on the interstate and waited, as always, for her fear to strike. She gripped the steering wheel in anticipation, but nothing happened! Surprised and baffled, she

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continued driving. She knew that she did not understand the causes or the meanings, and yet the fear seemed to be gone. She reported feeling a great deal of relief. Conscious insight is not a fundamental or necessary component of hypnotic learning. At times, change will occur spontaneously and naturally, and it can be welcomed. The unconscious can heal itself through a corrective emotional experience, without insight (Dorcus, 1956).

Case 13.7 Weight Control Sometimes clients know things but do not consciously understand them. Unconsciously they can access inner resources, often found in their past. By allowing associations and the flow of thoughts, feelings, and memories in trance, positive unconscious abilities in the client are freed to make connections, learn, develop, and help bring about change. A woman requested hypnotherapy for a problem with overeating. She was a cashier at a restaurant. She complained of feeling vaguely bored with her life. She passed her breaks eating one delicious snack after another. She spent much of her working time thinking about what she would be eating next. She enjoyed going into trance and discovered she could relax deeply. Using indirect suggestions, we initiated an inner search whereby she could explore her life choices. She realized she was unhappy in her life. Snacking did not satisfy her true hunger. Instead of fulfilling herself in life, she was, in a symbolic sense, filling herself with food. She was an intelligent woman who was interested in many areas of learning but had not permitted her wonder and curiosity to be satisfied. In trance, we encouraged her to activate her enjoyment of learning by stimulating her early memories of being in school and first learning new subjects. She started to read during her breaks instead of snacking. As time went by, she became less and less interested in overeating, eventually went back to school, and now pursues a profession, truly fulfilling herself.

CONCLUSION From its earliest beginnings, hypnosis has been a powerful method for healing. Hypnosis theory and practice evolved from more than 150 years of rigorous scientific investigation. Modern hypnosis has earned its place as a well-researched method for effective psychotherapy. Understanding of hypnotherapy continues to evolve from the inspirational discoveries of great masters and the tireless work of large professional hypnosis organizations. Today, skilled practitioners can confidently apply hypnosis to many clinical problems, either as the main therapeutic intervention or as an adjunct to other forms of treatment. With training and supervision, students can learn how to hypnotize their clients and utilize trance to bring about lasting therapeutic change. Careful and sensitive supervision of hypnosis training will foster this development. REFERENCES Allison, D. B., & Faith, M. S. (1996). Hypnosis as an adjunct to cognitive-behavioral psychotherapy for obesity: A meta-analytic reappraisal. Journal of Consulting and Clinical Psychology, 64, 513–516. Barber, T. (2000). A deeper understanding of hypnosis: Its secrets, its nature, its essence. American Journal of Clinical Hypnosis, 42 (3/4), 208–272.

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Barber, T., Spanos, N., & Chaves, J. (1974). Hypnosis, imagination, and human potentialities. New York: Pergamon Press. Battino, R., & South, T. L. (2005). Ericksonian approaches: A comprehensive manual. Wales, United Kingdom: Crown House. Benson, H. F., Apfel, F. H., Daniels, R., Schniewind, M. D., Nemiah, H. E., Sifneos, J. C., et al. (1978). Treatment of anxiety: A comparison of the usefulness of self-hypnosis and a meditational relaxation technique—An overview. Psychotherapy and Psychosomatics, 30(3/4), 229–242. Bernheim, H. (1973). Hypnosis and suggestion in psychotherapy. New York: Aronson. Binet, A., & F´er´e, C. (1888). Animal magnetism. New York: Appleton. Bowers, K. S. (1984). On being unconsciously influenced and informed. In K. S. Bowers & D. S. Meichenbaum (Eds.), The unconscious reconsidered (pp. 227–272). New York: Wiley. Braid, J. (1960). Braid on hypnotism. New York: Julian Press. Bramwell, J. M. (1903). Hypnotism: Its history, practice, and theory. London: Grant Richards. Bryant, R., Moulds, M. L., Guthrie, R. M., & Nixon, R. D. V. (2005). The additive benefit of hypnosis and cognitive-behavioral therapy in treating acute stress disorder. Journal of Consulting and Clinical Psychology, 73, 334–340. Combs, A. W. (1989). A theory of therapy: Guidelines for counseling practice. Newbury Park, CA: Sage. Cooper, L. F., & Erickson, M. H. (1982). Time distortion in hypnosis. New York: Irvington. Crawford, H. J. (1994, July). Brain dynamics and hypnosis: Attentional and disattentional processes. International Journal of Clinical and Experimental Hypnosis, 42 (3), 204–232. Crawford, H. J. (2001). Neuropsychophysiology of hypnosis: Towards an understanding of how hypnotic interventions work. In G. Burrows, R. Stanley, & P. Bloom (Eds.), International handbook of clinical hypnosis (pp. 61–84). New York: Wiley. De Pascalis, V. (1998, December). Brain mechanisms and attentional processes in hypnosis. Invited symposium presented at the 5th Internet World Congress on Biomedical Sciences, Hamilton, Ontario, Canada. Available from www.mcmaster.ca/inabis98/woody/de pascalis0311/index.html. Dorcus, R. M. (1956). Hypnosis and its therapeutic applications. New York: McGraw-Hill. Erickson, M. H. (1959). Further techniques of hypnosis: Utilization techniques. American Journal of Clinical Hypnosis, 2, 3–21. Erickson, M. H. (1964a). An hypnotic technique for resistant patients: The patient, the technique, and its rationale and field experiments. American Journal of Clinical Hypnosis, 1, 8–32. Erickson, M. H., & Rossi, E. L. (1980). The collected papers of Milton H. Erickson (Vol. 1). New York: Irvington. Erickson, M. H., & Rossi, E. L. (1992). Creative choice in hypnosis. New York: Irvington. Frank, J. D., & Frank, J. B. (1993). Persuasion and healing. Baltimore: Johns Hopkins University Press. Gordon, B. (1949). The physiology of hypnosis. Psychiatric Quarterly, 23, 317–343. Groeger, J. A. (1984). Evidence of unconscious semantic processing from a forced-error situation. British Journal of Psychology, 75, 305–314. Habermuller, M.-S., & Revenstorf, D. (2006). The effectiveness of hypnotherapy—A scientific review of the efficacy of hypnosis treatment. Milton H. Erickson Foundation Newsletter, 26 (1), 12–13. Hilgard, E. L. (1965). Hypnotic susceptibility. New York: Harcourt, Brace & World. Hilgard, E. L. (1977). Divided consciousness: Multiple controls in human thought and action. New York: Wiley. Hilgard, E. L., & Hilgard, J. (1975). Hypnosis in the relief of pain. Los Altos, CA: Kaufman. Hornyak, L. M., & Green, J. P. (2000). Healing from within: The use of hypnosis in women’s health care. Washington, DC: American Psychological Association. Hull, C. (1968). Hypnosis and suggestibility. New York: Appleton-Century-Crofts. Janet, P. (1925). Psychological healing (Vols. 1 & 2). New York: Macmillan. James, W. (1896). The principles of psychology (Vols. 1 & 2). New York: Holt. Kihlstrom, J. F. (1987, September 18). The cognitive unconscious. Science, 237, 1445–1452. Kihlstrom, J. F., Barnhardt, T. M., & Tataryn, D. J. (1992). The psychological unconscious: Found, lost, and regained. American Psychologist, 47, 788–791. Kirsch, I., Montgomery, G., & Sapirstein, G. (1995). Hypnosis as an adjunct to cognitive-behavioral therapy: A meta-analysis. Journal of Consulting and Clinical Psychology, 63, 214–220. Kroger, W. S. (1977). Clinical and experimental hypnosis in medicine, dentistry, and psychology. Philadelphia: Lippincott. Lewicki, P., Hill, T., & Czyzewska, M. (1992). Nonconscious acquisition of information. American Psychologist, 47, 796–801. Marucci, F. S., & Meo, M. (2000). Suggestibility and imagery during attribution of meaning to ambiguous figures. Hypnosis International Monographs, 4, 167–175.

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Miller, M. E., & Bowers, K. S. (1986). Hypnotic analgesia and stress inoculation in the reduction of pain. Journal of Abnormal Psychology, 95, 6–14. Pavlov, I. P. (1960). Conditioned reflexes: An investigation of the physiological activity of the cerebral cortex. New York: Dover. Platinov, K. (1959). The word as a physiological and therapeutic factor. Moscow: Foreign Languages Publishing House. Rainville, P., Hofbauerb, R. K., Pausb, T., Duncana, G. H., Bushnella, C., & Pricec, D. D. (1999). Cerebral mechanisms of hypnotic induction and suggestion. Journal of Cognitive Neuroscience, 11, 110–125. Ray, W., Blai, A., Aikins, D., Coyle, J., & Bjick, E. (1998, December). Understanding hypnosis and hypnotic susceptibility from a psychophysiological perspective. Invited symposium presented at the 5th Internet World Congress on Biomedical Sciences, Hamilton, Ontario, Canada. Available from www.mcmaster.ca/inabis98/woody/ray02556/index.html. Raz, A., & Shapiro, T. (2002). Hypnosis and neuroscience: A cross-talk between clinical and cognitive research. Archives of General Psychiatry, 59, 85–90. Ritterman, M. (2005). Using hypnosis in family therapy. Phoenix, AZ: Zeig, Tucker & Theisen. Rossi, E. L. (2002). The psychobiology of gene expression: Neuroscience and neurogenesis in hypnosis and the healing arts. New York: Norton. Sarbin, R. R. (1950). Contribution to role-taking theory: Pt. I. Hypnotic behavior. Psychological Review, 57, 255–270. Schoenberger, N. (2000). Research on hypnosis as an adjunct cognitive-behavioral psychotherapy. International Journal of Clinical and Experimental Hypnosis, 58, 150–165. Simpkins, C. A., & Simpkins, A. M. (2000). Effective self-hypnosis: Pathways to the unconscious. San Diego: Radiant Dolphin Press. Simpkins, C. A., & Simpkins, A. M. (2001). Timeless teachings from the therapy masters. San Diego: Radiant Dolphin Press. Simpkins, C. A., & Simpkins, A. M. (2004). Self-hypnosis for women. San Diego: Radiant Dolphin Press. Simpkins, C. A., & Simpkins, A. M. (2008). An exploratory outcome comparison between an Ericksonian approach to therapy and brief dynamic therapy. American Journal of Clinical Hypnosis, 50(3), 217–232. Sleep temple. (2006). Retrieved March 9, 2008 from http://en.wikipedia.org/wiki/Healing temple/. Tinterow, M. M. (1970). Foundations of hypnosis: From Mesmer to Freud. Springfield, IL: Charles C Thomas. Weitzenhoffer, A. (1957). General techniques of hypnotism. New York: Wiley. Wolpe, J. (1990). The practice of behavior therapy. New York: Pergamon Press. Yapko, M. (2001). Treating depression with hypnosis: Integrating cognitive-behavioral and strategic approaches. New York: Brunner Routledge. Yapko, M. (2003). Trancework: An introduction to the practice of clinical hypnosis (3rd ed.). New York: Brunner Routledge.

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C H A P T E R 14

Supervision of Paraprofessional Human Service Workers STEVEN WALFISH and ELLIS GESTEN

workers in roles traditionally reserved for those with specialized professional training has been an integral component of contemporary mental health service delivery. Under the labels of nonprofessionals, paraprofessionals, and mental health volunteers, these individuals compose a significant portion of those who deliver mental-health-related service. Albee (1959) pointed out that the availability of manpower in the human service fields was critically inadequate in relation to the needs of society. Furthermore, he predicted that the glaring deficiencies in the care and treatment of the mentally ill would not be improved without an increase in the recruitment and training of mental health manpower commensurate with the population trend. This is even truer today when the U.S. population has grown beyond 300 million people. In this chapter we highlight roles paraprofessionals play in the service delivery system, underscore their cost-effectiveness, and discuss issues related to the training and supervision of these workers. We elaborate on a cognitive model of supervision and focus on countertransference management issues that may emerge for paraprofessionals. We then highlight these concepts within three groups of paraprofessional workers: telephone crisis counselors, substance abuse counselors, and school-based workers.

USING NONPROFESSIONAL

R O L E S F O R PA R A P R O F E S S I O N A L S That paraprofessional workers can be trained to perform in a wide variety of therapeutic roles has been well documented in the literature. These roles include telephone crisis counselor (Lester, 2002), home visitor with substance-abusing mothers (Grant, Ernst, Pagalilauan, & Streissguth, 2003), stress management trainer (deJong & Emmelkamp, 2000), home-based counselor (Culbreth, Woodford, Levitt, & May, 246

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Supervision of Paraprofessional Human Service Workers 247 2004), tutor for high-risk children (Dowrick & Yuen, 2006), interventionist for Hmong refugees (Goodkind, 2005), prevention specialist for adolescent violence (Meddings, Knox, Maddaleno, Concha-Eastman, & Hoffman, 2005), combat stress counselor (Forsten & Schneider, 2005), peer counselor with behavior-disordered children (Malmgren, Causton-Theoharis, & Trezek, 2005), prevention specialist with parents of young children in a poverty- and violence-stricken neighborhood (Calzada et al., 2005), special education aide (Broer, Doyle, & Giangreco, 2005), telephone interventionist for those experiencing anxiety in a war zone (Somer, Tamir, Maguen, & Litz, 2005), interventionist for adults with mental retardation (Oliver, Miller, & Skillman, 2005), child-centered play therapist (Johnson, Pedro-Carroll, & Demanchick, 2005), and sex offender counselor (Hossack & Robinson, 2005). These are recent documentations in the literature of roles for paraprofessionals. The 1960s and 1970s saw the emergence of a variety of roles for nonprofessionals (Cowen, Gardner, & Zax, 1967). These included individual therapist (Rioch et al., 1963), group therapist (Poser, 1966), behavior modifier (Tharp & Wetzel, 1969), companion to mental patients in a state mental hospital (Rappaport, Chinsky, & Cowen, 1971), and high school student peer group facilitator (Cooker & Cherchia, 1976). Decades ago, Hobbs (1964), outlining the concepts of public health, pointed to the need for extensively trained professionals to guide the work of service providers who have little formal training. More emphatically, Durlak (1973) viewed the future delivery of appropriate mental health services to the general population to be ultimately related to the profession’s ability to make maximum and judicious use of paraprofessional workers in direct service roles. With the growing need for effective and expanded services, it is currently imperative that a comprehensive framework and paradigm be developed to ensure a place for these workers in the service delivery system. Christensen, Miller, and Munoz (1978) viewed the role of the paraprofessional as one who works beside, along with, and under the supervision of trained professionals. C O S T- E F F E C T I V E N E S S O F PA R A P R O F E S S I O N A L S Zax and Spector (1974) outlined the advantages of utilizing nonprofessional workers to meet manpower needs, capitalizing on the unique assets of the nonprofessional and improving the life of the nonprofessional. Another important aspect is the cost-effectiveness of utilizing these workers. Christensen et al. (1978) and Holland (1998) indicated that paraprofessionals are more available and less expensive than mental health professionals. If nonprofessionals can provide effective services, then their utilization is more cost effective than that of their professional counterparts. Another advantage suggested by Christensen et al. derives from the fact that paraprofessionals often maintain greater contact with clients in the clients’ natural environments. Cowen (1982) demonstrated the degree of nontraditional helping that takes place in the community by natural caregivers. These assets can be capitalized upon with paraprofessional helpers. There are two parts of the cost-effectiveness equation. The first is cost. It is clear that paraprofessionals, volunteers, and students are less expensive than highly trained professionals. However, without being able to demonstrate effectiveness it

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would be unethical to design interventions for the community based on cost savings alone. Durlak (1979) examined 42 available studies comparing the effectiveness of professional and paraprofessional helpers with respect to outcome and adequacy of design. Paraprofessionals consistently achieved clinical outcomes equal to or significantly better than those obtained by professionals. The strongest support for paraprofessional positive outcomes came from programs directed at the modification of specific target problems in college students and adults. Durlak concluded that in terms of measurable outcome, professionals may not possess demonstrably superior clinical skills when compared with paraprofessionals. Moreover, professional mental health education did not appear to be a necessary prerequisite for being an effective helping person. Durlak’s review has been replicated and extended by several researchers. In a meta-analysis of 39 studies, Hattie, Sharpley, and Rogers (1984) found that clients who sought help from paraprofessionals were more likely to achieve resolution of their problem than those who consulted professionals. In their review, Berman and Norton (1985) found professional and paraprofessional therapists to be generally equal in effectiveness. Professional therapists performed better in brief treatment and therapy with older patients, but these differences made them only slightly superior to paraprofessional therapists. It appears that paraprofessional interventionists are able to adequately satisfy both sides of the cost-effectiveness equation. Christensen and Jacobson (1994) suggested that the lack of differences between the two groups does not mean that professional therapists are dispensable. Durlak (1979) suggested that paraprofessional effectiveness may be due to the carefully systematic and standardized treatment programs developed by professionals, which in turn may be easily administered by these less trained personnel. Furthermore, clinical success by these workers may be closely related to professionals’ abilities to define, order, and structure effective sequences of helping activities when training or supervising paraprofessionals. Christensen et al. (1978) suggested that effective use of paraprofessionals will allow professionals to spend less time on routine and well-specified procedures. Professional therapy time can then be devoted to cases in which more complex interventions are required. This shift in professional role away from primarily direct clinical services and toward the development of interventions and supervision of others is consistent with the clinical scientist role for clinical psychology (McFall, 1991) as well as current practices in the provision of managed mental health services. T R A I N I N G A N D S U P E RV I S I O N O F PA R A P R O F E S S I O N A L S Carkhuff (1971) argued that most paraprofessional volunteers come into training with a low range of interpersonal skills needed to become an effective helper; therefore, training should be an essential component of any program utilizing these nontraditional workers. Freudenberger (1973), taking a historical perspective, pointed out that during the early stages of paraprofessional utilization the role and importance of training was less clear. Prospective helpers who were motivated and seemed “reasonably healthy” were selected for their natural helping skills or reflexes and placed in a wide variety of settings. However, as these workers became a greater part of the service delivery system, the need to measure outcomes

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Supervision of Paraprofessional Human Service Workers 249 increased along with the associated development. Today, most programs utilizing paraprofessional workers provide training specifically targeted to the population and services to be provided. Christensen et al. (1978) outlined a model for training nonprofessionals and suggested that a thorough approach include at least general communication and counseling skills, instruction in ethics and responsibility of the worker, training in the specific treatment procedures to be applied, and continuing supervision. Danish and Hauer (1973) pointed out that although there are major differences in training programs, almost all are concerned with providing “relationship development skills.” The goal of this approach is to help create a therapeutic relationship in which action-oriented change can be successful. These skills generally fall under the heading of facilitative conditions and are based on the work of Truax and Carkhuff (1969). These general skill areas are then followed up with training that targets the specific goal of the intervention. According to Christensen et al. (1978), a thorough training program for paraprofessional therapists consists of four elements. These include (1) instruction that includes role-playing of general communication and counseling skills, (2) instruction in issues of professional responsibility and ethics, (3) specific training in the well-defined intervention to be delivered, and (4) continuing supervision. In addition, these researchers suggested that paraprofessionals will be effective when the specific components of a treatment method have been well defined. Many researchers and trainers have written about the importance of supervision to the development, maintenance, and evolution of clinical competence over time. Hess (1997, 2001) outlined several learning tasks that should take place in effective supervision. These include the demystification of the counseling process, the teaching of technique, and the development of the counselor’s personality Watkins (1997) indicated that supervision is most effective when it is guided by a set of goals and tasks shared by supervisor and supervisee; roles are clearly defined; and feedback is provided in a constructive, specific, and clear manner. Many investigators have emphasized the need for professional supervision of nonprofessional workers as a control for quality assurance (Blau, 1969; Christensen et al., 1978). Sobey (1970) reported that the large majority of projects hiring nonprofessionals regularly provided them with supervision. Similarly, Bartels and Tyler (1975) in their survey found that 87% of community mental health centers reported spending time supervising these individuals. However, paraprofessionals themselves feel differently about supervision. Many report receiving little supervision and a lack of appropriate in-service training, and, in fact, few perform tasks under close supervision (Alley & Blanton, 1976; Young, True, & Packard, 1976). Clearly, although many professionals see the need for supervision and see themselves as providing an adequate amount of supervision, the paraprofessionals themselves report the need for more. A C O G N I T I V E M O D E L O F S U P E RV I S I O N In supervising paraprofessionals Azar (2000) described a model that emphasizes the need to provide a “safe and supportive” space for the worker to discuss aspects of his or her cases and the nature of the work. She suggested that this is especially

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important when working with cases (e.g., trauma) in which the risk for burnout is quite high. Azar presented a model of supervision primarily based on cognitive therapy principles. She contended that understanding the paraprofessional’s underlying core beliefs about the work can help identify the sources of negative reactions to clients. One example is the belief that “parents and children want my help and will view my efforts positively.” Understanding such core beliefs and the conflicts they pose for day-to-day helping in the real world is crucial for effective supervision. Interventions can be planned during supervision, for example to reduce the negative impact of client behaviors on the paraprofessional. Azar described a cognitive-behavioral approach to supervision as including three stages: (1) identifying irrational beliefs regarding the role of the paraprofessional as a human service provider, (2) challenging these irrational beliefs, and (3) replacing these beliefs with flexible and adaptive beliefs. Azar (2000) believed that is important for the supervisor to provide the paraprofessional with a “revised worldview” that is more consistent with the realities of human service work in which limitations and failures will be encountered. This is important as many clients improve, but a portion will receive no benefit, and some will even regress as a result of mental health interventions (Lambert & Ogles, 2004). This would allow the paraprofessional to maintain meaning in his or her work at times when clients are not responding to the paraprofessional’s best efforts. This is important as “naive enthusiasm” (Poser, 1966) is one of the strengths that a paraprofessional brings to the human service delivery system. A balance between maintaining enthusiasm and purpose with the realities and limitations of the work is the optimal goal to strive toward. Azar (2000) suggested that it is important, from a cognitive therapy perspective, for supervisees to examine their roles or cognitive schema regarding both the clients with whom they are working, as well as their own expectations of themselves as human service professionals. She suggested that these represent core beliefs that may be deeply ingrained and resistant to change. Ellis (1988) described these as one’s “shoulds.” We believe that when helpers “should on themselves” they are prone to depression, anxiety, and guilt as a result of not living up to their own expectations in the therapeutic interaction. A consistent dose of this will only result in a demoralized paraprofessional. Conversely, when helpers “should on clients” they are prone to being disappointed, angry, or resentful when the individuals they are trying to help do not live up to the helpers’ expectations. A consistent dose of this will only lead to the paraprofessional viewing the clients with contempt. C O U N T E RT R A N S F E R E N C E M A N A G E M E N T Ongoing supervision of paraprofessionals is optimal if it includes a didactic component in which new skills are taught, old skills are refined, and focus is placed on the therapeutic relationship. Research has suggested a relationship between the therapeutic alliance and treatment outcome (Samstag, 2006) in professionals, and at least one study has noted this relationship for case managers working with psychotic patients (Hopkins & Ramsundar, 2006). Gelso and Hayes (2001) reviewed the literature on countertransference, which provides a useful framework for

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Supervision of Paraprofessional Human Service Workers 251 supervision with paraprofessionals. They identified the five interrelated factors in countertransference management as consisting of the following: 1. Therapist insight: Awareness of one’s own feelings and understanding of one’s origins. 2. Therapist integration: Possession of an intact healthy character structure. 3. Anxiety management: Allows the helper to control and understand his or her own anxiety so it does not interfere with responses to those being helped. 4. Empathy: Allows the helper to focus on the helpee’s needs. 5. Conceptualizing ability: Allows for a theoretical framework for understanding the client’s behavior and the therapeutic relationship. Effective supervision, focusing on the issues outlined by Azar (2000) and Gelso and Hayes may help to prevent burnout in paraprofessional workers. Maslach, Schaufeli, and Leiter (2001) identified three components of burnout: emotional exhaustion, cynicism, and inefficacy in the work. With these issues in mind, we now turn to three separate types of human service workers to highlight supervision practices with these paraprofessionals: telephone crisis counselors, substance abuse counselors, and interventionists in the school system. TELEPHONE CRISIS COUNSELING One service delivery component that has relied almost exclusively upon the nonprofessional worker is the telephone hotline (Lester, 2002). The development of telephone-based counseling services has been credited by Auerbach and Killman (1977) as providing the main impetus for the growth of the crisis intervention movement in the United States. These agencies, often referred to as suicide prevention centers, crisis services, or hotlines, are typically staffed by paraprofessional workers who are trained in the basic concepts of crisis intervention. Counseling by telephone is an approach that differs from traditional modes of psychotherapy. Bleach and Claiborn (1974) outlined four characteristics that most hotlines generally share. First, they operate at times when traditional helping services are not available. Most centers operate on a 24-hour, 7-day per week schedule for the entire year (including holidays, which can be a particularly stressful time for, and lead to an increased risk of suicide attempts among, the most socially isolated and alienated). Second, they are staffed by nonprofessional workers who come from many walks of life. Third, they accept calls from anyone in the community and will talk about any topic the caller presents. Finally, they offer advice, information, and referral services. One unique aspect of telephone counseling is that anonymity can be provided to callers to a hotline so that those who might not seek out mental health services might instead call a hotline without being concerned about the stigma of going to a professional’s office for such care. The early focus in the telephone counseling movement was on the prevention of suicide. However, it quickly became apparent that callers to these agencies most often were not suicidal but rather were experiencing general problems in living. For this reason the current goals of telephone counseling have greater breadth.

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France (2007) suggested that crisis counselors utilize effective communication and a positive relationship to guide clients through a series of problem-solving steps. Workers emphasize client initiative and competence, and they employ the least amount of control necessary. They seek to enhance rapport and trust by using the interpersonal skills of empathy, warmth, and genuineness. Telephone crisis counselors typically complete a training program that initially focuses on the development of listening skills and is followed by the development of skills in task-oriented work (Walfish, Tulkin, Tapp, Slaikeu, & Russell, 1974). Kalafat (2002) presented a competence-based training program that involves the ongoing identification of specific behaviors, knowledge, and attitudes that characterize effective job performance. Because paraprofessional counselors may only have limited skill development in didactic lectures and reading and role-playing, ongoing supervision is essential to the development of telephone counselors’ skill levels and comfort in providing intervention services. One way to plan for supervision with telephone crisis counselors is to identify the types of clinical interaction situations they find problematic. Walfish (1983) conducted a survey of telephone crisis counselors regarding their degree of comfort in a variety of interactions with callers. Of the 100 situations surveyed, 32 were identified as producing a high level of discomfort. These areas of difficulty were rationally grouped into seven categories: suicide, obscene calls, client anger toward the counselor, client expectations of positive affect toward the counselor, client resistance, physical and sexual abuse, and anger toward others. A caller calls the crisis center and begins, “I’m calling because I feel like I’m at the end of my rope. I’ve tried and tried and tried. Nothing seems to be working out for me, and I can’t ever imagine things working out for me. I figure I might as well put me and everybody else around me out of my misery.” Being confronted with an individual who is suicidal can be alarming for an experienced professional let alone a paraprofessional volunteer. In discussing issues related to suicide, the supervisor must ensure that the paraprofessional has the necessary technical skills (e.g., to assess lethality, to make appropriate referral) to intervene in such a crisis. However, it is our experience that this particular clinical interaction is discomforting due to a sense of responsibility the counselor would feel if a suicide actually ensued. In this regard, Azar’s (2000) concept of examining the counselor’s irrational beliefs regarding his or her responsibility for the client’s life may be helpful. Supervision could focus on the limitations of the counselor and the counseling process. The irrational belief could be replaced with an adaptive response set that implies responsibility to the client to provide good quality care but not ultimate responsibility for the client. If a client does ultimately kill himself or herself, this is certainly unfortunate and sad, but was it the responsibility of the paraprofessional? Unfortunately, a small percentage of callers do not use telephone crisis centers as a resource to talk about problems but rather in an inappropriate way to make obscene calls. This is most often demonstrated in a male caller masturbating to the voice of a female paraprofessional. Because this is not the appropriate focus for a call to a crisis hotline, this tends to produce distress and anger in the counselor. Didactic techniques for recognizing that this is taking place and ways to handle such a call are presented by Brockopp and Lester (2002). From a supervision perspective, working on anxiety management and providing a theoretical framework

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Supervision of Paraprofessional Human Service Workers 253 may reduce the countertransference reaction to this noxious behavior. Similarly, the reality that these calls take place will likely not match up with the preexisting expectations of what types of calls the paraprofessional would receive when volunteering to be a telephone crisis counselor. An examination of expectations (and reactions to these expectations not being met) versus the reality of the infrequent situation actually taking place may be amenable to cognitive reframing: “Not that it is good that these calls take place, but statistically they are to be expected.” This may help to modify the expectations of the counselor, thus reducing the intensity of the emotional upset to these types of calls when they unfortunately occur. Furthermore, it may be possible to reconceptualize the situation from dealing with a noxious caller to an individual with significant social skill deficits who cannot get his or her needs met without calling a phone line worker. This may help the paraprofessional move from putting the caller off to having more empathy for the troubled individual. The third and fourth types of situations found by Walfish (1983) as producing a high level of discomfort in telephone crisis counselors focus on relational aspects between the caller and the counselor. Paraprofessionals experience difficulty when the client expresses anger or positive statements toward them. A client expressing anger is an area of difficulty not only for paraprofessionals, but also for counselors in training (Gately & Stabb, 2005; Hess, Knox, & Hill, 2006) and professional therapists as well (Pope & Tabachnick, 1993). Paraprofessional counselors are there to help, and they may view the client having a negative reaction as defeating the purpose of why they volunteered in the first place. For these issues, developing self-insight, assuring therapist integration, heightening empathy for the client’s extreme reaction, and developing a conceptual explanation for the client’s anger may be helpful in toning down a countertransference reaction. Similarly, understanding in supervision that anger is likely fueled by the client “shoulding on the counselor” and that it stems from an irrational belief on the part of the client may help provide solace to counselors on the receiving end of this anger. Often a caller becomes angry when counselors do not simply provide solutions or tell him or her what to do. This anger may be an impetus for the client to act on one of the number of solutions that the telephone counselor helped him or her generate in their task-oriented work together. Sometimes a paraprofessional counselor has difficulty with callers expressing positive emotions toward him or her or asking if they are special to the counselor. If this is discussed in supervision, focus could be placed on what this means to the counselor and what belief systems about himself or herself or the role he or she is in are at play in causing the discomfort. Enhancing empathy and having a theoretical framework as to why callers would engage in such discussion would likely be fruitful as well. The last two areas identified by Walfish (1983) are related to issues of physical and sexual abuse. These are often emotionally laden and difficult situations for professional counselors as well (Jones, Robinson, Minatrea, & Hayes, 1998). This reaction can be heightened if the paraprofessional counselors themselves have ever been victims of abuse (Azar, 2000). If violence is involved, countertransference reactions may emerge for those who have experienced violence and may interfere with a counseling interaction. Azar presented an excellent discussion regarding

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working with clients in situations in which abuse has taken place with a special focus on violations of counselors’ deeply held expectations and beliefs regarding this emotionally sensitive area. In supervision it would be beneficial for paraprofessional counselors to explore their own “shoulds” (e.g., you should leave him, you should not tolerate such inappropriate behavior) toward the client and the situation and perhaps increase their empathy to help better understand why someone would remain in an abusive situation. S U B S TA N C E A B U S E C O U N S E L I N G Haaga, McCrady, and Lebow (2006) suggested that clients with substance abuse problems present numerous challenges in treatment. This is because the problems of these clients tend to be chronic and recurrent, the problems are usually accompanied by comorbid physical and psychological conditions, and the motivation for client change often wavers. Although behavioral self-control programs are emerging in the addictions field, most treatment programs for drug and alcohol abuse are based on the 12-step model of Alcoholics Anonymous (AA). In reviewing research trials, Humphreys (2006) concluded that referral to a 12-step self-help group leads to higher group involvement and better outcomes. In a longitudinal study, Moos and Moos (2006) found individuals who participated in AA for 27 weeks or more during their initial treatment had better 16-year outcomes. Subsequent AA involvement was also associated with better 16-year outcomes. Most residential treatment programs are based on the Minnesota model in which clients are introduced to the AA program and philosophy of life (Walfish, Massey, & Krone, 1990). Culbreth and Borders (1999) suggested there is a historical bias in favor of recovering versus nonrecovering counselors in the substance abuse field. With counselors who themselves have had similar problems clients would be able to identify with someone who has faced his or her own struggles and succeeded. There are a large number of such paraprofessional counselors working in a field that does not necessarily require an advance degree for certification. Juhnke and Culbreth (1994) stated that the supervision process with addictions counselors may be idiosyncratic, as many of these counselors do not have formal counseling training. They suggested that because of this, the supervision milieu must contain a strong educational component to ensure a minimal level of skill. Culbreth and Borders (1999) pointed out that state-certified substance abuse counselors with only a high school diploma may work side by side with practitioners who have graduate degrees in counseling. These authors found that the most important aspect of supervisee satisfaction with supervision regardless of recovery status of the supervisor was the quality of the supervisory relationship. Interpersonal qualities of the supervisor received higher ratings than technical skill and didactic aspects of supervision sessions. Of interest, however, is that these authors found a better supervision fit based on the recovery status of the counselor and supervisor. That is, recovering counselors were most satisfied with recovering supervisors, and nonrecovering counselors were most comfortable with nonrecovering supervisors. This may have reflected ideological differences between the two groups. Culbreth (1998) suggested that it is the responsibility of the supervisor

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Supervision of Paraprofessional Human Service Workers 255 to discuss the issue of recovery status in a clear and open manner. This may also model for the counselor how to discuss this same issue with his or her own clients. Culbreth and Borders (1999) cited research to suggest that counselors in recovery are more rigid in their treatment beliefs, less flexible and more conventional when dealing with clients, and more concrete in their thinking patterns than nonrecovering counselors. Therefore, recovering counselors could be expected to have more “shoulds” both for their expectations about themselves as interventionists and for their clients and their response to treatment. From a cognitive perspective, it may be helpful for the supervisor to explore these “shoulds” and see how they are helpful for producing positive outcomes with clients and how they may produce negative outcomes for the client. Given the rigid belief system of many counselors in recovery, one would expect a similar treatment plan for each client that does not allow for individual differences. For example, following primary treatment it is not unusual for counselors to prescribe “90 in 90” for clients. This means to attend 90 AA meetings in 90 days. Although this may be a good general prescription because AA attendance is related to positive outcome (Moos & Moos, 2006), this may not be feasible for every client given individuals’ life situations and responsibilities. The supervisor may challenge the belief that this should be expected with every client. These beliefs may be replaced by those that demonstrate flexibility and adaptability for the situation at hand (e.g., “Given that she works 50 hrs a week to support her family and also has two children to take care of, perhaps three meetings a week would suffice”). The supervisor may expect resistance from a counselor who adheres to a rigid model (any rigid model for that matter). Supervision could focus on building empathy (rather than the counselor projecting onto the client his or her own experience and reactions) and enhancing conceptual frameworks (e.g., not everyone recovers in the same manner, and treatment plans are optimal when individualized). Culbreth (2003) found that professional insecurity in substance abuse counselors was the reaction most commonly manifested in their supervisees. He suggested that supervisors be skilled in assisting their supervisees in managing and working through their professional insecurities. This was consistent with Gelso and Hayes’s (2001) conclusion that anxiety management must be mastered to avoid negative transference reactions. Of interest is that recovering supervisors were more likely than nonrecovering supervisors to consider supervisee anxiety and resistance as a function of an authority conflict. This also suggests that there may be a rigidity in recovering supervisors as well, thus accounting for differences in the match–mismatch of supervisor–supervisee based on recovery status. Previously Culbreth (1999) had found recovery status to influence the supervision process. Recovering counselors indicated a preference for supervisors to use more influence and support in the supervision session; spend more time discussing legal and ethical issues; and focus more on client types, client conceptualization skills, professional support, and avoidance of burnout. Juhnke and Culbreth (1994) indicated that recovering helpers may be particularly vulnerable to imposing their personal experiences and unconscious beliefs on a client. In this regard, Azar’s (2000) suggestion of supervisees examining their expectations of clients, even though at times they are irrationally based, may merit exploration in supervision (e.g., “This program worked for me, why can’t you

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make it work for you?”). This further suggests that a relapse (which is a ubiquitous component in the development of long-term recovery) may negatively affect the counseling relationship. Walfish et al. (1990) suggested it is important for the supervisor to understand the culture of AA and the recovery process if he or she is to provide effective supervision. There are data to suggest that many substance-abusing clients would benefit more from a harm reduction approach to treatment (Marlatt & Witkiewitz, 2002) than an abstinence-only treatment approach. Brown (1985) suggested that the concept of controlled drinking is threatening to someone who has obtained his or her recovery through an AA-oriented treatment process. Acceptance of the lack of control over one’s drinking (i.e., powerlessness) is viewed as the core of recovery and sustained abstinence. To introduce the possibility of controlled drinking as a possible treatment outcome can become personally threatening to the integrity of the recovering counselor. Because paraprofessional counselors may lack formal training in ethical issues, one important component of supervision with addictions counselors should focus on this crucial area. Dove (1995) reviewed common ethical concerns for addictions counselors, including interfacing with AA and other programs, treatment of court referrals, and dual relationships. Hollander, Bauer, Herlihy, and McCollum (2006) examined the beliefs of substance abuse counselors regarding multiple relationships. The results suggested that counselors receiving supervision found more multiple relationship behaviors to be ethically problematic than those not receiving supervision. This suggests that continued supervision may be beneficial for substance abuse counselors to optimize ethical behavior. PA R A P R O F E S S I O N A L S I N T H E S C H O O L S Historically, perhaps no other setting has employed as many paraprofessionals in as many varied roles as the nation’s public schools. Current service delivery trends for child and adolescent mental health services make it likely that this trend will accelerate over the next decade. We focus on one program, the Primary Mental Health Project (PMHP; Cowen et al., 1996), whose success is due in large part to the work of its paraprofessional child associates, who are the direct service providers. This project is singled out as an exemplar because of its singular longevity—50 years in 2007 (!)—and unique dissemination efforts and outcomes. In addition, one of us (Ellis Gesten) was fortunate enough to work in a variety of PMHP roles in the 1970s and observe and participate regularly in training, supervision, and consultation activities with the paraprofessionals who make up its heart and soul (Cowen et al., 1996). The PMHP is a school-based early intervention/prevention project for young, at-risk youth with early signs of adjustment/behavioral problems. With headquarters in Rochester, New York, at The Children’s Institute, the PMHP has five core components: (1) focus on kindergarten through Grade 3; (2) systematic early mass screening; (3) the use of child associates, trained paraprofessionals to provide 1:1 and group services to children; (4) a modified role for school-based mental health professionals who train and supervise project associates; and (5) the use of ongoing program evaluation to inform and modify program practices. Recognition and

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Supervision of Paraprofessional Human Service Workers 257 promotion by numerous state and national organizations combined with 30 years of systematic dissemination efforts via workshops, the development of regional centers, internships, and work with state legislators from across the country have led to several thousand project replications. Currently there are programs in 120 New York State school districts, as well as more than 1,000 districts nationwide in more than 12 states including several that have developed statewide dissemination procedures with budgetary support (New York, California, Washington, and Connecticut). The PMHP’s abiding commitment to weekly supervision and ongoing child associate training are central to the positive outcome data, low staff turnover, and strong project loyalty that characterize this program. Each part-time associate (15–20 hr per week) works 1:1 with 10 to 15 children at a time to promote effective verbal and play-related expression and communication in well-equipped, developmentally appropriate playrooms. Despite the project’s preventive thrust and careful efforts to screen and refer children in need of more extensive clinical or special education services, project children often present with significant problems, challenges, and, at times, trauma. As Azar (2000) indicated, clinical work with children poses unique risks for burnout, underlining the need for regular and effective supervision. One critical and obvious point often overlooked is that for supervision to be effective, it must first of all occur. Contrary to stated program guidelines in many settings, paraprofessionals often find themselves largely on their own, or at the least with less support and instruction than they report being promised or needing. The PMHP identified and addressed two of the main reasons for this discrepancy—lack of supervisor time and the absence of specific supervision training. The PMHP model significantly reduces the time spent in direct service provision by school psychologists and social workers, allowing them to significantly expand their reach, and the number of children served, through the activities of the 3 to 5 associates they supervise. Role changes for the professional supervisor must ensure, at a minimum, that supervision of paraprofessionals is not an add-on to an already overcommitted schedule but rather a central and organizationally supported responsibility. The PMHP offers a variety of opportunities including training materials, consultation, and modeling to assist school-based mental health professionals in developing supervision skills. Supervision is also most effective when it is directed or informed by ongoing feedback from those receiving the service. This is done at many levels in the PMHP, one of the most instructive examples of which was a systematic survey of the discomfort associates experienced in response to a wide range of challenges posed by children with adjustment problems and the frequency with which these challenges occurred (Cowen, Lorion, & Caldwell, 1975). The most significant discomfort reported related to children’s expression of aggression. Although not entirely a surprise, the extent of the concern and its centrality to the project’s mission led to a decision to develop a new training program to assist both the associates and their supervisors to constructively explore the sources of child aggression, set boundaries on its behavioral expression, and explore alternative coping strategies. This model for collecting information to help focus supervision can be applied to a wide range of paraprofessional activities, for example in work with telephone crisis counselors as mentioned earlier (Walfish, 1983). Some may argue that service agencies have

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little time to collect such information, or that paraprofessionals (and professionals!) are already required to complete too much paperwork. In fact, this information is easy to organize, collect, and score. Perhaps more important, when information collected in this manner is used to modify a program and provide direct benefits, staff resistance is much reduced. Being listened to is perhaps as important to paraprofessional staff as it is to the clients they serve. The investment in supervision and identification of specific supervisory activities is similarly enhanced by collecting information about program outcomes and sharing this in an appropriate manner with the paraprofessional service providers as well as their supervisors. In the PMHP, the mechanism for this is regularly scheduled assignment, progress, and termination or “graduation” conferences in which children’s progress is monitored via specific behavior rating scales as well as qualitative reports from key informants including teachers and other school staff. Information provided in these meetings helps both members of the supervisory dyad identify what works and what aspects of the interventions with children require reconceptualization or a change in approach. Although programs employing paraprofessionals vary in the types and amount of program evaluation data collected and available, providing this information and feedback can provide invaluable and iterative. Supervision is most effective when it is embedded in a broader context of ongoing opportunities for training and professional growth. As an illustration, PMHP associates and their supervisors in most replication settings have several regularly scheduled meetings with consultants from community mental health centers, universities, or other settings to discuss either specific cases or broader issues such as approaches to working with children of divorce, crisis intervention methods, or other clinical or program issues. These sessions are highly valued and anticipated by program staff and frequently generate rich follow-up material to be further developed during follow-up supervision. Furthermore, the choice of specific consultants and topics in a given year is frequently determined by issues raised in supervision sessions. A significant challenge for supervisors of both paraprofessionals and professionals in training is determining the appropriate balance between focusing on disorder or problem-specific techniques versus developing and promoting certain relationship based so-called common factors. A useful and detailed listing of these factors provided by Lambert and Ogles (2004) includes such variables as reassurance, therapist warmth, empathy, acceptance, feedback, insight, mastery, as well as the therapeutic alliance (which can be conceptualized as an aggregation of component behaviors and therapist–client interactions). Along with evidence of empirically supported treatments for certain disorders in efficacy studies is a large body of evidence that these common factors account for a substantial amount—and perhaps most—of the gains from clinical interventions, especially when symptoms are less severe as is typically the case in preventive interventions (Lambert, Garfield, & Bergin, 2004), the primary focus of the efforts of PMHP child associates. An example from one group supervision-consultation session illustrates both the focus on relationship factors that promote children’s openness and coping with problems as well as the utility of Azar’s (2000) cognitive-behavioral approach to working with supervisees. The context was a meeting in which a child associate fairly new to the project repeatedly expressed considerable frustration and upset

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Supervision of Paraprofessional Human Service Workers 259 about a second grader’s increasing expressions of anger—verbal, behavioral, and symbolic—in the playroom. Not coincidentally, this child had been referred due to similar behaviors in the classroom with his classmates at a time his family was experiencing significant disruption. Dealing with client anger—especially when directed at the therapist—is a challenge for even the most experienced professional therapist. This supervisee held the cognitive belief that it was a sign of her failure, and she was at the same time unaware of how her personal discomfort, which could be conceptualized as countertransference (Gelso & Hayes, 2001), was affecting the child and their therapeutic relationship. The supervisor, with input from more experienced associates, helped this person to reframe those expressions of anger as a sign of the child’s growing comfort in the relationship that allowed emotional expression, and thus progress. In addition, specific techniques were suggested and role-played in the group to set appropriate boundaries on some of these behaviors and help the child develop better ways of coping with this stress at home and in the classroom. This intervention began the process of reshaping the client’s (inner) view of her work and was accompanied by the (external) systems change or intervention that Azar (2000) indicated is often complementary to the supervisory process and equally essential. In this case that intervention included assistance for the classroom teacher, communication with the family, and follow-up training for the associate in one of the PMHP’s specialized workshops. CONCLUSION Paraprofessionals are an essential component of the human service delivery system. Cost-effective care is optimized when professionals are involved in designing an intervention that paraprofessional workers can implement. Proper training and supervision of paraprofessionals ensures continued delivery of effective services. We believe two avenues of research merit further attention. First, studies by Cowen et al. (1975) and Walfish (1983) attempted to identify specific clinical interaction problems for paraprofessional counselors with their target populations (e.g., maladapting school children, telephone crisis counselors). Those working in other areas should be encouraged to conduct similar studies with their unique populations so idiosyncratic problems regarding their target groups can be identified. These problem areas can then become the focus of in-service training and ongoing supervision. Second, there is little research on effective supervision with paraprofessional workers other than the work of Culbreth and his colleagues cited earlier in this chapter. It is reasonable to assume that effective clinical supervision with seasoned professionals is different than effective clinical supervision with graduate students in training and should also be different from effective clinical supervision with paraprofessionals. Research identifying successful components and approaches to supervision with this population can only serve to enhance the effectiveness of this bottomless cup of human service delivery workers. REFERENCES Albee, G. (1959). Mental health manpower trends. New York: Basic Books. Alley, S., & Blanton, J. (1976). A study of paraprofessionals in mental health. Community Mental Health Journal, 12, 151–160.

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Supervision of Paraprofessional Human Service Workers 261 France, K. (2007). Crisis intervention: A handbook of immediate person-to-person help (5th ed.). Springfield, IL: Charles C Thomas. Freudenberger, H. (1973). Developing a paraprofessional staff enrichment program in an alternative institution. Professional Psychology, 4, 429–433. Gately, L., & Stabb, S. (2005). Psychology students’ training in the management of potentially violent clients. Professional Psychology: Research and Practice, 36, 681–687. Gelso, C., & Hayes, J. (2001). Countertransference management. Psychotherapy: Theory, Research and Practice, 80, 418–422. Goodkind, J. (2005). Effectiveness of a community-based advocacy and learning program for Hmong refugees. American Journal of Community Psychology, 36, 387–408. Grant, T., Ernst, C., Pagalilauan, G., & Streissguth, A. (2003). Postprogram follow-up effects of paraprofessional intervention with high-risk women who abused alcohol and drugs during pregnancy. Journal of Community Psychology, 31, 211–222. Haaga, D., McCrady, B., & Lebow, J. (2006). Integrative principles for treating substance abuse disorders. Journal of Clinical Psychology, 62, 675–684. Hattie, J., Sharpley, C., & Rogers, H. (1984). Comparative effectiveness of professional and paraprofessional helpers. Psychological Bulletin, 95, 534–541. Hess, A. K. (1997). The interpersonal approach to the supervision of psychotherapy. In C. E. Watkins (Ed.), Handbook of psychotherapy supervision (pp. 63–83). New York: Wiley. Hess, A. K. (2001). Learning psychotherapy. In S. Walfish & A. Hess (Eds.), Succeeding in graduate school: The career guide for psychology students (pp. 249–261). Mahwah, NJ: Erlbaum. Hess, S., Knox, S., & Hill, C. (2006). Teaching graduate trainees how to manage client anger: A comparison of three types of training. Psychotherapy Research, 16, 282–292. Hobbs, N. (1964). Mental health’s third revolution. American Journal of Orthopsychiatry, 34, 822–833. Holland, D. (1998). The cost-effective delivery of rehabilitation psychology services: The responsible utilization of paraprofessionals. Rehabilitation Psychology, 43, 232–245. Hollander, J., Bauer, S., Herlihy, B., & McCollum, V. (2006). Beliefs of board certified substance abuse counselors regarding multiple relationships. Journal of Mental Health Counseling, 28, 84–94. Hopkins, M., & Ramsundar, N. (2006). Which factors predict case management services and how do these services relate to client outcomes? Psychiatric Rehabilitation Journal, 29, 219–222. Hossack, A., & Robinson, J. (2005). Treated sex offenders as “paraprofessional” co-workers in the treatment of the sex offender. Journal of Sexual Aggression, 11, 103–113. Humphreys, K. (2006). The trials of Alcoholics Anonymous. Addiction, 101, 617–618. Johnson, D., Pedro-Carroll, J., & Demanchick, S. (2005). The Primary Mental Health Project: A playintervention for school-age children. In K. L. Reddy, T. Files-Hall, & C. Schaefer (Eds.), Empirically based play interventions for children (pp. 13–30). Washington, DC: American Psychological Association. Jones, K., Robinson, E., Minatrea, N., & Hayes, B. (1998). Coping with reactions to clients traumatized by child sexual abuse. Journal of Mental Health Counseling, 20, 332–343. Juhnke, G., & Culbreth, J. (1994). Clinical supervision in addictions counseling: Special challenges and solutions. Eric Digest. Greensboro, NC: ERIC Clearinghouse on Counseling and Student Services. (ERIC Document Reproduction Service No. ED372355) Retrieved from http://eric.ed.gov/ERICDocs/data/ericdocs2sql/content storage 01/0000019b/80/15/c6/ 95.pdf. Kalafat, J. (2002). Training telephone counselors. In D. Lester (Ed.), Crisis intervention and counseling by telephone (pp. 260–286). Springfield, IL: Charles C Thomas. Lambert, M. J., Garfield, S. L., & Bergin, A. E. (2004). Overview, trends, and future issues. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (pp. 805–821). Hoboken, NJ: Wiley. Lambert, M. J., & Ogles, B. M. (2004). The efficacy and effectiveness of psychotherapy. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (pp. 139–193). Hoboken, NJ: Wiley. Lester, D. (2002). Crisis intervention and counseling by telephone (2nd ed.). Springfield, IL: Charles C Thomas. Malmgren, K., Causton-Theoharis, J., & Trezek, B. (2005). Increasing peer interactions for students with behavioral disorders via paraprofessional training. Behavioral Disorders, 31, 202–213. Marlatt, G. A., & Witkiewitz, K. (2002). Harm reduction approaches to alcohol use: Health promotion, prevention, and treatment. Addictive Behaviors, 27, 867–886. Maslach, C., Schaufeli, W., & Leiter, M. (2001). Job burnout. Annual Review of Psychology, 52, 397–422. McFall, R. (1991). Manifesto for a science of clinical psychology. Clinical Psychologist, 44, 75–88.

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Meddings, D., Knox, L., Maddaleno, M., Concha-Eastman, A., & Hoffman, J. (2005). World Health Organization Teach-VIP: Contributing to capacity building for youth violence prevention. American Journal of Preventive Medicine, 29, 259–265. Moos, R., & Moos, B. (2006). Participation in treatment and Alcoholics Anonymous: A 16-year follow-up of initially untreated individuals. Journal of Clinical Psychology, 62, 735–750. Oliver, M., Miller, T., & Skillman, G. (2005). Factors influencing direct-care paraprofessionals’ decisions to initiate mental health referrals for adults with mental retardation. Mental Retardation, 43, 83–91. Pope, K., & Tabachnick, B. (1993). Therapists’ anger, hate, fear, and sexual feelings: National survey of therapist responses, client characteristics, critical events, formal complaints, and training. Professional Psychology: Research and Practice, 24, 142–152. Poser, E. (1966). The effects of therapist’s training on group therapeutic outcome. Journal of Consulting Psychology, 30, 283–289. Rappaport, J., Chinsky, J., & Cowen, E. (1971). Innovations in helping chronic patients: College students in a mental institution. Oxford, England: Academic Press. Rioch, M., Elkes, C., Flint, A., Usdansky, B., Newman, R., & Silberg, E. (1963). NIMH pilot study in the training of mental health counselors. In B. Guerney (Ed.), Psychotherapeutic agents: New roles for paraprofessionals, parents and teachers. New York: Holt, Rinehart & Winston. Samstag, L. (2006). The working alliance in psychotherapy: An overview of the invited papers in the special section. Psychotherapy: Theory, Research, Practice, Training, 43, 300–307. Sobey, F. (1970). The nonprofessional revolution in mental health. New York: Columbia University Press. Somer, E., Tamir, E., Maguen, S., & Litz, B. (2005). Brief cognitive-behavioral phone-based intervention targeting anxiety about the threat of attack: A pilot study. Behaviour Research and Therapy, 43, 669–679. Tharp, R., & Wetzel, R. (1969). Behavior modification in the natural environment. New York: Academic Press. Truax, C., & Carkhuff, R. (1969). Toward effective counseling and psychotherapy. Chicago: Aldine. Walfish, S. (1983). Crisis telephone counselors views of clinical interaction situations. Community Mental Health Journal, 19, 219–226. Walfish, S., Massey, R., & Krone, A. (1990). Conducting psychological evaluations with AA-oriented alcoholism treatment programs: Implications for practical treatment planning. In J. N. Butcher & C. D. Spielberger (Eds.), Advances in personality assessment (Vol. 8, pp. 161–185). Hillsdale, NJ: Erlbaum. Walfish, S., Tulkin, S., Tapp, J., Slaikeu, K., & Russell, M. (1976). The development of a contract negotiation scale for crisis counseling. Crisis Intervention, 7, 136–148. Watkins, C. E. (1997). Some concluding thoughts about psychotherapy supervision. In C. E. Watkins (Ed.), Handbook of psychotherapy supervision (603–616). New York: Wiley. Young, C., True, J., & Packard, M. (1976). A national study of associate degree mental health workers. Journal of Community Psychology, 4, 89–95. Zax, M., & Spector, G. (1974). An introduction to community psychology. New York: Wiley.

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PART FIVE

DEVELOPMENTAL PERSPECTIVES

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C H A P T E R 15

The Supervision of Child Psychotherapy ROBERT M. LEVE

about the difficulties of clinical supervision at the very beginning of my career as a child psychotherapist. At the time I was a beginning postdoctoral fellow at Children’s Hospital Boston, and Dr. Richard Brody was my major therapy supervisor. Dick was an excellent supervisor, and I was constantly amazed at his insightful and clever therapeutic analysis. However, we both learned that even the most innovative clinical suggestions can meet with complete failure. At the time I was seeing Harold, a depressed 12-year-old boy, and I was having a difficult time getting him to talk about or deal with his depressive feelings. Although he liked to come to our twice-weekly sessions, he never initiated any conversation about himself or his depression and answered my questions in the most bland and neutral way. Usually he just wandered about my office picking up objects and looking under them. Session upon session went on with me feeling that I was not making any progress, so I discussed my difficulties with Dick. We agreed that Harold was unable or unwilling to talk about himself due to traumatic events in his past, and he avoided talking about any feelings as a protection against the pain caused by his depressive memories. Dick suggested the following approach: “You need to try to have him get to his difficulties in an indirect way that avoids raising his sad feelings directly. Why don’t you ask for his help in terms of a fictitious kid? Just start by describing what he is doing in terms of another youngster, and ask him what he thinks.” The next session I said, “Harold, I have a problem and maybe you can help me. I know this boy, and he seems sad and uninterested in things. He walks around my office hardly ever talking, just looking under things.” I then continued to describe him and his behavior and ended by asking, “What do you think is going on, and why do you think he acts the way he does?” Harold thought a minute, smiled at me, and answered, “Why ask me? You ought to ask that kid.” And then he went on

I LEARNED

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quietly wandering my office with his same bland demeanor. That’s when I realized that even astute supervisory suggestions can be undone by a clever child client and that humility is a necessary attribute for a clinical supervisor. Psychotherapy involving children is a complicated endeavor for many reasons, the main one being that there are more physical, cognitive, social, and emotional changes during the years of childhood than at any other time in a person’s life. The adult years are a time of comparative stability compared to childhood (Leve, 1995). Although many adults may go through life transitions, career changes, and a process of maturation to old age, these changes tend to be slower and less profound than the developmental transitions of childhood. Because of these normal and constant changes, psychotherapy with children requires an expert knowledge not only of the individual characteristics and personality of each particular child, but also how the constant developmental processes interact with and complicate the treatment of that child. In this chapter I discuss the many issues that a supervisor must be cognizant of in providing child clinical supervision to both beginning and advanced students. In general, I address such topics as (a) the role of a supervisor in providing a student with a general method of child treatment, (b) how to integrate the theories of child development into child psychotherapy, (c) how to help a student generate a therapeutic model that harmonizes with his or her particular skills and personality, (d) the use and difficulties of child diagnosis, (e) understanding the influence of moral development on treatment, (f) confidentiality and its complexities, (g) the use of play therapy, (h) relationships with and treatment of a child’s family, and (i) how a supervisor helps in the future psychotherapy development of a student. T H E U N I Q U E A S P E C T S O F C H I L D T R E AT M E N T Every supervisor of beginning child therapists must impart this essential fact to his or her student therapists: Child psychotherapy is qualitatively different from adult forms of psychotherapy. If students do not grasp all the ramifications implicit in this idea, they can never become competent child therapists. Although some basic techniques may be similar, many are vastly different, and the unique culture of childhood demands a different understanding of the therapeutic process (Mash & Barkley, 1989; Semrud-Clikeman, 1995). Students need to realize that for the majority of children, the goals and outcome of treatment are not set by the child but rather are set by the adults in the child’s life (including parents, teachers, and other adult authority figures), and often the goals of the adults may conflict with the goals of the child. For example, a teacher may demand that a child who is disruptive in class change, whereas the child may see such inappropriate social behavior as enjoyable and have no motivation to behave differently. A child may not be bothered by his or her frequent angry outbursts, but those outbursts give the parents fits. There are instances when the child and parents will be agreement on the emotional and behavioral changes that are needed, but this is uncommon; on delving further, the therapist will see that often the child is merely going along with his parents, but there is little internal motivation for change. School is another difference between the culture of childhood and adults and is often a focus in therapy. I try to emphasize this point to my students by saying,

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The Supervision of Child Psychotherapy 267 “School is the career of a child,” but even this statement does not completely capture the importance of school in a child’s life. An adult can change jobs or even careers, and it will still not have the importance that school difficulties will have for a child, because success or failure in school affects every aspect of the child’s later life. Some adults may seek treatment related to occupational difficulties, but a child who is not learning is quickly identified and special education intervention and/or psychological treatment is almost always invoked. Adults can choose therapeutic treatment for themselves, but children are usually referred or brought to treatment by parents or teachers. Aside from the fact that adults decide when children’s behavior requires therapeutic intervention, children are dependent on adults for certain essentials associated with psychotherapy. Not only are the fees for treatment borne by parents, but also most children are not able to arrange the scheduling or necessary transportation. All of these observations are an indication of the powerless of children compared to adults, and a supervisor must be sure students are cognizant of these differences. This is best done by direct discussion of these issues, but that is only the first part of a supervisor’s role. The more sensitive and difficult aspect is to be sure that the student is able to recognize how these differences affect the particular child he or she is treating. For example, how does the child react to his parent’s demands that he stop beating on his brother when he sees nothing wrong with that behavior? This kind of disagreement is likely to become a therapeutic issue, and the supervisor needs to have the student become aware of how it will determine the focus of treatment. T H E R O L E O F T H E C H I L D P S Y C H O T H E R A P Y S U P E RV I S O R The role of any supervisor is complicated, but it is especially so in relation to child therapy. A competent supervisor needs to be a teacher of theories and therapeutic techniques, a mentor who facilitates the unique therapeutic talents of the student, a role model whose talents and skills invite imitation, and an ethical professional who usually assumes the ultimate responsibility for a case usually without having direct contact with the child and his or her family. As a teacher, a supervisor usually finds that although most students come to their therapy practicum and internships having completed some child treatment courses, such theoretical material tends to be didactic and general. The supervisor’s role is to show how such material is applied in idiosyncratic situations with individual children and their families. In addition, a supervisor can provide far greater detail than any course and provide insights as to which theories are applicable for which children and which will not result in a successful outcome. Perhaps the most enjoyable aspect of being a supervisor is having discussions with students about their cases and getting into the complexities and details that are different from one child to another. Sometimes this is done in a direct fashion through advice and instruction, but often it is best done by facilitating students as they generate their own approaches. This requires sensitivity and creativity on the part of the supervisor, but it is most useful in the long run. Of course it depends on the experience level and talent of the students as to the balance between direct supervisory instruction and indirect facilitation of the students’ own ideas.

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A useful way to conceptualize supervision is for the supervisor to realize that he or she is initiating a developmental process that is the pivotal starting point in an individual’s career. A good supervisor is a role model who will likely generate life-altering effects for both the therapy student and the children he or she will treat for many years. As I am nearing the end of my career as a child therapist, I still fondly remember my early supervisors and am aware of the ways that they guided me and led me into an awareness of areas that have become an important part of my later work. A concept that is difficult to define, but crucial for all therapists, is clinical judgment, and supervisors must be alert for students lacking this skill. Clinical judgment involves knowing and doing what is appropriate for a situation and being aware of a child’s level of comfort. Although most therapy students come to supervision with a good sense of clinical judgment, supervisors need to be alert for students who mistakenly introduce ideas that are too emotional or inappropriate for the child’s level of development and help them recognize when their actions are improper. Unfortunately, if students’ inept clinical judgment cannot be changed, then supervisors must counsel them to find another way of using their education. Poor clinical judgment in whatever form can be especially damaging in child psychotherapy because children are naive compared to adults and are more likely to be damaged by such blunders. As an example, I am familiar with a situation in which a student began to have detailed discussions about masturbation with a 10-year-old boy. Given that this youngster’s emotional state was quite fragile, such discussions were too stimulating and within a few weeks the boy had a psychotic episode and needed to be hospitalized. Another situation involved a student therapist bluntly pointing out a host of personal faults to an 11-year-old girl about why her school friends were avoiding her. The girl was so upset she refused to come to any more therapy sessions. In both of these cases the supervisors involved should have been aware of their students’ lack of judgment. One of the predominant ways in which poor clinical judgment appears is in the form of premature interpretations and overzealous advice. There is a natural tendency among inexperienced therapists to give advice to their child clients in an effort to genuinely help them deal with difficult situations; however, clinical supervisors need to caution their students against giving psychodynamic interpretations or advice, as that is the area where students can do the most damage. Students need to learn that these should rarely be used, and then only when the therapists are sure the child can understand and accept such interventions. Perhaps the most difficult part of supervision is allowing the student to find those methods and therapeutic nuances that best fit his or her personality. I believe that each therapist develops a style that fits him or her and is woven into his or her treatment of each individual child. This is best conceptualized by thinking of each therapist as having a different and unique type of therapy that is his or hers alone. A competent supervisor encourages this development by helping a student to realize that there are many ways to conceptualize and develop clinical interventions, and a student should find ones that fit his or her personality and are most helpful to a child. Listening to the student’s oral narratives of a session or to tape recordings gives a supervisor ample opportunity to compliment and positively

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The Supervision of Child Psychotherapy 269 reinforce the student’s individual therapeutic technique, whether the intervention is an interpretation, a corrective emotional experience, or simply listening. In addition to helping them develop their own personal style, there is the question of exposing student therapists to differing therapeutic orientations and techniques. Perhaps some experienced psychotherapists will disagree with this suggestion as they are dualistic therapists (Prochaska, 1984) and believe that their theoretical orientation and therapeutic intervention is the correct one; however, that view has been losing acceptance. As both adult and child treatment has matured over the past decades, most therapists have become relativistic therapists (Norcross, 1986; Norcross & Guy, 1989) who believe they must have different types of treatments to fit the different kinds of emotional problems, personalities, and cultures they will meet in the course of treatment. Even if a strong adherent to a particular treatment, a supervisor has a responsibility to provide students with a diverse experience and expose them, without bias, to a range of treatment alternatives. There is nothing wrong with a supervisor pointing out why he or she has adopted a theoretical orientation and how it seems to work in treatment cases; however, students are likely to need different approaches with the different children and different emotional problems they will treat. Sometimes a student may decide to adopt one therapeutic approach prematurely. Perhaps this is done as a way of trying to simplify the confusion of learning the complexities and nuances of child psychotherapy or because they have been unduly influenced by a dualistically oriented previous teacher or supervisor. Such a truncation of learning early in one’s career when the student has had insufficient experience and a lack of perspective is not a wise decision, and a supervisor has a responsibility to discuss the problems inherent in such a premature choice and how it may decrease both the future flexibility and ultimate competence of the student therapist. Certainly, no clinical child therapist can be equally proficient with all kinds of treatments, but they need to become competent with as many types of treatment as they can and need at the least to be knowledgeable about a wide range of treatments (Allen, 1979; Johnson, Rasbury, & Siegel, 1997). Obviously, becoming proficient with many types of treatment allows an individual to treat a wider range of emotionally disturbed children. Of course, there is a relationship between different types of therapist personalities and interests and different types of psychotherapy, and there is little point in trying to master a form of treatment that is basically incompatible with the talents of an individual therapist. Perhaps the aspect of clinical supervision that requires the greatest sensitivity and experience focuses on the relationship between a student’s developing his or her own personal therapeutic style and mastering the many different types of psychotherapy treatments. This concept, which may at first seem confusing, is better understood if one realizes that whether a therapist is following a cognitivebehavioral therapy model or helping a child explore a past emotional trauma through a psychodynamic approach, each therapist does this in his or her own unique way. For example, some students find that they are comfortable and make better therapeutic progress when they are more empathic, whereas others naturally are more probing. Similarly, some students emphasize comforting a child in distress, whereas others tend to focus on the solution to distressing emotional problems. Ultimately, whatever form of psychotherapy is used, treatment is a complex

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personal interaction between a therapist and a child determined by the personalities of both the child and therapist. Supervisors should discuss the personal style of their students and make them aware of how this affects the children they are treating. My own personal style tends to focus on problem solving, and I am comfortable using play material and games. I am appreciative that this was pointed out by my first clinical supervisor and we then were able to discuss the nuances of my approach, how this either facilitated or hampered my work with particular children, and how it could be integrated into the different forms of therapy I was using with different children. The important point to remember is that all forms of treatment, even more structured treatments such as applied behavior analysis or cognitive-behavioral therapy, will be affected by the personality of the therapist, and students should become aware of this fact. Perhaps the most obvious yet crucial role of a clinical supervisor involves taking on the treatment responsibility for the child and the child’s family. Although the actual legal ramifications may vary from state to state according to state licensing statutes, the moral and ethical implications are very clear. The supervisor is the individual ultimately responsible for a child’s treatment. A student therapist may provide the direct contact and actual treatment; however it is the supervisor who is the licensed professional, and the student can only provide treatment that is directed and approved by the supervisor. Ultimately, treatment decisions must be approved by a single individual and a student cannot be that person by virtue of the fact that he or she is likely not licensed or is not a staff member of the institution. This issue is the fundamental difference that separates consultation from supervision. An important advantage in having a supervisor bear the ultimate responsibility for treatment is that the student need not worry that he or she is making some unchecked terrible blunder because the student has the advice and protection of the supervisor. Also, the student knows he or she is not alone in the case of a therapeutic crisis. The question of responsibility becomes more important in treating children than adults because children are more vulnerable to therapeutic blunders, and the effects of poor or inadequate treatment are longer lasting. In addition, children are less likely to know when treatment is not meeting their needs and so are not likely to seek changes in their therapy. Adults have direct control of their treatment, are usually experienced enough to know when a therapist is not meeting their needs, and can inform their therapist or terminate the relationship to seek another therapist. In child therapy, parents are in control of treatment, but unless they are present at sessions they do not have direct experience with their child’s sessions so are unlikely to be aware of problems in treatment. THE ROLE OF THE STUDENT THERAPIST Just as a child therapist usually structures therapy in the first session so a supervisor should structure the supervision so that students are aware of expectations and responsibilities. For example, at the beginning of supervision I tell my students that they should not rely on their memory of a session but should come to supervision with their therapy notes and questions they would like to discuss. I also tell them that there may be sessions that we might want to audio- or videotape, and I explain

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The Supervision of Child Psychotherapy 271 how this is done with the approval of the child and his or her parents. I believe that early in supervision students need to be told that maintaining therapy notes is not only important but is usually mandated by the rules of most state licensing laws, and such material must be kept for certain periods of time (usually years according to the particular state). Such notes have to be kept even after therapists have left the clinic or hospital. Because the supervisor is responsible for the case this really falls on that individual; however, students need to become aware that this will be their responsibility once they are licensed. Obviously, we set up a mutually convenient time for their supervision, and, without being overly rigid, that is a schedule that must be adhered to unless the session is cancelled ahead of time for vacations or in the case of an emergency. Adherence to a scheduled time for supervision is in the interest of students, as that is their time for learning and the reason why they have decided to train as a child therapist. I also explain that though I want them to develop their own style of treatment, as a licensed supervisor I am responsible for the child and his or her treatment and together we must provide the best treatment for the child. I also explain that there are certain skills that students should have or develop over the course of supervision. Obviously, I expect them to be ethical in their work and respect confidentiality (this is discussed in a later section). I assume they come to their work with sympathy and interest in children, and they will need to hone this attribute into sensitivity for recognizing and understanding a child’s emotions. Over the course of their work they will need to acquire knowledge of the local child environment in terms of communities and school districts. In addition, they should come to understand the socioeconomic differences and complexities of the local community and how these create differences in each child’s case. Finally, I tell students that having a bit of a childlike attitude and an enjoyment of children’s activities is also a helpful attribute. Students also need to realize that not all of their therapy cases will be successful, and there will be disappointments and failures. Some children may not make satisfactory therapeutic progress, and as therapists students will encounter therapeutic obstacles. In addition, there will be frustrating times when parents may prematurely and ill advisedly terminate treatment and the therapists, in spite of intense consultation, will be powerless to stop the termination. Of course, the role of a competent supervisor is to help students learn to deal with and overcome such disappointments. Many beginning students find child psychotherapy confusing and even overwhelming. I still remember the day when, in frustration, I went to my first clinical supervisor and said, “Dr. Pumroy, I’m not exactly sure I know what I’m supposed to do.” After overcoming his surprise at my naivet´e he gave me the best succinct explanation of the stages in therapy I have ever heard: “Well, Bob, as you build a trusting relationship you assess the child’s problems. Then get the child to understand the problems in his own way and next help him to change. The most important part is getting the kid to realize his difficulties because if you can do that they often figure out how to change on their own.” Sometimes beginning students like me need concrete guidance, and in addition to supervisory help they may benefit from reading some handbooks or therapy guides such as Dodds (1987); Jongsma, Peterson, and McInnis (1996); Kronenberger and Meyer (1996); or Brems (2002).

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DEVELOPMENTAL PERSPECTIVES T H E D E V E L O P M E N TA L P R O C E S S A N D CHILD PSYCHOTHERAPY

Perhaps a useful metaphor for child psychotherapy is that it is similar to shooting at a moving target. Children are always changing due to the normal process of maturation, so attempts to bring about emotional and behavioral changes must be appropriate for the present state of a child’s development and for where the youngster will be at a future time because children change over the course of treatment both due to normal maturation and as a result of therapy. For example, the peer social skills needed by a 10-year-old fifth-grade girl will be quite different when that youngster is a year older and must face the often complicated and demanding social skills needed to deal with the cliques, friendships, and not uncommon rejections of a sixth-grade middle school classroom. The supervisor of a beginning child therapy student needs to be sure that the student is aware of this issue. A good way to point this out is to ask the student to think of what his or her client will be like 6 months, a year, or 2 years in the future. Ask the student to consider what maturational changes are likely to occur and what changes the child must make in order to cope with the coming changes in the child’s individual environment. In what ways are the social and group relationships likely to become more complicated, and in what ways will the academic demands of school change? Of course, such changes are dependent upon the particular cultural environment of the child, so these are likely to be different for a child living in an inner city culture as opposed to a child growing up in an upper middle-class suburban community. In guiding the student therapist the supervisor need not provide accurate predictions for the student, but rather have the student consider the issues and how such changes will influence treatment. Depending on their age, children have different and less sophisticated verbal abilities than adults, and this means there is an inherent disconnect between children and their therapists. The communication skills of adult therapists are precise, with words conveying accurate meaning in respect to everyday events and especially emotions. Children do not have this sophistication, and they tend to communicate with actions that are less precise. Hence, a competent child therapist must develop the skill to interpret children’s communication. Obviously, the younger the child is the more likely his or her therapeutic communications can be misunderstood or the child will not talk at all. This is less of a problem for older, verbally developed children, but the child therapist must adjust his or her communication attempts to a level that children will understand and avoid engaging in “adult talk.” This is best done with both supervisor and student listening to recorded therapy sessions that provide direct feedback about verbal interactions. In addition, the supervisor should encourage the student to study developmental literature in order to learn how children develop verbal abilities and which skills are appropriate for which ages. Most students who are interested in working with children are likely to have taken a child development course at some point, and this may provide a basis for understanding the unique aspects of childhood. However, students need to understand the implications of child development for the therapeutic process and how to integrate those concepts into their individual work with a child (Leve,

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The Supervision of Child Psychotherapy 273 1980). This is a rather complex process that takes time and supervisory guidance. Questions may include “How does that issue relate to the child’s world?” or “On what cognitive level is the child likely to understand what you are discussing?” or “Is that issue best dealt with by talking or through some play activity?” or “Given the child’s ability to understand adult words, how could you present that idea through an concrete example?” I find that asking students to read the writings of Jean Piaget on cognitive stages of development is useful, as is reading the work of others such as Daniel Stern and Jerome Kagan. Piaget is an excellent starting point because his work encompasses all the childhood and adolescent years and provides a sequential picture of the many cognitive changes and the general ages at which they occur. Most child developmental theorists tend to identify discrete stages in a child’s development, and though this is helpful when conceptualizing large groups of children it is misleading when considering individual children. Developmental stages are not discrete, and there is a great deal of overlap and differences as they apply to individual children, so stages of a developmental theory should only be seen as a guide for identifying future changes and cannot be taken as descriptive of a particular child in treatment. In addition to understanding the cognitive level of children, students need to understand the emotional and behavioral levels of development. Children’s ages are related to the type of disorders they will develop and the emotional reactivity they display (Kessler, 1988). For example, eating disorders mainly occur in adolescent girls and are rarely seen before sixth grade. Conversely, failure to thrive is characteristic of young preschool children. Many anxiety symptoms such as a fear of the dark and fear of large animals are common in preschool and elementary-age children and are not of great concern. However, full-blown phobias such as school refusal or a debilitating fear of diseases usually occur in older children, fifth and sixth graders, and are not part of a normal developmental process. I was referred a 12-year-old girl who experienced a panic reaction and ran shrieking out of her dentist’s office, streaming dental devices and dental gown behind her. That was certainly not a common emotional reaction for a seventh grader. Conversely, separation anxiety, although upsetting to parents, is not uncommon in preschoolers or first and second graders. However, that reaction should be temporary and not last longer than weeks. If it continues for 3 or 4 months it indicates a pathological reaction that may require psychological intervention. Of course, if it occurs in eighth grade or high school, it is aberrant and likely a sign of other emotional difficulties. Ethics, morality, and altruism are often an important focus of treatment, and the student must be aware of the relationship between these behaviors and age. In this area the work of Kohlberg and Piaget are important, as they show that a child’s understanding of morality is based on his or her level of cognitive development, and that is correlated with age. The student needs to understand that age-related egocentrism determines a child’s ability to take the perspective of another individual, and when a child cannot view the world from another person’s perspective his or her concept of morality will be severely limited. Knowledge of developmental morality and how it emerges is crucial to many aspects of child psychotherapy because it underlies a child’s social, familial, and especially peer relationships.

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There is no point in trying to bring a child to understand why he or she should not do something if the child does not have the necessary cognitive level and is incapable of understanding the flaws in the ethical behavior. A therapist must approach a child’s difficulties with morality quite differently depending on whether the child is capable of understanding his or her actions. When a child is incapable of understanding reciprocal fairness (if I am fair to you, you will be fair to me) or is too egocentric to take another person’s perspective, then a therapist must alter the approach. If a child can understand such ethical concepts the therapist can use verbal methods to bring about a change in behavior; however, if the child does not have such an ability then there is little point in trying reason about such things and the therapist must turn to behavioral techniques that modify the child’s difficulties without the child necessarily understanding the reasoning behind the change. In this situation the supervisor is critical in helping the student decide on which particular approach is best with an individual. D I A G N O S I S A N D S U P E RV I S I O N Diagnosis is an important skill that supervisors must cover in their work with their students; however, there is more to this skill than becoming competent practitioners of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) or its latest revision (American Psychiatric Association, 2000). Because the DSM-IV is the commonly accepted method for categorizing children in therapy, students are usually familiar with this volume and how to use it, but whatever the level of student sophistication supervisors should include a discussion of the DSM category of each of the students’ clients (Rapoport & Ismond, 1996). A serious problem that has existed throughout the many editions of the DSM is lack of interrater reliability, which has always hovered around .4 (Achenbach & Edelbrock, 1978). This lack of interjudge reliability usually ensures that there will be supervisor–student disagreements. The disagreements themselves are less important than the discussions that can emerge and should lead students to a deeper questioning of the DSM. In terms of pragmatic consideration students must become familiar with the DSM-IV because of its general acceptance and the fact that managed care companies require a DSM diagnosis before they will provide third-party reimbursement. Students should develop a general and robust appreciation of the diagnostic process, which includes more than skill in using the DSM-IV. They should realize that there are many reasons for diagnosis and many problems. For one thing, diagnosis is a form of simplification in that it reduces the emotional, social, and behavioral complexities of a child to a shorthand label or numerical classification that introduces many inaccuracies and uncertainties (Quay & Werry, 1986). Usually, giving a child a diagnosis categorizes the child, but it does not do a good job of explaining or understanding the historical reasons for such behavior. Another inadequacy of a DSM diagnosis is that it is not accurate in predicting a prognosis for treatment (Leve, 1995). With some categories it may provide a general indication of the intensity and length of treatment required or whether psychotherapy should be inpatient or outpatient, but an accurate prediction of the prognosis of therapy requires much more detailed information than is included in a DSM categorization. Of course, many managed care companies try to use it in this fashion, but students

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The Supervision of Child Psychotherapy 275 need to understand that the DSM-IV is ill suited for such uses. Choosing the best treatment options depends on cognitive, environmental, and socioemotional variables, and many aspects of these factors are not included in the DSM process. The general system of predicting treatments is referred to as dispositional diagnosis, and a discussion of and method for dispositional diagnosis can be found in the text Child and Adolescent Psychotherapy: Process and Integration (Leve, 1995). In addition to mastering diagnostic skills, students need an in-depth understanding of childhood psychopathology. Because this is an extensive compendium of knowledge, I often suggest that they read a text such as Kessler’s (1988) Psychopathology of Childhood, Wicks-Nelson and Israel’s (1997) Behavior Disorders of Childhood, or Kearney’s (1999) Casebook in Child Behavior Disorders. If they have had a course in this area or have done extensive reading I still suggest that they reread those sections that relate to the child they are treating, as this not only helps them become more familiar with that child but also shows them that children usually do not fall neatly into a single neat cluster of symptoms. The more common occurrence is that an emotionally disturbed child has many and varied symptoms that are unique, and this is a good lesson showing students that psychopathology is only a general guide, and that there is much more to understanding emotionally disturbed children. Some cases deserve more supervisory attention because they provide a better learning experience for the student. One would like to think that all child cases deserve the same amount of supervision, but that is not what happens in real clinical supervision. Some cases are not as complex, and the student is able to handle these with ordinary supervisory attention. If the treatment process is straightforward, the child is making therapeutic progress, and the child and his or her family are not facing any critical situation or serious life changes, then a competent student will not need as much supervision. Other cases require extensive attention because of an emerging or ongoing crisis. There will be yet other cases that do not present a crisis, but the child and his or her family present interesting therapeutic problems and a special focus on that case will provide clinical nuances that enrich a student’s competence. THE COMPLEXITIES OF CONFIDENTIALITY Confidentiality is an often confusing and complicated issue in child psychotherapy. Students must be aware of state rules as to who has confidentiality: Is it restricted to physicians, attorneys, and clergy only, or does it also apply to licensed clinical psychologists, school psychologists, and other health professionals? And at what academic level? Master’s? Doctoral? The supervisor needs to know and tell students whether they also have legal confidentiality. Another confusing issue that students must understand is that confidentiality usually applies to the child’s parents and/or guardians, but not the child. That means that the parents can ask the therapist to keep clinical information confidential from others, but the child usually cannot insist that the therapist keep clinical information from his or her parents. Of course that depends on the age of the child and state laws, but because parents have ultimate responsibility for the child’s welfare, it is a rare situation when a child has complete confidentiality. Usually parental access to clinical

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information is only denied when the child is emancipated, under a court order, in a well-documented clinical emergency, or when the child is old enough (at least 16) and capable of making his or her own decisions. However, confidentiality must be waived in cases of abuse, and how this is done and under what circumstances depends on relevant state laws. In cases of abuse students should know who is a mandated reporter under state laws (therapists and therapy students almost always are) and what constitutes abuse and neglect. The supervisor must be sure that students are familiar with these laws, as ignoring them not only is dangerous to the child but also exposes both student and supervisor to severe legal action. This situation is complicated further by the federal Health Insurance Portability and Accountability Act (HIPAA), which put restrictions on how clinical information is kept secure and private. Students need to be aware of HIPAA because there are serious legal consequences for violating those rules. Another complication is the role of managed care companies and other third-party payments. Clinical information is demanded by managed care companies if they are to cover the costs of treatment; however, providing this information may come in conflict with the rules of HIPAA and confidentiality in general, so students usually need guidance as to what constitutes the ethical and legal transfer of information, especially electronically transferred information. Parents also need to be informed about what information will be given to outside parties, as they have the ultimate control over what, if any, information can be provided. Many parents are fearful of the consequences of disseminating clinical information to third parties, as they worry that once the information is in corporate computers it can be accessed later in the child’s life and perhaps affect sensitive political or employment situations. Similarly, student therapists must be careful about the kinds of information they provide to school staff during school consultations. Usually teachers and school administrators have little use for therapeutic information, and the information that is most useful to them is suggestions as to what they can do to facilitate their work with a child or ideas on how they might handle the child’s classroom difficulties. The problem with confidentiality is that children need to be reassured that what they say and discuss is kept private, because if they think their therapist is not keeping secrets they are not likely to tell the therapist very much. Such an inhibition against sharing difficulties will greatly interfere with treatment. This situation presents a real difficulty for students, and they usually need some definitive guidance. I tell students at the beginning of supervision that they need to give parents an explanation that reassures them and still maintains confidentiality for the child. I suggest telling parents that for treatment to be effective their child needs reassurance that what he or she tells the therapist will be kept in confidence, but if the child is doing something self-destructive or dangerous the parents will be told. However, children often tell their therapist things that they think are bad, but in reality these things are reasonably innocuous and to have parents wanting to know such things would be detrimental to the main goal, which is the emotional health of their child. This explanation reassures parents and seldom do any difficulties arise; however, if parents do not go along with that request it is an indication of overcontrol and a possible sign of future difficulties that need to be addressed. The child needs to understand the idea of confidentiality, and students should discuss this during the first session; however, the explanation needs to be couched

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The Supervision of Child Psychotherapy 277 in terms appropriate to the child’s age and verbal ability. After parents have agreed to allow limited confidentiality, I usually have students explain some variant of this simple explanation: “I just want you to know that what we talk about is confidential, and I will not tell your parents what you tell me unless it is something that is dangerous to you or someone else or might get you into lots of trouble.” I then suggest that students provide an example or two of what they would not tell anyone and an example of something that they would have to tell the child’s parents. Children usually have one of two reactions to this explanation. Either they do not seem to care, or they are pleased and rather intrigued by being treated with such unusual adult-like importance. The key is providing a simple explanation that reassures the child without giving him or her information that is far beyond the child’s ability to comprehend. PA R E N T – T H E R A P I S T C O N TA C T S Dealing with parents is often a difficult area for student therapists and one in which they often need additional attention from their supervisor. Students need to realize that parents are always a part of treatment, though there are many different ways parents can be involved. Reisman (1973) listed four general types of parental participation: (1) parents who refer their child but do not participate, (2) parents who are counseled as the sole form of treatment without child participation, (3) parents who are treated by one therapist while the child sees another, and (4) parents who are treated by the same therapist as treats their child (in these cases, parents and child might be seen together). Although these four alternatives broadly cover the range of treatments, there are many nuances between them and students have to learn that each family situation is unique. For the most part parental motivations tend to determine the frequency of contact, but the therapist should feel free to suggest whatever type of contact he or she feels is most useful. Parents may disagree with the suggestion by either not making themselves available or openly disagreeing with the suggested schedule, and often there is little the therapist can or should do to change the parents’ attitudes and behavior. Certainly, openly challenging the parents on this issue risks destroying the therapeutic relationship and may cause the parents to refuse treatment completely. Therapists almost always meet with parents at the beginning of treatment to obtain a history (Ollendick & Hersen, 1993), identify symptoms, discuss administrative matters, and discuss the child’s therapy sessions. This is usually the best time to suggest and discuss the type and timing of a meeting schedule with parents. Doing this openly and early on often sets the parents’ expectations, and they are more likely to comply and feel a part of their child’s treatment. Because parental involvement can become a delicate issue, supervisors should prepare students beforehand for this first parent meeting and go over alternatives that might arise. The kind of involvement parents will have in their child’s treatment is closely related to the child’s emotional and behavior problems. As a very general rule the more serious the pathology and the more the child’s problems are related to parents and home, the more parents will need to become involved in treatment. However, this is a general rule, and the actual involvement will always depend on the type of treatment and idiosyncratic aspects of the child and the family.

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For example, frequent parental counseling will be needed with a youngster who is acting out or having temper tantrums at home. Similarly, in the treatment of children with Asperger’s or autistic spectrum parents are likely to be the main focus of treatment. The opposite may be true for children who are having peer problems or are socially isolated. Parents should be involved in treatment, but aside from their giving the child encouragement and providing opportunities for social contacts, the main focus of treatment will be on the child. Beginning students often become overfocused on their direct psychotherapy with a child and overlook the extent to which parents can be valuable change agents. I usually remind my students that whereas they will see a child for an hour or two a week, parents are spending far more time with the child, and parent involvement should never be forgotten. Dealing with parents is an area that often produces many transference and countertransference difficulties for students. One problem is the age differential between parents, who are often in their 40s and 50s, and students, who are likely in their mid to late 20s. Also, most students have not have had the experience of rearing a child and may not even be married or in a serious relationship. I imagine that astute students cannot help but be aware of this difference, and feelings of inadequacy should be recognized and openly discussed as part of supervision because all child therapists, whether students or someone with years of experience, need to feel confident in their work. A supervisor can be helpful by telling students that such feelings are to be expected, but they should not be allowed to affect students’ consultations with parents. Although parents may have childrearing experience, psychotherapy with children is a different and specialized skill that the students have and the parents do not have. Parents have come to them as experts in treatment because the methods the parents have utilized have not been successful. Hence, parents are in a dependent position and will see students as special professionals who can help their child. Sometimes students may overidentify with the child they are treating and develop a conscious or unconscious negative reaction to the parents. They are likely to hear the child’s complaints about the parents and then take the child’s side in child–parent disagreements. Often they will become aware of the parents engaging in maladaptive behaviors, or being overly restrictive or too punitive, and in some cases the parents’ self-defeating traits may be so ingrained that they are characterological and cannot be changed. A common beginning therapist’s response is to become frustrated and angry at the parents. Of course, harboring negative or hostile reaction to parents is not an adaptive reaction that will be helpful in treatment, and supervisors need to watch for such student reactions and help students put aside their feelings. I find that just making students aware of their feelings usually results in a positive change, because competent students are astute enough to know that the ultimate goal is to help the child. Discussing countertransference feeling toward parents is a valuable learning experience and can lead to a more general discussion of transference and countertransference issues. Of course, supervisors need to be alert to personal issues students might have toward their own parents that might affect their relationship with a child’s parents. Although supervision is not personal psychotherapy, students should be aware of such residual personal issues as that will affect not only the present case but also future therapy situations.

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The Supervision of Child Psychotherapy 279 I often tell students who are frustrated by inappropriate or insensitive parental behavior that they need to also see the positive attempts of parents, including the fact that they were concerned enough to seek help for themselves and their child. Students should realize that parents are often limited by their own emotional difficulties, but they almost always love their child and want to help them. Supervisors should point out that no matter how inept the parents’ attempts, students should assume the parents did the best they could. That assumption leads a student therapist to think parents can change and that the therapist’s task is to bring about positive changes. Cooperation with parents is a better course than resentment or frustration. P L AY T H E R A P Y Any observer of children knows that they spend a great deal of their day involved in play activities. The statement “Play is the work of the child” is true, because it is through play that children learn and are able to try out new behaviors, ideas, and understandings. Because child psychotherapy is a form of learning new things and correcting inappropriate understandings, it follows that play can be a useful part of treatment. Of course, the use and type of play depends upon the age of the child, and there are a number of books that delve into this technique in greater detail than can be explored here (e.g., Axline, 1947; Leve, 1995; Schaefer & O’Connor, 1983; Winnicott, 1971). These texts cover the many kinds of play material, games, and activities that can be used in treatment, and I suggest that the more of these a therapist is familiar with, the more options he or she has in treatment. Earlier I suggested that a good attribute for a child therapist is the ability to enjoy and be facile with childlike activities (Freeman, 1982). That certainly is an advantage in play therapy. There are many different ways for a therapist to interact through play, and because most beginning students are not familiar with this technique, helpful advice from a supervisor is valuable. For example, in some situations the child and therapist will participate together in play, whereas in others the child plays while the therapist watches and makes comments. Whatever the form of interaction, play is inherently helpful as a corrective emotional experience because in everyday life the child seldom has adult attention and participation in his or her activities with the sole focus being on the child. Play is important because verbal interactions are not the main means of communication for children, and play provides a more direct interaction (Landreth, Homeyer, Glover, & Sweeney, 1996). Unfortunately, most student therapists have long since given up play as a means of communication, so they must go back and learn to communicate through play. This is not easy, and they often need the help of their supervisor to understand the nuances of this difficult work. I find that this is an area of supervision where students are appreciative of direct suggestions. Interacting through play means that therapists must understand the motivations that are being expressed and then respond with some play interaction that attempts to provide a new understanding of those motivations. Alternatively, the therapists’ play responses should suggest a new and more appropriate way to express emotional difficulties and provide suggestions on how such behavior

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could be changed. Understanding emotions disguised in play activities and trying to respond through a play technique is subtle and is not a skill quickly learned. Another complication is that the world of play and play materials change over time, and student therapists need to be aware of the contemporary world of childhood to stay abreast of what they will utilize in their work. Of course, if therapists become out of touch, the children they treat are likely to let them know rather quickly and directly. In fact, I find that a good way of staying current with changes in the world of childhood is to listen to my child patients. Unfortunately, some contemporary changes do not fit well into play therapy, and here I am referring to the growth of computer games, which can be addicting for kids. The problem with computer games is that they tend to be solitary activities that are so engrossing they do not leave much room for social interaction between child and therapist. Even an interactive game requires such attention that it precludes allowing emotional issues to emerge or be dealt with. For that reason, I do not encourage my supervisees to use such games. The problem is that children like and are accustomed to these activities, and they are not as enthusiastic about games and activities that allow more therapist–child interaction. The alternative of avoiding play therapy means the session will involve direct verbal interactions, and that may not be as therapeutic, especially if the child seems to understand the therapist’s words but does not really grasp the meaning. This is a danger, as I have often had children nod their heads in agreement to what I was saying, yet later I realized they really did not understand. Perhaps supervisors should reflect on how child therapy has changed during their career as a way of alerting students to the fact that this will happen to them in the future. THE BEGINNING AND END OF CHILD PSYCHOTHERAPY As in adult psychotherapy, the beginning and ending sessions are unique and have special structured requirements. In respect to beginning sessions, I tell my supervisees what I was told as a student: “The main goal of the first session is to have the child come back to a second session.” In other words, make sure the child has fun and do not try to delve into difficult or traumatic issues in the first session. If done well, this early interaction starts the process of developing a positive therapeutic relationship between therapist and child. Beyond that there are a number of obvious issues, such as the therapist telling the child his or her name, saying when and how soon they will meet again, giving an explanation of limited confidentiality. And I suggest giving a simple statement of what will happen in the sessions, such as, “When we get together we can talk and play games and things.” I also tell my students to be sure to put the child at ease and not to ask too many questions. Also, a good way to begin is to ask, “Did your mom or dad tell you why they want you to meet with me?” as that provides an insight into the child’s expectations, and the therapist can correct any misconceptions. I have had children tell me the following: “Because I beat up my sister,” “They’re mad at me,” “I didn’t do my homework,” and “I don’t know why.” One child even told me that his dad said he had to get on a couch and tell me secrets, but the child was relieved to see I did not have a couch. Aside from allowing the therapist to correct these misconceptions, these answers present good starting points. Other issues can be raised in the first session, and these can be found in

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The Supervision of Child Psychotherapy 281 Chethik (1989), Haworth (1994), Leve (1995), Morris and Kratochwill (1998), and Reisman (1973). Termination involves both deciding when treatment should cease and preparing the child and his or her parents for the end of therapy. Obviously, the best criterion for termination is the complete remission of symptoms and a belief that the youngster will be able to cope with future difficulties. That is a rather general description, and a more detailed set of criteria can be found in child psychotherapy texts such as Leve (1995) and Morris and Kratochwill (1998). However there are times when treatment must be terminated for other reasons related to parental dissatisfaction with therapy, family relocation, financial difficulties, or the student therapist moving to a new training site. Supervisors should discuss how the student ought to handle such premature terminations, which can be difficult for the child, his or her parents, and the student. The other aspect of termination is preparing the child for the end of therapy. There is universal agreement that ideally therapists should tell the child well ahead of the last session, but there is likely some disagreement as to the exact timing and method that should be used. Supervisors should discuss what reactions might be expected from individual children. For example, some children may feel a sense of loss or show signs of insecurity; older symptoms may reemerge. Some children may not have any observable reaction. Although reactions will differ from one child to another, students need to be sensitive enough to recognize whatever individual reaction emerges and reassure and help the child cope with these feelings. I find that often children seem not to have any emotional reaction, however students should still not assume that is the case. The longer and more intense the treatment, the deeper the therapeutic relationship, and in that case children are likely to have feelings about termination even if these are repressed. Of course, the same holds true for student therapists, especially because the first children they treat in their careers are likely to have special significance. Hence, supervisors should expect to help students recognize their feelings and how they can be accepted. There are many other issues concerning termination, and these can be different depending on the type of psychotherapy employed. A more detailed description can be found in most texts that focus on particular types of child treatment (e.g., Leve, 1995; Prochaska, 1984; Wolberg, 1982). EMERGING TRENDS IN CHILD PSYCHOTHERAPY Over the past two decades cognitive behavior therapy has emerged as the most common form of treatment for both children and adults (Ross, 1980), and that likely reflects social and economic changes that have occurred in American culture. An important influence has been the control of the medical economy as a result of the emergence of managed care companies. Students need to be aware of how economic and cultural developments have affected psychotherapeutic treatment in the past and how such factors will affect them over the course of their future careers. At the present time there is an emphasis on evidence-based treatments, partially due to the influence of data-based and statistically oriented managed care insurance companies, and that has encouraged the popularity of cognitive treatments that are more compatible with quantitative research studies. Also, the economic accountability emphasis of managed care companies has dictated a

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tendency toward short-term, less intensive treatments. Supervisors should discuss these temporal changes with their students, and a good way to do that is to reflect on and describe the changes that have occurred during their careers. This is also a good starting point to ask students to reflect on the present economic changes that they are aware of and what future changes are likely to affect them over the course of their careers. An emerging new area related to treatment that may present problems for supervisors is the role of psychotropic medication with children. Many mature (I prefer mature to older) supervisors began their careers when the use of medication with children was infrequent and handled completely by psychiatrists or pediatricians, and so we have had little experience in this area. However, that is not likely to be the situation with students, many of whom have had a class in pharmacology while still in their graduate programs. Although the prescription privileges of clinical psychologists and other nonmedical therapists are still restricted in most states, the frequent use of many medications with children means that students need to be knowledgeable about their uses, side effects, and contraindications. That means that supervisors need to educate themselves in this area if they are to be helpful to their students. Also, more and more psychologists are in the position of recommending the use of psychotropic medications to physicians, nurse practitioners, and others, even if they are not the individuals writing the actual prescriptions or deciding on the best drug. I suppose that if supervisors want to stay one step ahead of their students, they had better find appropriate online continuing education courses on the use of psychotropic medications. S U P E RV I S I O N F O R T H E F U T U R E Supervision is preparation for the remainder of students’ careers, and although direct psychotherapy instruction is needed in the beginning stages of students’ careers, supervision should encourage students to increasingly generate their own treatment solutions. Most child supervision has a present time orientation focusing on active cases and the skills and techniques relevant to those cases; however, supervisors need to think about how they can start students on developing the more sophisticated and complex skills that may not reach fruition until years after the present supervision is finished. Typically, supervisors direct their students into selecting the best type of treatment for a child, but choosing an appropriate treatment modality is a subtle skill that requires knowledge of treatments and years of experience. Beginning therapists do not have this broad base of experience, however supervisors can orient and direct them into developing this skill. When students are assigned a new case, rather than guiding them into a particular treatment modality supervisors should discuss which treatment approaches would be appropriate, which would be inappropriate, and why. Though this skill is not likely to develop within a typical 11-month year of supervision, supervisors should start students thinking about this issue. An even more complex skill involves the integration and blending of different treatment modalities. Although cognitive-behavioral therapy is currently the most popular treatment, students need to be exposed to many types of treatment alternatives, because problem children are not all the same and there is little reason

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The Supervision of Child Psychotherapy 283 to assume that a one-size-fits-all approach will be useful. Also, children change over time through normal development and therapeutic progress, so a therapeutic approach that was appropriate at one point in time can become inappropriate at a later time. Therapeutic blending has two aspects. The first is the ability to integrate therapeutic techniques at the start of treatment to create the appropriate psychotherapy for a particular child. To do that a therapist needs to be skilled in the many types of treatments in order to know which techniques will fit together, because although many elements will blend harmoniously, some are too different and should not be integrated. Of course, a child therapist can only be competent with those treatments that fit his or her personality and therapeutic style, but supervisors can help the student to learn about therapeutic integration. They can also help a student learn which techniques will fit together for a particular child and which techniques are too different to work well. Most important, they can help a student realize which techniques will fit his or her unique personality and orientation. The heuristic approach to treatment can be helpful in this learning process, as it focuses on the most basic processes underlying child psychotherapy and aids a student in recognizing the similarities and differences among various therapeutic techniques (Leve, 1995). This method brings a child to question his behaviors and thoughts, allowing the child to see if such activities are dysfunctional and selfdefeating. That kind of insight provides the motivation and opportunity for a child to change his or her behaviors. A comprehensive survey of therapy techniques generated by Grencavage and Norcross (1990) identified the many therapeutic elements common to all forms of treatment and can help students understand this complex process. This list and the accompanying explanations provide students with the beginning structure they need to understand this level of therapeutic sophistication. The second aspect of blending refers to changing therapy techniques during the course of treatment to meet the changes in the child due to treatment and normal development. Such blending is difficult and requires therapist sensitivity because the therapist is attempting to change something a child has become accustomed to. For example, a therapist should not go from an approach that emphasizes warmth and empathy to one that is confrontational and demanding. Such a disparate blending of techniques is likely to create serious problems. Also, techniques that require a change in the therapist–child relationship are likely to be problematic, so switching from an approach that provides a good bit of verbal reinforcement and praise to one that has little reinforcement is not likely to work. Obviously, the sequence and timing of any changes in technique are crucial, and treatments should be blended into one another at a rate that is comfortable for the child. This requires a good bit of experience and sensitivity on the part of the therapist. Other issues also must be considered (Leve, 1995), as they are important to the success of any attempts at blending from one treatment to another. CONCLUSION Because child psychotherapy is such a unique and complex enterprise, the supervisor of a new child therapist faces a difficult task. That supervisor must teach

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new and unfamiliar skills that are difficult to master in addition to monitoring the course of treatment and the progress of the student. The constant changes that occur due to normal development and the communication differences between adults and children make child psychotherapy a difficult process to master, as does the fact that the influence of parents must be considered and treated. Other aspects of psychotherapy such as diagnosis and confidentiality also become more complicated, and child psychotherapy students must master these as well. Perhaps the difficulty of the work of a supervisor of child psychotherapy is best understood when one realizes that treatment involves trying to bring positive changes into a complex child–parent situation while the object of treatment, the child, is always changing.

REFERENCES Achenbach, T., & Edelbrock, C. (1978). The classification of child psychopathology: A review and analysis of empirical effects. Psychological Bulletin, 85, 1275–1301. Allen, F. H. (1979). Psychotherapy with children. Lincoln: University of Nebraska Press. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Axline, V. (1947). Play therapy: The inner dynamics of the child. New York: Houghton Mifflin. Brems, C. (2002). A comprehensive guide to child psychotherapy. Long Grove, IL: Waveland Press. Chethik, M. (1989). Techniques of child therapy. New York: Guilford Press. Dodds, J. (1987). A child psychotherapy primer. New York: Human Sciences Press. Freeman, R. (1982). Tried and true: Games for children’s activity therapy groups. College Park: University of Maryland Press. Glencavage, L., & Norcross, J. (1990). What are the commonalities among the therapeutic factors? Professional Psychology: Research and Practice, 21, 372–378. Haworth, M. (1994). Child psychotherapy: Practice and theory. Northvale, NJ: Aronson. Johnson, J., Rasbury, W., & Siegel, L. (1997). Approaches to child treatment. Needham Heights, MA: Allyn & Bacon. Jongsma, A., Peterson, L., & McInnis, W. (1996). The child and adolescent psychotherapy planner. New York: Wiley. Kearney, C. A. (1999). Casebook in child behavior disorders. Belmont, CA: Brooks/Cole. Kessler, J. (1988). Psychopathology of childhood. Englewood Cliffs, NJ: Prentice Hall. Kronenberger, W., & Meyer, R. (1996). The child clinician’s handbook. Needham Heights, MA: Allyn & Bacon. Landreth, G., Homeyer, L., Glover, G., & Sweeney, D. (1996). Play therapy interventions with children’s problems. Northvale, NJ: Aronson. Leve, R. M. (1980). Childhood: The study of development. New York: Random House. Leve, R. M. (1995). Child and adolescent psychotherapy: Process and integration. Needham Heights, MA: Allyn & Bacon. Mash, E., & Barkley, R. (1989). Treatment of childhood disorders. New York: Guilford Press. Morris, R., & Kratochwill, T. (1998). The practice of child therapy. Needham Heights, MA: Allyn & Bacon. Norcross, J. (1986). Eclectic psychotherapy: An introduction and overview. In J. C. Norcross. (Ed.), Handbook of eclectic psychotherapy. New York: Brunner/Mazel. Norcross, J., & Guy, J. (1989). Ten therapists: The process of becoming and being. In W. Dryden & L. Spurling. (Eds.), On becoming a psychotherapist. London: Tavistock/Routledge. Ollendick, T., & Hersen, M. (1993). Handbook of child and adolescent assessment. Needham Heights, MA: Allyn & Bacon. Prochaska, J. (1984). Systems of psychotherapy. Homewood, IL: Dorsey Press. Quay, H., & Werry, J. (1986). Psychopathological disorders of childhood. New York: Wiley. Rapoport, J., & Ismond, D. (1996). DSM-IV training guide for diagnosis of childhood disorders. New York: Brunner/Mazel. Reisman, J. (1973). Principle of psychotherapy with children. New York: Wiley. Ross, A. (1980). Psychological disorders of children: A behavioral approach to theory research and therapy. New York: McGraw-Hill.

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The Supervision of Child Psychotherapy 285 Schaefer, C., & O’Connor, C. (1983). Handbook of play therapy. New York: Wiley. Semrud-Clikeman, M. (1995). Child and adolescent psychotherapy. Needham Heights, MA: Allyn & Bacon. Wicks-Nelson, R., & Israel, A. (1997). Behavior disorders of childhood. Upper Saddle River, NJ: Prentice Hall. Winnicott, D. (1971). Playing and reality. New York: Basic Books. Wolberg, L. (1982). The practice of psychotherapy. New York: Brunner/Mazel.

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C H A P T E R 16

Supervising Psychotherapy with Adolescents KATHRYN D. HESS

SUPERVISION OF psychotherapy with adolescents presents a variety of issues meriting attention. There are more adolescents now than at any other time in history. Almost 1.5 billion people in the world today are between the ages of 10 and 25 years old (United Nations Fund for Population Activities, 2007). In the United States alone there are more that 29 million teenagers (Holtz, 2007), and their numbers are increasing at a rate double that of the total population. The adolescence of today’s 10- to 21-year-old is not the adolescence of the beginning therapist or of the therapist’s supervisors. Although many adults think they know about adolescence because they experienced their own teen years, the world of today’s youth is markedly different. For example, adults today never dealt with cyber-bullying in adolescence. An adolescent’s psychotherapy issues are not the same as those of either younger children or slightly older adults. This chapter focuses on four areas necessary to provide good supervision of therapists of adolescents. First, current definitions of adolescence and the biological, psychological, social, and societal aspects of the various stages of adolescence are presented. Second, concerns or problem areas peculiar to adolescents are discussed. Third, specific issues related to the process of psychotherapy and supervision are examined. Finally, the involvement of third parties and their impact on both psychotherapy and supervision is considered.

PA RT I : D E S C R I B I N G T H E A R E N A DEFINING ADOLESCENCE Adolescence has many definitions. It may be described psychophysiologically or psychosocially. At one time, adolescence was synonymous with the years 13 to 286

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Supervising Psychotherapy with Adolescents 287 19 years of age. As individuals began to mature earlier and to remain financially dependent on their parents later in life, the age range lengthened, so now adolescence is thought of as the period between about the age of 10 to the early 20s (Steinberg, 2002). Development during adolescence can be seen as a series of transitions from immaturity to maturity. Biologically, adolescence begins with the onset of puberty and ends when the individual is fully capable of reproduction. Simultaneous with the biological changes, cognitive changes occur. Individuals at this stage show improvement in considering hypothetical situations and dealing with abstract concepts; they develop the ability to plan ahead, to resolve social dilemmas, and to win arguments. Any parent or teacher will notice the increase in logically reasoned disputes during this phase of development. Another way to view the transitions of adolescence is through social changes, or rites of passage, as adolescents enter and assume new roles such as driving, living independently, managing work, or even marrying. Adolescents may find themselves faced with many different options to evaluate and choose from as they progress toward adulthood. Adolescents’ “normal” psychosocial developments concern a number of areas of change, including the development of identity and self-esteem, an increase in autonomy, changes in intimacy and the resulting formation of interpersonal relationships, burgeoning sexuality, and educational and vocational achievement. Although these five psychosocial areas affect both younger and older individuals, it is during the adolescent period that dramatic development occurs. UNDERSTANDING THE LITERATURE The psychotherapy supervisor tasked with helping the supervisee develop skills for working with adolescents needs to ensure that the supervisee understands the developmental changes and challenges of adolescents. The most current information regarding adolescent development and psychotherapy of adolescents should be discussed with the supervisee. If, for example, the last time either the supervisee or supervisor was exposed to basic information on adolescence was during his or her sophomore year in college or in a first-year graduate school course, he or she might be surprised to learn of the amount of recent research on adolescents. In fact, in recent years there has been an increase in the number of journals devoted to this developmental period, and some of the long-held common beliefs are no longer considered to be true. For example, the adage that all adolescents have stormy relationships with their parents has recently been called into question. According to Steinberg (2002), only about 5% of families that experienced good relationships in childhood have serious problems in adolescence. If a supervisee is under the impression that all 15-year-olds always are rebellious toward their parents, he or she may be prone to underdiagnose parent–adolescent problems. In this example, one of the first tasks of the supervisor might be to assess how current the supervisee’s knowledge of adolescents is and to recommend recent texts and specific journal articles. Classic texts such as Hill (1980) should be supplemented with updated texts (e.g., Kroger, 2007; Papalia, Olds, & Feldman, 2007; Steinberg, 2002) and journals such as Adolescence, Journal of Youth and Adolescence,

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Adolescent Psychiatry, Journal of Child and Adolescent Group Therapy, and Journal of Adolescence. Holmbeck and Updegrove (1995) discussed the clinical-developmental interface. The clinician must know developmental norms, levels, transitions, predictors, and psychopathology. This allows the clinician to more acutely recognize when a client is delayed or advanced in an area and determine if the variation is a source of, or modifies, the problem. Although the primary changes (biological, cognitive, and social) occur first and impact the secondary features (autonomy, identity, sexuality), there is variation in the age at which these changes occur. Notably, the rate of change and the particulars of the family in which these changes occur also vary. Consider, for example, two 14-year-old boys, one of whom has not begun pubertal changes and another who has almost completed puberty. The social lives of these two and how the boys are perceived might be entirely different. The latter may be picked first for team sports, seen as ready for dating, and more likely to obtain the after-school job requiring physical labor. The less developed youth may not be able to compete for these markers because physically he is not at the same level. Similarly, expectations within their families may be different as the boys may or may not be at the same level cognitively and emotionally. Parenthetically, one can see this phenomenon with children when large 5-year-old children have far greater expectations placed on them than smaller, younger-looking age mates. TREATMENT EFFICACY The emotional and cognitive changes of adolescence may affect the efficacy of treatments. Piaget (1972) credited adolescence as the period of formal operational thinking when adult level reasoning first takes place. Adolescents, when they approach the adult level, can think complexly, hypothetically, abstractly, and planfully. This also allows them to disagree with parents’ and teachers’ views and to see the flaws in others’ arguments. This leads to their seeing the flaws in their parents, in organizations, and in the world. It allows them to hypothesize about future careers and relationships. Related to cognitive skills are those of social cognition, the understanding of others and their behaviors, and the development of role-taking and empathy skills. Rites of passage affect adolescents’ social redefinition during these years. Being allowed to work, drive, or vote or being subject to a juvenile or adult court system all occur during adolescence and may be occasions for the development of conflicts. Changes in family relationships transform both adolescents and their families. Older adolescents may be expected to transport younger siblings to their activities during what they believe should be their social time. Therapists should be aware that such transformations occur and that some normative intrafamily problems may arise because of the difficulty in managing this transition (Holmbeck & Updegrove, 1995). Therapists also need to evaluate whether intrafamily problems are continuations of problems that arose in early or middle childhood. Family therapy (see Chapter 11) can be useful in resolving problems of transition into adolescence. Peer relationships in adolescence are also the result of successfully

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Supervising Psychotherapy with Adolescents 289 passing through a series of developmental stages (Erikson, 1968; Piaget, 1972; Sullivan, 1953). Sullivan felt that chumships, or child–child relationships, are a critical accomplishment of early adolescence, forming a template for later close relationships. Therefore, therapists will want to encourage such relationships in early adolescents if they are lacking, either through increasing extracurricular activities, participating in sports or social and academic clubs, or being included in group therapy with peers. The development of identity is a major psychological task of adolescence. Identity is developed through role expectations, commitments, and accomplishment (and coping with failure) across a variety of venues: academic, religious, interpersonal, sexual, and occupational. Although the belief that all adolescents experience an identity crisis seems to be a myth, identity formation is an important task (Harter, 1999). An adolescent’s career decisions have lasting impact, so one who has developed the cognitive skills to make best use of the decision points (e.g., course selection, whether to stay in school or drop out, employment) has an advantage in later adolescence. Sexual maturity is often a problem for both the adolescent and parents (Katchadourian, 1990). Because the therapist may often be called on to educate and to mediate, he or she must be aware of his or her own conflicts and values regarding sexual issues and be clear, direct, and thorough in educative efforts. The therapist should also have knowledge of the physical and hormonal changes that the adolescent will experience at different stages of his or her development. Friendships become more emotionally charged as adolescence progresses and the individual is able to form more intimate relationships. These relationships are characterized by mutual trust, self-disclosure, and a sense of loyalty and helpfulness. An adolescent develops friendships with opposite- as well as same-sex peers. As social cognitions change, so do friendship patterns, with the friendships becoming more mature, complex, and intimate. These changes may benefit therapeutic relationships. Peer relationships may facilitate change by being available for support and for the adolescent to try out therapy suggestions. For example, if Alex, a shy 14-year-old, rehearses meeting peers in therapy, supportive peers will provide reinforcing experiences for Alex. Autonomy, a multidimensional concept, comes to the forefront during adolescent development. Autonomy may be emotional (e.g., the ability to relinquish dependencies on the parents; Fuhrman & Holmbeck, 1995) or behavioral (e.g., the ability to make one’s own decisions with less influence from either parents or peers). As adolescents become autonomous they contrast their idealizations of their parents with the realities of their parents to see them as people and to be less dependent on them for immediate emotional support. Being behaviorally autonomous does not mean that adolescents never ask anyone else for help in making a decision, but instead that they are better able to recognize when they can make the decision on their own and when they would benefit from input from a peer or parent. Because one of the tasks of adolescence is learning to gain increasing levels of autonomy without losing the attachment to parents, it seems that over the course of adolescence the relationship between parent and child changes from one

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of unilateral authority to one of mutuality and cooperation (Allen, Hauser, Bell, & O’Connor, 1994; Kroger, 2007). The following case illustrates these factors.

Case 16.1 Cindy, an attractive 14-year-old girl, had been referred to a community mental health clinic for assessment and psychotherapy. Cindy was being seen by an advanced student who was doing her practicum at the clinic. At 14, Cindy was 5’6” tall, slim, but appeared well through puberty. She was at grade level in school, however her grades had recently begun dropping to C’s and D’s. Cindy was having difficulty relating to others her own age and had stopped communicating with the male head of household, a nonparental relative. If her grades continued to drop, her participation in track, the extracurricular activity that she enjoyed and at which she excelled, was in jeopardy. History revealed that Cindy and her siblings had been removed from her parents at the age of 6 due to the incarceration of her father and the drug and alcohol abuse of her mother. The siblings occasionally saw one another but were all living with extended family members over a three-state area. Cindy had seldom lived in one place more than 6 months at a time due to family stressors in the custodial families. A birth of a child, loss of a job, or illness would result in Cindy moving to live with another aunt, cousin, or grandmother. Her current custodial parents had told her that she would always have a home with them, but she was often sent to another cousin for weeks at a time to help with child care. Her father was now out of prison and sporadically visited, but neither parent was seen by the State as a possible caregiver. The student therapist found Cindy to be compliant but not forthcoming. She responded to direct questions but volunteered little elaboration. One day, due to an emergency at the clinic, Cindy’s therapist’s usual therapy room was not available, and the only open office was the play therapy room, a serendipitous event. Cindy gravitated to the play house and then the sand tray and began discussing her interfamily concerns with “villages” in the sand tray. She expressed through play her fears of not knowing where or when she would be sent to a different relative and her lack of input into the decision or knowledge of what, if any, of her behaviors contributed to the decision. Although intellectually 14 years old and biologically 14 years old, Cindy was in many ways still the 6-year-old abandoned child. Cindy’s attachment needs, unmet in childhood, were still a problem for her in adolescence. Her current custodial parents were both fearful of her developing sexuality and the possibility that she might become pregnant, and desirous of her successfully completing high school and going to college. Any concerns that Cindy had regarding her physical development tended to be met with either denial or “must nots” by her caregivers. At the suggestion of the supervisor, the therapist continued to see Cindy in the play room for some time. Cindy continued to form a relationship with the therapist, albeit a somewhat tenuous one given her history of instability in living arrangements. It seemed Cindy was never sure when or if she would be going to stay with another relative in another state. The therapist was able to assess Cindy’s interest in developing friendships with boys and to help her develop academic vocational plans. Cindy’s grades improved, pleasing the custodians, and she won a poetry contest, increasing her status in school. She continued in track and did well. The therapist consulted with the custodians regarding age-typical behavior, keeping in mind Cindy was not emotionally functioning at a 14-year-old level. Given the fact Cindy’s custodial parents had been adolescents several decades earlier, it is quite definite that their adolescence and Cindy’s differed in many ways. With the support of the therapist, her caregivers were able to take these generational differences into account and work to increase Cindy’s feelings of security.

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Supervising Psychotherapy with Adolescents 291 PA RT I I : A R E A S O F A D O L E S C E N T C O N C E R N Anyone working with adolescents must have a good sense of the issues faced by contemporary youth. Many patterns of unhealthy behavior originate during the adolescent years. It is a time when one quarter of U.S. high school students report binge drinking, one half report drug experimentation, and pathological gambling begins. Car accidents are the leading cause of death among adolescents, and one half of the newly reported cases of sexually transmitted diseases and HIV infections are found in adolescents (Reyna & Farley, 2006). Clearly, the dangers of contemporary adolescence are much graver and more lethal than those of adolescents’ parents and probably their therapists, and quite unlike those of therapists’ supervisors. Similar to the adage regarding stormy parental relationships, research in the past decade (Reyna & Farley, 2006, p. 34) has found that contrary to conventional wisdom adolescents do not perceive themselves to be invulnerable and that perceived invulnerability declines with age. Although many current interventions aim to enhance the accuracy of risk perceptions, adolescents generally overestimate the important risks such as HIV or lung cancer. One implication of these findings is that traditional interventions stressing increasing accurate risk perceptions may backfire or be ineffective because adolescents already overestimate their risk. Reyna and Farley (2006, p. 36) developed a list of empirically supported recommendations for decreasing risky behavior. It would benefit therapists of adolescents and their supervisors to discuss this list when developing treatments. The recommendations include reducing risk by retaining or implementing higher drinking ages, lowering the number of peers in cars of younger drivers, and avoiding exposure to potentially addictive substances. Researchers should also develop psychometric instruments to determine which individuals make decisions on the basis of perceived risks and benefits and which react to environmental triggers (suggestions of peers, availability of alcohol). Supervisors may also help supervisees develop treatments that provide frequent reminders of the relevant knowledge and risk avoidant values in a variety of presentations and allow adolescents to practice recognizing cues in the environment that signal possible danger before it is too late to act. RISKY BEHAVIORS Suicide Suicide is the third leading cause of death among adolescents, accounting for a greater number of deaths in 15- to 24-year-olds than the next seven causes combined (Centers for Disease Control and Prevention, 2006). The Centers for Disease Control and Prevention reports that about 1 in 5 adolescents in high school made a suicide attempt in 2005. There are major differences between ethnic groups in the rates and contexts of adolescent suicide attempts. For example, the rate of suicide deaths differs by a factor of 20 between the lowest risk group (African American girls) and the highest risk group (American Indian/Alaska Native boys; Goldston et al., 2008). Supervisors and their supervisees need to know cultural or ethnic group

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norms and triggers, and youths’ proclivity or resistance for asking for help. For some cultural groups, such as Asian Americans, the shame of loss of face for not meeting family expectations may lead to suicidal thoughts or behaviors. For other groups, lack of information regarding availability of services (recent immigrants) or a belief that their group is not at risk for suicidality (African Americans) or that such problems should be dealt with by family or church (recent Latino and Asian immigrants) reduces the chance that adolescents will seek help. An awareness of the cultural norms and expectations of the adolescents’ group must be considered by therapists and supervisors when planning treatment and assessing suicidality. Self-Mutilation Self-harming behaviors were considered a form of suicide or parasuicide for many years, however recent theory conceptualizes them as a method of averting suicide. Self-mutilative behavior refers to the direct and deliberate destruction of one’s own body tissues without conscious suicidal intent (Bolognini, Plancherel, Laget, Stephan, & Halfon, 2003). Adolescents have high rates of self-mutilative behavior, with rates of 14% to 39% in community populations and rates of 40% to 61% in clinical populations. Nock and Prinstein (2005) reviewed the theoretical models and noted that these behaviors may be performed to define boundaries, to reduce tension, or to communicate with others. Whereas some self-mutilating behaviors are culturally sanctioned—such as rituals that serve to mark the passage from one stage of life to another, gang or social group markers, or ear- and nose piercing—others fall into the category of deviant pathological self-mutilation. Four characteristics stand out in the current definitions self-mutilating behaviors: (1) deliberateness, (2) tissue damage without intent to die, (3) social unacceptability, and (4) typical repetitiveness (Messer & Fremouw, 2008). The typical self-mutilator is female, adolescent or young adult, single, intelligent, from a middle- to upper middle-class socioeconomic background, and cuts her wrists or arms (Messer & Fremouw, 2008). Among adolescents, cutting is the most common behavior. Selfhitting; pinching; scratching; biting; sticking pins, needles, or staples into the skin; or burning with cigarettes are also common. Discussions of the etiology of these behaviors in adolescents needs to be pursued in supervision in order to guide the treatment. Disordered Eating Disordered eating is another area that receives increasing media attention and occurs at a time of dramatic changes in physical appearance. Disordered eating refers to a pattern of behaviors and attitudes about eating that are unhealthy and can range from a preoccupation with weight and body image to the more severe pathologies of anorexia nervosa and bulimia. Although the incidence rates are not high, supervision can help therapists assess the possible symptoms that may mask these disorders. Steinberg (2002) noted that national surveys have found that nearly 20% of adolescents in the United States are overweight and 5% are obese, whereas 3% are bulimic and less than 1% are anorexic. Anorexia and bulimia are more prevalent in girls than boys and are rarely seen before puberty. Although the prevalence of anorexia and bulimia is low, nearly 70% of girls and 33% of boys in one study wished to be thinner, and such dissatisfaction with one’s body

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Supervising Psychotherapy with Adolescents 293 leads to eating problems (Paxton et al., 1991). Society does not help adolescents when members of sports teams such as football linemen are expected to gain large amounts of weight and gymnasts and wrestlers are expected to deny themselves food for weeks and months during competition seasons. PA RT I I I : T E C H N I C A L C O N S I D E R AT I O N S I N S U P E RV I S I O N As noted, psychotherapy with adolescents is slightly different from psychotherapy with younger children or older young adults. This section considers the management of adolescent psychotherapy with particular reference to the contributions of supervision. Supervision may begin in one of several ways. The instigation may be as a result of a state of emergency when the adolescent, parent, therapist, administrator, or a combination of the four calls for the supervisor’s help. The supervisor’s first question may be the following: Who is the client? If the supervisor accepts the supervision at the request of the therapist, then the main client is the supervisee, and generally the supervisor provides a collegial peer model of supervision. If the supervision is part of an ongoing practicum, the supervisor may work with the supervisee from the beginning of the case. In this situation the supervisor may help prepare the supervisee for the case, help in the selection of an appropriate beginning case, and help answer any doubts that the supervisee may have. Discussions that may occur in the first supervisory session may be of possible problems, such as the following: What if the parent wants to sit in on the session? What if the parent brings in an adolescent who refuses to talk? How can I distinguish this reticence from the beginnings of a schizophrenic withdrawal? Will I be likely to hurt the client in the first session? As noted earlier, one of the primary tasks of the supervisor is to assess the knowledge base of the supervisee and provide suggested readings, notice of workshop opportunities, or additional training. Roberts, Lazicki-Puddy, Puddy, and Johnson (2003) discussed the effectiveness of types of therapies for a variety of problem areas. Currently there are a large number of good texts on doing psychotherapy with adolescents that might well serve the supervisee (Dishion & Kavanagh, 2003; Leve, 1995; Mufson, Dorta, Moreau, & Weissman, 2004). An adolescent can be quite pointed in his or her questioning. The uncertainty about what therapy is can provoke direct questions of the therapist, including direct personal questions. Several therapists suggest answering them within reasonable limits, demonstrating some self-disclosure and openness (Holmes, 1964; Lynch, 1974; Schoenfeld, 1969). Depending on location, specific questions may arise: “Did I see you at the riverfront concert?” “Who was the little curly-haired girl I saw you with at the soccer game last Wednesday?” “Are you married?” “How many children do you have?” “Are you seeing me only because I was assigned to you?” Evasiveness on the part of the therapist is a poor role model, can dampen the therapeutic atmosphere, and fails to make use of the client’s involvement. Supervisor and supervisee might assess the function of self-disclosure. The client’s feelings of being acknowledged as a person worthy of self-revelation and engagement are useful. If the questions serve a defensive function, the disclosure may disarm the anxiety stimulating the defense. Later, when a foundation of trust is established, the adolescent may tolerate encountering the defense such as “You seem to want

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to talk about me,” or when enough data are gathered for an interpretation the therapist might respond “Might you be wondering if I am interested in you?” How the supervisee uses the adolescent’s personal questions can be discussed in supervision. The error of using the disclosure to be a good guy or a friend without regard for the therapeutic strategy is unsound and would benefit from supervisory review. Even more of an error is the therapist who takes the questioning as an opportunity to begin a self-centered account of his or her children’s success on the soccer field or his or her role as assistant coach. An adolescent’s tendency to issue ultimatums will also show itself in therapy. Statements such as “I’m here, but you can’t make me talk,” “If you agree with my Mom’s curfew, I won’t take the advanced placement test,” or “I can hook up with anyone I want and nobody can do anything about it” can be difficult to encounter and are grist for the supervision session. Is there an element of moralizing or parroting parents’ rules in the therapist’s statements? And, could the adolescent be responding to similar rules or restraints in his or her environment? One might also deal with the intensity of the statement. For example: “When you issue an ultimatum like that, you leave little room for discussion,” or “I suppose that you feel that you have no room either when people lay down the rules.” When an ultimatum is challenged, the teen may be obliged to act out. Often an adolescent is brought to therapy because the parents have run out of solutions and present the therapist to the adolescent either explicitly or implicitly as someone who is going to “fix” him or her. The therapist and supervisor need to determine how the therapy will be presented to the client and how to deal with confidentiality issues in the first session. Similarly, any necessary limits that the therapist sets need to be a subject of supervision. Both the therapist’s failure to intervene and the therapist’s setting of limits are likely to tap conflicts that the therapist brings to the therapy. Reviewing in supervision the setting of limits will be useful in helping the supervisee determine other issues that might need to be explored with the adolescent. Manipulation and argumentation are two other forms of acting out that the therapist of an adolescent will need to address in supervision. The therapist may feel he or she is making a good bargain by interceding with a parent to let a client stay after school to study in the library only to find later (often directly from the adolescent) that the student was nowhere near the library, not studying after school, nor did his grades improve. The task of the supervision will be to process the supervisee’s reactions to being defeated by the manipulation. An adolescent can sometimes helpfully manipulate his or her parents in the cause of therapy, as seen in the following vignette.

Case 16.2 Jennifer, a 16-year-old who had not been attending school for the past 4 years, had along history of family dysfunction and appeared in need of separation from her family in order to learn to function as an adolescent. Jennifer had made several superficial suicidal acts during the past 7 years, each of which resulted in her receiving outpatient counseling and then being removed when the therapist recommended a return to school or when Jennifer began showing independent behaviors. On the current occasion she had been referred for an overdose consisting of six aspirin, two

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multipurpose vitamins, and three cold tablets. When the therapist began discussing residential placement, the client’s parents began crying and Jennifer loudly began insisting that she really would succeed in killing herself if she were to go anywhere but home. The therapist reported that she felt that Jennifer had less chance to do that in the residential setting than at home but that the decision would be left up to Jennifer and her parents (as legally the therapist could not force her to enter the residential program). Jennifer quickly took control of the situation and not only convinced her parents that it would indeed be too dangerous for her to stay at home and that they should file for commitment for her, but also explained her need for hospitalization to the judge at the time of her commitment hearing.

GROUP THERAPY Often adolescents are better served by group psychotherapy than individual longterm therapy. Peer support and pressure can result in greater change possibilities than individual therapy. The supervisor and therapist need to consider a variety of issues such as size and composition of the group; age, sex, and psychopathology of the participants; and the way in which new members are added. Adolescents in group therapy may feel more comfortable with peers as opposed to in a one-onone session facing an adult and being expected to maintain a conversation for 50 minutes on their own. The presence of peers allows for more experimentation by the adolescents. It allows them to learn vicariously what they are not ready to try experientially. Often learning that one is not alone in having conflict with or neglect from parents, difficulty with peers in school, or concerns in a particular area can be reparative. The therapist and supervisor can see behaviors that they had only heard about from third-party sources as well as have continued opportunity for ongoing assessment of how the client is relating to peers. Leader (1991) provided suggestions for therapists and supervisors developing groups.

PA RT I V: T H I R D - PA RT Y R E L AT I O N S H I P S , C O N F I D E N T I A L I T Y, A N D C O N S E N T T O T R E AT M E N T Third parties are often involved in the treatment of adolescents. The younger or more pathological the adolescent, the more intense the parental involvement. This provides one more layer of discussion and interpretation for the supervisory session. The therapist may be dealing with resistance on the part of not only the client but also his parents, and thus the use the supervision to focus on the interrelationships between the adolescent, his parents, and the therapist is crucial. Positive relationships between parents and therapists predict successful completion of an adolescent’s therapy (Robbins et al., 2006). The issue of confidentiality becomes critical with third parties and the treatment of adolescents (Fischer & Sorenson, 1995; Koocher, 2003). Supervisors are well advised to discuss with the therapist what he or she will tell an adolescent and his or her parents about confidentiality. Perhaps they will want to review the appropriate section of the American Psychological Association (2002) Code of Ethics regarding the limits of third-party involvement and confidentiality. The supervisee might want to rehearse in supervision what he or she plans to tell the adolescent and

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his or her parents about the parameters of treatment. What information will be revealed and under what circumstances? Who, such as insurers or school systems, may receive released information regarding the treatment? What information will the parent receive? Will secrets be maintained, or at least kept until the adolescent determines how he or she wants to share them? Often it is useful to provide clear explanations regarding these issues to the adolescent and parent jointly prior to beginning treatment. Depending on age, adolescents have varying degrees of say in their treatment. They can enter treatment voluntarily or through the authority of their parents or an agency such as the court or department of child welfare. Although minors under the age of 18 are generally not considered legally competent and thus are unable to consent to treatment in many states and provinces in North America without the consent, either expressed or implied, of their parents (Hesson, Bakal, & Dobson, 1993; Parekh, 2007; Slovenko, 2006), there is a great variability by state in the ages of consent for specific issues (e.g., drug treatment or use of birth control). Many states are currently evaluating their laws regarding the ages at which adolescents may assume responsibility for treatment; thus, the supervisor and supervisee must be aware of local statutes. For example, in Alabama Health Insurance Portability and Accountability Act forms can be completed without parental co-signatures at age 14 for general medical treatment. In some states the laws take into consideration the advice of mental health professionals on the individual determination of the right to consent (and conversely the right to refuse) treatment, whereas other states base their laws solely on those of neighboring states or prior case law (Weisleder, 2007). Stanley and Galietta (2006) reviewed research showing that children as young as 9 years old reach treatment decisions in much the same way as adults and by the age of 14 understand the consent forms as well as adults and are able to make informed birth control and pregnancy decisions. Situations may occur in which the parents must be involved in order to help make arrangements for an appropriate treatment modality or arrange for payment. Although there is little legal clarification, most professionals are unwilling to force treatment upon a nondangerous adolescent who, following evaluation, chooses not to cooperate in treatment. Similarly, many professionals are reluctant to treat adolescents without parental knowledge or consent. Hesson et al. (1993) noted that this may be because the professionals feel that parental involvement is optimal in adolescents’ treatment and suggested that therapists explore with adolescents the potential advantages of involving their parents. They noted, however, that if mature teens continue to resist parental involvement, the rights of the adolescents override those of the parents. Though it is not an ethical issue, parental payment for services may be more likely if there is parental consent and involvement. When considering the rights of the adolescent to confidentiality, the supervisee may have difficulty providing the parents with sufficient information to satisfy them without breaking the confidentiality of the adolescent. One mother called following each session to ascertain the time of the next session—and to inquire if Josh had remembered to discuss X, Y, and Z. Supervision explored the strategic handling of this, including the possibility of a session with the parents to explore their needs and to continue to inform them of the nature of the confidentiality with Josh and of the therapist’s working style.

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Supervising Psychotherapy with Adolescents 297 PA RT V: C O N C L U S I O N Adolescence is special for several reasons. The stresses and strains of the adolescent may resonate with stresses and strains in the parents’ lives when they were teens. The adolescent’s problems are cumulative, so problems in childhood may not provide a firm foundation for adolescence. The best of all worlds is to have a stable parent so the adolescent can experiment in life and know that he or she can return to a stable base of support. When psychotherapists are involved, they become a base of stability. And many of them, fraught with their own histories, rely on supervision to sort out any resonances with their own sensitivities. Concordance between these layers provides the basis for both transference distortions and empathic understanding. The most important part of adolescent psychotherapy is to enjoy it; to have fun; to enable growth in the psychotherapist, the parents, and the adolescent. If a therapist is in tune with these issues, plenty of opportunities to share the joys of adolescence will become clear. In fact, there is no more enjoyable and meaningful group I have worked with than adolescents—and their psychotherapists. These therapeutic triumphs reverberate through generations—of happier teens, more able parents, skilled psychotherapists, and generative supervisors. REFERENCES Allen, J., Hauser, S., Bell, K., & O’Connor, T. (1994). Longitudinal assessment of autonomy and relatedness in adolescent-family interaction as predictors of adolescent ego development and self esteem. Child Development, 65, 179–194. American Psychological Association. (2002). Ethical principles of psychologists and code of conduct. American Psychologist, 57, 1060–1073. Bolognini, M., Plancherel, B., Laget, J., Stephan, P., & Halfon, O. (2003). Adolescents’ self-mutilation relationship with dependent behavior. Swiss Journal of Psychology, 62 (4), 241–249. Centers for Disease Control and Prevention. (2006, June 9). Youth risk behavior surveillance: United States, 2005. Morbidity and Mortality Weekly Report: Surveillance Report, 55, 1–108. Dishion, T. J., & Kavanagh, K. (2003). Intervening in adolescent problem behavior: A family centered approach. New York: Guilford Press. Erikson, E. (1968). Identity youth and crisis. New York: Norton. Fischer, L., & Sorenson, G. P. (1995). School law for counselors, psychologists, and social workers (3rd ed.). White Plains, NY: Longman. Fuhrman, T., & Holmbeck, G. N. (1995). A contextual analysis of emotional autonomy and adjustment in adolescence. Child Development, 66, 793–811. Goldston, D. B., Molock, S. D., Witbeck, L. B., Murakami, J. L., Zayas, L. H., & Nagayama Hall, G. C. (2008). Cultural considerations in adolescent suicide prevention and psychosocial treatment. American Psychologist, 63 (1), 14–31. Harter, S. (1999). The construction of self. New York: Guilford Press. Hesson, K., Bakal, D., & Dobson, K. S. (1993). Legal and ethical issues concerning children’s rights of consent. Canadian Psychology, 34, 317–328. Hill, J. P. (1980). Understanding early adolescence: A framework. Carrboro, NC: Center for Early Adolescence. Holmbeck, G. N., & Updegrove, A. L. (1995). Clinical developmental interface: Implications of developmental research for adolescent psychotherapy. Psychotherapy, 32 (1), 16–33. Holmes, D. J. (1964). The adolescent in psychotherapy. Boston: Little, Brown. Holtz, R. L. (2007, November 30). Teenage brains seem set for recklessness, yet tend to avoid risk. Wall Street Journal, pp. B1, C1. Katchadourian, H. (1990). Sexuality. In S. Feldman & G. Elliott (Eds.), At the threshold: the developing adolescent (pp. 330–351). Cambridge, MA: Harvard University Press. Koocher, G. P. (2003). Ethical issues in psychotherapy with adolescents. Journal of Clinical Psychology, 59, 1247–1256.

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Kroger, J. (2007). Identity development: Adolescence through adulthood (2nd ed.). Thousand Oaks, CA: Sage. Leader, E. (1991). Why adolescent group therapy? Journal of Child and Adolescent Group Therapy, 1 (2), 81–93. Leve, R. M. (1995). Child and adolescent psychotherapy: Process and integration. Needham, MA: Allyn & Bacon. Lynch, C. (1974). Psychotherapy with adolescents: Some suggestions. Family Therapy, 1 (10), 98–104. Messer, J. M., & Fremouw, W. J. (2008). A critical review of explanatory models for self-mutilating behaviors in adolescents. Clinical Psychology Review, 28, 162–178. Mufson, L., Dorta, K. P., Moreau, D., & Weissman, M. M. (2004). Interpersonal psychotherapy for depressed adolescents. New York: Guilford Press. Nock, M. K., & Prinstein, M. J. (2005). Contextual features and behavior functions of self-mutilation among adolescents. Journal of Abnormal Psychology, 114, 140–146. Papalia, D. E., Olds, S. W., & Feldman, R. D. (2007). Human development (10th ed.). New York: McGrawHill. Parekh, S. A. (2007). Child consent and the law: An insight and discussion into the law relating to consent and competence. Child Care, Health, and Development, 33 (1), 78–82. Paxton, S., Wertheim, E., Gibbons, K., Szmukler, G., Hillier, L., & Petrovich, J. (1991). Body image satisfaction, dieting habits and weight loss behaviors in adolescent girls and boys. Journal of Youth and Adolescence, 20, 361–380. Piaget, J. (1972). Intellectual evolution from adolescence to adulthood. Human Development, 15, 1–12. Reyna, V. F., & Farley, F. (2006). Risk and rationality in adolescent decision making. Psychological Science in the Public Interest, 7 (1), 1–44. Robbins, M. S., Liddle, H. A., Turner, C. W., Dakof, G. A., Alexander, J. P., & Kogan, S. M. (2006). Adolescent and parent therapeutic alliance as predictors of dropout in multidimensional family therapy. Journal of Family Psychology, 20 (9), 108–116. Roberts, M. C., Lazicki-Puddy, T. A., Puddy, R. W., & Johnson, R. J. (2003). The outcomes of psychotherapy with adolescents: A practitioner-friendly research review. Journal of Clinical Psychology, 59, 1177–1191. Schoenfeld, W. A. (1969). Trends in adolescent psychiatry. Current Psychiatric Therapies, 9, 52–62. Slovenko, R. (2006). Civil competency. In I. B. Weiner & A. K. Hess (Eds.), The handbook of forensic psychology (3rd ed., pp. 190–210). Hoboken, NJ: Wiley. Stanley, B., & Galietta, M. (2006). Informed consent in treatment and research. In I. B. Weiner & A. K. Hess (Eds.), The handbook of forensic psychology (3rd ed., pp. 211–239). Hoboken, NJ: Wiley. Steinberg, L. (2002). Adolescence. New York: McGraw-Hill. Sullivan, H. S. (1953). The interpersonal theory of psychiatry. New York: Norton. United Nations Fund for Population Activities. (2007). Framework for action on adolescents and youth opening doors with young people: 4 keys. Retrieved December 20, 2007, from www.unfpa.org/upload/libpub-file/filename-adolescent.pdf. Weisleder, P. (2007). Inconsistency among American states on the age at which minors can consent to substance abuse treatment. Journal of the American Academy of Psychiatry and the Law, 35, 317–322.

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C H A P T E R 17

Supervising Novice Geropsychologists NORMAN ABELES and MARK ETTENHOFER

DISCUSSIONS CONCERNING psychotherapy and intervention often emphasize the importance of evidence-based treatment. Barlow (2005) suggested that psychologists should differentiate between psychological treatments (interventions) designed to ameliorate pathological conditions in contrast to more generic treatments that deal with problems of living that fall under the general rubric of psychotherapy. This is a particularly relevant issue for work with older adults. For example, is treatment for urinary incontinence, aggressive behavior, and wandering (conditions common in nursing home residents) within the purview of psychotherapy, or is it included as part of psychological intervention even though third-party payers often do not reimburse treatment for these conditions? In a similar vein, does the establishment of friendships and social contacts for patients with mild dementia constitute psychological treatment, or does this fall under the more generic psychotherapeutic intervention with minimal focus on evidence-based treatments? Does this have implications for supervision? For one thing, this reduces the number of trainees who are likely to work in nursing homes simply because there are not sufficient numbers of psychologists able or willing to supervise them. More important, however, many nursing home administrators do not see a great need for services by psychologists. Mental health care is most often provided by social workers, and assessments are provided by the nursing staff and by physicians or psychiatrists who are on call. Families of nursing home residents are only rarely willing to pay for contractual services and may be more concerned with medication reviews rather than with psychosocial interventions or psychotherapy. Nursing homes are usually quite willing to accept volunteer help, though this is usually under the supervision of activity directors. For individuals with serious mental health problems, medical and psychiatric personnel are most likely to be utilized. 299

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The shortage of professionals in clinical geropsychology is an acute and critical problem, as Hudson (2003) discussed in Emerging Crisis: The Geriatric Care Workforce. The report noted that the prevalence rate for psychiatric disorders in the elderly is about 13%, excluding dementia. This implies that there are about 4.5 million people older than 65 in the United States today. However, population projections suggest that by the year 2030 there will be twice as many people older than 65, so there will be 9 million older adults with mental illness. Reasons for this increase may be a function of lower mortality from mental illnesses in younger people because of more successful treatments. However, prevalence rates of mental illness and substance abuse seem to be higher among the baby-boomer generation. The current mental health system ensures undertreatment (Shea, 2003), especially in the absence of prescription drug coverage. Furthermore, we as a nation have come to depend on nursing homes and jails to take care of older adults with mental illnesses. It should be noted also that the suicide rate of older adults (those older than 75) is the highest of any group. Fewer than 1% of all psychologists can be considered to be geropsychologists, even though it is estimated that there are close to 80,000 clinically trained psychologists in this country. Some estimate that there ought to be a minimum of 10.2 geropsychologists per 100,000 older adults. This would suggest a need for more than 3,500 psychologists compared to the 200 to 700 qualified geropsychologists practicing today. However, there appears to be a trend toward fewer trainees in psychology. As Shea (2003, p. 10) pointed out, the number of students studying psychology has dropped by 20% since 1995. Furthermore, only about 30% of accredited psychology programs offer elective courses in aging, and only 10% offer an aging emphasis to doctoral students. The Guidelines for Psychological Practice with Older Adults (American Psychological Association [APA], 2003) point out that few psychologists have received specialized training in working with older adults and see psychotherapy with older adults as simply an extension of their work with adults in general. According to the Guidelines, fewer than 20% of psychologists surveyed have had any practicum or internship training in working with older adults (p. 5). Formal recognition of clinical geropsychology as a specialty is still some time in the future, although the APA Council of Representatives recognized clinical geropsychology as a proficiency in 1998. Proficiency is viewed generally as a step toward eventual recognition as a specialty. The Guidelines also support the contention that some problems of older adults are the same as or similar to those of younger adults, and the general skills obtained by professionals working with younger adults may be suitable for those working with older adults. There is some evidence that students might be attracted to the field if there were more academic courses available to them. Others have argued that early positive experiences with grandparents make a difference, though at least one study has disputed this (Haley & Gatz, 1995). Some have observed that early volunteer and work experiences may contribute to interest in working with older adults. In addition, practicum experiences certainly provide an opportunity for students to become directly involved. At Michigan State University, for example, all of the practicum students in our program are required to complete at least one child assessment, an aging assessment, and a learning disability assessment as part of their practicum every year. The aging assessments take place at a state veterans’ home, and mentoring is by advanced students (under supervision) who are familiar

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Supervising Novice Geropsychologists 301 with neuropsychological as well as aging assessments. This provides exposure to working with older adults, and students interested in further assessment work with older adults complete a cognate of four to five additional courses as part of their doctoral program in clinical psychology and elect to see more older adults for psychotherapeutic interventions. It should be noted that although the topic of this chapter is dedicated to psychotherapy supervision as contrasted to more holistic interventions such as diet compliance, weight management, or family services, assessment is inextricably intertwined with psychotherapy interventions. It is for this reason that we later comment about assessment supervision for older adults. Still another factor that impacts psychotherapy with older adults is what some have labeled the industrialization of mental health care (Norcross & Knight, 2000). Often access to treatment is restricted, the amount of psychotherapy is limited, and providers are master’s- or bachelor’s-level therapists because they cost less. Referrals are often channeled only through primary care physicians, and patients may not have a choice with regard to providers and treatments (Norcross & Knight, 2000, p. 260). Conditions set by managed care organizations certainly impact services, and in the public sector the provision of mental health services certainly influences the supervision of treatments for older adults. In the following sections we cover some specific topics related to supervision, address clinical supervision as a primary training mode, and then consider theoretical and research underpinnings related to supervision training in geropsychology. Extensive prior discussion of psychotherapy supervision can also be found in Hess’s (1980) book as well as in Watkins’s (1997) handbook on this topic. Specific topics addressed in this chapter include age, multicultural issues, medications, and physical disability (both for outpatients and for nursing home residents). Following those we address supervisory issues in psychotherapy and assessment. AGE Age is the preeminent feature of geropsychology. Thus, a case vignette is helpful in providing supervisees material for discussion.

Case 17.1 Assume a psychology trainee is working as an intern in the gerontology section of a large hospital. His task is to become familiar with the concerns and problems of older adults and to become more effective in performing various treatment modalities. One patient who suffers from numerous physical concerns and who is taking a number of medications confides in the trainee that he has an agreement with his physician to let up on medications so that the patient can die a natural death in order not to be an excessive burden on his family. The patient insists that the trainee not discuss this with his physician. The trainee discusses this with his supervisor, who believes that individuals have the right to make these decisions about themselves and suggests he accept the patient’s statement as part of the therapy and deal with the feelings involved. In checking the medical records the trainee finds out that, indeed, the medications administered have decreased over the past week.

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The usual question to the supervisee is what should the trainee do now? Obviously there are many issues to consider in addition to age. Among the many topics raised are the issue of confidentiality, the relationship between the trainee’s supervisor and the trainee, the issue of the medications, the cognitive and affective status of the patient, and the all-important topic of the right to die. Occasionally someone asks about the age of the patient. Is the overarching issue how old the patient is, or does the patient’s infirmity or being a burden to the family take precedence in trying to make a helpful decision regarding this patient? With regard to age, how old is old? Is it young-old (age 65–75), older old (age 75–85) or oldest old (age 85 and older), as researchers tend to classify older adults (Abeles et al., 1998)? This topic blends into ageism, which has been defined by Robert Butler as systematic stereotyping and discrimination based on age (Daniel, Roysircar, Abeles, & Boyd, 2004). Should one treat patients differently because of their age? One misperception held by many individuals is that the health-care system provides special heroic and exceptionally aggressive treatment at the end of life. The Alliance for Aging Research (1997) labeled this as a myth and pointed out that there is a negative relationship between receipt of aggressive care and age for individuals who are thought to be dying. In fact, when compared to younger individuals, do-not-resuscitate orders are more frequently written for patients older than 75 independent of their prognosis (p. 4). No wonder the supervisee is uncertain about what to do, though the supervisor shows no confusion. Perhaps the supervisee suspects some collusion between the physician and the patient. CONFIDENTIALITY Now what about confidentiality? What does the supervisee do about that? Most clinicians who work in hospitals expect chart notes to indicate what is going on with a patient regarding treatment. Is there not a team approach, in which all relevant information is to be shared? Is the patient–therapist privilege a team obligation rather than the obligation of only the therapist? Note, however, that the privilege of disclosing information rests with the patient, and it is up to the patient to give permission to release relevant information. And what about the student’s supervisor, who states that the patient’s confession should be viewed as part of the therapy? Maybe the confession is a cry for help. Why would a patient who is serious about committing suicide tell someone else about this plan? Let us look at other options. First, it would appear that an assessment is in order so that the trainee can learn more about the patient’s psychological status. Second, there is most likely a need for a medication check. The supervisee did state that he checked out the medications and they had been reduced. Consultation with a pharmacist or other medication expert would certainly be helpful. Perhaps the medications were given in cycles, with more medications one week and less the following week. ASSISTED SUICIDE A related issue concerns the topic of assisted suicide. The U.S. Supreme Court in 2006 upheld a Oregon law called the Death with Dignity Act rather than an

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Supervising Novice Geropsychologists 303 assisted suicide law. It requires that one be suffering from a terminal disease and be judged to be competent to make the judgment to terminate one’s own life with the help of a physician (Abeles & Barlev, 1999). Interestingly enough, when physicians in Oregon were polled about this law, more than half favored this legislation. However, only 6% thought they could adequately assess in one session whether a terminally ill patient had impaired judgment. Perhaps general practice physicians are not comfortable making such judgments. However, psychiatrists were more confident about assessing judgment abilities because they were likely to have had more experience in making these determinations. The great majority of the psychiatrists did not believe a patient was mentally disordered simply because the patient had requested physician-assisted suicide. This contrasts with the view of Callahan (1994), who stated that most suicidal individuals show impaired judgment as a consequence of depression or some other mental illness.

COHORT EFFECTS Another issue that may confront the supervisee is the impact of cohort effects on treatment. Cohort effects refer to life influences faced by groups of individuals who were born around the same time. Thus, a patient who was born in the 1930s during the Great Depression may be hesitant to disclose personal information because he or she was taught that mental health services are only suitable for extremely disturbed, “crazy” individuals. Cohort effects may also impact how problems are presented (Duffy & Morales, 1997, p. 373). Thus, complaints about being fatigued, needing to take frequent naps, and experiencing nonspecific pains may be indicators of depression or anxiety (Knight, 1996) in younger adults, but they are more frequent in older adults in part because older adults experience more physical symptoms and in part because of cohort effects that make it more acceptable to talk of physical concerns rather than anxiety or depression.

M U LT I C U LT U R A L I S S U E S CULTURAL, ETHNIC, AND RELIGIOUS ISSUES Certainly for older adults facing end-of-life issues, values become preeminent. Thus, cultural and religious perspectives should be examined (APA, 2002a). It has been pointed out that the practice of psychology as well as the supervision of those involved in practice is based on Western, Euro-centric, and biological perspectives and assumptions (APA, 2002b, p. 61). Constantine (2005) suggested that supervisors explore their own attitudes about cultural issues and experiences, including their own biases, in order to provide supervisees with a way to discuss their own attitudes. She suggested that supervisors may adversely affect the training of supervisees as well as the mental health of clients by avoiding emphasis on cultural factors or by excessively emphasizing cultural differences. Supervisees may not feel comfortable disclosing culturally relevant issues to their supervisors because full disclosure may adversely affect the supervisor–supervisee relationship. According to Pederson, Draguns, Lonner, and Trimble (2002), both ageism and racism have been discussed in the literature, though much of the focus has been

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on younger rather than older adults. Pederson et al. noted the importance of social support with regard to cross-cultural gerontological treatment. He stated, for example, that minority elders were less likely to live on their own than were older adults of Euro-American backgrounds. He emphasized that therapists should examine their own views about what defines social support and how this should be utilized. Hays (2001) provided some examples in her book. The following case history utilizes some of her conceptual framework but provides a different example.

Case 17.2 Sandra, born in Mumbai, India, to an upper middle-class family, works as a trainee in a private psychological practice. Her supervisor is African American. Sandra meets a new client, Walter Washington, a 72-year-old African American who is accompanied by his 40-year-old daughter, a social worker. Walter’s wife of 45 years died about 4 months ago. Walter retired from his job as a lead worker in an automotive plant in Michigan where his job was working as a foreman replacing doors, fenders, and other new metal car parts that were slightly defective. He moved to Michigan many years ago from Mississippi, where he completed the eighth grade. Later he went to school in Michigan and, although he did not graduate, he eventually passed the general equivalency diploma examination, giving him the equivalent of a high school education. Walter tells Sandra that he wants his daughter to be present because otherwise he would not come for counseling. His daughter explains to Sandra that her dad is sad and somewhat depressed and that she had become worried about his memory even before the death of his wife. She says he recently received his first speeding ticket, and most of the time he comes to a rolling stop rather than a full stop. Sometimes he cannot find his car in the supermarket parking lot and misplaces his keys. Furthermore, he forgets to return his daughter’s phone calls. Walter does not say much but agrees that he is sad about his wife’s death and he might need some grief counseling for a short time. But he thinks his memory is really okay. He says he does not believe in “shrinks” and has come mainly because his daughter insists on his coming to this clinic and because he does not want to move in with his daughter, her husband, and her three teenage children.

There are a number of concerns that appear to be important for the trainee to consider and to prioritize. First there is the issue of assessment. Does Walter have a memory problem, and, if so, is it associated with age or a function of his current grief? One option for the trainee is to request that Walter seek a psychological assessment including neuropsychological testing. That would most likely be done by someone other than the trainee. This could also help deal with any issues related to Walter’s competence should this issue arise. The second major concern has to do with transference and countertransference issues. The trainee ought to discuss with her supervisor the issue of Walter’s daughter sitting in on the intake interview and how this affected the trainee, especially as the daughter is a mental health professional. The trainee should also discuss with her supervisor any concerns she might have about being able to deal with Walter’s apparent ambivalence about continuing therapy beyond grief counseling.

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Supervising Novice Geropsychologists 305 The third issue concerns multicultural topics. The trainee needs to familiarize herself with the cultural background of her client and how she can optimize her communication skills so that Walter (and his daughter) perceive her as a competent mental health professional. It is fortunate that the trainee’s supervisor is African American, because he may be able to assist the trainee in the task of becoming effectively engaged with her client. This can include having a discussion of countertransference issues relating to the trainee’s own upbringing and her relationship with her parents, which may influence her therapeutic effectiveness. A final issue that the trainee should discuss with her supervisor is which therapeutic modality is likely to be most helpful to her client. Shouldn’t the trainee utilize an empirically validated treatment in consultation with her supervisor? The trainee should also review the available treatment options for older adults to determine the best therapeutic approach for this client. M E D I C AT I O N S Working with older adults requires some understanding and awareness of medication side effects and the ability to call on a practitioner who is familiar with prescribing medications. As Gitlin (1996) pointed out, older adults are much more likely to take ongoing medications. He reported studies that indicate older adults average 4.5 medications daily, though medically ill older adults can average 10 or more medications daily. Thus, there should be consultation with geriatricians and pharmacists, especially when patients are also being prescribed psychotropic medications. This is an important issue for both the supervisor and the supervisee. It may be important for the supervisor to initiate contact with a health care professional who is able to prescribe medications and then have the supervisee follow up and continue such consultations in conjunction with the supervisor. Currently, psychologists have prescription privileges in Louisiana, New Mexico, and Guam, but in the rest of the country consultation will be needed. A related issue is the topic of frailty. There appears to be some early evidence that exercise can reduce frailty, and such symptoms as muscular weakness can be treated by medications. Supervisors should also be aware that additive effects of medications can cause sedation and/or confusion. This also applies to medications taken for high blood pressure, some pain killers (those that contain narcotics), and sleeping pills. Supervisors and supervisees should also be aware of the effects of alcohol use and possible abuse. In addition to all of this, Gitlin (1996) noted that overthe-counter remedies can also cause sedation. Supervisees should note that there are differences between young-old patients and those in their 80s, although there has been little research evaluating medications for the older-than-80 age group. By and large, the oldest old are usually prescribed medication based on studies done with younger individuals (Schneider, 1996). Compounding all of these issues is the fact that older adults may be more forgetful concerning their medications, and supervisees need to be aware of this fact because it impacts on medication compliance. Supervisors and their supervisees must also be aware that there is a greater likelihood of medical disorders in older adults that require medications, and that it is not always clear whether symptoms are primarily psychological or are a result of medications or an interaction of psychological and medication effects. Current

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medications taken by older adults should be a concern of both supervisors and supervisees; understanding them may require some specialized knowledge and a consultation with geriatricians and pharmacists. All of these factors can impact the therapeutic approach and need to be discussed in supervision. THEORETICAL ISSUES One can rightfully ask whether there is a theory of supervision specific to working with older adults. That, of course, leads to the larger issue of whether there exists a theory of supervision in general. Watkins (1997) pointed out that a theory should answer the question “why” and should “represent an effort to understand, organize and predict relative to some phenomenon” (p. 6). He suggested that one’s theory of psychotherapy supervision provide additional information, integration, and understanding about such variables as supervisee growth, the supervisor–supervisee relationship, and the ability of the supervisee to encourage the client to move toward constructive change. Watkins raised the important question of whether the supervisor’s theory of therapy and theory of supervision is similar to or different from that of the supervisee, and whether that makes a difference in client outcomes. He suggested that it may be better to consider supervisory models that are more like analogies. These are likely less precise than theories, but they can help describe, predict, and explain what is going on in the process of supervision. He described several aspects of this model, including supervisory style (consistent manner of relating to the supervisee), roles/strategies (e.g., case reviewer, teacher, mentor, collegial peer), foci (elements that receive the most attention during supervision), format (e.g., individual or groups), and techniques (e.g., facilitative, supportive, confrontational, conceptual; Watkins, 1997, p. 7). A somewhat different but related theoretical view formulates that supervision is a distinctive professional competence that requires systematic graduate education and clinical training (Falender et al., 2004). Supervision competency is viewed as a lifelong developmental process that requires that attention be paid to all forms of diversity and to legal and ethical issues. Furthermore, training will be impacted by personal as well as professional elements (e.g., values, beliefs) and requires regular self- and peer assessments (p. 776). Some common themes in geropsychology supervision further highlight the issues of values and beliefs (Qualls, Duffy, & Crose, 1995). Many older adults are unsure that younger adults can really understand their problems. They believe that if one cannot understand another’s problems, one cannot be optimally helpful. Younger supervisees often struggle with their own concerns about their futures and their conceptualizations regarding death. Experiences with their grandparents influence supervisees’ relationships to their parents. Perceptions of older adults are influenced by personal experiences in the process of maturing into adulthood. This would appear to be true whether or not one calls this countertransference. Supervisees may also be overwhelmed by the sheer number of problems presented by older adults and may have difficulties prioritizing their client’s concerns. This can lead to feelings of hopelessness and avoidance on the part of supervisees, especially if they are not familiar in the use of available community and referral sources for specific sets of problems. This may be the case especially if the

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Supervising Novice Geropsychologists 307 supervisees’ prior experiences have been with clients who present primarily with emotional problems that are fairly well defined. Often supervisees may try especially hard to be the caring, good child in order to compensate for the lack of care given to the older client by his or her own children. In contrast, some supervisees with prior training in traditional psychodynamic modalities may reject or resent being placed in a case management role by some patients. For example, as Qualls et al. (1995) pointed out, many supervisees would totally reject the idea of home visits. Another problem area for some is the topic of sexuality in older clients, and some supervisees might prefer to ignore this topic. For many younger trainees, the possibility that older clients could be sexually attracted to them comes as a surprise and somewhat of a shock. This may be especially true for trainees who have not been exposed to psychodynamic theories of therapy or for some who have been trained primarily to administer stereotypical cognitive-behavioral treatments. These are all complex issues that are important for intense review and discussion between supervisees and supervisors. PRACTICAL ISSUES Duffy and Morales (1997) asserted that clinical supervision is the primary training method in geropsychology because practicum placements in and of themselves do not ensure professional competence. These authors pointed out that some trainees obtain experiences in working with older adults through volunteer activities in settings developed for older adults. These can include assisted living facilities, nursing homes, private and state hospitals, as well as veterans’ facilities. Often these settings do not employ psychologists, and supervision may be performed by other professionals who may not have had extensive experiences and/or training in psychological treatment methods. As Gallagher-Thompson and Thompson (1995) suggested, supervisees should be taught that age-related events such as reactions to stress induced by bereavement and grief are issues very common to older adults and often require treatment. Other factors such as reactions to change in status as a consequence of work-related factors (switch to part-time work, downgrading of job assignment, mandatory retirement) warrant appropriate counseling strategies. Supervisors need to be familiar with the world of work, as are many counseling psychologists. Additionally, supervisees need supervisors who can help them assess and deal with diagnoses such as major depression, anxiety, less frequently occurring disorders such as paranoia, and other psychotic disorders occurring late in life. Settings that include older adults should have supervisors who have experience and familiarity with a range of mental health services including consultation; psychoeducation; crisis intervention; behavioral medicine; and, of course, individual, group, and family therapy. This familiarity should encompass both short-term and long-term therapies as well as knowledge and experience in the use of behavioral techniques. The supervisee ought to receive supervision in multiple settings such as retirement homes, assisted living centers, skilled nursing homes, senior centers, evaluation centers, as well as inpatient and outpatient medical settings. The supervisee

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needs to develop the ability to work with members of allied professions including nursing, rehabilitation, dentistry, occupational therapy, physical therapy, geriatric medicine, pharmacy, and general medicine, among others. A S S E S S M E N T S U P E RV I S I O N Psychological assessment is an important antecedent to psychotherapy and can help to answer a number of questions that ultimately impact treatment. In some situations, psychological assessments of older adults are done informally by the treating therapist or other staff involved in the intake and processing of the patient. A formal assessment in the pretreatment protocol can result in substantial benefits for the patient, helping to guide and streamline therapy and providing a baseline of information from which to coordinate the patient’s care. Many psychologists will agree that formal assessment can be useful for all patient populations. For older adults, however, there is a greater likelihood that patients are experiencing coexisting health problems, taking one or more medications, and are involved in ongoing medical care (National Academy on an Aging Society, 1999). Many psychologists in training have not had sufficient prior coursework or experience in assessing older adults (Qualls, Segal, Norman, Niederehe, & GallagherThompson, 2002). So it is important to enhance clinicians’ relevant skills as well as their attitudes toward working with older populations. Clinicians who are less experienced with the assessment of older adults may initially benefit from a relatively high degree of structured direction; more advanced trainees can benefit from a more finely textured supervision related to the vicissitudes of the aging patients’ responses. The overall purpose of assessment supervision is twofold: (1) to enhance the trainee’s clinical proficiency and (2) to ensure that the services provided are of high quality. As with psychotherapy in an aging population, the ultimate quality of assessment services that are provided depends on strong general skills combined with an appropriate dose of population-specific considerations. Although general clinical and supervisory skills are not discussed at length here, a number of important considerations and issues that are specific to supervision of clinicians performing assessments with an aging population are described later. CLINICIAN ATTITUDES TOWARD AGING When cognitive screening or testing is part of the assessment protocol, negative attitudes and stereotypes about the aging process sometimes surface. For example, a clinician who assumes that aging and senility are part and parcel of the same process may either overpathologize an older client or assume that cognitive problems are normal (Goodstein, 1985). In contrast, a clinician who is susceptible to reverse ageism (i.e., a patient reminds him or her fondly of a grandparent) may give a patient the benefit of the doubt when scoring the patient’s responses. Thus, the clinician may downplay findings demonstrating cognitive difficulties because of his or her belief in the patient’s capabilities (Braithwaite, 1986). In both of these instances, supervision should serve to provide the clinician with the knowledge and experience that he or she lacks and determine the most appropriate interpretation of findings.

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Supervising Novice Geropsychologists 309 PATIENT MEDICAL STATUS AND ASSESSMENT We have noted earlier that the majority of older adults have at least one chronic health condition and are likely taking one or more medications regularly (National Academy on an Aging Society, 1999). Supervisors should place special emphasis on the importance of obtaining all available information on medical history and current medications (including over-the-counter medications and supplemental herbal treatments). This requires the clinician to refer to and be able to decipher primary sources such as medical charts and reports. Depending on their own level of medical knowledge, supervisors can then provide direct consultation or provide reference to medical resources that the clinician can use to obtain information related to each illness and medication or other treatment issues.

PATIENT MISUSE AND ABUSE OF SUBSTANCES A significant proportion of older patients abuse alcohol or other drugs or take prescription medications inappropriately, either intentionally or unintentionally (Blow, Oslin, & Barry, 2002). From an assessment standpoint, substance abuse or misuse is both a general medical condition and an assessment confound, as it may cause chronic impairment and is likely to affect assessment results. Clinicians in training should be advised to assess for substance abuse and be familiar with signs of possible drug intoxication. There may be instances when both cognitive assessment and psychotherapy may need to be delayed until after detoxification or substance abuse treatment has been completed.

PATIENT SENSORY AND MOTOR ABILITIES Level of performance may be impacted by a patient’s individual abilities to see, hear, and respond via body movements or verbal responses. Although it is possible that sensory and perceptual difficulties can occur from brain impairment, in many older adults problems in vision and hearing are related more directly to the eyes and the ears than to brain functioning. In a similar fashion, motor difficulties such as tremors, weakness, paralysis, and limitations in movement may be related to physical injuries, general medical condition, neurological illnesses, as well as various forms of cerebral impairment. Supervisees who have limited familiarity with older adults are more likely to miss signs of sensory and motor impairment or may misinterpret their significance. Supervisors should provide specific instructions and training with regard to the assessment of these abilities. This can be done through interview, review of records, as well as observation via one-way mirror (with the patient’s permission). It is also important to remind clinicians to make sure the patient is wearing his or her visual or hearing aids, if necessary. In many cases, information about sensory and motor abilities can be helpful in its own right in providing necessary referrals to an ophthalmologist, audiologist, physical therapist, or other professional who may be able to help the patient compensate for sensory limitations. With regard to the psychological assessment process, it is important that the clinician learn how to use this information in order to obtain the fullest, most valid results possible. In some cases this requires

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substituting more appropriate measures, but the clinician can modify testing procedures as necessary if this is needed. It should be noted that modifying test procedures may reduce the accuracy of normative scores for standardized tests. Discussing these modifications with the supervisor and describing them in the report permits the clinician to make judgments about the validity of task results and can reveal possible distortions in the estimation of abilities. APPROPRIATENESS OF NORMATIVE DATA Confusion about normative data complicates the assessment of older adults. Lack of availability of age- and population-appropriate normative data for many tests poses a problem (Hunt & Lindley, 1990). This can be confusing to the supervisee, who may wonder whether it is acceptable to use 75-year norms for an 83-yearold patient. The use of norms should be discussed throughout the assessment process with an eye toward training the supervisee to think critically about what a given score really means in consideration of all relevant characteristics of both the patient and the test. Supervision should also serve to help the clinician begin to use test scores to inform his or her final judgments rather than make absolute determinations. The overall aim is to train the clinician to describe the assessment process appropriately in any reports that are written. PATIENT BEHAVIORAL DISTURBANCES Some older patients—for example, those suffering from mid- to late-stage dementia, delirium, severe mental illness, substance abuse, frontal lobe injury, or some combination of these disorders—may exhibit behavioral disturbances that cause concern. These might include physical or verbal aggression, manipulation of others, sexual inappropriateness, or generally impaired interpersonal skills. When present, behavioral disturbances such as these are often the primary motivators in the initial referral for assessment or intervention. Completing an assessment with an individual who has these types of problems can be difficult, especially for clinicians who are not accustomed to working with populations in whom this behavior is common. In addition, for some clinicians in training the fear of disappointing their supervisors can increase the likelihood that they will try to persist in situations they find excessively uncomfortable or possibly dangerous. For example, one supervisee was advised by her supervisor to administer the Minnesota Multiphasic Personality Inventory to older adult patients if at all possible. Because the supervisee was concerned about displeasing her supervisor, she persisted in administering the Inventory despite some protestations by the client. Midway through the testing the patient tore up the answer sheet and refused to participate in further testing and verbally abused the clinician. The clinician reported to her supervisor that she was simply trying to do her job and follow the directions given by her supervisor to administer the assessment instrument. Balancing the clinical needs of the patient with the clinician’s need for training and security (both physical and psychological) can be trying. By discussing these issues openly (preferably before they occur), supervisors can prepare the clinician with methods for setting limits with patients and controlling the overall assessment

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Supervising Novice Geropsychologists 311 environment to minimize the chances of disruptive or inappropriate behaviors. As with any patient, the likelihood of behavioral problems should be considered when patients are assigned to a given supervisee based on that clinician’s overall prior experience with difficult patients. Additionally, the clinician should be encouraged to think about what his or her own personal limits are so he or she can confidently abort an assessment session if limits are exceeded by a patient.

CONCLUSION As Abeles et al. (1998) noted, as society continues to age psychologists will be asked to do increasing amounts of supervisory work not only with psychology trainees but with paraprofessionals who themselves provide health-related services to older adults. In addition, psychologists will continue to be asked to supervise in institutional settings such as skilled nursing homes, assisted living centers, outpatient clinics, and other agencies. Many of the requests for supervisory services will focus on a range of behavior problems or maladaptive interpersonal problems experienced by older adults. The White House Conference on Aging (2005) listed mental health issues related to depression and other mental disorders as one of the top 10 priorities for aging baby boomers. Continuing education is an avenue for additional consultative experiences that should be of assistance to those providing services to older adults. The APA’s Division 20 (Adult Development and Aging) and Division 12, Section 2 (Clinical Geropsychology), have been active in this regard. The Committee on Aging and the Office of Aging within the APA have also been helpful in stimulating activities related to supervision. The joint publication between the American Bar Association Commission on Law and Aging and the APA (2005) on the topic of the assessment of older adults with diminished capacity has important implications for assessment supervision. It is our opinion that interest in working with older adults is increasing markedly as society ages, and psychologists will continue to provide significant contributions to supervision in this arena.

REFERENCES Abeles, N., & Barlev, A. (1999). End of life decisions and assisted suicide. Professional Psychology, 30, 229–234. Abeles, N., Cooley, S., Deitch, I., Harper, M., Hinrichson, G., Lopez, M., et al. (1998). What practitioners should know about working with older adults. Professional Psychology: Research and Practice, 29, 413–427. Alliance for Aging Research. (1997). Seven deadly myths. Washington, DC: Author. American Bar Association Commission on Law and Aging & American Psychological Association. (2005). Assessment of older adults with diminished capacity: A handbook for lawyers. Washington, DC: Author. American Psychological Association. (1998). Presidential task force on the assessment of age-consistent memory decline and dementia: Guidelines for the evaluation of dementia and age related cognitive decline. Washington, DC: Author. American Psychological Association. (2002a). Ethical principles of psychologists and code of conduct. American Psychologist, 57, 1060–1073. American Psychological Association. (2002b). Guidelines on multicultural education, training, research, practice, and organizational change for psychologists. Washington, DC: Author.

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American Psychological Association. (2003). Guidelines for psychological practice with older adults. Washington, DC: Author. Barlow, D. (2005). Clarification on psychological treatments and psychotherapy. American Psychologist, 60, 734–735. Blow, F. C., Oslin, D. W., & Barry, K. L. (2002). Misuse and abuse of alcohol, illicit drugs, and psychoactive medication among older people. Generations, 26 (1), 50–54. Braithwaite, V. A. (1986). Old age stereotypes: Reconciling contradictions. Journal of Gerontology, 41, 353–360. Callahan, J. (1994). The ethics of assisted suicide. Health and Social Work, 19, 237–244. Constantine, M. (2005). Culturally competent supervision: Myths, fantasies, and realities. Retrieved September 28, 2005, from www.appic.org/conference2005/slides/Madonna.ppt/. Daniel, J., Roysircar, G., Abeles, N., & Boyd, C. (2004). Individual and cultural diversity competency: Focus on the therapist. Journal of Clinical Psychology, 60, 755–770. Duffy, M., & Morales, P. (1997). Supervision of psychotherapy with older patients. In C. E. Watkins (Ed.), Handbook of psychotherapy supervision (pp. 366–380). New York: Wiley. Falender, C., Cornish, J., Hatcher, R., Kaslow, N., Leventhal, G., Shafranske, E., et al. (2004). Defining competencies on psychology supervision: A consensus statement. Journal of Clinical Psychology, 60, 771–785. Gallagher-Thompson, D., & Thompson, L. (1995). Issues in geropsychology training at the internship level. In B. Knight, L. Teri, P. Wohlford, & J. Santos (Eds.), Mental health services for older adults (pp. 129–142). Washington, DC: American Psychological Association. Gitlin, M. (1996). The psychotherapist’s guide to psychopharmacology (2nd ed.). New York: Free Press. Goodstein, R. K. (1985). Common clinical problems in the elderly: Camouflaged by ageism and atypical presentation. Psychiatric Annals, 15, 299–312. Haley, W., & Gatz, M. (1995). Doctoral training and methods for attracting students to work in clinical geropsychology. In B. Knight, L. Teri, P. Wohlford, & J. Santos (Eds.), Mental health services for older adults (pp. 11–118). Washington, DC: American Psychological Association. Hays, P. (2001). Addressing cultural complexities in practice. Washington, DC: American Psychological Association. Hess, A. (1980). Psychotherapy supervision: Theory, research, and practice. New York: Wiley. Hudson,R. (Ed.). (2003). Emerging crisis:The Geriatric Care Workforce Public Policy and Aging Report (pp. 1–2). Washington, DC: Gerontological Society of America. Hunt, T., & Lindley, C. J. (Eds.). (1990). Testing older adults: A reference guide for geropsychological assessments. Austin, TX: PRO-ED. Knight, B. (1996). Psychotherapy with older adults (2nd ed.). Beverly Hills, CA: Sage. National Academy on an Aging Society. (1999). Challenges for the 21st century: Chronic and disabling conditions. Available from www.agingsociety.org/agingsociety/publications/chronic/index.html. Norcross, J., & Knight, B. (2000). Psychotherapy and aging in the 21st century. In S. Qualls & N. Abeles (Eds.), Psychology and the aging revolution (pp. 259–286). Washington, DC: American Psychological Association Pederson, P., Draguns, J., Lonner, W., & Trimble, J. (Eds.). (2002). Counseling across cultures (5th ed.). Thousand Oaks, CA: Sage. Qualls, S., Duffy, M., & Crose, R. (1995). Clinical supervision and practicum placements in graduate training. In B. Knight, L. Teri, P. Wohlford, & J. Santos (Eds.), Mental health services for older adults (pp. 119–128). Washington, DC: American Psychological Association. Schneider, J. (1996). Geriatric psychopharmacology. In L. Carstensen, B. Edelstein, & L. Dornbrand (Eds.), The practical handbook of clinical gerontology (pp. 481–542). Thousand Oaks, CA: Sage. Shea, D. (2003) Swimming upstream: The mental health workforce. In R. Hudson (Ed.), Public Policy and Aging Report (pp. 3–6). Washington, DC: Gerontological Society of America. Watkins, C. E. (Ed.). (1997). Handbook of psychotherapy supervision. New York: Wiley. White House Conference on Aging. (2005) The booming dynamics of aging. Washington, DC: Author Wong, T. M., Strickland, T. L., Fletcher-Jantzen, E., Ardila, A., & Reynolds, C. R. (2000). Theoretical and practical issues in the neuropsychological assessment and treatment of culturally dissimilar patients. In E. Fletcher-.

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PART SIX

SPECIAL POPULATIONS

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C H A P T E R 18

Supervising Psychotherapy of Abuse Survivors NANCY KASER-BOYD

MANY CLIENTS or patients appear in mental health, counseling, and medical settings with histories of abuse (E. A. Walker et al., 1999). One study of inpatient psychiatric admissions to a county hospital found that 70% had histories of physical or sexual abuse as children (Carmen, Rieker, & Mills, 1984). When the childhood experience was limited to sexual abuse, 51% of 105 female state hospital admissions were positive (Craine, Henson, Colliver, & MacLean, 1988). Craine et al. noted that in the majority of their cases, hospital staff were unaware that the patients had histories of sexual abuse. In all, 66% of the abused patients met the diagnostic criteria for Posttraumatic Stress Disorder (PTSD), although none had received that diagnosis. Studies of certain diagnostic groups have yielded a high number of patients with histories of abuse; for example, among patients labeled with Borderline Personality Disorder, many have histories of childhood abuse (Herman, Perry, & van der Kolk, 1989). Abuse unfortunately comes in many forms. Among the abused population are survivors of childhood physical or sexual abuse, witnesses to serious parental violence, battered women, kidnap victims and hostages, and patients traumatized by rape or criminal assault. Early research and clinical inquiry focused on each type of trauma as separate and distinct (e.g., rape trauma syndrome, battered woman syndrome, survivor of childhood sexual abuse), but as PTSD was more widely discussed, it became clear that highly similar symptoms come from interpersonal violence (Armstrong & Kaser-Boyd, 2005; Cling, 2004). The abused is a difficult population for a number of reasons. Patients who have been traumatized by another human being have suffered a violation of basic trust. They have become unsure whom to trust, who understands what they went through, who will blame them or be repulsed by their story. Patients who have been abused feel ashamed, as if they somehow caused their abuse or deserved 315

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it. Although they have sought some kind of psychological or medical help, they wish to avoid remembering and talking about the abuse because it stirs powerful and painful memories. Whole parts of their experience and emotions may be split off and inaccessible to the therapist, at least as therapy begins. If the abuse has been long term or if it began in childhood, patients may respond to the therapist as another abuser or may have developed a set of behaviors that evoke anger or rejection. Once abused patients begin to tell their stories, the details may be profoundly disturbing. The stories may evoke strong reactions in the therapist and the supervisor, feelings such as revulsion, anger, fear, or deep sadness. For some individuals in training to be therapists, this is a door to human depravity they wish to avoid. This population probably stirs more intense countertransference reactions than others. The therapist may have rescue fantasies or come to feel impotent—helpless to assist the patient to overcome long and deeply held feelings, and helpless like the patient. This population may call for more interface with the community than other patients; for example, interface with the courts for restraining orders, with state victim’s compensation funds, with shelters, or with the police. Finally, this population may cause the therapist and supervisor to spend more time assessing and dealing with the potential for danger. Some patients will continue in relationships with abusers who become angry at the therapist trying to create change. Some patients (and therapists) will be in danger when they try to break their connection to the abuser. These commonly observed dynamics raise special issues for the supervisor. In the first section of this chapter, different types of abuse are discussed separately with a focus on their unique symptoms, diagnostic issues, assessment, and treatment. In the second section, I discuss general diagnostic and assessment issues and treatment. In the third section, I discuss supervision issues such as evaluating and managing danger and managing countertransference. Although the discussion in this chapter sometimes uses the term victim, the preferable term is survivor of abuse, as it recognizes that many patients have endured terrible events and have struggled against odds, marshalling their coping resources and maintaining the will to overcome their painful experience. S U RV I V O R S O F C H I L D H O O D A B U S E Childhood abuse is a broad category and includes physical abuse, sexual abuse, neglect, abandonment, witness to parental violence, and victimization by a stranger (e.g., sexual abuse by a priest). As noted previously, a large number of patients seen in mental health and medical settings have early histories of abuse and may present with a disorder other than PTSD. Many such survivors appear with chronic depression, some have psychotic episodes, and some appear to have personality disorders. Some have dissociative disorders or complex somatic disorders. Symptoms vary depending on the type, severity, and duration of the abuse. Children abused by parents or caretakers (who should be trustworthy) are at special risk. They experience peaks of terror and physical pain with no one to turn to. Often the nonoffending parent is physically or psychologically absent or is in denial about the abuse. Many sexually molested women, for example, say that their father or stepfather abused them repeatedly while their mother was in the home,

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or that they told their mother about the abuse but she took no effective action. Of course, in many cases the mother was a victim, too—of physical or psychological abuse—and was psychologically unable to protect her children. In these situations, the children are utterly alone. Telling a teacher or any adult at all is fraught with the risk of more abuse. Physically and sexually abused children, like battered women, are often psychologically abused, so they come to feel that no one will believe them, or that people will think it is their fault that they are being abused, or simply that all adults are corrupt. They often feel despair and hopelessness or are caught in repetitive cycles of hope versus despair. Children who are exposed to an unsafe, unpredictable environment are more at risk than adult survivors of abuse (DeBellis & Putnam, 1994). This is largely because such high-anxiety situations are presented to them before they have developed the cognitive or emotional resources to cope with such events. When the abuse is at an early age, it may interfere with brain development (DeBellis, 2001). Abuse may disrupt developmental achievements and may cause delays or deficits of achievement in motor, emotional, behavioral, language, psychosocial, social, and cognitive skills (Cicchetti & Lynch, 1995). Trauma in childhood can lead to failures in behavioral and emotional regulation (Pynoos, Steinberg, & Wraith, 1995). Often the traumatic conditions occur at critical developmental phases, for example the development of basic trust or of identity, or moral development. When the cause of the trauma is a parent or another trusted authority figure such as a clergyman, there are additional insults to the developing child. Specifically, the formation of trust in authority figures is ruptured, perhaps irreparably. When the molestation is perpetrated by a person who is firmly rooted in the survivors’ beliefs as a good person (e.g., natural father, or priest or minister), the breaking of society’s sexual rules can be pathogenic because it seems too awful to be true. Survivors of this type of abuse may have additional impairments to reality testing. Many children who are abused will be revictimized (Herman, 1992a). Multiple traumas increase the damage to personality and worsen psychological symptoms (V. M. Follette, Polusny, Bechtle, & Naugle, 1996). Multiple traumas have what has been described as a “kindling effect” (Schumm, Stines, Hobfoll, & Jackson, 2005). DeBellis (2001) focused on the brain changes that result from chronic childhood abuse. He described decreased brain serotonin and dysregulation of the endogenous opiate system and the catecholamine and limbic-hypothalamic-pituitaryadrenal axis. DeBellis illustrated how symptoms of PTSD might arise from dysregulation in each of these systems. One of the biological consequences of stress for brain function is an elevated secretion of cortisol, which appears to have neurotoxic effects and leads to learning and concentration impairments secondary to damage to the hippocampus (Edwards, Harkins, Wright, & Menn, 1990). Studies of children with histories of abuse found them to have abnormally high and low levels of cortisol that suggest initial elevated secretion and then compensatory inhibition (DeBellis, 2001). Preliminary studies of adults with childhood histories of abuse showed smaller hippocampal volume (Bremmer et al., 1997; Stein, Koverola, Hanna, Torchia, & McClarty, 1997); smaller intracranial volume (DeBellis, 2001); and dysregulation of the prefrontal cortex (LeDoux, 1998), which is associated with executive functioning. Abused children had higher concentrations of the catecholamines epinephrine and norepinephrine in their urine compared

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with matched controls (DeBellis, Lefter, Trickett, & Putnam, 1994), which is related to higher cortisol levels. Finally, abnormal EEG activity was seen in 54% of patients with a history of early trauma but in only 27% of nonabused patients. The irregularities arose in frontal and temporal brain regions (Teicher, 2002) and were described as “limbic irritability,” which was postulated as a cause of greater emotionality and impulsivity. There is still much to learn about the structural and biochemical abnormalities brought on by early histories of abuse, but new brain imaging techniques hold promise for future research. PSYCHOLOGICAL EFFECTS The cognitive and emotional deficits in abused children are illustrated by survivors’ psychological test results. For example, Zivney, Nash, and Hulsey (1988) examined the Rorschach records of 80 girls aged 9 to 16 with histories of sexual abuse, dividing them into two groups by age at the beginning of the molestation (before age 9, after age 9). They found the most disturbed girls were those who experienced early abuse, and they reported that more than half of these subjects manifested disturbed cognition (more M- responses, low X+%, more Deviant Verbalizations [DVs], and Fabulized Combinations [FABCOMs]). These girls had more anxiety and helplessness (greater number of inanimate movements [m’s] and more diffuse shading [Y’s]), a damaged sense of self (more Morbids [MORs]), and a “preoccupation with themes of primitive supply” (p. 100). Leifer, Shapiro, Martone, and Kassem (1991) administered the Rorschach to 38 sexually abused girls aged 5 to 16 and 32 age-matched controls. A total of 73% of the abused subjects had experienced penile penetration. The sexually abused girls had more disturbed thinking and impaired reality testing (more Special Scores [WSum6], more form failures [X-%]). Leifer et. al. found higher levels of stress (es) relative to adaptive abilities (EA), higher levels of distress with a preponderance of negative affect (more shading responses), and higher Elizur Anxiety and Hostility Scores scores. These girls had more sexual responses and evidence of primitive, disturbed human relationships (the Mutuality of Autonomy Lowest Object Relations Score). Using the Thematic Apperception Test with physically and sexually abused children aged 6 to 11, Fish-Murray, Koby, and van der Kolk (1987) found the children to be fixated at the preoperational level of development. In comparison to controls, they had difficulty with time sequencing and deficits in social judgment, and they were deficient on measures of self-knowledge and impaired in the ability to shift roles or show flexible problem solving. On the Thematic Apperception Test, they exhibited an all-or-none response, either delivering a constricted, impoverished record or “gruesome tales of murder, kidnapping, beating and abandonment” (p. 100). Children who suffer serious physical and sexual abuse often develop symptoms of PTSD, but the symptoms that come from repetitive, inescapable abuse are more complex, severe, and chronic than the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision; DSM-IV-TR) would indicate. This is now being called complex PTSD or disorders of extreme stress. In DSM-IV-TR they are described under a section called “Associated Features.” See the section here on PTSD for a more complete discussion. These symptoms or effects may resemble a personality

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disorder, but when the source is understood as repetitive childhood abuse, the indications for treatment are clear. B AT T E R E D W O M E N Battering exists on a spectrum from mild to severe, and it can be psychological, physical, or sexual. Almost every relationship with domestic violence also includes a high level of psychological abuse. At the low end the verbal taunts attack selfesteem, but at the higher end they communicate serious potential for harm to oneself or others. The effects of domestic violence on the victim/survivor will vary depending on the types and severity of the abuse. Sexual abuse in the battering relationship also exists on a spectrum: from unwanted or too frequent sex to forced, painful acts or acts that are degrading or violate the woman’s moral standards. Physical abuse can also range from mild to moderate acts of physical aggression (pushing, slapping, hair pulling) to extraordinarily threatening and frightening acts of violence (being threatened with guns, thrown out of a moving car, choked to unconsciousness). The issue of severity is closely tied to ideas (and misconceptions) of the nature of battered woman syndrome. A simplistic view of a battered woman might be of someone who is rather dependent, with low self-esteem and rather passive and self-effacing. Some authors talk about “learned helplessness,” again indicating a passive, resigned state. Battered woman syndrome is really so much more than this. To underscore the reality that not all battered women are the same, experts now also refer to battered woman syndrome as the effects of battering. The effects can include some or all of the descriptions and symptoms formerly described under the syndrome, plus effects of the unique experiences women have had. Clearly, living in a violent and threatening relationship creates strong emotions (e.g., fear, anger, ambivalence) and dramatic methods of coping (e.g., denial, emotional numbing, avoidance, substance abuse). The powerful experience of fear cannot be overlooked. Many battered women conduct their daily lives unable to predict when the violence will erupt or knowing that a battering will occur over something innocuous (e.g., a neighbor comes by to say hello, igniting the batterer’s jealousy). As a result of these experiences, battered women have a high level of constant anticipatory anxiety or dread punctuated by moments or hours of extreme fear or terror. Chronic anxiety may interfere with sleep and concentration, impair the ability to work, and lead to numerous health effects associated with chronically stressful environments. The peaks of fear or terror, in contrast, bring about the full biological response to threat (Le Doux, 1996). The brain responds in a definite way to threat (see Fear, 2003; Kaser-Boyd, 2007). Battered women who have lived through episodes of terror or felt that their lives or the lives of loved ones were seriously threatened may develop the full complement of psychological and physiological symptoms to PTSD (see below for a more complete discussion). Some experiences of battered women deserve special attention because they are somewhat different than the experiences of other victims/survivors. Battered women are seemingly in these relationships voluntarily, and it is well known that they have difficulty leaving. One of the most frequently asked questions is “Why do they stay?” In the early years of psychiatry, that is, before Lenore Walker

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published her seminal work (L. E. A. Walker, 1979), it was assumed that such women had a masochistic streak. However, we as therapists are misguided if we do not understand that a portion of the relationship—sometimes a substantial portion—is positive. Batterers are often described as magnetic, charming men, as good lovers or good fathers. It was these attractive features that were apparent at the beginning of the relationship and created the battered woman’s attachment. Battered women are more likely to be nurturing and attachment prone. The violence typically begins after the relationship is cemented (e.g., by a pregnancy or a wedding), and in the early portion of the relationship it may not be extreme. This permits the battered woman to minimize or rationalize—or forgive—her husband’s violent outbursts. Meanwhile, the batterer is gaining psychological control by isolating the woman from her family and friends by controlling choices such as work, education, and social activities outside the relationship and by attacking her self-esteem. In the early years, the reasons battered women give for staying invoke love, attachment, keeping the family together, or hoping to help her husband. These feelings make the therapist’s job difficult, as it can take quite some time before battered women can accept that the husband may not change. Battered women come to feel damaged, worthless, and sometimes shameful. The experience of physical injury, violent sexual assault, and assault on self-esteem and psychological integrity leave battered women feeling fragmented—unsure whether to stay or go and unsure how to safely get away and, more important, get away along with their children. By this time, avenues of escape have become more limited. Children are critically important in the abuse paradigm. Most battered women have children, and often these are toddlers. Battered women often say they stay with their husband because they feel their children need a father. This belief overlooks the devastating developmental impact of witnessing violence. Women also report that the batterer has threatened to take the children away (e.g., flee across the border) or has told her that she would be found unfit in family court. There are usually a few local or national news stories about violent men who have killed their own children to get back at a wife who was trying to leave them. This understandably strikes terror in the heart of battered women. As the violence grows more severe and the batterer more decompensated and threatening, the reason for not leaving typically is fear. There has been little formal research on why women stay in abusive relationships, but Rhodes and McKenzie (1998), reviewing 3 decades of literature on this topic, emphasized that battered women are not a homogenous group: Some have low self-esteem, some have negative cognitive schema, some have poor coping skills, but none of these simple explanations accounts for the majority of battered women. Battered women did, however, suffer disproportionately from PTSD and depression, which are powerfully immobilizing forces. Herman (1992a) likened the experience of a battered woman to the experience of a hostage, illustrating how feelings of entrapment emerge out of being controlled by a dominant, mercurial, and threatening man: Prolonged contact with the perpetrator creates a special type of relationship, one of coercive control. This is equally true whether the victim is rendered captive primarily by physical force, or by a combination of physical, economic, social and psychological means (as in the case of religious cult members, battered women, and abused chil-

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dren). The psychological impact of subordination to coercive control may have many common features. As the victim is isolated, she becomes increasingly dependent upon the perpetrator, not only for survival and basic bodily needs, but also for information and even for emotional sustenance. Prolonged confinement in fear of death and in isolation reliably produces a bond of identification between captor and victim. This is the “traumatic bonding” that occurs in hostages . . . With increased dependency upon the perpetrator comes a constriction in initiative and planning. . . . Because of this constriction in the capacities for active engagement with the world, chronically traumatized people are often described as passive or helpless. . . . Prolonged captivity undermines or destroys the ordinary sense of a relatively safe sphere of initiative, in which there is some tolerance for trial and error. The sense that the perpetrator is still present, even after liberation, signifies a major alteration in the survivor’s relational world. The enforced relationship, which of necessity monopolizes the victim’s attention during captivity, becomes part of her inner life and continues to engross her attention after release. (pp. 383–384)

These are severe changes to personality functioning, especially to relational capacity and the functioning of the self. Damage in these domains can require longterm psychotherapy that is depth oriented and continues long after the battered woman has separated from the batterer and is safe. Battered women are at risk for related disorders. Commonly observed are substance abuse disorders. Sometimes battered women use drugs or alcohol to help them quell their anxiety and the other strong emotions that come from battering. L. E. A. Walker (1984) in her eight-state survey funded by the National Institute of Mental Health, found that 20% of battered women used alcohol in the time span of the more serious batterings, and 7% used street or prescription drugs. One can assume, given the natural tendency to underreport drug and alcohol abuse and the overall increase in drug and alcohol use in the past 20 years, that these figures are somewhat higher. Each case requires careful evaluation of the possible role of drug or alcohol abuse. Battered women also commonly report a significant amount of physical distress and illness (L. E. A. Walker, 1994). Some of this obviously comes from the battering itself, but other complaints or disorders seem to come from the effects of chronic anxiety (e.g., migraine headaches, lower back pain, high blood pressure, gastrointestinal disorders) or the biological dysregulation from trauma (e.g., serotonin depletion, sleep disruption, physical hyperreactivity). L. E. A. Walker indicated that chronic stress may impact immune system function but noted that research making this link is in its early stages.

R A P E S U RV I V O R S Rape is often described as a woman’s worst fear (Rose, 1986). This act of forced sex embodies complex meanings and effects. Many rape victims fear they will be killed. If this threat is not overt in the attack, rape is experienced as the annihilation or death of important aspects of the self. Rape overwhelms usual ego functions, profoundly affecting both cognitive and emotional resources. The violation of body boundaries leads to a profound sense of physical vulnerability, even when the rape

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is not violent (Hilberman, 1976). Rose (1986) emphasized the profound sense of loss that accompanies rape: Loss is the major theme in the psychodynamics and symptomatology of rape victims and in the responses to the victim by significant others and society. Loss is profound and devastating for the rape victim, intrapsychically touching on every stage of psychosexual development, self-concept, and object relations, as well as affecting sexuality and relationships with others. (p. 818)

Burnam et al. (1988) examined the connection between sexual assault and mental disorder in a large cross-section of an urban city. Lifetime diagnoses of nine major mental disorders were compared between those who reported that they had been sexually assaulted at some time in their lives and those who reported experiencing no sexual assault. Sexual assault predicted later onset of major depressive disorders, substance use disorders, and anxiety disorders. Those who were assaulted in childhood were more likely than those first assaulted in adulthood to report the subsequent development of a mental disorder. The first stop for rape victims is probably a rape crisis center, where the interventions include social support and help with testifying against a perpetrator. Rape victims may appear for therapy soon after this, or they may not seek psychological treatment until much later, when their trauma symptoms fail to abate. It is important for the clinical supervisor to understand the psychological reactions of rape survivors from the hours just after the rape to the years that follow. The earliest contemporary work on the effect of rape (Sutherland & Scherl, 1970) discussed a three-phase reaction. The first was the acute phase, characterized by shock and disbelief followed by or alternating with fear and anxiety. The second phase the authors called pseudoadjustment, and it involved denial, suppression of affect, and rationalization, all defense mechanisms used to regain equilibrium. They noted that in this stage the victim appeared to be adjusting and refused outside help. The victim, however, moved into a final phase, which they termed integration. This began with depression or flashbacks of the rape that began help seeking. They noted that self-blame and feelings of loss were common, as was anger toward the assailant. The now-classic work of Burgess and Holmstrom (1974) described a similar experience of rape and coined the term rape trauma syndrome. The authors summarized their findings about women in the emergency ward of a large eastern U.S. hospital who had been victims of forcible rape. They described a two-phase reaction. In the first phase or acute phase, the victims experienced a wide range of emotions from shock or disbelief to fear, anger, anxiety, and self-blame and a number of somatic reactions such as stomach pains or nausea, gynecological pain, headaches, and sleep disturbances. Their emotions were described as “disorganized,” and they had trauma dreams and nightmares. In the second phase, victims began to reorganize their lives, that is, moving or focusing effort on their safety. Burgess and Holmstrom described victims’ fear of threatening situations, likening it to clinical descriptions of war victims, but asserted that crisis counseling was usually sufficient to “reorganize” their lives. Subsequent articles questioned this benign view, noting that even with crisis counseling, symptoms of rape are still present long after the rape.

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Kilpatrick, Veronen, and Resick (1981) conducted thorough research on the longterm effects of rape, following victims for 2 years. They found that measures of anxiety, fear, and depression were high immediately after the event. At 3- and 6-month post-rape assessments, the initial distress had diminished but rape survivors continued to be significantly more fearful and anxious than control subjects. Santiago, McCall-Perez, Gorcey, and Beigel (1985) found that these symptoms continued beyond 2 years. Many rape victims seen in the clinical setting indicated that their rape was an event that changed them “forever.” There is support for this in research literature—lifetime effects of rape vary widely, from 2% to 80% of victims, varying with the definition of rape and the methodology of the study (Cling, 2004). Individual variation in coping and defense mechanisms undoubtedly affects the outcome of rape trauma. Meyer and Taylor (1986) examined typical responses to rape in 58 women from rape crisis centers and the association between coping responses and recovery. They found a clear connection between attribution for the rape and recovery. Women who were absorbed in self-blame (either for their behavior or their character) had a poorer adjustment, with more depression, more fear, and more relationship dysfunction. The authors also found a clear connection between post-rape behavior and adjustment. Women who stayed home and withdrew from others had more ongoing depression and fear. The most positive outcomes were seen in women who used stress reduction techniques (i.e., consciously attempting to reduce their anxiety with positive thoughts, keeping busy, and overcoming their inclination to withdraw). The clinical supervisor should not be surprised if the patient is still struggling with a sexual assault that occurred years earlier. The student or supervisor may have a “get-over-it” stance or a dismissive attitude that fails to take the trauma seriously or fails to look beneath what may appear to be shallow affect but what is actually emotional blunting or numbing and shock. This can impede the emotional work of psychotherapy. In addition to the classic symptoms of PTSD, treatment providers should expect high levels of self-blame; hypersensitivity to danger; sexual dysfunction; feelings of defilement, loss, or permanent damage; and serious issues with trust. Symptoms will vary in intensity based on the level of threat in the assault and the survivor’s constellation of coping and defense mechanisms.

P O S T T R A U M AT I C S T R E S S D I S O R D E R It is especially important that the clinical supervisor understand PTSD and its variants. The DSM-IV-TR (American Psychiatric Association, 2000) discusses the necessary precursors for PTSD. The presentation of diagnostic criteria in DSM-IV implies the continuous presence of “flooded” and “avoidant” criteria, when, in fact, there is a time sequence to trauma symptoms that makes sense when one thinks about the human capacity to cope and adapt. When patients are seen soon after a trauma (e.g., from immediately after to several months after), trauma memories are still fresh and coping or defense mechanisms have not congealed. Patients are likely experiencing intrusive recollections and nightmares and the emotions of fear, anger, despair, annihilation, and so on that accompany interpersonal trauma. They

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are likely hypervigilant and hyperaroused (sleeping poorly, easily frightened, and preoccupied with danger). As time goes on, most trauma survivors try hard to push these painful memories and feelings out of their awareness. Avoidance can come in the form of suppression or sometimes in the form of repression. During this stage, the patient is likely still hypervigilant, perhaps still experiencing poor sleep and symptoms of anxiety, but seems flat or detached. In the defensive avoidance stage of PTSD, the survivor appears to be emotionally constricted. In the process of avoiding the painful feelings from the trauma, it is as if all feelings are to be avoided lest the survivor again feel intensely vulnerable. Overt trauma symptoms (e.g., intrusive recollections, intense emotions) can emerge dramatically during stages of defensive avoidance in response to triggers that can bring back the traumatic memories and feelings in their full intensity. The avoidance stage of PTSD can continue for quite some time, perhaps assuming what appears like the new personality of the survivor. When abuse has come early in life and has been prolonged, the symptom picture may look considerably different than simple PTSD. This is a set of impairments to personality functioning that has been variously called complex PTSD (Herman, 1992a), disorders of extreme stress (van der Kolk, 2005), and personality disorders resulting from extreme stress (van der Kolk, Roth, Pelcovitz, Sunday, & Spinazzola, 2005). Impairments to personality functioning are described in six domains: 1. Alterations in regulation of affect and impulses: Deficits of affect regulation are illustrated by difficulty modulating affect and impulsive and self-destructive behaviors. 2. Alterations in attention or consciousness: There may be transient dissociative episodes or derealization and depersonalization. 3. Alterations in self-perception: These are exemplified by a sense of having been permanently damaged, shame, feelings of ineffectiveness, excessive guilt, and other indicators of an impaired sense of self. 4. Alterations in perceptions of others: These individuals develop distorted beliefs about others as the result of their distorted experiences of childhood. They swing from idealizing others to devaluing them. They have a pervasive inability to trust and may be preoccupied with hurting those who have hurt them. In their adult lives, they may be revictimized or may victimize others (with some gender differences here). 5. Somatization: Although survivors may not have chronic pain or illness, this somatic preoccupation is more common than in normal individuals. They may have compromised functioning in one domain (e.g., cardiopulmonary or digestive). They often have sexual symptoms and also often have conversion symptoms. 6. Alterations in systems of meaning: Survivors have difficulty sustaining hope and quickly feel helpless and despairing in crises. They may feel that nothing matters or that everyone is corrupt. This more severe level of personality impairment requires a more depth-oriented and long-term therapy than that for simple PTSD, described in the next section.

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ASSESSMENT Careful interventions usually begin with a competent assessment of the symptoms and their severity. Many clinicians begin with symptom checklists. These are useful adjuncts to the clinical interview, especially if the patient is in crisis, because they provide structure and assist new psychotherapists to be thorough in documenting of symptoms. There are a number of reasons, however, why a supervisor might urge therapists to conduct a more in-depth psychological evaluation of a patient. The overarching reason is to evaluate the extent to which the victimization has impacted cognitive and emotional resources and personality structure. A number of studies have delineated the short-term and long-term effects of abuse with psychological tests such as the Minnesota Multiphasic Personality Inventory (MMPI), the Millon Clinical Multiaxial Inventory (MCMI), and the Rorschach.

ADULT VICTIMS OF SEXUAL ABUSE Among the earliest studies using the MMPI, Meiselman (1980), with 16 adult survivors of sexual abuse in outpatient therapy, found mean T-score elevations of 70 or more on Scales 4, 8, and 2. Tsai, Feldman-Summers, and Edgar (1979), in a sample of 30 psychotherapy patients molested as children, found T-score elevations of 70 or more on Scales 2, 4, 6, and 8. Nash, Hulsey, Sexton, Harralson, and Lambert (1993), in a study with control groups of nonabused patients and normal subjects, discovered significant differences on Scales F, 1, 4, 6, 8, and 0. Griffith, Myers, Cusick, and Tankersley (1997) sampled clients in a community and university health center, compared 30 women with histories of childhood sexual abuse to 30 women with no sexual abuse history, and found that women with histories of abuse were significantly higher on Scales 1, 2, 4, 6, 7, 8, and 9. The two most common profiles were 4-8/8-4 and 4-5-6. Adolescents exhibit a similar profile. Scott and Stone (1986) reported on 22 adolescent incest victims, comparing them to their mothers, and found the daughters had significant elevations on Scales F, 4, and 8, whereas the mothers had unelevated profiles; two thirds of the daughters had the 4-8/8-4 profile type. Engels, Moisan, and Harris (1994) noted that many previous studies did not control for the presence of other risk factors in the lives of child sexual abuse survivors. They divided their large sample into physical abuse only, sexual abuse only, sexual and physical abuse, and no abuse. A majority of those reporting child sexual abuse also reported physical abuse. Almost one third of the sample reported both types of abuse, 16% reported sexual abuse only, 27% reported physical abuse only, and 29% reported no abuse. The profiles of the abused groups were remarkably similar, but those who reported both physical and sexual abuse had the most elevated profiles. The group reporting sexual abuse had a 2-4-8 profile, with additional elevations on Scales 1, 3, and 7. Women who reported physical abuse only had a 4-2-8 profile, also with additional elevations on Scales 1, 3, and 7. Those reporting both physical and sexual abuse had a 4-2-8 profile, also with elevations on Scales 1, 3, and 7. The functional significance of these results is that the profiles had multiple elevations characterized elsewhere in the literature as the “floating profile” of Borderline Personality Disorder (Friedman, Lewak, Nichols, & Webb, 2001).

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The classic 4-8 profile of the child abuse survivor might be summarized as follows: These women are distrustful of others and are socially withdrawn. They see the world as dangerous and other people as rejecting and unreliable. Women with 4-8 profiles are described as moody and emotionally inappropriate. Suicide attempts may be frequent. The 4-8 women have unpredictable and nonconforming behavior and may get into social and legal difficulties because of judgment and thinking problems or resentment of authority. Women with 4-8 profiles are described as harboring deep feelings of insecurity and an exaggerated need for attention and affection. BATTERED WOMEN The MMPI profiles of battered women have striking similarities to those of women with histories of child abuse. The earliest study with battered women (Rosewater, 1988) examined more than 100 women but failed to include a nonbattered control group. Battered women had elevations on Scales 4, 6, and 8 and low K and EgoStrength scores. Rosewater compared battered women in transition to formerly battered women and found similar profile configurations, but battered women in transition had higher overall elevations. Scale elevations on the MMPI were significantly related to the frequency and severity of battering. Kahn, Welch, and Zillmer (1993) reported on the MMPI results of 31 women in battered women’s shelters. The mean MMPI-2 profile revealed elevations on Scales F, 4, 6, and 8. The most frequent code types were 4-6, 4-8, 6-8, and 2-4. Elevations on Scales 4, 6, and 8 were present in 90% of the profiles. The women were also significantly elevated on the PTSD scales, Keane, Malloy, and Fairbanks’s (1984) posttraumatic stress disorder (PK), and Schlenger et al.’s (1989) Posttraumatic Stress Disorder Scale (PS) and had low scores on Ego-Strength. Regression analyses with history of abuse found that length of abuse was the best predictor of F scale elevation, and severity of psychological abuse was the best predictor of overall clinical scale elevation. Rollstin and Kern (1998) used the MMPI-2 with 50 battered women drawn from battered women’s shelters and support groups; the women had been out of the battering relationship from 1 to about 70 weeks. As with other MMPI studies with battered women in transition, mean elevations over 65 were found on Scales F, 4, 6, 8, 7, and 2. The most typical profiles were 4-6, 4-8, 6-8, and 2-7. Higher scores were found with greater severity of abuse. Similar findings have occurred in more recent studies (Morrell & Rubin, 2001). Several studies have looked at single MMPI scales with battered women. Perrin, Van Hasselt, Basilio, and Hersen (1996) used the Keane MMPI-PTSD scale (PK) with 69 battered women referred to an outpatient clinic program for domestic violence. The PK consists of 49 items that were found to reliably discriminate between Vietnam veterans with and without PTSD. Of 69 battered women, 48 were positive on PK. Elevation on PK covaried with PTSD; that is, those with higher frequency of battering and more severe types of abuse had higher PK scores. Rhodes (1992) compared battered and nonbattered women seeking outpatient therapy on Scale 4 (Pd); each group had 46 women. There was a significant difference between the two groups on Pd. The study also looked at differences on the Harris-Lingos

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subscales. Battered women scored significantly higher on Family Discord, Authority Problems, Social Alienation, and Social Imperturbability. Because the Scale 4 elevation is very common in the MMPI profiles of both battered women and women with histories of child abuse, caution should be used in employing cookbook or actuarial interpretations of Scale 4 when the patient has a history of abuse. Morrell and Rubin (2001) evaluated the effectiveness of the PK scale in discriminating between battered women with and without PTSD in a sample of 93 women from battered women’s shelters. They found that PK showed sensitivity to PTSD symptoms by generating rates of diagnostic accuracy similar to research reported for Vietnam veterans. Of interest is that they found that low K scores, combined with high Scale 1 scores, were more diagnostically accurate for PTSD in these women. Battered women produce a particular profile on the Millon personality tests. In my clinical work with battered women, I found they were frequently elevated on the MCMI-II scales Avoidant, Dependent, Self-Defeating, Anxiety, and Dysthymia. I subsequently conducted a research study comparing 25 battered women referred by a family court for exposing their children to domestic violence, with 23 women referred by the court for other reasons (Kaser-Boyd, 2004). There were statistically significant differences between battered women and controls on the personality pattern scales of Avoidant, Dependent, and Self-Defeating. The MCMI-II Avoidant scale includes items that are common in victims of interpersonal violence, such as a wish to be close to others but a fear of closeness. It also has items about internal numbness, flashbacks, and other PTSD symptoms. The MCMI-III, which is the current version, has a formal PTSD scale with items that inform the therapist about the degree to which the traumatic experiences are impacting current functioning. The Rorschachs of battered women, especially when the battering has been more severe and prolonged, resemble the Rorschachs of other individuals with PTSD (Kaser-Boyd, 1993, 2007). When women are tested shortly after leaving a battering relationship, they deliver Rorschach protocols flooded with images of harm and danger, with formal Rorschach scores that are associated with helplessness and a preoccupation with morbid and aggressive content. When time has elapsed, Rorschach protocols are more constricted—they are shorter records that are more form based, and patients seem to avoid seeing or mentioning morbid or aggressive percepts. Overall, psychological tests can be useful in identifying and measuring the severity of the effects of victimization. These can be organized by symptom, for example feeling profoundly fearful, feeling overwhelmed or helpless, feeling worthless, being exhausted, and feeling shame. DEFENSIVE AVOIDANCE Because PTSD is a biphasic disorder, the test profile varies depending on the phase of the patient at the time of psychological testing. This explains why some researchers find an entirely different profile with abuse survivors. For example, Roland, Zelhart, Cochran, and Funderburk (1985) reported elevated scores on Scales 1, 3, and 4.

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W. C. Follette, Naugle, and Follette (1997) examined the MMPIs of 85 survivors of sexual abuse and conducted cluster analysis, with the logic that the population of sexually abused women cannot be presumed to be homogenous. With 85 women who presented for group therapy at a university psychological service, the researchers found that a five-cluster solution provided the most meaningful description of the data. The clusters were as follows: Cluster 1 (n = 19) Cluster 2 (n = 15) Cluster 3 (n = 14) Cluster 4 (n = 17) Cluster 5 (n = 20)

6-2-7 8-7-2 4-8-3 8-7-2 Unelevated

Cluster 5 likely reflected women in the stage of defensive avoidance with elevated L and K scores and no report of current symptoms. Abuse survivors in the defensive avoidance state of PTSD show patterns of defensiveness on other psychological tests as well. On the MCMI-II and MCMIIII, for example, they elevate on Social Desirability and possibly on Compulsive or Histrionic Personality Pattern scales. On the Rorschach, as noted previously, they typically give highly constricted protocols, with lambda greater than 1.0 and an absence (i.e., avoidance) of trauma content (Kaser-Boyd, 1993, 2007). Having established the pervasive and intensive harm done to the abused, let us turn to what psychotherapy and supervision might accomplish by way of repair. T H E R A P E U T I C I N T E RV E N T I O N S F O R A B U S E D C L I E N T S Therapeutic interventions for the abused patient range from short-term, crisisoriented therapy to long-term, in-depth psychotherapy. Theoretical orientation is less important than an understanding of the impact of abuse. Approaches range from the behavioral (Foa, Steketee, & Olasov, 1989), cognitive-behavioral (Dutton, 1992; L. E. A. Walker, 1994), and interpersonal (A. K. Hess, 1997), to the feminist (L. E. A. Walker, 1994) and psychodynamic (Herman, 1992b). This chapter cannot do justice to each type of abuse and the variety of theoretical approaches or techniques that may be helpful but offers general principles of treatment and suggest references for further exploration. CRISIS INTERVENTION Many clients who have been abused will begin their contact with therapists when they are in crisis, and they will start by calling a suicide hotline or by fleeing to a battered women’s shelter. The needs of a client in crisis are different than those of the client who has achieved a measure of safety and is ready to start on rebuilding her life. In the crisis intervention stage, the primary focus is on safety, whether the client is a risk to herself or in fear of harm by another. In crisis intervention, the therapist needs to know her community resources. He or she needs to know how to get the client accepted into a safe house (or hospital, should self-harm be the issue), what to do about the client’s children, and how to file criminal charges

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against a perpetrator or apply for a temporary restraining order. In assisting with these practical interventions, the therapist may feel more like a social worker, but the therapeutic effects of these interventions are incalculable because they communicate the therapist’s understanding of the life-threatening nature of the problem and his or her sensitivity to the client’s fear and entrapment. Unfortunately, many clients return to an abusive situation after this type of intervention. For example, the clinical and empirical literature on shelter outcome suggests that about one third of the residents return to their batterer upon leaving the shelter. One follow-up study reported that 33% of the women intended to leave the batterer at discharge but 55% were still living with the batterer (Okun, 1988). For many, this is a result of simple economics—no job, no alternative housing, no way to feed children. Some are seduced back into the abusive relationship with apologies and promises to improve. Others find life at the shelter unbearable or find it difficult to give up hope that they can save their marriage. Many return simply because they feel more comfortable knowing what their battering husband is doing and thinking, having come to rely for survival on predicting his violence. In reality, leaving a batterer is dangerous. Half of battered women who leave their batterers continue to be harassed (Moore, 1979). One third of all women killed are killed by spouses, and women are more likely to be killed by a spouse than a stranger (Greenfield et al., 1998; Levy, 1984). In a Florida study (Bernard, Vera, Vera, & Newman, 1982) of the lethal assaults by men on their wives, 57% of the women had been trying to separate. A large U.S. Department of Justice survey of homicide rates indicated that two thirds of ex-spouses murdered by intimates were women (Greenfield et al., 1998). Battered women have real glimpses of the dangerousness of their partners, even though they have often been urged to ignore their gut feelings. The return of a victim to an abusive situation is demoralizing to the therapist. It will likely feel as if the therapist, too, is powerless and devalued, like the client. This activates countertransference issues that are central to supervision. It is conceivable that some abuse victims will be able to recover and move on with just crisis intervention. An immediate response to crisis intervention is more likely in situations of one-time trauma (e.g., a date rape). Repeated abuse by an intimate partner or multiple types of abuse (e.g., childhood sexual abuse plus intimate partner violence) are more likely to create levels of fear and dysfunctional adaptations that require therapeutic intervention.

PSYCHOTHERAPY Although psychotherapy has an important first stage that surrounds crisis intervention and the establishment of safety (Herman, 1992b), by definition it involves more long-term personality change, or, in a cognitive-behavioral context, a reworking of the ways the client thinks about herself and others. Therapy is a highly individualized endeavor, a set of working goals defined by the client’s needs and abilities and the therapist’s framework/orientation. Certain issues are more common to one subgroup of abused women than another. There are, however, some general guidelines.

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First, the client must be able to develop trust in the therapist. Trust is a paramount issue for a trauma survivor, and a significant amount of time may be needed to establish a trusting relationship. Because the survivor of abuse has been powerless, it is especially important that the therapist not assume a power role in the therapy. The principles outlined in handbooks of feminist therapy are important, even if the therapy is not being conducted from a feminist perspective. Therapist and client should be equals, mutually setting goals and evaluating progress. This may be difficult for some therapists, and it is a challenge if the client’s judgment has not yet improved. An abused client becomes a survivor of abuse when the therapy empowers her and she reestablishes some sense of control over her body and life. Part of building a trusting relationship is setting clear therapeutic boundaries (e.g., regarding the therapist’s policy of accepting emergency phone calls, and how cancelled sessions are handled). The therapist can model for a client who has poor boundaries the way to assert and maintain good boundaries. L. E. A. Walker (1994) explored the differences between effective therapy for survivors and traditional therapy techniques. Calling this survivor therapy, she emphasized careful listening and validation, education versus interpretation and the timing of confrontation, avoidance of victim blaming, building on client strengths rather than lengthy explorations of the causes of her choices, expansion of alternatives, empowerment, and restoration of clarity in judgment. Education is particularly important because it helps the abused person see common patterns of abusive people and therefore helps her overcome an inclination to deny or minimize abusive behavior and to engage in self-blame. Herman (1992b), from a modified psychodynamic perspective, described a three-stage process of treatment. In the first stage, the central task is the development of safety. This involves finding an environment with physical safety, as well as establishing a safe, trusting relationship with the therapist, learning that her symptoms are a normal response to trauma (i.e., she is not “crazy”), and establishing control over her body and her world. In the second stage of therapy, the client uses her own voice to describe the trauma. Many trauma therapists describe the therapeutic benefits of recalling and describing trauma memories, perhaps because the terrible memories are so often avoided and kept secret. The simple act of listening and validating can be therapeutic. In this stage of treatment, Herman stated, the patient grieves the losses that trauma causes—the loss of her sense of self, the loss of trust in others, the loss of friends and family, the loss of education and employment opportunities, and perhaps the loss of hope. In this stage, mourning is not different than the mourning of a death; that is, it is a human emotion that resolves in time, allowing the patient to move on. In the third stage, the therapeutic work surrounds helping the patient to reconnect. Herman described reconnection with the healthy aspects of the self, as well as the healthy parts of the community. Many survivors of abuse have either PTSD or complex PTSD (Herman, 1992a). They often find themselves stuck in alternating patterns of high arousal and high avoidance behaviors. Intrusive memories of the abuse and fear of future abuse are constant and interfere with building a new life. High levels of anxiety and fear can interfere with cognition and therefore with school or work. This means that treatment must address the client’s high level of fear and anxiety. Therapeutic schools differ in their approaches to fear/anxiety reduction.

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Individuals with PTSD are hypervigilant to danger. Their sensitivity is a survival strategy based on what they have learned in past situations of danger. As such, the goal of therapy is not to eliminate clients’ sense of danger but to keep it to realistic proportions and to help them structure their new lives in a way that minimizes danger. This involves different components in different cases. With a battered woman, it might mean moving to a new, undisclosed location, living with other people (e.g., roommates), getting a dog (for early warning), or filing a restraining order. Individuals who have been sensitized to violence may have lifelong anxiety that interferes with cognitive abilities and with sleep and relaxation. Psychology and psychiatry can offer many tools for coping with chronic anxiety. For intrusive trauma memories, some therapists might employ a guided imagery technique whereby the woman imagines herself fighting back and winning. Therapies to alleviate chronic anxiety include relaxation training, systematic desensitization, rational-emotive techniques, self-hypnosis, and assertiveness training. Psychiatrists can offer mild anxiety agents such as Ativan or trazedone or more powerful psychotropic drugs such as Abilify (a major tranquilizer) or one of the selective serotonin reuptake inhibitors (e.g., Prozac, Zoloft). Although there are often negative feelings about taking drugs, exposure to chronic stress has been associated with depletion of the essential brain chemical serotonin, and selective serotonin reuptake inhibitors address this depletion. Also, the problems of addiction and chemical escape and problem avoidance complicate the therapeutic use of drugs. Emotions may swing radically from one extreme to another, too. Because they have lived with a person who is unpredictable—sometimes psychologically, physically, or sexually abusive, but at other times interesting, fun, or loving—abused clients may find their feelings about the abuser swinging from love to fear or anger. When abused persons get free of an abusive relationship, they may swing between hope of recovery and a normal life, and despair, or the belief that there will be no safety or love in their futures. Not surprisingly, many survivors of severe, chronic violence receive diagnostic labels of mood disorder or schizoaffective disorder and are prescribed mood-stabilizing drugs such as Depakote. Although these may be helpful, it is important that psychiatric and psychological treatment providers understand that the cause of the symptoms is trauma, and the treatment cannot be solely psychopharmacological. For some women, the clinical picture is more one of depression with anxious features, and when they seek treatment they receive the diagnosis of major depressive episode. Again, it is important for the treatment provider to understand that the roots of the depression are abuse. Although antidepressants (such as Prozac or Zoloft) may be helpful in the short term, there is a significant need for other therapy interventions discussed here. Trauma survivors must grieve for what they have lost—a sense of the world as a good place, a belief in justice, lost or damaged parts of themselves, the idea that the abuser can be different (Herman, 1992b; L. E. A. Walker, 1994). Most trauma survivors develop intense sadness when they overcome their denial and avoidance of these painful realities. Therapy must keep alive the clients’ hopes for their own lives and for searching and finding healthy people in the midst of a flawed world. Anger is a normal reaction to abuse. Although revengeful or vindictive acts are actually quite rare among abused clients, the therapist needs to determine if revenge fantasies are present and determine whether they could be acted on.

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Anger can be an energizer and motivator to get on with life and to live well (L. E. A. Walker, 1994). The therapist should redirect anger into these channels. Severe trauma may result in serious symptoms such as dissociation or even psychotic episodes. Dissociation is, in fact, common in situations of painful or terrifying abuse (Herman, 1992a). The triggers for dissociative experience will be traumatic reminders and other triggers for anxiety; if these can be minimized, or if clients can develop effective coping strategies for high-anxiety situations, dissociative symptoms can be controlled. Intimate partner violence and other abuse by close others (e.g., a father, teacher, clergyman, or a therapist) causes the survivor to have difficulty differentiating people who might cause her harm (L. E. A. Walker, 1994). A survivors of abuse is often overwhelmed by a sense of themselves as permanently damaged. These are major impairments to sense of self and others and are crucial foci of therapeutic intervention. Healing may begin with the trusting, close relationship of therapy itself, but this is usually closely followed by guided involvement with healthy others. The therapist can provide education about red flags that warn about an abusive person, be a sounding board as the trauma survivor describes a new relationship, and can guide the survivor to resources in the community that help overcome her isolation and facilitate the “reconnection phase” (Herman, 1992b). The damaged self heals as abuse is avoided, safety becomes the norm, and successful experiences accumulate. Therapy with trauma survivors typically has many practical aspects as well. Most trauma survivors have had major disruptions in their education, training, or ability to support themselves, and these impede the development of independence and self-protection. Therapeutic support for setting training or financial goals is often crucial. Housing and child care for working mothers are other important issues. An ideal therapist knows his or her community, networks with other professionals, and can help trauma survivors follow the therapist’s lead in solving practical problems. Finally, for many trauma survivors, therapy will need to incorporate a substance abuse component. Many trauma survivors develop a habit of self-medication (Root, 1989). Sometimes this is with prescription drugs, such as Xanex or Vicodan. Common in contemporary culture is the use of easily obtained street drugs such as marijuana or methamphetamine. Alcohol abuse is also common. It would be difficult, if not impossible, to work on the goals of recovery from trauma so long as coping with symptoms involves addiction or drug/alcohol abuse. This may require admission to a rehabilitation program, outpatient drug/alcohol treatment, or perhaps attendance at a self-help group such as Alcoholics Anonymous or Narcotics Anonymous. The therapist may need to reframe some of the ideas from drug/alcohol treatment programs (see L. E. A. Walker, 1994), as concepts such as codependent and enabler are countertherapeutic in patients who have suffered abuse. Treatment plans for survivors of abuse need to be culturally sensitive. The United States and Western Europe now have citizens from all over the world, and many trauma survivors are from cultures where women have no power, suffer extreme abuse (such as genital circumcision), and face extreme social and economic hardship if they attempt to leave an abusive partner or family. L. E. A. Walker (1994) noted that the therapist must be careful not to encourage trauma survivors to give up those adaptive strategies on which their very survival depends. For example,

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hypervigilance to danger can seem paranoid and dysfunctional, but a battered woman has come to know the thoughts and behavior of her batterer, and her vigilance to signs of danger helps to keep her safe. This discussion has focused on individual therapy. Family therapy for trauma survivors may be considered, but the benefits will differ depending on the type of abuse in question. For example, it is generally not recommended for battered women (L. E. A. Walker, 1994). See L. E. A. Walker for a discussion of the pros and cons of group therapy. In-depth therapy may take some time to show effects. L. E. A. Walker (1994) described a successful case in which goals of safety, education, empowerment, and the development of choices were worked on for almost 2 years before the client left her abusive husband. Although most trauma therapists would urge their clients to get out of abusive and dangerous situations, the reality is that this is not always immediately possible.

S U P E RV I S I O N I S S U E S TRANSFERENCE/COUNTERTRANSFERENCE The stories and symptoms of abuse victims can vary from mild to severe; clearly, some accounts of abuse are horrible and cause the therapist to confront the depths of evil and to rework his or her own worldview. Some therapists in training have simply never been exposed to such human cruelty, and others, unfortunately, grew up in homes that were abusive. Hearing stories of abuse stirs strong feelings, and the telling of abuse stories evokes a strong reaction in the client. As a result, there is intensity inherent in the treatment, and it is here that the supervisor’s work is the most important. The abused client may have such a deeply ingrained mistrust of others that a significant portion of the therapy involves simply working on trust. She may have a deeply imbedded dependent interpersonal style, perhaps developed as a coping strategy that helped her survive or cope with anxiety. She may have developed seductive behaviors also as a coping strategy (i.e., to get protection or divert an abuser). She may see the therapist as a rescuer, which puts enormous pressure on the therapist. She may misinterpret the therapist’s words, hearing them as threatening or blaming. She may rapidly shift from idealizing to devaluing the therapist, from being adulating to mistrusting. These are all expected reactions to interpersonal abuse. Therapists, in contrast, may have difficulty hearing the trauma story. There can be muted symptoms of PTSD in those who work frequently with trauma survivors; that is, they can come to see the world as a negative place or people as untrustworthy. Therapists may develop rescue fantasies or, alternatively, may feel critical and blaming of the abused person. For example, in hearing stories of battered women, many ask, “Why didn’t you just leave?” Therapists coping with their own moments of powerlessness may resonate too deeply to the client’s feeling of powerlessness. They may feel angry at the client and move too quickly or strenuously for change. Therapists may also have to deal with their own fear of the perpetrator. This is a reality when, for example, an abusive father is a powerful

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member of the community, or when a batterer still lurks. These are power feelings to which the supervisor must attend regardless of the orientation of the therapy. In summarizing the transference and countertransference issues in the therapy of abused patients, Herman (1992b) stated as follows: Traumatic transference and countertransference reactions are inevitable. . . . Certain protections are required for the safety of both participants. The two most important guarantees of safety are the goals, rules, and boundaries of the therapy contract and the support system of the therapist. (p. 147)

Ladany, Friedlander, and Nelson (2005) distinguished between ordinary burnout in therapists and the emotional exhaustion and vicarious traumatization that occur in the therapists of abuse survivors. Burnout is more likely to appear in older therapists and is manifested by boredom, cynicism, and depression, whereas young therapists are more vulnerable to vicarious traumatization. Ladany et al. indicated that emotional exhaustion can occur when a therapist feels overloaded, hopeless, or weighed down from listening to painful clinical material. Vicarious traumatization, in contrast, results from the negative cognitive and emotional impact on the therapist’s personal sense of security from hearing the horrible stories of trauma survivors. They noted that the therapist may even develop signs of PTSD such as irritability or hyperarousal, as well as experience a change in perceptions about the nature of the world, about being safe in the world, and about being able to control one’s destiny. Supervisors need to be able to detect emotional exhaustion and vicarious traumatization; understand how these conditions arise; and be able to support the student, process the events, and use them as learning opportunities. The goals of supervision include teaching the trainee to balance workload and to work in the supervision hour toward assimilation. Ladany et al. noted that the use of empathy in supervision (i.e., empathy for the supervisee’s struggles with the issues and feelings of abuse and suffering) cannot be understated. The patient’s struggle to survive may merge in the supervisee with his or her anxiety about his or her professional survival, and the two levels of hazard may cause the therapy and the supervision to take on a life-and-death urgency (Alonso & Rutan, 1988). If the patient drops out of therapy, proceeds with self-injury, or commits suicide, the therapist may feel shame and fear the supervisor’s castigation and abandonment. Supervision should be sensitive to the dynamics of projective identification—these are the patients most sensitive to shame and fears of abandonment, feelings that may be disowned and projected onto the therapist, who comes to supervision as a target of negative projections (Alonso & Rutan, 1988). The supervisor may then be in a quandary about his or her exact role with the trainee—mentor, teacher, or therapist. This calls for openness and clarity of vision in the supervisor so that the trainee will feel contained and supported through a learning crisis. DANGEROUSNESS A chapter on supervision of the therapy of abused patients would be incomplete without attention to the potential for danger in these cases. Therapists and

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supervisors in cases involving a battered woman should be acutely aware of the psychological threat to the woman and perhaps to her therapist. The risk of harm to the battered woman attempting to separate from a batterer is high, as noted previously. In some cases, it is the batterer who is at risk, especially in the midst of an actual battering when the battered woman may perceive the need to defend herself. These are explosive, emotion-driven relationships, and, in reality, either partner can be at risk. L. E. A. Walker (1994) discussed the therapist’s role in helping battered women make an escape or safety plan should the level of danger escalate. A typical crisis plan starts with the recognition that when the abuse is escalating, the risk of being hurt is greater than before. Battered women are usually accurate in predicting a battering incident, although many say they are afraid to leave during those times because of fear of harm to children, pets, or valued possessions (e.g., heirlooms). Valued possessions can be slowly removed and stored for safe-keeping, but plans for children and pets are more difficult. Getting young children or multiple children out of the house is a daunting task that usually requires assistance from a family member, advocate, or the police. Pets are equally difficult; most shelters cannot accept pets but some have arrangements with local boarders or veterinarians. A safety and escape plan often involves hidden money, clothes, or provisions, perhaps stored with a friend or family member. The survival pack includes important papers, such as immigration papers, birth certificates for children; keys such as to safe deposit boxes; and financial records. Therapist and supervisor need to understand that encouraging a woman to leave a batterer may put her in danger (L. E. A. Walker, 1994), and they must help her prepare by making her aware of the potential for stalking and protection against stalking and future harm. The therapist and supervisor should be familiar with the procedure for filing for restraining orders in their jurisdiction. A truly violent abuser will not be stopped by a restraining order, but often the police will not respond effectively to stalking or other types of threatening behavior if a restraining order is not in place. Danger exists in a different form for survivors of incest or severe child abuse. Here, the danger is more likely suicide. Survivors of severe childhood abuse, as noted previously, may have come to feel permanently damaged. They may be overwhelmed, at times, with utter despair for themselves or the world. This is not unusual for people who have had a glimpse of evil. Sometimes they simply seek an end to their pain. The therapist and supervisor should create a plan to regularly monitor suicidal ideation. Some therapists make a suicide contract with the client, which involves an agreement to call the therapist or set up an emergency session. Some patients, however, lose hope even in their therapist and may not be able to follow such a plan when in deep despair. This requires the therapist to be acutely sensitive to patterns from prior suicide attempts. At times of anticipated crisis, an increase in the level of care (e.g., transfer to an inpatient setting) or a mobilization of another type of support (e.g., a temporary stay with a family member) may be required. These patients may also self-mutilate or engage in self-destructive and dangerous acts (e.g., polysubstance abuse, drunk driving). These behaviors should be regularly addressed in therapy to discover the precursors to self-destructive acts and search for alternative ways to act out anger or self-soothe.

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OTHER ISSUES The supervisor, who is likely a permanent or long-time resident of the community, should be able to teach the trainee, who is likely a new member of the community, about community resources. He or she should be knowledgeable about the jurisdiction’s laws surrounding domestic violence and child abuse (K. D. Hess, 2006a, 2006b) and be especially familiar with the ethical standards of psychologists and forensic psychologists (A. K. Hess, 2006). An important additional task of supervision in cases of abuse is teaching careful record keeping (L. E. A. Walker, 1994). Some of these cases will inevitably involve the justice system (i.e., child custody, criminal charges of spousal abuse, civil suits for emotional damage, even perhaps a domestic homicide or accusations of malpractice). This makes it crucial to keep good records. Particularly important in the legal context are the following:

r Documentation of the psychological and psychiatric effects of abuse: The clinical notes should indicate that the clinician has considered diagnoses related to abuse (e.g., PTSD, Dissociative Identity Disorder, complex PTSD), how these were assessed, and how the diagnosis relates to the abuse experience. r A written record of risk assessment: The clinical notes should specify in detail how risk to self or others was evaluated and what therapeutic plan was employed. CONCLUSION Working with an abused client can be one of the most difficult therapeutic assignments, challenging all of the therapist’s (and supervisor’s) preconceived beliefs about the world and himself or herself, but it can also be one of the most rewarding, especially when real progress toward psychological health, safety, and hope is made. REFERENCES Alonso, A., & Rutan, J. S. (1988). Shame and guilt in psychotherapy supervision. Psychotherapy, 25, 576–581. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Armstrong, J., & Kaser-Boyd, N. (2003). Projective assessment of trauma. In M. Hersen (Series Ed.) & M. Hilsenroth & D. Segal (Vol. Eds.), Comprehensive handbook of psychological assessment: Vol. 2. Objective and projective assessment of personality and psychopathology (pp. 476–484). New York: Wiley. Bernard, G. W., Vera, H., Vera, M., & Newman, G. (1982). “Till death do us part”: A study of spouse murder. Bulletin of the American Academy of Psychiatry and Law, 19 (4), 271–280. Bremmer, J. D., Licinio, J., Darnell, A., Krystal, J. H., Owens, M. J., Southwick, S. M., et al. (1997). Elevated CSF corticotrophin-releasing factor concentrations in posttraumatic stress disorder. American Journal of Psychiatry, 154, 624–629. Burgess, A., & Holmstrom, L. (1974). Rape trauma syndrome. American Journal of Psychiatry, 131, 981–986. Burnam, M. A., Stein, J. A., Golding, J. M., Siegel, J. M., Sorenson, S. B., Forsythe, A. B., et al. (1988). Sexual assault and mental disorders in a community population. Journal of Consulting and Clinical Psychology, 56, 843–850. Carmen, E. H., Rieker, P. P., & Mills, T. (1984). Victims of violence and psychiatric illness. American Journal of Psychiatry, 141, 378–383.

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Cicchetti, D., & Lynch, M. (1995). Failures in the expectable environment and their impact on individual development: The case of child maltreatment. In D. Cicchetti & D. J. Cohen (Eds.), Developmental psychopathology (Vol. 2 , pp. 32–71). New York: Wiley. Cling, B. J. (2004). Rape and rape trauma syndrome. In B. J. Cling (Ed.), Sexualized violence against women and children (pp. 13–40) . New York: Guilford Press. Craine, L. S., Henson, C. E., Colliver, J. A., & MacLean, D. G. (1988). Prevalence of a history of sexual abuse among female psychiatric patients in a state hospital system. Hospital and Community Psychiatry, 39, 300–304. DeBellis, M. D. (2001). Developmental traumatology: The psychobiological development of maltreated children and its implications for research, treatment, and policy. Development and Psychopathology, 13, 539–564. DeBellis, M. D., Lefter, L., Trickett, P. K., & Putnam, F. W. (1994). Urinary catecholamine excretion in sexually abused girls. Journal of the American Academy of Child and Adolescent Psychiatry, 33, 320–327. DeBellis, M. D., & Putnam, F. W. (1994). The psychobiology of childhood maltreatment. Child and Adolescent Psychiatric Clinics of North America, 3, 663–677. Dutton, M. A. (1992). Healing the trauma of woman battering: Assessment and intervention. New York: Springer. Edwards, E., Harkins, K., Wright, G., & Menn, F. (1990). Effects of bilateral adrenalectomy on the induction of learned helplessness. Behavioral Neuropsychopharmacology, 3, 109–114. Engels, M. L., Moisan, D., & Harris, R. (1994). MMPI indices of childhood trauma among 110 female outpatients. Journal of Personality Assessment, 63, 135–147. Fear: The brain plus emotions (2003, March). Discover Magazine, 33–39. Fish-Murray, C. C., Koby, E. V., & Van Der Kolk, B. A. (1987). Evolving ideas: The effect of abuse on children’s thought. In B. A. van der Kolk (Ed.), Psychological trauma (pp. 89–110). Washington, DC: American Psychiatric Press. Foa, E. B., Steketee, F., & Olasov, B. (1989). Behavioral/cognitive conceptualization of posttraumatic stress disorder. Behavior Therapy, 20, 155–176. Follette, V. M., Polusny, M. A., Bechtle, A. E., & Naugle, A. E. (1996). Cumulative trauma: The impact of child sexual abuse, adult sexual assault, and spouse abuse. Journal of Traumatic Stress, 9, 25–36. Follette, W. C., Naugle, A. E., & Follette, V. M. (1997). MMPI-2 profiles of adult women with child sexual abuse histories: Cluster-analytic findings. Journal of Consulting and Clinical Psychology, 65, 858–866. Friedman, A. F., Lewak, R., Nichols, D. S., & Webb, J. T. (2001). Psychological assessment with the MMPI-2. Mahwah, NJ: Erlbaum. Greenfield, L. A., Rand, J. R., Crave, D., Klaus, P., Perkins, & C., Ringel, C. (1998). Violence by intimates: Analysis of violence by former spouses, boyfriends, and girlfriends. Washington, DC: U.S. Department of Justice, Bureau of Justice Statistics. Griffith, P. L., Myers, R. W., Cusick, G. M., & Tankersley, M. J. (1997). MMPI-2 profiles of women differing in sexual abuse history and sexual orientation. Journal of Clinical Psychology, 53, 791–800. Herman, J. L. (1992a). Complex posttraumatic stress disorder: A syndrome in survivors of prolonged and repeated trauma. Journal of Traumatic Stress, 5, 377–391. Herman, J. L. (1992b). Trauma and recovery. New York: Basic Books. Herman, J. L., Perry, J. C., & Van Der Kolk, B. A. (1989). Childhood trauma in borderline personality disorder. American Journal of Psychiatry, 146, 490–495. Hess, A. K. (1997). The interpersonal approach to the supervision of psychotherapy. In C. E. Watkins (Ed.), Handbook of psychotherapy supervision (pp. 63–83). New York: Wiley. Hess, A. K. (2006). Practicing principled forensic psychology: Legal, ethical, and moral considerations. In I. B. Weiner & A. K. Hess (Eds.), The handbook of forensic psychology (pp. 821–850). Hoboken, NJ: Wiley. Hess, K. D. (2006a). Understanding adult domestic law issues: Marriage, divorce, and domestic violence. In I. B. Weiner & A. K. Hess (Eds.), The handbook of forensic psychology (pp. 73–97). Hoboken, NJ: Wiley. Hess, K. D. (2006b). Understanding child domestic law issues: Custody, adoptions, and abuse. In I. B. Weiner & A. K. Hess (Eds.), The handbook of forensic psychology (pp. 98–123). Hoboken, NJ: Wiley. Hilberman, E. (1976). Rape: The ultimate violation of the self. American Journal of Psychiatry, 133, 436–437. Kahn, F. I., Welch, T., & Zillmer, E. A. (1993). MMPI-2 profiles of battered women in transition. Journal of Personality Assessment, 60, 100–111. Kaser-Boyd, N. (1993). Rorschachs of women who commit homicide. Journal of Personality Assessment, 60, 458–470. Kaser-Boyd, N. (2004). Battered woman’s syndrome: Clinical features, evaluation, and expert testimony. In B. J. Cling (Ed.), Sexualized violence against women and children (pp.41–70). New York: Guilford Press.

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Kaser-Boyd, N. (2007). Battered woman syndrome: Assessment-based expert testimony. In C. Gacano, F. B. Evans, N. Kaser-Boyd, & L. Gacano (Eds.), Handbook of forensic Rorschach psychology (pp. 467–488). Mahwah, NJ: Erlbaum. Keane, T.M., Malloy, P. F., & Fairbank, J.A. (1984). Empirical development of an MMPI subscale for the assessment of combat-related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 52, 888–891. Kilpatrick, D. G., Veronen, L. J., & Resick, P. A. (1981). Effects of a rape experience: A longitudinal study. Journal of Social Issues, 37, 105–122. Ladany, N., Friedlander, M. L., & Nelson, M. L. (2005). Critical events in psychotherapy supervision. Washington, DC: American Psychological Association. LeDoux, J. (1996). The emotional brain: The mysterious underpinnings of emotional life. New York: Simon & Schuster. LeDoux, J. (1998). Fear and the brain: Where have we been, and where are we going? Biological Psychiatry, 44, 1229–1238. Leifer, M., Shapiro, J. P., Martone, M. W., & Kassem, L. (1991). Rorschach assessment of psychological functioning in sexually abused girls. Journal of Personality Assessment, 56, 14–28. Levy, B. (1984). Skills for violence-free relationships. Santa Monica: Southern California Coalition on Battered Women. Meiselman, K. C. (1980). Personality characteristics of incest history psychotherapy patients: A research note. Archives of Sexual Behavior, 9 (3), 195–197. Meyer, C. B., & Taylor, S. E. (1986). Adjustment to rape. Journal of Personality and Social Psychology, 50, 1226–1234. Moore, D. M. (1979). Battered women. Beverly Hills, CA: Sage. Morrell, J. S., & Rubin, L. J. (2001). The MMPI-2 posttraumatic stress disorder and women domestic violence survivors. Professional Psychology: Research and Practice, 32, 151–156. Nash, M. R., Hulsey, T. L., Sexton, T. C., Harralson, T. L., & Lambert, W. (1993). Long-term sequelae of childhood sexual abuse, perceived family environment, psychopathology, and dissociation. Journal of Consulting and Clinical Psychology, 61, 276–283. Okun, L. (1988). Termination or resumption of cohabitation in women battering relationships: A statistical study. In G. Hotaling (Ed.), Coping with family violence: Research and policy perspectives. Newbury Park, CA: Sage. Perrin, S., Van Hasselt, V. B., Basilio, I., & Hersen, M. (1996). Assessing the effects of violence on women in battering relationships with the Keane MMPI-PTSD Scale. Journal of Traumatic Stress, 9, 805–816. Pynoos, R. S., Steinberg, A. M., & Wraith, R. (1995). A developmental model of childhood traumatic stress. In D. Cicchetti & D. J. Cohen (Eds.), Developmental psychopathology (Vol. 2, pp. 72–95). New York: Wiley. Rhodes, N. R. (1992). Comparison of MMPI psychopathic deviate scores of battered and nonbattered women. Journal of Family Violence, 7 (4), 297–307. Rhodes, N. R., & McKenzie, E.B. (1998). Why do battered women stay? Three decades of research. Aggression and Violent Behavior, 3, 391–406. Roland, B. C., Zelhart, P. F., Cochran, S. W., & Funderburk, V. W. (1985). MMPI correlates of clinical women who report early sexual abuse. Journal of Clinical Psychology, 41, 763–766. Rollstin, A. O., & Kern, J. M. (1998). Correlates of battered women’s psychological distress: Severity of abuse and duration of the postabuse period. Psychological Reports, 82, 387–394. Root, M. P. P. (1989). Treatment failures: The role of sexual victimization in women’s addictive behavior. Journal of Orthopsychiatry, 59, 542–549. Rose, D. S. (1986). “Worse than death”: Psychodynamics of rape victims and the need for psychotherapy. American Journal of Psychiatry, 143, 817–824. Rosewater, L. B. (1988). Battered or schizophrenic? Psychological tests can’t tell. In K. Yllo & M. Bograd (Eds.), Feminist perspectives on wife abuse (pp. 200–216). Newbury Park, CA: Sage. Santiago, J. M., McCall-Perez, F., Gorcey, M., & Beigel, A. (1985). Long-term psychological effects of rape in 35 rape victims. American Journal of Psychiatry, 142, 1338–1340. Schumm, J. A., Stines, L. R., Hobfoll, S. E., & Jackson, A. P. (2005). The double-barreled burden of child abuse and current stressful circumstances on adult women: The kindling effect of early traumatic experience. Journal of Traumatic Stress, 18, 467–476. Scott, R. L., & Stone, D. A. (1986). MMPI measures of psychological disturbance in adolescent and adult victims of father-daughter incest. Journal of Clinical Psychology, 42, 251–259. Stein, M. B., Koverola, C., Hanna, C., Torchia, M. G., & McClarty, B. (1997). Hippocampal volume in women victimized by childhood sexual abuse. Psychological Medicine, 27, 1–9.

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Sutherland, S., & Scherl, D. J. (1970). Patterns of response among victims of rape. American Journal of Orthopsychiatry, 10 (8), 503–511. Teicher, M. H. (2002, March). Scars that won’t heal: The neurobiology of child abuse. Scientific American, 68–75. Tsai, M., Feldman-Summers, S., & Edgar, M. (1979). Childhood molestation: Variables related to differential impacts on psychosexual functioning in adult women. Journal of Abnormal Psychology, 88, 407–417. van der Kolk, B. A. (2005). Developmental trauma disorder: Towards a rational diagnosis for chronically traumatized children. Psychiatric Annals, 35, 401–408. van der Kolk, B. A., Roth, S., Pelcovitz, D., Sunday, S., & Spinazzola, J. (2005). Disorders of extreme stress: The empirical foundation of a complex adaptation to trauma. Journal of Traumatic Stress, 18, 389–399. Walker, E. A., Unitzer, J., Rutter, C., Gelfand, A., Saunders, K., VonKorff, M., et al. (1999). Costs of health care use by women HMO members with a history of childhood abuse and neglect. Archives of General Psychiatry, 56, 609–613. Walker, L. E. A. (1979). The battered woman. New York: Harper & Row. Walker, L. E. A. (1984). The battered woman syndrome. New York: Springer. Walker, L. E. A. (1994). Abused women and survivor therapy. Washington, DC: American Psychological Association. Zivney, O. A., Nash, M. R., & Hulsey, T. L. (1988). Sexual abuse in early versus late childhood: Differing patterns of pathology as revealed on the Rorschach. Psychotherapy—Theory, Research, and Practice, 25, 99–106.

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C H A P T E R 19

Supervising Substance Abuse Treatment: Specific Issues and a Motivational Interviewing Model MICHAEL B. MADSON, EMILY E. BULLOCK, ALAYNA C. SPEED, and SHIRLEY A. HODGES

TREATING SUBSTANCE use disorders (SUDs) is full of unique issues that are absent from general mental health services. These issues include (a) a changing paradigm in relation to the treatment of SUDs, (b) gaps in training, (c) the need to address coexisting conditions, (d) an increasing emphasis on evidence-based practices (EBPs), and (e) service provision by recovering and nonrecovering individuals. As a result, clinical supervision of those providing treatment for SUDs also consists of unique issues that affect the supervisory relationship, required expertise of the supervisor, and how supervision may be provided. Specifically, the clinical supervisor needs to be cognizant of the historical perspectives relating to treatment of SUDs, mental health supervisees’ education and training gaps, clinician attitudes toward substance abusers, and the differences in supervising recovering and nonrecovering clinicians. These issues provide unique challenges to the clinical supervisor. In addition to discussing the unique issues related to providing supervision for those treating SUDs, we present an approach to providing supervision in this and other settings based on the principles of motivational interviewing (MI), an active, directive approach to exploring and resolving ambivalence related to behavior change (Miller & Rollnick, 2002). It is our stance that the founding principles of MI are highly applicable to clinical supervision and translate well to the various roles of a clinical supervisor.

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Supervising Substance Abuse Treatment 341 H I S T O RY A N D D E V E L O P M E N T S In order to provide effective supervision of those treating SUDs, one needs to understand the historical context and developments in this area. Traditionally, SUD treatment was based on what is often referred to as the disease model of treatment (Wallace, 2003). This model consisted of intensive long-term specialty treatment in a hospital or residential setting that focused solely on treating the substance use problem, often to the exclusion of other mental health and social issues (Miller & Carroll, 2006). These services were often provided by individuals who themselves were in recovery and who had no formal training in how to offer counseling services (Culbreth & Borders, 1998). As a result, services were often confrontational and directed at removing denial, rather than empathic and focused on building a therapeutic relationship. Similarly, clients were expected to fit into this traditional treatment system (e.g., confrontation, long term) as opposed to receiving individualized treatment. Although this traditional approach, based on the disease model of treatment, was the standard treatment for decades, limitations of this model exist in today’s complex view of substance use problems (K. M. Carroll & Miller, 2006). One major limitation that results from a belief in this traditional approach to treating SUDs is the stigma associated with those who abuse substances (e.g., dependent or not, breaking through resistance, all users morally deficient) and with treatment of these problems (K. M. Carroll & Miller, 2006). More specifically, SUD specialty services provided in inpatient or residential treatments tended to be targeted toward individuals diagnosed as dependent on a substance, focusing solely on the substance problem while not addressing other psychiatric or social problems. The problematic use of substances does not occur in isolation. It often affects other aspects of individuals’ lives (e.g., work, relationships, physical health) and coexists with other mental health problems (Blanchard, 2000). As a result of a stigma and specificity often associated with traditional substance abuse treatment, individuals at risk for developing significant SUDs often present to mental health workers in outpatient settings primarily to address related problems (J. J. Carroll, 2000; Miller & Carroll, 2006). Furthermore, treatments emphasizing confrontation and “breaking the person down” communicate a message of distrust and a belief that substance use is immoral or wrong (Richmond & Foster, 2003). For this reason, a number of individuals at risk for developing significant substance use problems do not receive services, as they avoid entering the traditional SUD treatment system (Westermeyer, 2005). There is a changing paradigm in the treatment of SUDs. This change relates to the recognized need for treatment that includes primary care in addition to specialized care (McLellan, 2006). Furthermore, research has shown that counseling services have a positive impact on length of involvement and compliance with treatment, participation in comprehensive peer support services, and retained abstinence (Moos, 2003). Given the demonstrated importance of counseling in relation to substance use problems, it is imperative that those providing treatment for SUDs receive formal training in counseling and mental-health-related services (Culbreth & Borders, 1999). Yet there appears to be a gap in the training and practice of many mental health supervisees in relation to their ability to work with those who abuse

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substances, which leaves room for skilled supervisors to intervene by providing guidance.

S P E C I A L S U P E RV I S I O N I S S U E S I N S U B S TA N C E USE DISORDERS EDUCATION AND TRAINING GAPS Those providing mental health services (we are using the term supervisee to represent all mental health professionals) are increasingly called to assess and intervene when problem substance use arises (J. J. Carroll, 2000). Yet often, in reality, problematic substance use goes unnoticed and untreated by the mental health supervisee. The supervisee may not identify substance use problems because he or she (a) maintains counterproductive attitudes about problematic substance use and its treatment, (b) has minimal training in how to assess and treat SUDs, or (c) views SUD treatment as being outside his or her competency (Washton & Zweben, 2006). These factors may interfere with a supervisee’s ability to recognize and intervene with these problems. Given these issues, it is becoming increasingly imperative that clinical supervisors, especially those providing psychotherapy supervision, address substance use issues in supervision. These issues need to be addressed whether the case relates directly to a SUD or the substance use is part of a larger presenting problem (e.g., previous mental illness for which substance[s] were used to self-medicate, marital or family problems, work-related problems).

CLINICIAN ATTITUDES TOWARD CLIENTS WITH SUBSTANCE ABUSE PROBLEMS Because supervisees’ counterproductive attitudes about problematic substance use and its treatment was cited as an issue that may inhibit mental health supervisees from identifying substance use problems (Washton & Zweben, 2006), supervisors may find this to be an important topic to address with supervisees. In this section, this issue is defined and supervisory suggestions are provided. Attitudes are best conceptualized as behaviors, thoughts, and feelings relevant to one’s (a) likability, (b) approval, (c) attraction, or (d) trust toward someone or something that have developed from life experience and are based on one’s value systems (Eisner, 1986). It has been well documented that mental health supervisees from various backgrounds (e.g., social work, professional counseling, psychology, psychiatry) hold negative attitudes toward substance abuse problems and SUD treatment (Johnson, Booth, & Johnson, 2005; Richmond & Foster, 2003; Spaid & Squires, 2005). A variety of reasons can be provided as to why mental health supervisees hold negative attitudes toward substance abuse problems. For example, attitudes toward those who abuse substances can be affected by psychological phenomena like transference or countertransference, models of the etiology of SUDs such as a moral or disease model, and one’s personal use of substances (Chappel, 1992). Regardless of origin, attitudes have an impact on one’s behavior. For example, J. J. Carroll (2000) found that the attitude a supervisee holds toward substance use (i.e., progressive disease vs. contextual problem) influences their willingness

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Supervising Substance Abuse Treatment 343 to intervene, with supervisees viewing the situation as a disease more likely to intervene. Furthermore, West, Mustaine, and Wyrick (2002) suggested that without formal graduate academic training in SUDs a supervisee’s treatment provided can be heavily influenced negatively by personal attitudes and beliefs. Perhaps most important, however, in the changing context of substance use treatment, one’s ability to experience empathy can be adversely affected by negative attitudes. Empathy, or the ability to see the world through another individual’s eyes, is becoming an increasingly important variable in the new substance use treatment environment. For example, Miller and Carroll (2006) highlighted that client perceptions of counselor warmth and empathy are related to more positive outcomes in treatment. Thus, the ability to express accurate empathy is vital in newer treatment approaches, such as MI, aimed at creating an environment counter to the traditional model of treating SUDs (Adams & Madson, 2006). In fact, Miller and Moyers (2006) suggested that the first step in developing skill in MI involves integrating the spirit of MI, which has a strong foundation in the core conditions (e.g., empathy) of person-centered therapy (Rogers, 1957). Given that attitudes affect one’s behavior, and that the ability to form and express accurate empathy is influenced by attitudes, it behooves training programs to address student attitudes toward substance abuse and its treatment. Furthermore, it appears imperative that clinical supervisors pay particular attention to supervisee attitudes related to substance abusers and substance abuse treatment. TRAINING AND COMPETENCY Another major barrier that inhibits mental health supervisees from treating substance use problems is minimal training in how to assess and treat SUDs (Washton & Zweben, 2006). For example, several studies conducted within the psychology profession have suggested that there exists a major gap between practice needs and training practices relating to substance use treatment (e.g., Cardoso, Pruett, Chan, & Tansey, 2006; Cellucci & Vik, 2001). Lack of training in treating SUDs may lead mental health supervisees to become disinterested or view the treatment of SUDs as being outside their competency. Furthermore, disinterest and feelings of incompetence reinforce the traditional model of substance abuse treatment in which specialists, recovering therapists, or those with specific training in SUDs provide these services as opposed to mental health supervisees. One unfortunate result of this belief is that mental health supervisees may be quick to refer clients into specialty service without trying to address the problem themselves in less intensive care. Referring all clients that present with substance use issues counteracts the increasing call for substance abuse treatment to be integrated with mental health care and provided as primary versus specialty care (Adams & Madson, 2006). In order to address this call for SUDs to be treated in the primary care setting, clinical supervisors in any mental health setting will bear an increasing burden for helping supervisees appropriately assess and treat a variety of substance use issues (Bernard & Goodyear, 2004; Holloway, 1995; Powell, 2004). If the goal of the changing paradigm in substance abuse treatment is to provide more holistic treatment, then clinical supervisors will have to educate and assist

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supervisees in working with SUDs. Supervisors must then face the question of what information is important to impart to supervisees. Although many mental health supervisees have general training in assessment, diagnosis, and treatment, it will behoove supervisors to be familiar with specific issues practitioners face in relation to substance abuse treatment. Powell (2004) suggested that those supervising alcohol and drug abuse counselors hold advanced knowledge about (a) the etiology and course of alcohol abuse and dependence; (b) the role of social, medical, behavioral, and psychological factors; and (c) various treatment approaches. In addition, supervisees need to be informed of the unique nature of providing SUD treatment. Specifically, supervisees would benefit from discussions about (a) the potential for a client to underrepresent substance use—both in type and quantity of substances used; (b) the fact that it is important, as treatment providers, to gain an accurate understanding of a client’s use; (c) the fact that as treatment providers, supervisees may be responsible for monitoring use (e.g., monitoring drug screens); (d) the importance of providing ancillary services to a client’s family (as individuals affected by client’s use or as a enablers of use); (e) the strong potential for a client to return to using (i.e., relapse). Finally, clinical supervisors need to introduce new approaches to SUD treatment such as MI. This unique approach that focuses on (a) expressing empathy for the client’s difficulties, (b) helping the client develop discrepancy between his or her values and use behaviors, (c) rolling with resistance versus confronting it, and (d) supporting the client’s beliefs in his or her ability to change. Furthermore, we suggest that clinical supervisors hold a strong awareness of the unique role of coexisting conditions and be knowledgeable about the increased need to implement EBPs in substance abuse treatment. COEXISTING CONDITIONS Coexisting (also referred to as comorbid or co-occurring conditions or dual diagnosis) psychiatric disorders and SUDs (e.g., an individual carrying a diagnosis of alcohol dependence and Major Depressive Disorder) appear to be the rule rather than the exception in today’s treatment environment. More specifically, lifetime prevalence rates of coexisting psychiatric disorders and SUDs range from about 30% in mood and anxiety disorders to about 50% in Bipolar Disorder (Blanchard, 2000). These prevalence rates rise to about 60% to 80% of coexisting disorders for persons in alcohol and drug treatment. Thus, regardless of treatment setting, mental health and substance abuse treatment supervisees will encounter coexisting conditions as part of their clinical practice. Although coexisting conditions are a reality, few treatment supervisees are adequately prepared to assess and treat them (Hunter et al., 2005). Consequently, supervisees will focus on treating a psychiatric disorder or SUD, often missing the coexisting problem. Considering that few treatment supervisees currently offer comprehensive services for individuals with coexisting conditions, it appears that clinical supervision is one method through which to enhance these services. In order to provide effective supervision of those treating SUDs, supervisors have to be familiar with issues surrounding the coexistence of psychiatric disorders and SUDs. Within the context of SUDs, assessment and diagnosis become increasingly important issues. In particular, treatment supervisees need to be able to discern

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Supervising Substance Abuse Treatment 345 whether an individual’s symptoms are related to a psychiatric disorder or are the effects of using a substance (Washton & Zweben, 2006). For example, chronic use of alcohol can lead to mental status, social, emotional, and biological debilitation that can appear as depression, cognitive deficits, or antisocial personality disorder. In order to address coexisting conditions well in supervision, supervisors need to be familiar with the prevalence rates of psychiatric disorders and SUDs. Furthermore, it is imperative for supervisors to be versed in assessment and diagnosis of both psychiatric disorders and SUDs. This should include knowledge of the interaction of using substances on one’s psychiatric presentation, how substance use exacerbates psychiatric symptoms, and how the removal of substance use affects one’s behavior. In addition to assessment, supervisors need to be aware of different approaches to treating coexisting conditions (e.g., parallel, sequential, or integrated treatment) as well as treatment decision-making models (Mueser, Drake, Turner, & McGovern, 2006). Finally, supervisors need to be aware of the potential problems associated with prescribed medication use in working with coexisting conditions. Some in the SUD treatment field are adamant against using medications at all; however, some individuals with significant psychiatric conditions may benefit from medication use (Washton & Zweben, 2006). As a result, supervisors must be aware of the arguments for and against the use of medication and their own personal attitudes, as well as potential reactions by supervisees, regarding clients’ use of medications in this context. EVIDENCE-BASED PRACTICE The increasing emphasis on the use of EBP in treating SUDs has highlighted the need for the profession to focus on how efficacious treatments are effectively transferred from research to practice (Campbell, Daood, Catlin, & Moskovitz, 2005). For example, the National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism are emphasizing the integration of research findings into professional practice (Campbell, Catlin, & Melchert, 2003). As a result, researchers, educators, and clinicians are examining effective methods of disseminating EBP (Miller, Zweben, & Johnson, 2005; Sholomskas et al., 2005). Research relevant to the use of EBP in supervision (K. M. Carroll & Miller, 2006) has increased the call for educators and clinical supervisors to provide more rigorous evaluations of clinicians using EBPs. In order to do this, those providing feedback need to assess clinician adherence to the model and how competently the EBP was implemented. Falender and Shafranske (2004) noted that formative and summative assessment of competent practice would be enhanced by the availability of reliable and valid assessment tools. Quality measurement tools would assist many educators and supervisors in conducting empirically based evaluations as opposed to relying solely on clinical experience in providing evaluations. These instruments are especially important when an intervention involves complex concepts and evaluators are trying to assess competence, which has been referred to as a “moving target with an elusive criterion” (Robiner, Fuhrman, & Ristvedt, 1993, p. 5). The need for evaluation tools is a necessity for the effective dissemination and implementation of many EBPs (Roberts, Borden, Christenson, & Lopez, 2005).

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The increasing emphasis on EBPs has a significant impact on the supervision process. Most notable is that clinical supervisors will have to develop or maintain competency in the various forms of EBP. The development and refinement of EBPs continues at a fast pace, and, as a result, supervisors will need to maintain a strong connection to these developments in order to foster knowledge and skill developments among their supervisees. To do this, supervisors may need to attend trainings, follow the literature, and participate in practice experiences aimed at enhancing competency relating to a particular EBP. In addition, supervisors will need to develop competency in conducting evaluations of services provided by their supervisees. Providing evaluation is one of the major aspects of clinical supervision (Bernard & Goodyear, 2004). However, as mentioned previously, evaluation within the context of EBPs requires a new set of skills and familiarity with evidence-based assessment tools. Like the EBP movement, the development of evaluation tools is moving rapidly and will require supervisors to follow this evolution closely. New supervisee evaluation tools are discussed later in the chapter. Finally, supervisors will have to develop a keen understanding of the potential conflicts between traditional treatment approaches (e.g., 12-step programs) that have little empirical support (Miller, Wilbourne, & Hettma, 2003) but much allegiance, and treatment approaches that deviate from traditional approaches but have empirical support of their efficacy (e.g., cognitive-behavioral therapy or MI). Differences between supervisee and supervisor in relation to attitudes toward EBPs could have a negative effect on the therapeutic relationship and be viewed as a lack of respect for traditional treatment and one’s experience providing treatment. RECOVERING VERSUS NONRECOVERING SUPERVISEES A unique issue related to supervision within the SUD context is that services are provided by both recovering and nonrecovering helpers. It is important for supervisors to remember that the traditional approach to treating SUDs was to engage individuals involved in their own recovery and who were often laypeople with minimal training in assessment and treatment. However, many of these supervisees gained a vast amount of experience through many years providing treatment. Thus, an important factor for clinical supervisors to account for as a critical part of the supervisory relationship is supervisees’ recovery status (West et al., 2002). Several potential supervisory issues arise when supervising recovering SUD counselors. Similar to minimal training of mental health supervisees to provide SUD services, many recovering counselors, often referred to as paraprofessionals (see Chapter 14), have not received formal training in important treatment issues such as assessment or counseling skills (West et al., 2002). Without formal training there is a potential for counselors in recovery to revert back to the process through which they recovered, and the services provided under these circumstances are more susceptible to the counselors’ personal attitudes and beliefs (West et al., 2002). Therefore, supervisors working with recovering counselors who have not received any formal training need to be particularly cautious. Supervisors must also pay particular attention to their own recovery status in relation to the supervisory relationship when supervising those working with SUDs.

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Supervising Substance Abuse Treatment 347 The impact of supervisor and supervisee recovery status was highlighted in two studies. Culbreth and Borders (1998) suggested that if recovery status was going to be an issue in supervision, it was the responsibility of the supervisor to address it. Building on this study, Culbreth and Borders (1999) found that recovery status did have a significant effect on supervisees’ ratings of the supervisory relationship. Specifically, satisfaction ratings were higher when there was a match between supervisee and supervisor on recovery status for both recovering and nonrecovering supervisees. Competence in managing the supervisory relationship is an important highlight of the Culbreth and Borders studies. More specifically, a supervisor may be taught to think of the supervisory relationship similar to how he or she would approach any diversity-related relationship and pay particular attention to the potential diverse issues between supervisee and supervisor in relation to recovery status. Burkard et al. (2006) addressed the importance of being responsive to diversity issues in supervision and the fact that this responsiveness has a positive impact on the supervisory relationship. More specifically, within the context of the cross-recovery dyad, particular attention could be placed on how to facilitate potentially conflict-laden conversations in supervision relating to differences between supervisor and supervisee. For example, a responsible supervisor would be ready, willing, and able to address issues such as recovery status effects on treatment approaches and how different approaches may impact the supervisory relationship. In training new supervisors to address potentially confrontational conversations and to manage differences between supervisee and supervisor, it may be helpful to train supervisors to adapt a flexible supervisory approach. Motivational interviewing may be a good fit for supervision within the SUD context, as it is a highly utilized therapeutic approach that has a wealth of scientific support (Burke, Arkowitz, & Menchola, 2003; Hettma, Steele, & Miller, 2005) in this setting and provides a foundation to address differences between two people relating to behavior change. Thus, the next section discusses MI as a supervisory style and focuses on training and supervision issues related to this approach.

M O T I VAT I O N A L I N T E RV I E W I N G A S A N I N T E RV E N T I O N A N D S U P E RV I S I O N M O D E L Although social psychology influenced the development of MI (Moyers, 2004), the roots of MI originate in the client-centered psychotherapy of Carl Rogers (Miller & Rollnick, 2004). The focus on the client’s personal motivation and strength is the common bond between MI and the humanistic person-centered approach. Motivational interviewing uses the client’s own resources to help the client move past his or her ambivalence to change (Miller & Rollnick, 2004). Although the techniques and skills of MI are necessary to effectively practice this therapeutic approach, they are not sufficient without the therapist adopting the spirit of MI. According to Miller and Rollnick (2002), the spirit of MI “lies in understanding and experiencing the human nature” (p. 34). Key components of the spirit of MI include emphasizing collaboration, eliciting change from the client

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versus bestowing knowledge on the client, and understanding that the client is responsible for any change that occurs (Miller & Rollnick, 2002). Furthermore, MI emphasizes the client’s internal motivation for change, the normalcy of ambivalence to change, the therapeutic partnership, and the client’s personal responsibility for making positive change (Miller, 2000). Whereas the traditional forms of substance use treatment involve compelling the client to change and confronting the client’s ambivalence to change (Allsop, 2007), MI works with the client’s resistance to change, allowing the client to explore ambivalence (Miller & Rollnick, 2004). PRINCIPLES OF MOTIVATIONAL INTERVIEWING In attempting to offer more specific guidelines for implementing the spirit of MI into practice, Miller and Rollnick (2002) outlined four general principles: (1) Express empathy, (2) develop discrepancy, (3) roll with resistance, and (4) support selfefficacy. The emphasis is on developing a philosophy of MI, not just going through the motions of the techniques. Expressing empathy allows the client to feel accepted, liberating him or her then to change his or her behavior. This skill is crucial to MI and is practiced throughout the process. The attitude that the counselor conveys is one of understanding and respect. This acceptance is not the equivalent of agreeing with or endorsing a client’s particular behavior or opinion; instead, it communicates freedom to change and to explore ambivalence to change. Developing discrepancy permits the client rather than the counselor to argue for a change in his or her behavior. Here, the counselor creates a climate that clarifies the difference between a client’s current actions and his or her future goals and desires. The term discrepancy refers to the importance of changing a behavior, not how much one needs to change (which in MI is termed the behavioral gap). To avoid a client feeling pressured into change while still accomplishing the goal of change, the counselor must aid the client in seeing that a behavior change is vital and must offer an environment in which the client feels comfortable voicing arguments against a current behavior. Rolling with resistance involves avoiding arguing for change with a client and understanding that resisting change is a natural phenomenon. With this understanding, the counselor does not try to persuade or coerce the client to change but rather respects the individual’s choice to change or not to change. Although a counselor offers new information and a different viewpoint, he or she also offers an attitude that allows the client the freedom to take what is useful, leaving the rest behind. Experiencing resistance is a signal to the counselor to modify the approach and move to another way of responding, trusting the client has the key to solving the present problem (Miller & Rollnick, 2002). Self-efficacy lies at the heart of MI. Assuming that the client can choose to change, and providing that he or she wants help, the therapist will be there to offer support. An individual’s opinion about how possible and plausible change is in his or her life is a predictor of how effective treatment will be. Building confidence in one’s ability to change behavior is a goal of MI and, if instilled effectively, should communicate that the client alone is responsible for and capable of personal change. The therapist is simply there to guide and assist in the process, not to take responsibility for changing the client.

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Supervising Substance Abuse Treatment 349 AMBIVALENCE Behavior change is often riddled with ambivalence, or feeling two opposing ways about a situation, decision, or person. In terms of changing a behavior, ambivalence can cause clients to seem stuck in a problem, where troublesome behaviors can become more frequent and challenging. However difficult ambivalence is to experience or observe in an individual, the feeling is a common part of being human and often accompanies the change process (Miller & Rollnick, 2002). Overcoming the conflicting feelings, then, is a necessity for moving forward in the stages of change. Conflicts are categorized into four types, each with its own set of predicaments (Lewin, 1935). The first, the approach–approach conflict, describes a situation in which an individual has two appealing selections with favorable features and can only choose one. The second is the avoidance–avoidance conflict, which has two negative options from which a person must choose. Next, the approach–avoidance conflict consists of an option with both attractive and disagreeable qualities. Last, for the double approach–avoidance type the person must decide between two choices with negative and positive facets. Here, the individual is caught in a trap of seeing the advantages to B and disadvantages to A clearer as he or she comes closer to choosing A and vice versa (Miller & Rollnick, 2002).

TRAINING ISSUES RELATED TO MOTIVATIONAL INTERVIEWING A sense of openness and support is at the essence of developing sound MI knowledge and skills. One strong predictor of success in learning MI and ultimately involving the client in the process of counseling is the interpersonal skill of the counselor (Moyers, Miller, & Hendrickson, 2005). A skill that is indicative of good interpersonal relating and that is central to the spirit of MI is reflective listening, first articulated by Rogers (1957). Reflective listening can be described as conveying acceptance, congruence, and specificity with the goal of trying to understand the client’s experiences from his or her point of view without judgment. Other essential skills needed to maximize interpersonal connections with a client include (a) asking open questions, or questions that cannot be answered with a yes or no response; (b) affirming, or supporting the client in his or her experience; (c) reflecting, or restating what was just said and addressing its meaning to the client and the process; and (d) summarizing, or reflecting and restating a large amount of information in order to solidify meaning or transition into a new topic. Miller and Moyers (2006) outlined eight stages conducive to the mastery of MI. Developing openness to collaboration with the client’s expertise sets the foundation as the first stage of learning MI. This process entails recognizing that the client is an expert on his or her own life and valuing a collaborative work style. After embracing the collaborative nature of counseling, one needs to become proficient in client-centered counseling skills, such as (a) conveying accurate empathy, (b) making open statements, (c) affirming, (d) reflecting, and (e) summarizing (Stage 2). The third stage involves the trainee learning to identify parts of the client’s speech that bring about change (i.e., identifying change talk). Learning this skill is essential to learning the directive aspect of MI, as the probability of successful

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behavior change is contingent on the client following this change talk with a verbal commitment (Amrhein, Miller, Yahne, Palmer, & Fulcher, 2003). However, the trainee needs to learn how to elicit and strengthen this change talk while being careful to avoid evoking resistance. Resistance may happen; however, as the trainee advances, he or she develops the ability to roll with resistance. Once he or she has developed the foundation skills for developing the relationship and exploring ambivalence and evoking change talk, the trainee learns how to work with the client to develop a change plan (Stage 6) and build commitment to implement the change plan (Stage 7). A goal of MI is to help the client change his or her motivation in favor of changing, thus the skills developed at these stages are important to the active phases of the therapeutic approach. Upon developing skill in the relationshipbuilding and change-evoking aspects of MI, the trainee learns to develop the ability to blend MI with other evidence-based treatments such as cognitive-behavioral therapy to facilitate active change in the client (Miller & Moyers, 2006).

M O T I VAT I O N A L I N T E RV I E W I N G A S A S U P E RV I S O RY S T Y L E Motivational interviewing as a therapeutic approach places emphasis on helping individuals explore and resolve ambivalence about behavior change in the hopes that positive change will occur. Many have suggested that MI is an interpersonal style versus a set of techniques (Moyers, Miller, et al., 2005), and as such we suggest that MI can be translated easily into a style of providing clinical supervision. In fact, Miller, Yahne, Moyers, Martinez, and Pirritano (2004) found that a training process including coaching with objective observational feedback (i.e., clinical supervision) showed the most promise in facilitating the clinician’s continued use of MI. Rather than providing an additional review of the theoretical information presented previously, in this section we discuss how aspects of MI fit with the roles and processes of supervision. Specifically, we focus on the roles and functions of a supervisor, the supervisory relationship, and the process through which MI can be integrated into supervision.

ROLES AND FUNCTIONS OF THE SUPERVISOR AND THE MOTIVATIONAL INTERVIEWING FIT Many definitions of clinical supervision have been provided throughout the literature (e.g., M. Carroll, 1996; Haber, 1996; Hess, 1986). Although each of these definitions has some variation, there are common elements across all of these definitions: specifically, that clinical supervision is a distinct intervention that involves an ongoing relationship in which a more senior professional provides education, consultation, support, quality assurance, and evaluation to a junior professional with the goals of increasing competence and enhancing professional development (Bernard & Goodyear, 2004). Therefore, within the supervision context, a supervisor may adopt roles as educator, consultant, supporter, and evaluator. There are distinct functions in which a supervisor may engage while in a certain role, and we discuss how a supervisor can perform these from a MI perspective.

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Supervising Substance Abuse Treatment 351 Educator One of the most common roles a supervisor assumes, providing education in supervision, is a hallmark activity. Within the supervision of substance abuse treatment are several unique issues about which a supervisor may need to educate a supervisee. These issues include how to address situations in which a supervisee feels lied to by a client, how to address issues of confidentiality, and how to work with a client who is in the midst of a relapse. One’s approach to substance abuse treatment, facility policies, and professional ethics will guide the type of education provided in relation to these issues. In educating a supervisee who has felt lied to by a client, a supervisor can discuss the nature of substance use and the fact that this behavior by the client can be expected. However, based on one’s theoretical approach, the discussion can go in different directions. More specifically, a supervisor wanting to emphasize a more traditional approach may encourage the supervisee to directly confront the perceived lie and further provide examples of how to confront the client’s inconsistencies. In contrast, a supervisor wishing to emphasize an approach more consistent with the changing paradigm in substance abuse treatment may (a) explore the supervisee reaction to the perception of being lied to, (b) provide education about the therapeutic relationship and how the client’s behavior may be a signal that something is amiss in the relationship (e.g., the supervisee and client are at different stages of readiness to change), and (c) instruct the supervisee about less confrontational techniques the supervisee can use to address discrepancies in client information (e.g., using double-sided reflections—reflections that highlight both sides of an argument). Unlike other psychological problems, a client’s relapse (i.e., returning back to using a substance) presents a treatment provider with unique situations that may require education and supervision. Relapse can be a tenuous situation for the treatment provider and the client to navigate, as it can be fraught with negative emotions such as disappointment and shame as well as avoidance behaviors (e.g., dropping out of treatment). In helping a supervisee navigate this difficult situation, a supervisor needs to educate him or her about (a) the nature of relapse (e.g., that it is often a natural part of recovery; Marlatt & Donovan, 2005), (b) how to manage his or her personal reactions to a client relapse, and (c) how to help the client learn from a relapse and prevent future relapses. Confidentiality is also an issue when a client is relapsing. Specifically, a supervisor may need to educate a supervisee about how to manage the relapse in the context of client confidentiality. Depending on agency policy, a supervisee may need to disclose that a client has resumed use of a substance, thus breaking client confidentiality. This situation requires a supervisor to help the supervisee navigate the need to break confidentiality while keeping the therapeutic relationship intact. To do this the supervisor can provide the supervisee with strategies to address the situation. For example, the supervisor can role-play with the supervisee a discussion around the relapse and the need to break confidentiality, demonstrating how to relate respect and concern for the client yet acknowledge that he or she must break confidentiality. On the surface, one may see distinct differences between the educator role and MI as a supervision approach. Specifically, education involves providing direct

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information about a certain topic, taking an expert role, and imparting information versus eliciting information. These activities, to some, appear antithetical to the underpinnings of MI that place emphasis on avoiding the trap of seeing oneself as the expert (Miller & Rollnick, 2002) and focusing on behavior change interactions as a collaborative interpersonal process (Moyers, Miller, et al., 2005). On the contrary, the theory of MI is not opposed to providing feedback and education, but given the emphasis on the interpersonal style, it places more emphasis on how the information is provided to the individual (in this case, a supervisee). For example, some supervisors using other models of supervision may explicitly direct a supervisee to implement a certain intervention with a client and proceed to provide education and guidance on how to implement that intervention. This is a process consistent with many models of clinical supervision, but it could be modified slightly to fit more consistently with MI. In providing education, a supervisor incorporating a MI style could begin by first acknowledging the supervisee’s strengths and skills or eliciting from the supervisee areas of knowledge and experiences in relation to working with a particular client or issues. This process is consistent with the MI principles of supporting selfefficacy, eliciting strengths, and affirming (Miller & Rollnick, 2002). Upon evoking from the supervisee strengths and areas of previous clinical experience, the supervisor could shift the discussion to areas for future development. In other words, the supervisor could explore with the supervisee areas in which the supervisee feels the need to receive guidance or education (Martino et al., 2006). This whole process of exploring strengths and areas for development could be equated to the assessment process involved in MI, in which all aspects of one’s behavior and knowledge are evaluated without judgment with the goal of identifying where more information is needed. In essence, the supervisee is teaching the supervisor what he or she needs in relation to education, which parallels the spirit of MI in working with clients (Miller, 2000). Finally, in preparing to provide some guidance and education in supervision, a supervisor utilizing the MI approach may first ask for permission to provide some education and guidance about how to proceed with a particular client. Asking permission to provide information is an important aspect of the interpersonal process of MI (Miller & Rollnick, 2002), communicating respect and the collaborative nature of the supervisory dyad. Consultant Consultation within the supervision context is a more informal problem-solving process. In this process, two or more individuals identify relevant difficulties one of the two therapists may be experiencing in working with a specific client. The therapists can collaborate about some intervention options and then assess the results of the chosen intervention (Bradley & Kottler, 2000). As a therapeutic approach, MI has a central theme of the collaborative nature with which the therapist approaches working with a client (Miller & Rollnick, 2004). This central theme can easily transfer to the supervision relationship. The therapist using MI places emphasis on the client as an expert on his or her experience and the clinician as an expert with experience helping others to make behavior change. As a supervisor applying an MI style, one should adopt a mindset that the supervisee has some

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Supervising Substance Abuse Treatment 353 level of knowledge regarding what he or she needs to develop as a supervisee and that the supervisor has some expertise in how to manage specific situations raised in supervision. The supervisor’s role then is to help the supervisee explore the issues raised in supervision from various standpoints, develop potential options of action, and facilitate supervisee evaluation of the options with the goal of helping the supervisee determine the best course of action from his or her perspective. Supporter Beginning supervisees typically have little exposure to the functions of a therapist (e.g., assessment, psychotherapy). As a result, many beginning therapists experience anxiety about their lack of ability or difficulty learning these functions (Stoltenberg, McNeill, & Delworth, 1998). This can lead to a time of confusion, disorientation, anxiety, and obsession with mistakes. As such, this time may also be filled with great ambivalence about becoming a counselor, working with particular clients, or learning a new skill. Therefore, an important function of the supervisor is to provide support for supervisees during these turbulent times. Supervisors need to provide an environment in which supervisees can examine their behavior; disclose their fears and concerns; and work through areas of weakness, confusion, and conflict (Bradley & Kottler, 2000). Given MI’s emphasis on addressing ambivalence and providing a supportive environment, an MI perspective appears to be a sound approach for this supervisory role. Motivational interviewing borrows from humanistic psychology the concept that if given a supportive environment, people will naturally change in a positive direction (Miller & Rollnick, 2004). Given this perspective, heavy emphasis is placed on the common factors (i.e., empathy, nonjudgmentalness, genuineness) involved in developing a sound working relationship (Harris, Aldea, & Kirkley, 2006). These common factors are vital to the establishment of any working relationship and help the supervisee to feel safe and supported in the relationship. When a supervisee feels safe and supported, he or she may be more willing to address more complex issues, such as his or her anxiety or ambivalence about working with a particular client or issue. Incorporating MI can be a valuable approach to supporting a supervisee through ambivalence given that a major aim of MI is helping an individual explore and resolve ambivalence about behavior change. Learning new counseling skills or a different intervention technique can involve a sense of ambivalence on the part of the supervisee. For example, consider a beginning counselor who needs to begin addressing client inconsistencies in order for the client to make positive change. Developmentally, this can be an anxiety-provoking situation for a supervisee (Stoltenberg et al., 1998). Through use of an MI approach a supervisor, rather than directing a supervisee to begin challenging more, could begin a discussion exploring the pros and cons of discussing client inconsistencies. The supervisor could first ask the supervisee to describe the reasons for not challenging the client, followed by a discussion of the reasons to challenge the client. Throughout this process, the supervisor would remain neutral about the supervisee choice. The supervisor would reflect and ask questions about the supervisee’s responses, highlighting important comments made by the supervisee and paying particular

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attention to the supervisee’s statements that support changing his or her behavior (i.e., change talk). After discussing both sides of the issue in depth, the supervisor can directly ask the supervisee (a) how willing he or she is to discuss client inconsistencies in session and (b) how confident he or she is in his or her ability to discuss client inconsistencies. This is similar to a decisional balance approach to helping a client see the need for change, in which the therapist and client explore the issue, and the therapist elicits change talk from the client, amplifies and reinforces the change talk, and then directly asks the client about willingness and confidence to change (Miller & Rollnick, 2002). The goal of this process in supervision would be to facilitate behavior change without evoking resistance by the supervisee. In addition to exploring supervisee ambivalence in a fashion that may reduce resistance, this approach also models for the supervisee an approach to dealing with difficult discussions with clients. Evaluator Some authors have stated that a defining characteristic of supervision is the evaluation component (M. Carroll, 1996; Holloway, 1992). Through evaluation, the profession attempts to protect the public by controlling who will be eligible to practice and ensuring quality of care. Although evaluation is a critical component of supervision, some supervisors struggle with the role of evaluator, as they see it as inconsistent with their role as a helper. However, evaluation has many positives, providing supervisees with direct and constructive feedback. This feedback can address supervisees’ most and least effective behaviors with the aim of helping supervisees develop as counselors (Bradley & Kottler, 2000). This view of evaluation provides less difficulty for supervisors, as it is consistent with what they may do within psychotherapy. Within the MI context, evaluation is gaining increasing importance as a tool to help supervisees develop (Madson & Campbell, 2006). In fact, feedback is a hallmark activity that often takes place in several adaptations of MI as a therapeutic approach (e.g., motivational enhancement therapy; Miller & Rollnick, 2002). More important than whether to provide feedback is the process through which one provides feedback. More specifically, as an interpersonal style of providing supervision, it is important for a supervisor using MI to provide feedback in an objective and nonjudgmental fashion. This being the case, Rollnick, Miller, and Butler (2008) provided some general guidelines for providing MI-consistent feedback:

r Ask permission to provide feedback to create a climate of respect and trust. r Encourage self-assessment by asking the supervisee for his or her perspective of how the session went.

r Limit the amount of feedback provided by choosing a few important areas. The goal of limiting feedback is to avoid overwhelming the supervisee.

r Provide specific information about observations, perhaps giving direct examples for the supervisee to understand these points.

r Consider the timing of the feedback, keeping in mind that the supervisee may not be ready to hear the feedback.

r Focus the feedback on behaviors rather than on personality traits, and remain nonjudgmental.

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r Offer both positive comments and areas for development in an attempt to offer balanced feedback. Like giving general feedback, it is important to end the supervisory interaction on a positive note. Similarly, the Motivational Interviewing Network of Trainers (2006) offered several guidelines for supervisors to follow in providing feedback from an MI approach. This process is often referred to as the feedback sandwich and is similar to how a therapist would provide feedback to a client using an MI approach (Martino et al., 2006). The feedback sandwich involves (a) eliciting positive experiences from the supervisee, (b) providing affirmation by agreeing with or summarizing some aspect of what the supervisee discussed and perhaps providing additional positive comments, (c) eliciting from the supervisee what he or she might do differently the next time, (d) agreeing with and summarizing areas for growth by providing additional suggestions, and (e) eliciting the supervisee’s reactions to the feedback. In addition to allowing one to provide feedback in a way that facilitates trust and respect, following this method models to the supervisee an effective approach to providing feedback to clients (Martino et al., 2006). In addition to structuring an approach to providing feedback, many in the MI community have placed an emphasis on using evidence-based evaluation tools to facilitate supervisee development in MI. These developments have evolved out of concern about therapist competence and skill in implementing MI. Several measures have been developed to address concerns about MI fidelity and competence (e.g., Lane et al., 2005; Madson, Campbell, Barrett, Brondino, & Melchert, 2005; Moyers, Martin, Manuel, Hendrickson, & Miller, 2005). Although in-depth descriptions of these measures are beyond the scope of this chapter, many of the methods have utility in supervision settings as they offer an evidence-based approach to assessing in-session counselor behavior related to MI. Furthermore, it may appear that these tools are specific to MI, and to some extent they are; however, as many of them assess interpersonal skills vital to any therapeutic approach, they may be valuable to supervisors in general in addition to those utilizing a MI supervisory style. Similar to other models of supervision based on psychotherapeutic approaches, MI appears to be applicable as a supervision approach. Specific aspects of MI such as its interpersonal emphasis, its goals of exploring and resolving ambivalence, its style and process for providing feedback, and the importance it places on the use of evidence-based evaluation tools fit well with the many roles and functions of a supervisor. Furthermore, MI appears to have a developmental perspective, based on its belief in stages of learning, and hence it fits well with developmental approaches to counselor development. All of these factors indicate that MI would be valuable as a supervisory approach. CONCLUSION Little has been written about clinical supervision of treatment of SUDs. However, those who provide supervision in SUD settings must be cognizant of a variety of issues such as recovery status (Culbreth & Borders, 1999), treatment of coexisting conditions (Washton & Zweben, 2006), and allegiance to a traditional treatment

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approach versus empirically based approaches (Miller et al., 2003). These issues will have an impact on the supervision process. Supervisors need to possess a certain skill set that involves knowledge about content issues such as EBP for SUDs, the interplay of SUDs and psychiatric disorders, and the impact of traditional approaches to treating SUDs. Furthermore, unlike the supervision of general mental health services, supervisors of substance use treatment services must be aware of the unique needs of those with less formal training in counseling or those who may be recovering themselves. More specifically, in working with those with less formal training, supervisors may need to focus initially on core counseling skills, the counseling process, and relationship development. Furthermore, in working with recovering counselors, supervisors may need to be able to address differences of opinion in relation to treatment as well as be aware of and able to address counselors’ personal relapses. All of these distinct issues can shape the attitudes of clinicians in relation to treatment and to supervision. This chapter offered an approach to supervision based on the principles of MI. Supervisors can navigate this approach in clinical supervision of SUDs and general mental health settings. Specifically, MI’s emphasis on collaborating, supporting self-efficacy, viewing ambivalence as natural, and eliciting need for change supports the many roles of a supervisor. Furthermore, MI’s emphasis on developing therapy skills and expressing empathy fit with a developmental approach to supervision. Finally, the specific approach of MI to offering feedback provides supervisors a good model for evaluating and giving feedback in a fashion that is aimed at reducing supervisee resistance. More development of MI as a supervisory approach is warranted, but there appears to be a good fit.

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Miller W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). New York: Guilford Press. Miller W. R., & Rollnick, S. (2004). Talking oneself into change: Motivational interviewing, stages of change, and therapeutic process. Journal of Cognitive Psychotherapy, 18, 299–308. Miller, W. R., Wilbourne, P. C., & Hettma, J. (2003). What works? A summary of treatment outcome research. In R. K. Hester & W. R. Miller (Eds.), Handbook of alcoholism treatment approaches: Effective alternatives (3rd ed., pp. 13–63). Boston: Allyn & Bacon. Miller, W. R., Yahne, C. E., Moyers, T. B., Martinez, J., & Pirritano, M. (2004). A randomized trial of methods to help clinicians learn motivational interviewing. Journal of Consulting and Clinical Psychology, 72, 1050–1062. Miller, W. R., Zweben, J., & Johnson, W. R. (2005). Evidence based treatment: Why, what, where, when, and how? Journal of Substance Abuse Treatment, 29, 267–276. Moos, R. H. (2003). Addictive disorders in context: Principles and puzzles of effective treatment and recovery. Psychology of Addictive Behaviors, 17, 3–12. Motivational Interviewing Network of Trainers. (2006). Resources for trainers. Unpublished manual. Available with membership from www.motivationalinterview.org. Moyers T. B. (2004). History and happenstance: How motivational interviewing got its start. Journal of Cognitive Psychotherapy, 18, 291–298. Moyers, T. B., Martin, T., Manuel, J. K., Hendrickson, S. M. L., & Miller, W. R. (2005). Assessing competence in the use of motivational interviewing. Journal of Substance Abuse Treatment, 28, 19–26. Moyers, T. B., Miller, W. R., & Hendrickson, M. L. (2005). How does motivational interviewing work? Therapist interpersonal skill predicts client involvement within motivational interviewing sessions. Journal of Consulting and Clinical Psychology, 73, 590–598. Mueser, K. T., Drake, R. E., Turner, W., & McGovern, M. (2006). Comorbid substance use disorders and psychiatric disorders. In W. R. Miller & K. M. Carroll (Eds.), Rethinking substance abuse (pp. 115–133). New York: Guilford Press. Powell, D. J. (2004). Clinical supervision in alcohol and drug abuse counseling: Principles, models, methods (2nd ed.). San Francisco: Jossey-Bass. Richmond, I. C., & Foster, J. H. (2003). Negative attitudes towards people with co-morbid mental health and substance misuse problems: An investigation of mental health professionals. Journal of Mental Health, 12, 393–403. Roberts, M. C., Borden, K. A., Christenson, M. D., & Lopez, S. J. (2005). Fostering a culture shift: Assessment of competence in the education and careers of professional psychologists. Professional Psychology: Research and Practice, 36, 355–361. Robiner, W. N., Fuhrman, M., & Ristvedt, S. (1993). Evaluation difficulties in supervising psychology interns. Clinical Psychologist, 46, 3–13. Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21, 95–103. Rollnick, S., Miller, W. R., & Butler, C. C. (2008). Motivational interviewing in health care: Helping patients change behavior. New York: Guilford Press. Sholomskas, D. E., Syracuse-Siewert, G., Rounsaville, B. J., Ball, S. A., Nuro, K. F., & Carroll, K. M. (2005). We don’t train in vain: A dissemination trial of three strategies of training clinicians in cognitive behavioral therapy. Journal of Consulting and Clinical Psychology, 73, 106–115. Spaid, W. M., & Squires, S. P. (2005). Changing social work students’ attitudes toward substance abusers through the use of an abstinence assignment: A pilot study. Journal of Teaching in the Addictions, 4, 45–62. Stoltenberg, C. D., McNeill, B. W., & Delworth, U. (1998). IDM supervision: An integrated developmental model of supervising counselors and therapists. San Francisco: Jossey-Bass. Wallace, J. (2003). Theory of 12-step oriented treatment. In F. Rogers, J. Morgernstern, & S. T. Walters (Eds.), Treating substance use disorders: Theory and technique (2nd ed., pp. 9–30). New York: Guilford Press. Washton, A. M., & Zweben, J. E. (2006). Treating alcohol and drug problems in psychotherapy practice: Doing what works. New York: Guilford Press. West, P. L., Mustaine, B. L., & Wyrick, B. (2002). Apples and oranges make a nice start for a fruit salad: A response to Culbreth and Borders (1999). Journal of Counseling and Development, 80, 72–80. Westermeyer, J. (2005). Historical and social context of psychoactive substance use disorders. In R. J. Frances, S. I. Miller, & A. H. Mack (Eds.), Clinical textbook of addictive disorders (3rd ed., pp. 16–36). New York: Guilford Press.

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C H A P T E R 20

Supervising Therapists Treating the Severely Mentally Ill BERTRAM P. KARON

A PATIENT of Gaetano Benedetti (1987) described it well: There was a corpse. Benedetti went into the land of the dead to get the corpse. Benedetti did not want to be there. According to the patient, Benedetti did not like the land of the dead. It scared him. He liked the land of the living. But he went in anyway to get the corpse. He did not try to just bring the corpse out, because you cannot. He dragged the corpse deeper into the land of the dead and through the land of the dead and out the other side. And the corpse came to life, and the corpse, said the patient, was me. How do you teach a student to go into the land of the dead for a patient, go deeper with the patient, and come out the other side? How do you get a student to accept that being uncomfortable is a necessary part of the process, and that not being certain of what is going on is a sign of a good therapist? Certainly not from a manual. To work with the severely disturbed is to be frightened, angry, depressed, bored, discouraged, and confused, because the patients are frightened, angry, depressed, bored, discouraged, and confused, although patients also deal with their confusion by clinging to premature closure. When patients complain that psychotherapy is making them confused, I always say, “Good. You are not sick because you are confused, you are sick because you are sure of things which are not true.” Much of psychopathology consists of believing things that are not true. In addition to delusions, hallucinations, and obvious transferences are false beliefs learned from one’s family or others and reasonable, but wrong, conclusions based on trying to make sense of unusual experiences. These false beliefs usually solve an immediate problem but in the long run make a satisfying life impossible. Rarely are student therapists told that being confused is normal, in fact essential to successful work with severely disturbed patients. Moreover, good therapy with 359

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severely disturbed patients almost always involves improvisation. If what we try works, we continue it. If it does not work, we stop and try something else. The rest of this chapter consists of discussions of conscious resistance (the most important difference between working with psychotics and working with neurotics), supervisory technique, frequency of sessions, phrasing of interpretations, the difference between supervision and psychotherapy, useful didactic material, and the difference between psychoanalysis and psychoanalytic therapy. C O N S C I O U S R E S I S TA N C E A N D T H E R A P I S T C O N F U S I O N What is most confusing to any therapist is that severely disturbed patients not only do not understand their experiences, they do not tell the therapist even what they do understand. They do not trust the therapist. This is the most important difference between neurotics and psychotics.

Case 20.1 A 10-year-old paranoid schizophrenic boy illustrated most clearly the difference between treating a severely disturbed patient and treating a neurotic. After being in treatment between 8 to 12 months, he described a dream. I commented about it, but the patient said nothing. I added, “Well, maybe I’m wrong.” A slight smile appeared on the patient’s lips. “How often do you think you’ve been wrong, Doc?” “I don’t know. Perhaps half the things I say to you don’t fit.” Broader smile. “You haven’t been wrong yet, Doc.” What a beautiful statement about a positive transference! But this was the first time that he had ever indicated that anything had been correct.

Those of us who have worked only with less disturbed patients or neurotics are not prepared for such massive conscious resistance. With less disturbed patients, we usually are told when we are correct or when things improve. We may even get feedback in the form of angry denials or accusations of stupidity for correct interpretations. But such reactions are helpful in guiding the therapy. What is not usual is no apparent reaction at all, a characteristic of the psychotically disturbed. Severely disturbed patients may not want to tell you accurately what their symptoms, experiences, thoughts, fantasies, or feelings are, for fear that such disclosures will get them in trouble or get you to insist on an unhelpful, inappropriate, or even destructive treatment. This is not only transference from unhelpful parents; it is also a transference from unhelpful mental health professionals. PREVIOUS MENTAL HEALTH PROFESSIONALS A group of patients who were participating in peer counseling sessions that they found useful described their reason for seeking out peer counseling: “If you are really hurting, really angry, really depressed, feel like killing yourself, you can’t tell a mental health professional. They don’t want to hear it; they will do something to shut you up or quiet you down. Only another patient will let you talk when you

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Supervising Therapists Treating the Severely Mentally Ill 361 are really hurting.” It would be comforting if we could dismiss their statements as unrealistic. They ought to be unrealistic, but unfortunately they are not. All of these patients reported similar experiences with professionals, even though no patient should ever be treated that way. Some of this may have been due to the professionals’ reaction (e.g., fear, anger, loathing) to the patients’ bizarre symptoms, lack of cooperativeness, apparent lack of control, or apparent dangerousness, as well as to the wrong theories and inadequate resources available to the professional. But the professionals’ motives are not important. What is important is the effect on the patients. The patients need to be able to consciously think about what happened and be able to talk about the fact that it was destructive. Otherwise the patients will usually assume without questioning that they themselves were solely responsible for their mistreatment and that whatever other professionals did was justified. Even if patients believe the professionals were not justified, the patients usually believe that you will defend the bad things the other professionals did, and that you will require the patients to pretend that their mistreatment was justified. It is important to let patients know that you are interested in the truth and in helping the patients to cope with the truth, whatever it is. They will not really believe you initially, but they will begin to consider the possibility that you might mean what you say. Of course, you cannot be sure what happened when you were not there, but you can start with the patient’s version (which usually is true), and you and the patient will discover inaccuracies together. This is no different from discussing any other destructive experiences. But many mental health professionals do not want to know about painful experiences. They really do dismiss bad life experiences as delusional and shut the patient up when the patient wants to talk about them, especially if the patient wants to talk about his or her experiences with strong feelings. Such professionals are more comfortable with treatments that diminish feelings or that do not require listening or understanding at all. That is why it is important to train a new generation of therapists who will let the patient talk. PARENTS AND CONSCIOUS RESISTANCE I have never worked with a psychotic whose life, once I understood it as it was experienced, would not have driven me crazy. Psychotics are more sick than neurotics because their lives have been more painful. John Read and his colleagues (e.g., Read, Goodman, Morrison, Ross, & Aderhold, 2004; Read & Ross, 2003) have documented the abundant evidence that serious disorders can usually easily be found to have arisen from horrible life experiences. Thus, for example, the incidence in persons with schizophrenia of both childhood sexual abuse and childhood physical abuse is far higher than in the general population or in patients with other psychiatric diagnoses. Parents are often concerned that they will be blamed for their child’s disorder. Of course, some parents have been obviously hurtful and destructive. But most parents of schizophrenics are admirable people who will go to great lengths to attempt to get help for their children. Although there are always destructive life experiences in the etiology of schizophrenia, sometimes these experiences have

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nothing to with the parents. Where parents have been hurtful, it is often the result of bad professional advice, an automatic repetition of their parents’ mistakes or of their own childhood traumas (e.g., Fraiberg, 1977), or even a reaction, later, to the child’s symptoms. Frequently, as demonstrated by a series of Thematic Apperception Test studies (Karon & Widener, 1994; Meyer & Karon, 1967), parenting mistakes are the result of unconscious defenses, which like all unconscious defenses are unchangeable until brought into awareness, and consequently are not matters of good or evil but simply problems to be solved. Parents of schizophrenics also have been found to tend to discourage the use of people from outside the family as sources of information and corrective identifications. For most people, these extrafamilial influences are correctives that diminish the bad effects when parents make mistakes (as all parents do). Although discouraging extrafamilial influences may lead to greater family harmony, it has the unintended effect of enormously magnifying the bad effects of any parental mistakes. For most patients, there was a succession of small hurts, each of which changed the conscious and unconscious fantasies that gave meaning to subsequent experiences. The psychotic symptoms are always a reasonable reaction to the events of patients’ lives as subjectively experienced, but not necessarily as an outside observer would evaluate them. When parents ask what caused their child’s disorder, it is helpful to say, truthfully, that you do not know and ask them what they think. They often will tell you.

Case 20.2 The parent–child experiences that lay the basis for conscious resistances (not wanting to tell the therapist even what you know and understand) in severely disturbed patients was best described by the mother of a schizophrenic 6-year-old boy. I discussed the issue of punishment with her. I asked whether she could use some method of punishment other than hitting him. She said, “You don’t understand, doctor. He never lets us know what he likes. If we knew what he liked, we would take it away from him, of course. But he never lets us know what he likes.”

In addition to being afraid that the information will be used by the therapist to hurt them, severely disturbed patients often do not want to tell you how bad their lives have been and in what way, because it feels like disloyalty to the only parents they had, and to whom they still feel loyal. Of course, as Fairbairn (1954) so insightfully described, the most terrifying idea to anyone is that his or her parents were really bad in some way. Then there is no hope. But if what seemed bad is the result of one’s own transgressions, that seems safer, because then there is hope. In Fairbairn’s words, it is better to be morally bad than for things to be unconditionally bad. But then many people could not change because they would discover that their parent would not change. Even when patients complain of their parents, it is often with the hope (usually unconscious) that the professional will tell them they are wrong and urge them to take responsibility for their own defects rather than blame others. That is why when the therapist does not blame the patient, but points out the weaknesses of a parent, or even simply accepts the patient’s complaints about his or her parents, some

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Supervising Therapists Treating the Severely Mentally Ill 363 patients become angry or afraid rather than being relieved. It is also, according to Fairbairn, why some patients irritate you or try to get you to mistreat them. Then they can maintain the belief that, at least as compared to everybody else, including their therapist, their parents were good. S U P E RV I S O RY T E C H N I Q U E Far more important than the technique of supervision is whether the supervisor has anything to teach. You cannot teach what you do not know. If you are not a competent clinical psychoanalyst, you cannot supervise psychoanalysis adequately. If you do not practice psychoanalytic therapy well, you cannot supervise psychoanalytic therapy adequately. If you do not know how to work with severely disturbed patients, the patients will not benefit from the treatment you supervise (e.g., May, 1968). Although supposed experts like to talk about supervisory technique, no supervisory technique will work if the supervisor is teaching what he or she does not know, and any supervisory technique is likely to be helpful to the novice if the supervisor is knowledgeable. In supervision, particularly with early students, the supervisor is a safety net. The student has the security that there is backup for any crisis. The supervisor, however, does not take over the case. I tell supervisees that they know much more about their patients than they can ever communicate to me, and they must use their best judgment, even if they are wrong, and then tell me about it and what happened. “Supervision,” I usually tell supervisees, “is not a substitute for your own judgment. But I can tell you what I hear, and what I would do, and if you cannot think of anything better to do, you can always do what I would do. And, of course, I expect you to review with me everything you do and what happened.” A supervisor can be helpful in providing a solid basis from which the student can operate and can let the supervisee know that a lack of clear information about the progress of the treatment is to be expected. But if the student continues to use his or her own best judgment and does reasonable things, most patients will get better, and they will let the student know eventually what is going on and that he or she is helping them. Not understanding and making mistakes is inevitable, but learning with the patient what needs to be known to cure them is what psychoanalytic therapy is all about. A supervisor should make it safe for the student to experience uncomfortable feelings, including fear, anger, depression, and inadequacy as well as confusion, and should let the student know that not only are such uncomfortable feelings inevitable and simply part of the process, but they are a useful source of information.

Case 20.3 A chronic catatonic schizophrenic man in his 20s had been unsuccessfully treated as a child at several residential centers for disturbed children, underwent a short period of unsuccessful psychoanalytic therapy as an adolescent, and then was unsuccessfully treated at several well-known hospitals. He had been continuously hospitalized at his latest hospital for years. He was mute and immobile, had to be force fed, and was (continued)

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urinally and anally incontinent, although he defecated only approximately once every 6 weeks. He would come out of his catatonic pseudo-stupor (catatonics in fact are aware of everything that is going on), yell one word—“You!” or “Room!” or “Dear!”—and then swing violently. He might hit himself, or the furniture, or you. He did not seem to care if he hit himself, but he had broken furniture. He also had broken the jaws of several attendants at a previous hospital. Consequently, he was usually kept in restraints. I was scared of him. Because of his lack of toilet training, he was also disgusting. But I realized that in addition to being scared and disgusted, I did not like him. It was more than being scared and disgusted; those were rational feelings. I did not like him. My associations led to my childhood. He reminded me of some other boys: “dirty little bastards” who used to beat me up. After a while I grew big, so they stopped beating me, but they continued to beat other boys. At that point it was obvious that it was not fair to hate my patient because of what other “bastards” had done to me as a child. But then I began to think. “Dirty little bastards.” In fact, they were not big guys. Maybe they were scared. My patient was not a big man, although he was muscular. The next time he started to get angry and seemed about to be violent, I said, “I know how scared you are. Why don’t you use my strength to protect you?” He quieted right down, and his violence was never a problem in his treatment after that, because the same reassurance would consistently defuse his violence. Later I learned that as a child he had been thrown out of some of the residential treatment centers for beating up other children. The attendants at his current institution (who were all former college football players) were amused. “Your strength? Do you know what he could do to you?” As an out-of-condition intellectual, I did. That is why I was scared of him. But the patient desperately wanted someone to protect him.

SUPERVISORY POSTURE Supervisees identify with supervisors. If they are treated kindly and supportively, they tend to treat their patients kindly and supportively. If their difficulties and pain as therapists are shared, they can share the patients’ pain and difficulties. If supervisors are cold or punitive, students become cold or punitive. If supervisors are curious, are accepting of the human condition, see the value in “mistakes,” are comfortable with the unconscious, and expect students to be first rate, then the students tend to value their curiosity, learn from their mistakes, learn about the unconscious, and become first rate. I recall my first supervisory hour with Richard Sterba. It was my second psychoanalytic control case. After driving 100 miles on a Sunday, feeling both anxious and excited, I presented the case material. His first supervisory comment was “Do you mind if I make a suggestion?” And he waited for an answer. I was startled. “Of course. Please.” He then said, “I would have said it differently,” and proceeded to suggest a far more therapeutic phrasing of the interpretation. But in that first supervisory intervention, before he communicated specific information, he communicated a feeling of respect for the other person, which hopefully I internalized. Of course, one must also serve as a kindly superego and parent figure. Supervisees need to know that if a crisis occurs that they cannot handle, they have

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Supervising Therapists Treating the Severely Mentally Ill 365 immediate access to someone who will be there. Even when their handling of the crisis is appropriate, they need a kindly superego who will tell them that it was appropriate and allow them to tolerate their anxiety (and even learn from it about themselves and the patient). Indeed, even experienced professionals sometimes need that kind of sharing when dealing with crises or the apparent lack of progress of severely disturbed patients. In the face of difficult resistances, and the pessimism of colleagues, supervisees need the optimism of the supervisor that if they do as reasonable a job as they can, the odds are that the patient will respond. Supervisees also need to know that their experience of the treatment as difficult occurs because it is difficult work. The pessimism and alarmism of most of their professional colleagues are a function of the latter’s experience of working, as most mental health professionals do, with inadequate training. If supervisees are treating the kind of patient whose defenses do not permit him or her to communicate that the therapist is being helpful, the support and evaluation of an experienced supervisor becomes essential. Supervisees need to be reminded that most appropriately treated patients benefit greatly, that the patient cannot give the feedback the therapist would like, but that their procedures and interpretations seem appropriate and should be continued or should be modified in specific ways and for these specific reasons.

FEEDBACK The supervisor should also tell the supervisee to pay attention to feedback when it occurs. Often the ward staff, if the patient is hospitalized, or family members, if the patient is living with them, will tell the therapist about improvements. Repeated psychological testing, if it is available, can be useful. Sometimes the patient will tell the therapist about improvement by describing other people as having become nicer. The patient may even tell the therapist about improvement paradoxically by complaining about things that could not be problems if the patient had not made considerable improvement.

Case 20.4 “Goddammit, Karon, you’re not helping me. I’m going to lose my B average, and you don’t care, and you’re not helping me!” But if this patient was taking college courses and had a B average to lose, she had made enormous improvements. Initially her minister and her boss had brought this schizophrenic woman to my office instead of the state hospital. “I don’t enjoy sex and I get involved with the wrong kind of men. And you’re not doing anything about it!” This patient believed, when she started therapy, that no man would be interested in her. But if a man were interested in her and wanted sex and she said no, the man would kill her. That is what men do. But if she had sex, she believed, the sex would kill her. For her to be having sex without enjoying it and to be involved with the wrong kind of men were both serious problems, but she had to have made enormous progress to have those problems.

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Once a supervisee has continued the treatment of a difficult patient about whom other professionals have been pessimistic, until the patient has palpably improved, the successful treatment of the severely disturbed patient can be a benign trauma from whose effects the supervisee never recovers. FREQUENCY OF SESSIONS For any therapy with any patient, it is my experience that the more time available, the easier it is for both patient and therapist. Unfortunately, the therapist’s schedule, the patient’s schedule, the need to charge a fee, and the limited financial resources available all lead to briefer therapy, both in time and in number of sessions per week. Every genuine therapist feels the conflict between wanting to help as many people as possible and wanting to do a therapy that is thorough and helpful. But we know best how to do that in ways that take time. Every genuine therapist also knows the conflict between wanting to be available to everyone irrespective of financial status and wanting to live in the way that a decent income permits (or, if part of an agency, the need to maintain the fiscal solvency of the agency, particularly if the agency provides real help). Of course, even worse are the consequences of “managed care.” Decisions about the number of sessions are made on the basis of financial considerations by people neither primarily concerned with, nor capable of evaluating, what is in the best interests of the patient. There is, as far as I know, no systematic research on the effects of number of sessions per week per se on the nature and content of the hour or on the course of the treatment. The nearest to a systematic study was the report of Alexander and French (1946) that reducing the number of sessions per week seemed more compatible with effective treatment than cutting down the calendar time. People take time to grow. Technically, Alexander and French suggested that in once- or twice-per-week therapy more of the transference reactions outside the therapy hour had to be analyzed as opposed to analyzing the transference neurosis itself (i.e., transference reactions within the therapeutic session). Under even the most stringent institutional restrictions, I would recommend strongly that the first week of treatment for psychotic individuals be five sessions, although the length of the session may be shortened to half an hour. Even if the treatment is going to be continued on a once-per-week basis, the patient needs to know the therapist is there, the therapeutic alliance needs to be established, and the therapist and patient need to have a chance for the transference and countertransference dynamics to begin to be apparent. I have never been able to help a patient at a frequency of less than once per week, although I have tried it either to save the patient’s money or to accommodate a patient’s schedule. Consequently, I share that information and insist that the patient be seen at least once, and preferably twice, per week if I am going to supervise the case. For psychoanalytic candidates, of course, I insist on a minimum of three times per week. During periods of crisis or when the patient is undergoing unusual stress, the frequency may be increased. The Michigan State Psychotherapy Research Project (Karon & VandenBos, 1981) found that most of even the most severely disturbed of a

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Supervising Therapists Treating the Severely Mentally Ill 367 group of chronic inner city schizophrenics were able to function outside the hospital within 8 weeks of psychoanalytic therapy 5 days per week without medication. Benedetti and Furlan (1987) reported from Italy and Switzerland a series of 50 severely schizophrenic patients treated with intensive psychoanalytic therapy by supervisees with excellent results in 80% of the cases. The patients were seen for two to five sessions per week for 3 to 10 years; median frequency was three times per week, median length of treatment was 5 years. Surprisingly, in the Michigan State project, those economically poor inner city severely schizophrenic patients who came in intermittently during crises did as well as those who came in regularly once per week. If people are poor, the reality problems are so huge that psychotherapy seems like a luxury. The therapist may know, but the patients do not, that the patients’ reality problems would be easier to handle if they saw their therapist. But during a crisis, if seen immediately, the patients work hard and change. When the crisis is over, the therapist is ready to continue in a traditional way, but the patients disappear, only to reappear with a later crisis. These sorts of patients have taught me the importance and the value of psychoanalytic crisis therapy. Even when they come in during a later crisis, it takes more stress before they break down again, and they again make good use of the crisis therapy to continue growing. Fears that too intensive a frequency will cause too much regression, particularly for borderline patients, are common. But it is not the frequency per se, which is disabling, but the character of the sessions. An unresponsive therapist, a cold and condemning therapist, or a therapist who sits behind the patient and does not talk are disasters for severely disturbed patients. Such therapists simply repeat earlier traumas. Deeply disturbed patients, as well as some who are not deeply disturbed, usually experience silent or unresponsive therapists (who believe they are simply being neutral) as rejecting them. The patients may experience a nontalking therapist or one who sits behind them and is quiet as someone who does not want to relate to them, or sometimes, if they are psychotic, as someone who is not there. If the patients come from criminal or delinquent subgroups, they do not trust anyone they cannot see. It is essential that the therapist or analyst be willing to provide as much structure and support as the defenses of the patient require. This is not a one-time diagnostic judgment but a reaction in each hour to the patient as he or she experiences that therapy hour, so that the patient’s ability to cope with the anxieties aroused by his or her memories and transference reactions is not exceeded. One particularly destructive pattern is the therapist who at first encourages patients to be open about everything and to go deep into themselves and their lives. The therapist may even be initially supportive and helpful. But when the patient opens up and reveals deep parts of themselves, the therapist’s defenses give out. Then the therapist tries to get the patient to shut up. The therapist may suddenly become punitive. If even their therapist cannot stand their lives or feelings, what chance do these patients have to face the terrors alone? The therapeutic hour becomes a trauma, and the patients get sicker rather than improving. It is not uncommon to hear that too few sessions are so unhinging that the patient had better not be treated psychotherapeutically at all, but medicated, punished,

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advised, or left alone. The problem, as before, is the character of the session. The most frequent danger with too low a frequency is that nothing of importance will happen. Not only is it harder for the therapist to obtain the necessary information about the therapy to guide the process optimally, but the lack of supportive contact makes independent growth seem too scary for the patient. In my experience, a low but acceptable frequency is once per week. LOW FREQUENCY FORCED BY PATIENTS

Case 20.5 Sometimes a low frequency of sessions is forced by the defenses of the patient. One psychotic depressive woman moved to her parents’ house instead of to a hospital. They lived some 40 miles away and could only bring her once a week. This turned out to be an advantage. Like many psychotic depressives, this lady was irritating. It was possible for her to have a reasonable, kind, but active therapist once a week, although by the end of most of her early hours my countertransference was such that I usually felt enraged at her. By the next week, however, she once more had a rational and kind therapist for most of her hour. The treatment progressed to a satisfactory outcome. Not only did her psychosis remit, but she handled her five children more appropriately, had a better relationship with her husband, including a better sexual relationship, and held a part-time job successfully for the first time in her marriage. In part because of their better relationship, her husband became more effective and was able to earn more money, which was important for their way of life. But given the intensity of my emotional reaction, it is questionable that such a benign outcome would have been possible had she been seen more frequently, particularly at the beginning.

Case 20.6 An ambulatory paranoid patient with a delusion that there was a rumor that he was a homosexual was unable to work. Previous therapy had enabled him to finish schooling and embark on a professional career (not in the psychological professions). However, this rumor had followed him, he said, from city to city and now was preventing him from being able to practice his profession. Despite offers to cut his fee, he insisted on being seen not more than half an hour once per week because he “could not afford any more.” He would sit in the furthest corner of the room and stated that he had “no thoughts, no feelings, no dreams. What do you want to talk about?” It was possible nonetheless to help him, in the minimal weekly time he permitted, to be able to work, to relate to friends, and to date, with the “rumor” gradually subsiding. When he would not talk about his thoughts or his feelings or his dreams, I decided to try the Thematic Apperception Test. Each session I gave him one card, asked him to tell a story, and then asked him to associate to the story. He was able to cooperate. By the time all the cards were exhausted, a real psychotherapeutic process was well underway. Although the treatment was terminated prematurely by the therapist’s standards, with many neurotic traits remaining and far short of our analytic ideal, the treatment was a success by the patient’s standards, was well worth the time involved, and has led to stable functioning and a successful professional career for years to date.

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Case 20.7 An ambulatory depressive had been in treatment for 20 years with various psychiatrists, some of whom were psychoanalysts, but all of whom medicated him, sometimes accompanied by psychotherapy. He was still depressed and was referred to me. He was told that, given the length of his problems, he should be seen a minimum of three times a week, and that although no firm estimate could be made, he would need to be in treatment at least 2 or 3 years. He was irate: “You are just trying to run a bill on me. I know. I have friends who work in an HMO [health maintenance organization]. They treat people in 16 sessions. That’s all anyone needs. And I’m not coming in more than once a week.” I told him that, although I disagreed, I would certainly do what I could for him in the time he allowed. At the tenth session, I reminded him that he had only six more sessions and asked how he felt about it. He was furious that I would not see him more than 16 sessions. After he berated me, I told him that if he felt that strongly, I would continue treating him. Shortly thereafter he became furious that I refused to see him more than once a week. After allowing him to berate me, I told him I would be willing to see him twice a week. After a few months he became furious that I refused to see him more than twice a week. Again, after allowing his rage, I agreed with his demand for three times a week. The analytic treatment then proceeded successfully with, of course, the difficulties usual for severely depressed, hostile patients. He would get angry at my rigidity because I would not treat him with medication. Patients get to know our weak spots. I informed him each time he raised the issue that if he would prefer to be treated with medication I would be glad to refer him to a competent medicating psychiatrist who would prescribe the right medication at the right dosage and monitor side effects carefully. If he would prefer a combination, I would refer him to a competent medicating psychiatrist who would prescribe the right medication at the right dosage, but who would also talk with his patients. Or if he wanted to work hard, he could stay and work with me. “Won’t you work with me if I get medication?” “No, but I’ll be here after you’ve tried it, if you want to come back.” I then gave him a brief lecture on the evidence to explain my position. He would always get furious at my rigidity. But he continued in treatment. Eventually I realized what was actually happening, and said to him, “Last session you raised the issue of medication, and I gave you my little lecture as I always do, and you were furious at me. And you should have been furious at me, because I was stupid. I think you raise the subject when there is something important to talk about that you do not want to talk about, and you know I will give my regular comment. What is it we should have been talking about?” There was something important, and whenever afterward he raised the issue of medication, there was always something more important to talk about. Raising the issue of medication when there is something more important to talk about is a resistance frequently used by patients who are physicians or nurses.

The general therapeutic principle is that if you know something of importance to the patient’s well-being that you think the patient does not know, you tell him or her. If, as often happens, they want to make use of the information but cannot, then the two of you can investigate why. But it is usually not necessary to give the patient the information more than once. I wondered how he could have been in treatment, including therapy, for 20 years and still be so depressed. He told me at the end of treatment that none of his psychiatrists, including the psychoanalysts, had ever related his depression

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to the way his mother or his father had related to him. “I guess they helped me. I limped through life more or less, but I guess I have never really been in therapy until now.”

PHRASING A condemning therapist obviously is traumatic, but it is important to remember that even neurotic patients tend to experience every interpretation as an accusation. That is why the phrasing of an interpretation is critical. Thus, for example, a wellmeaning therapist may say something about the patient having a sexual or angry feeling. The therapist believes he or she is being kind and is giving the patient permission to have that feeling, or letting the patient know that such a feeling is normal or justified. But that is not what the patient hears. He or she implicitly adds “and you shouldn’t” to anything the therapist says. Therefore, the therapist must try to phrase interpretations and comments so that they cannot be twisted into accusations of crime. Phrasings like “Anyone would feel . . .” or “It would only be human to feel . . .” help. Almost anything, no matter how anxiety provoking, can be discussed from the standpoint of the defense: “I wonder if you are afraid that you might . . .” The phrase “I wonder if . . .” structures the intervention not as a contest of wills or an authoritarian verdict of doom but as an idea to be considered, and even possibly rejected. A rejected interpretation, if it is correct, will come back at a later time with new material or when the patient has had time to think about it. Therapists often are annoyed that patients at a later time will say “I had a new idea” and then discuss something the therapist said earlier that was rejected initially. In most cases the patient really has forgotten the origin of the idea. The student needs to know that, although the student’s feeling of annoyance is normal, the origin of the idea is of no importance and should not be an issue. The patient does not need another parent who will not let him or her have any ideas of his or her own but insists that anything good comes from the parent. Even the word why is usually heard by patients as a condemnation. After all, when parents ask “Why did you do that?” it is usually a rebuke and not a request for information. One difficult thing for a therapist to talk about in therapy is when the patient is genuinely annoying. It may be important to discuss, but on a transference basis it may be too frightening for a patient to think his or her therapist is angry at the patient. One possibility is to phrase it as follows: “If I were not your therapist, I would be annoyed (or angry) when you . . .”

Case 20.8 A deeply depressed woman described not being able to stand her 3-year-old granddaughter, who, like most 3-year-olds, was not always easy to control. She talked as if it were normal not to like a 3-year-old. I can tolerate and deal with many irritating ideas and actions, including felonies and attempted assaults on me, but I found this outrageous. I did not immediately comment because I was too angry to be able to intervene helpfully. It was too important not to talk about in her treatment, but deeply depressed people do not need to be told they are bad. It took me 2 weeks to think

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through a way of raising the issue without traumatizing the patient: “There is something puzzling. You are basically a kind person. You may disagree with me, but you are basically a kind person. But your feelings toward your granddaughter are discrepant from that. It seems to me that something must have happened to you when you were her age, when you were three years old.” “But you know I can’t remember anything from that age.” “Yes, but that doesn’t mean nothing happened or that it did not have an effect. We tend to react to bad things that happened to us when our children or grandchildren are the same age we were when it happened.” She insisted that she could not remember anything, and we talked about that period without achieving closure, although she reported possible bad events that she had heard of that period. Her mother had been going through obvious stresses in the dissolution of her marriage. The patient considered the possibility that her mother might have found her independence and uncontrollability hard to bear (the aspects of her granddaughter she reported as making the child dislikable). After our discussion, she noticed and reported that her granddaughter seemed irrationally to like being with her, wanted to sit next to her in the car, and liked her stories. Their relationship progressed to a healthy one.

THE SEQUENCE OF TRAINING Most people who think about the issue of the ideal training of a psychoanalytic therapist recommend that the novice first experience a thorough personal psychoanalysis, then conduct traditional psychoanalyses of neurotics under supervision, and then be trained in briefer psychoanalytic therapies or in working with more severe patients. Thus, the therapist will really understand, from his or her own analysis, what therapy is about, learn from supervised analyses what would come to the surface if there were sufficient time and a cooperative patient, and then be able to utilize this in briefer psychoanalytic therapy and in working with difficult patients. Almost nobody goes through the sequence of training in that rational order. For example, no graduate student in our program practices psychoanalysis, in the narrow sense. The only practitioners I supervise in psychoanalysis are psychologists and social workers in the community who are in private practice or community agencies, have been analyzed, and have taken seminars in analytic technique and wish eventually to be trained as psychoanalysts. Graduate students, often without any prior personal therapy, begin by doing brief psychoanalytic therapy. Most of the competent ones obtain some personal psychotherapy before they finish graduate school but, primarily for financial reasons, do not begin personal psychoanalysis until they are out in the field. Before we despair, however, we should note that the first generation of psychoanalysts, whose contributions displayed a level of insight, creativity, and therapeutic competence far above what is usual today, went through what we would consider haphazard training. Of course, these were bright, creative, highly motivated individuals who lived psychoanalysis (Richard Sterba, personal communication). They learned as much as possible about psychoanalysis in the broadest possible sense. One may argue, as Robert Knight (1954, pp. 24–25) did, that they were less well adjusted than the present generation, but better analysts. Knight argued that

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his generation of candidates was motivated to learn as little as possible about psychoanalysis, get through their training quickly, and open an office, and this led to a necessary proliferation of explicit requirements. But this very proliferation of explicit requirements appealed to that kind of candidate he deplored, while discouraging the creative individuals to whom psychoanalysis appealed earlier. Many of our current creative psychoanalysts have gone through unusual routes in their training. The question is: Does the irrational route that we have created in graduate school make any sense at all? Given the unfortunate number of faculty in psychology, psychiatry, and social work who know little about psychotherapy and who discourage learning about psychotherapy, the obvious answer is that any sequence of training is better than no training. SELECTION I believe in self-selection. I have found that it works best to supervise only students or professionals who choose to be supervised by me. This is now a general rule in our psychological clinic. I like the kind of clinicians, whether students or practicing professionals, who get themselves into the dilemma: “I think I can help this patient, but my colleagues/supervisors/setting says that it should be interrupted or can’t be done, and I think they are wrong, but I need supervision from someone experienced. Maybe I’m wrong (although I don’t think so), or maybe I’m getting in over my head, but this patient is treatable, and they are not going to treat him or her, if I don’t. You [Karon] are the only one I know who would encourage me to treat this patient.” Because my own patients rarely see me for fewer than 2 years, I require that the students I supervise make a commitment to be available to the patient for a minimum of 2 years, even though that is not the academic requirement. In addition to being a reasonable requirement, it weeds out those who are not highly motivated. One bright graduate student asked me if it was alright if he saw a severe borderline patient 5 days a week. Surprised that a graduate student wanted to work that hard, I agreed because he was insightful, highly motivated, and seeing me in supervision once per week. He did a brilliant job of psychoanalytic therapy. S U P E RV I S I O N O F T H E R A P Y There are many disagreements about the philosophies and techniques of supervision. In particular, how much of the student’s dynamics do you delve into, how much is didactic, how much do you focus only on the patient, should you use audiovisual aids or observe the actual interview? The supervisor, I believe, should remember that he or she is not the student’s therapist. Although the anxieties involved in doing psychoanalytic therapy are contained by the supervisor, the supervisor does not delve into the student’s dynamics. The opposite stance is experienced by the student as intrusive, punitive, and scary. It is useful to say the following: “I wonder if there is a personal issue here that you might want to discuss with your therapist. Think about it and you decide. You don’t need to discuss it with me.” For a student not in therapy: “I wonder if this isn’t making you anxious. This is very difficult material (or this is

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Supervising Therapists Treating the Severely Mentally Ill 373 a very difficult person). This might be a good time to start your own therapy. You don’t need to discuss your personal issues with me, but think about it.” The injunction “you don’t need to discuss it with me” allows students the privacy and maturity they need and allows them to discuss freely some aspects of it if they choose. They usually do choose to discuss what seems most pertinent. If you really think the dynamics are critical to discuss, it may be brought up as follows: “Some people have a problem with . . . and that would lead them to do . . .” The important principle is not to be experienced as intrusive or punitive, because that will make it impossible for the student to be honest in the future. I rarely use mechanical aids. In my project in treating schizophrenics with psychoanalytic therapy, the early hours of both the experienced therapists and the trainees were viewed on videotape and discussed for training purposes. That was initially useful. It was also reassuring to the novice dealing with unpredictable patients that the sessions were being simultaneously watched by colleagues who could intervene if necessary. Nonetheless, the student therapists on the Michigan State Psychotherapy Research Project then, and the students at the university since then, reported that they generally did not find the discussion of their tapes remarkably helpful, but observing my tapes was helpful. In my graduate seminar on the psychotherapy of psychosis, I either treated a patient in front of the group (usually with a oneway mirror) or had students observe videotapes of the treatment of a psychotic patient. The model of my correct interventions helped, but even more they noticed that I was sometimes tired, distracted, insensitive, and had countertransference reactions, and, despite that, even difficult patients obviously improved. Therefore, the psychotherapy of the deeply disturbed cannot be a trick that only some gifted, superbly trained individual can practice, but something that intelligent and respectful human beings who want to be helpful can learn to do. In my experience, the traditional supervision hour, with the student recounting from notes, is, in general, best. I request that the notes be written after the hour, as Freud (1912/1958) recommended, not during it. What the students bring up is what is puzzling to them, and then anything you say has an effect in changing their understanding and technique. Your insights meet their need, help resolve their anxieties or curiosities. When you bring up something from a tape, it does not have the same effect in facilitating students’ learning, because it does not meet their needs. I must admit that one psychopathic student was able to lie to me successfully in ordinary supervision hours. But supervision is not police work. For the bulk of students this is the optimal way to go. You cannot corrupt the teaching process because one liar can take advantage of you. In supervision of psychoanalysis, the supervisee is more experienced, so less time need be spent on basic mechanics that the supervisee has already learned. More time is available to listen to the subtle aspects of the fantasy material, which are usually more available in the presentations of experienced therapists during the supervision hour, and the supervisee is more sensitive to the transference and countertransference issues. Most often the experienced supervisee is held back by one formulation of the material, including the transference and countertransference, which has prevented him or her from hearing a different, more relevant formulation. But the difference in supervision is one of degree; that is, the process

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of supervision is basically the same except that, the more experienced and knowledgeable the supervisee, the more one can focus on subtler issues. Of course, supervisees at any level vary widely in what they already know. As Richard Sterba pointed out (personal communication), supervision is easier than psychotherapy because the supervisee’s unconscious almost always organizes the material so that only the addition of the last link is needed, even though the supervisee seemingly does not consciously understand what the material is all about. D I D A C T I C M AT E R I A L Those who choose to be supervised by me already have a strong interest in psychoanalysis. Obviously, I expect even the most inexperienced student to have read Freud’s Introductory Lectures (Strachey, 1961–1963) and New Introductory Lectures on Psychoanalysis (Strachey, 1964). I ask them to read his papers on technique (1963) and at least one paper of mine, “The Tragedy of Schizophrenia Without Psychotherapy” (Karon, 2003). I then require them to read Fromm-Reichmann’s Principles of Intensive Psychotherapy (1960), if they have not already done so, and David Malan’s book on brief therapy, Individual Psychotherapy and the Science of Psychodynamics (1979). I have never had a novice therapist who did not get enthusiastic about that book. Any other reading will be based on the individual case. If the patient has psychotic features, obviously I assign my book (Karon & VandenBos, 1981). The best paper I know on the treatment of manic-depressive patients is Teixeira (1992), although I also like Karon (2005). There is, of course, some didactic material that is so essential that it gets discussed with every psychotherapy student. They need to know at least the following:

r If the patient is schizophrenic, that schizophrenia is a chronic terror syndrome. r r r r

r

All the symptoms of schizophrenia are manifestations of or defenses against terror. There is no schizophrenic language, but each patient has a language we must learn. That apparently weak affect is actually chronic terror, which blanches out other affects. That inappropriate affect is usually socially inappropriate, not inappropriate to the patient’s subjective experience. Catatonic stupor is not a stupor, but a biologically evolved chronic terror state, the last stage of defense for prey in the clutch of predators, a state in which enormous pain can be inflicted with no apparent response, although the animal or human is fully conscious of everything that is going on. Indeed, patients will tell you they felt like they would die if they moved, and they usually respond to a verbal reassurance: “I won’t let anyone kill you.” Hallucinations are waking dreams, fully understandable by Freud’s theory of dreams, with minor modifications (e.g., there are no universal meanings to symbols, only frequently occurring meanings), and the analysis of hallucinations is as useful in therapy as the analysis of dreams. Dreams and

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Supervising Therapists Treating the Severely Mentally Ill 375 hallucinations may occur in any sensory modality, but in schizophrenia the primary modality is auditory, although other sensory modalities may also be involved. Delusions have four major bases (Karon, 1989): 1. Transference to the world at large—like the obvious meaning of the two alien giants—a green male and a silver female—whom a patient needed to find and have a relationship with because they controlled the world. 2. Defenses against pseudo-homosexual impulses. 3. Strange meanings to concepts that are found within a particular family but that the patient erroneously believes everyone knows and believes. 4. The need to have a more or less consistent view of oneself and one’s world. If one has unusual experiences, both in reality and in one’s symptoms, the resultant beliefs seem bizarre, but they are never more bizarre than is necessary. Because this is a normal process used for abnormal problems, a nonfrightened, nonhumiliating therapist can suggest better alternatives based on his or her better knowledge of the real world, of other people, and, most of all, of how the human mind works. With severely depressed patients, it is important to know that they tend to use isolation as a defense. If you ask them what happened just before their depression or other symptom started, they will typically say, “Nothing.” If you insist that they were alive, that something must have been happening, they will say, “Nothing important.” If you insist they tell you the unimportant things, they will typically tell you things that would depress anyone. Just because the patient or other professionals say the patient is depressed does not mean you know what the patient’s affect really is. Find out. It may be sadness, guilt, shame, distress, self-contempt, anger, anxiety, undifferentiated negative affect, or no feelings at all. Psychotic depressives often have no conscious affect, apparently repressing the pain. When they begin to feel sad or weep, they are usually getting better. There is no such thing as a spontaneous panic attack or anxiety or an endogenous depression. The affect is always appropriate—if you are anxious, there is something to be scared of; if you are depressed, there is something to be depressed about; if you are angry, there is something hurting you. If it is not conscious, it is unconscious. If it is not in the present, it is in the past and something in the present symbolizes it. A patient who talks about suicide should be taken seriously. Hopelessness is a necessary but not a sufficient cause for suicide. Nonetheless, the therapist must create hope that through therapy a relation is possible and the problems are in principle solvable. Because suicide is often aggressive retaliation, consciously or unconsciously, the therapist must let the patient know that it really does not hurt the intended victim that much. Suicide often involves the projection of one’s superego into someone else. That is why a suicidal patient almost always tells someone, implicitly asking “Do I deserve to live or die?” And if the other person does nothing, that patient interprets that as deciding that the patient deserves to die. Therefore, the therapist must indicate by word and action that he or she does not

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believe the patient deserves to die. Finally, suicide is often the result of a belief that the patient’s parent wanted the patient dead, and that needs to be explored. It is well known that some depressed patients seem to be getting better but then kill themselves. It is usually stated that they did not have enough energy before. That is not what is going on. According to Atwood (1972), some patients decide to solve their problems by killing themselves. They seem to be getting better, and then they carry out their solution: 1. If depressed patients are actually getting better, they develop more insight into why they were depressed. If they are going to kill themselves, they seem to be getting better, but they have no more insight into why they were depressed. 2. If they are actually getting better, they talk more about the future. If they seem to be better but are going to kill themselves, they do not talk more about the future, because they do not have a future. 3. If they are getting better, they will talk about suicide, if you bring up the subject. If depressed patients seem to be getting better but are actually going to kill themselves, they will not talk about suicide, or they will tell you unemotionally that they are going to kill themselves. If all three indices are in the right direction, the patients are getting better; if all three are in the wrong direction, they are going to kill themselves unless you intervene. Hospitalization is a resource. Having someone stay with the patient continuously is a resource. Electroconvulsive therapy (ECT) is not a resource. It defers suicide (until enough of the patient’s memory returns) but does not prevent it. The fear of electroconvulsive therapy is often a precipitant of suicide. Moreover, the patient has to live with permanent aftereffects (Breggin, 1997; Robertson & Pryor, 2006). Antidepressant medication is a double-edged sword. It may make some patients less suicidal, but it makes others more suicidal (Breggin & Cohen, 1999; Jackson, 2005). Almost all psychiatric medications have strong withdrawal effects that often give the patient and the treating professionals the feeling that no matter how badly the patient feels, he or she would be worse off without the medication, because the patient becomes markedly more ill if he or she tries to stop too quickly. Jackson (2005) provided the most accurate description of the biochemical nature of currently used psychiatric medications, evidence for their effects and effectiveness, side effects, and withdrawal effects. Breggin and Cohen (1999) offered the best guide for how to safely withdraw from anti-anxiety medication, antidepressants, antipsychotics, and mood stabilizers, both in general and with respect to specific medications. It is my view from both clinical experience as well as available research findings (Karon & VandenBos, 1981) that for any patient the most effective treatment is psychoanalytic therapy with a knowledgeable therapist without medication if the patient, the therapist, and the setting can tolerate it. If the patient asks for it (which is rare), or if the therapist cannot tolerate severe symptoms or a disorganized patient, or if the setting (e.g., hospital, family) cannot tolerate the symptoms or patient,

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Supervising Therapists Treating the Severely Mentally Ill 377 medication may be used. Medication may also be used to cope with a crisis. But in any case it should always be considered a temporary solution and the medication withdrawn as the patient can tolerate it. Research (e.g., Karon & VandenBos, 1981) has shown that this is a good way to work. Psychotherapy plus continuing medication is better than medication alone, but it is not as effective in the long run as psychotherapy alone or psychotherapy with initial medication that is withdrawn as the patient can tolerate. P S Y C H O A N A LY S I S A N D P S Y C H O A N A LY T I C T H E R A P Y I stress the continuity between psychoanalysis and psychoanalytic therapy. Since the 1940s, psychoanalytic therapy has been distinguished from psychoanalysis proper. In the earlier literature (e.g., Sterba, 1935/1987), psychoanalytic therapy was used simply to indicate that what was being discussed was psychoanalysis as therapy, or its therapeutic action. Freud, while decrying “wild analysis” (1910/1957), was not rigid as to the technique he utilized—as evidenced by his case histories (e.g., the “Rat Man,” 1909/1955)—or the techniques he accepted in his students and colleagues (e.g., Aichhorn, 1936). One of my early psychoanalytic instructors defined psychoanalytic therapy as being as much like psychoanalysis as the defenses of the patient, the time available, and the skill of the therapist permit. That has always seemed to me a proper definition. The continuity that is implied is real. As my students have pointed out, I am apt to use the phrase real treatment to mean psychoanalysis or psychoanalytic therapy, as in the following sentence: “After years of medication, behavior modification, cognitive therapy, and so forth, the patient finally began real treatment.” Both psychoanalysis and psychoanalytic therapy treat a person, never just a single symptom. All problems are treated in terms of their importance to the patient, whether or not they correspond to conventionally labeled symptoms and whether or not they were the presenting complaint. Any psychoanalysis that is not good therapy cannot be good psychoanalysis. Psychoanalytic theories provide the basis for proper technique, whether standard or modified. Suitable modifications, or parameters, of psychoanalysis and psychoanalytic therapy are always used by competent clinicians as required by the defenses of the patient. Where the dividing line between psychoanalysis and psychoanalytic therapy is drawn varies from writer to writer. It may be that psychoanalysis is (a) any investigation that takes seriously the unconscious and repression, resistance and transference, or (b) any technique that consists of doing what needs to be done, to the best of your ability, on the basis of a psychoanalytic understanding of the patient and the treatment process—two definitions that I like. Or, more restrictively, only if the patient in addition is seen at least 3, 4, 5, or 6 days a week, on a couch, facing away from the analyst, and suffers from neurotic or certain characterological problems. Or only if structural change is produced, or only if a full “transference neurosis” occurs and is resolved, or only if the sole therapeutic agent is interpretation, narrowly defined. Thoma and Kachele (1987) pointed out how difficult such criteria are to use scientifically, and the clear continuity between various psychoanalytic therapies and psychoanalysis, and how everything that is learned about psychoanalysis illuminates the psychoanalytic therapies and

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everything that is learned about the psychoanalytic therapies illuminates the process of psychoanalysis. It really makes no difference in treatment where the dividing line is drawn, as long as the technique used, whether called psychoanalysis or psychoanalytic therapy, is appropriate to the defenses of the patient in the best judgment of the analyst or therapist.

FINAL COMMENT Bruno Bettelheim (1983) once said, “If you treat the patient with common courtesy, and treat them the way you would want to be treated, you will almost always do the technically correct thing.” And I would add, “If you treat supervisees with common courtesy, and treat them the way you would want to be treated, both you and they will almost always do the right thing.”

REFERENCES Aichhorn, A. (1936). Wayward youth. London: Putnam. Alexander, F., & French, T. M. (1946). Psychoanalytic therapy: Principles and applications. New York: Ronald Press. Atwood, G. (1972). Note on a relationship between suicidal intentions and the depressive mood. Psychotherapy: Theory, Research and Practice, 9, 284–285. Benedetti, G. (1987). Psychotherapy of schizophrenia. New York: New York University Press. Benedetti, G., & Furlan, G. M. (1987). Individual psychoanalytic psychotherapy of schizophrenia. In G. Benedetti, Psychotherapy of schizophrenia (pp. 198–212). New York: New York University Press. Bettelheim, B. (1983). Supervision of a borderline patient. University of Detroit Advanced Psychotherapy Workshop, MI. Breggin, P. R. (1997). Electroshock for depression. In Brain-disabling treatments in psychiatry: Drugs, electroshock, and the FDA (pp. 129–156). New York: Springer. Breggin, P. R., & Cohen, D. R. (1999). Your drug may be your problem: How and why to stop taking psychiatric medications. Cambridge, MA: Perseus Books. Fairbairn, R. W. D. (1954). An object-relations theory of personality. New York: Basic Books. Fraiberg, S. (1977). Selected writings of Selma Fraiberg. New York: Basic Books. Freud, S. (1955). Notes upon a case of obsessional neurosis. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 10, pp. 153–318). London: Hogarth Press. (Original work published 1909) Freud, S. (1957). “ Wild” psychoanalysis. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 11, pp. 219–230). London: Hogarth Press. (Original work published 1910) Freud, S. (1958). Recommendations to physicians practicing psychoanalysis. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 2, pp. 109–120). London: Hogarth Press. (Original work published 1912) Freud, S. (1963). Therapy and technique. New York: Collier Books. Fromm-Reichmann, F. (1960). Principles of intensive psychotherapy. Chicago: University of Chicago Press. Jackson, G. E. (2005). Rethinking psychiatric drugs: A guide for informed consent. Bloomington, IN: AuthorHouse. Karon, B. P. (1989). On the formation of delusions. Psychoanalytic Psychology, 6, 169–185. Karon, B. P. (2003). The tragedy of schizophrenia without psychotherapy. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 31, 89–118. Karon, B. P. (2005). Recurrent psychotic depression is treatable by psychoanalytic therapy without medication. Ethical Human Psychology and Psychiatry, 7, 45–56. Karon, B. P., & VandenBos, G. R. (1981). Psychotherapy of schizophrenia: The treatment of choice. New York: Aronson. Karon, B. P., & Widener, A., J. (1994). Is there really a schizophrenogenic parent? Psychoanalytic Psychology, 11, 47–61.

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Supervising Therapists Treating the Severely Mentally Ill 379 Knight, R. P. (1954). The present status of organized psychoanalysis in the United States. In R. P. Knight & C. R. Friedman (Eds.), Psychoanalytic psychiatry and psychology (pp. 7–26). New York: International Universities Press. Malan, D. (1979). Individual psychotherapy and the science of psychodynamics. London: Butterworth. May, P. R. A. (1968). Treatment of schizophrenia: A comparative study of five treatment methods. New York: Science House. Meyer, R. G., & Karon, B. P. (1967). The schizophrenogenic mother concept and the TAT. Psychiatry, 30, 173–179. Read, J., Goodman, L., Morrison, A. P., Ross, C. A., & Aderhold, V. (2004). Childhood trauma, loss, and stress. In J. Read, L. R. Mosher, & R. P. Bentall (Eds.), Models of madness: Psychological, social, and biological approaches to schizophrenia (pp. 223–252). New York: Brunner-Routledge. Read, J., & Ross, C. A. (2003). Psychological trauma and psychosis: Another reason why people diagnosed schizophrenic must be offered psychological therapies. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 31, 247–268. Robertson, H., & Pryor, R. (2006). Memory and cognitive effects of ECT: Informing and assessing patients. Advances in Psychiatric Treatment, 12, 228–238. Sterba, R. (1987). Psychoanalytic therapy. In H. Daldin (Ed.), The collected papers (pp. 71–86). Croton-onHudson, NY: North River Press. (Original work published 1935) Strachey, J. (Ed.). (1961–1963). The standard edition of the complete psychological works of Sigmund Freud: Vols. 5 & 6. Introductory lectures on-psychoanalysis. London: Hogarth Press. Strachey, J. (Ed.). (1964). The standard edition of the complete psychological works of Sigmund Freud: Vol. 22. New introductory lectures on psychoanalysis. London: Hogarth Press. Teixeira, M. (1992). Psychoanalytic theory and therapy in the treatment of manic-depressive disorders. Psychoanalysis and Psychotherapy, 11, 81–96. Thoma, H., & Kachele, H. (1987). Psychoanalytic practice. Berlin, Germany: Springer Verlag.

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C H A P T E R 21

Clinical Supervision in Correctional Settings MAX J. MOBLEY

NOT LONG ago this chapter would seem out of place in a volume on clinical supervision. After World War II, approximately 78 clinical psychologists (14 of whom had PhDs) were working in correctional settings (Burton, 1948). Corrections has been a growth industry for psychologists, with the field employing more than 600 holders of doctoral and master’s degree by 1980, and more than 2,000 some 20 years later (Boothby & Clements, 2000). The need has been accelerated largely by three factors: (1) an increase in rates of incarceration, (2) loss of longterm institutional care for the mentally ill, and (3) the impact of interpretation of constitutional rights by the federal courts on administration of departments of correction.

R AT E O F I N C A R C E R AT I O N The growth of the incarcerated population has far outstripped the growth of the U.S. population. For many years (from 1925 to the mid-1970s), the prison population was relatively stable, with a slight growth trend holding at about the same rate (roughly 90–125 per 100,000), the rate most European countries currently show. In the late 1970s and early 1980s, criminal justice policies appeared to change, calling for more and longer incarceration (Mauer, 2003). This may have been an unintended side effect of Martinson’s (1974) heralded “nothing works” and a general loss of faith in the potential for rehabilitation. Whatever the cause, the rate of incarceration increased to 486 per 100,000 in 2004 (Beck & Harrison, 2005). It now appears to have reached a plateau. This may be partially an effect of the increased emphasis on drug and mental health courts in many states that both ease the prison population pressures and prove more effective in handling selected offenders. 380

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Clinical Supervision in Correctional Settings 381 M E N TA L D I S O R D E R Teplin (1984) found evidence that mental disorder increases the likelihood of arrest. On the other side of the equation, Steadman and Ribner (1980) wrote that the closure of psychiatric beds was associated with an increase from 9% to 12% in the number of prison inmates with previous psychiatric hospitalizations. Many law enforcement officers privately admit that they prefer incarceration in “The System That Cannot Say No” (Levinson, 1984) to the mental health system for securing their communities from deviant behavior. Current wisdom is that about 16.2% of all state prison inmates can be identified as mentally ill (Beck & Maruschak, 2001). The rate is considerably less for federal prisoners (estimated at about 7.4%; Ditton & Beck, 1999). All such statistics are open to question, as measures have ranged from lifetime diagnosed (prevalence rates) to currently seriously mentally ill (incidence rates). Furthermore, assessments have been based on a variety of diagnostic instruments, operational definitions of mental illness, cutoff levels, and techniques, further muddying the water. In fact, it is likely that many inmates with serious mental illness do not get diagnosed. This happens in some cases because some problems are missed or denied at intake by offenders wanting to get off medications or avoid “the crazy jacket.” In other cases, inmates were incarcerated before intake screening became sufficiently sophisticated to identify them. Many inmates in these groups may do well enough in a structured environment never to come to the attention of mental health professionals, but they decompensate upon release. This happens in other cases because inmates exercise their right to refuse treatment and do not get clearly diagnosed or treated. There is also a third group of inmates whose behavior is so dangerous that they are kept isolated from the population and do not know how to, or choose not to, access services. At the other end of the diagnostic pole are inmates who have sought diagnoses and prescriptions for psychoactive medications for various reasons on the street and enter the system with a diagnosis, or often multiple diagnoses, that is less than stringently applied. Family practice or general practice physicians may have issued these diagnoses based on the drug seekers’ sophistication or symptom exaggeration.

C O U RT A C T I O N Federal law 42 U.S.C. ğ 1983 originated as part of the Civil Rights Act of 1871 as a remedy for depredations of the Ku Klux Klan. It holds that any person who deprives another of a right or immunity guaranteed by the U.S. Constitution may be held civilly liable. In the late 1970s, the federal courts entered a period of close scrutiny of ğ 1983 actions. The lawsuits typically claim Eighth and Fourteenth Amendment violations (Eighth Amendment—cruel and unusual punishment; Fourteenth Amendment—equal protection). Many suits involve conditions of confinement, use of force, and access to the courts and prison regulations. But often these suits focus on the right to access medical and mental health services (Estelle v. Gamble, 1976). The legal standard for deliberate indifference or neglect of medical needs is difficult to meet, as it involves “deliberate indifference” to “serious medical needs”

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resulting in “unnecessary and wanton infliction of pain” (Estelle v. Gamble, 1976, 429 U.S. at 104). Misdiagnosis, disagreement with diagnosis or treatment, negligence, request for outside consultants or services, and the like are generally not cognizable complaints by the courts. Generally, psychologists employed by the government have qualified immunity in civil suits. This does not prevent suits from being filed against them. It may limit their financial exposure by virtue of their being sued in a professional rather than personal capacity. Usually the government entity reimburses any damages levied in the discharge as the agent of that entity, provided the damages occurred in the regular performance of assigned duties and were not due to deliberate indifference or malpractice. Typically losses in the successful suits with which I am familiar have been in the range of $5 to a few hundred dollars, but these are assessed in a miniscule portion of cases filed. The relatively small number of successful lawsuits and the low monetary awards do not seem to discourage inmates from filing suit. A few spectacular wins have encouraged inmates to continue throwing the dice. More often litigation is one of the few methods of fighting back against the perceived oppression and abuses of the system (Gould, 2003) or is a product of the offender’s egocentric sense of entitlement. There have also been suits that have had dramatic effects on correctional systems and the employment of psychologists. Involvement of the courts has led to many state prison systems, or parts or operations thereof, being found unconstitutional or entering into consent decrees that require that certain actions be taken, documented, and reported to the court over several years. These consent decrees have often led to the wholesale hiring of medical and mental health professionals and support staff. A recent case (Coleman v. Wilson, 1995) found that the California Department of Corrections was unconstitutional and that officials showed deliberate indifference in meeting the needs of mentally ill inmates. In addition to court response to individual suits, the U.S. Department of Justice has set up a special litigation section, the Civil Rights of Institutionalized Persons Act (1980), that takes complaints from or on behalf of prisoners (and other institutionalized persons), conducts investigations, and issues findings that may lead to memoranda of agreements, consent decrees, or lawsuits. No one who works in corrections is immune from being sued. I have been sued for living in a closet, sneaking out at night, and injecting an inmate with neuroleptics; for failing to stop a three-pack-a-day smoker from smoking; for depriving a smoker of his right to smoke; and for failing to rehabilitate (several times). I have also been called as a witness in a trial in which a fleeing felon claimed he had an anxiety disorder caused by the police shooting back at him (they missed). Fortunately the Prison Litigation Reform Act (1997) requires that inmates with assets pay filing fees for lawsuits. This response cost has had some damping effect on spurious lawsuits. The psychologist who follows the accepted practices of the field, adheres to ethical standards, and does good documentation is unlikely to be sued successfully. Malpractice insurance should be considered in light of the immunity, legal defense, and recompense for losses provided by the agency under whose aegis the facility operates. One drawback of corrections is that malpractice carriers occasionally fail to discriminate lawsuits filed by prisoners from those filed by members of the

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Clinical Supervision in Correctional Settings 383 community, and it may take some work by a psychologist later entering private practice to convince the carrier that the numerous lawsuits should not apply to rates or insurability in free-world practice (i.e., outside the confines of incarceration).

TRAINING AND RESOURCES TRAINING Currently about 15 graduate programs offer PhD or PsyD degrees in clinical psychology and the law (American Psychology-Law Society, n.d.). Unfortunately, there are not nearly enough psychologists with training and background to meet the demand. After 30 years of recruiting, and never having all of its psychologist positions filled (except the first year when there was only one), the department of correction for which I worked recently hired its first psychologists with correctional training and established a supervised internship in corrections. The Federal Bureau of Prisons currently lists 10 predoctoral internship sites and has trained more than 400 doctoral-level psychologists over the past 30 years. The Association of Psychology Postdoctoral and Internship Centers (www.appic.org) lists 44 internships sites, including those in the Federal Bureau of Prisons. (See also American Psychiatric Association, 2004, for a sample of programs and a link to its approved programs.) Ax and Morgan (2002) also outlined the growing internship opportunities in correctional psychology.

RESOURCES A handbook was published for psychologists and psychiatrists in corrections shortly after World War II (Lindner & Seliger, 1947). Few (3 of 46) of the contributors were psychologists, and the audience, as shown by an earlier American Association for Applied Psychology survey (Darley & Berdie, 1940), was similarly lacking in psychologists, consisting of only 64, fewer than half of whom held doctoral degrees. (For a more thorough history of the early development of the field of correctional psychology, see Watkins, 1992.) Since the federal court interventions of the 1970s and 1980s, the number of psychologists has increased. Handbooks have multiplied, covering a variety of perspectives of this highly complex and varied field. These include Bartol and Bartol (2004, 2006), Brandt (2005), Correia (2001), Fagan and Ax (2003), Hollin (2001), Magaletta and Verdeyen (2005), McGuire (2001), Schwartz (2003), Scott and Gerbasi (2005), Smith and Sabatino (1990), and Weiner and Hess (2005). With the growth in the number of psychologists doing forensics work, there has also been a strengthening of professional associations and resources. The American Correctional Association (ACA) has developed standards for health care, including mental health, and also has added a health services component to its annual congress and winter meeting. The ACA standards are accepted as the benchmark by most departments of correction. Members of the ACA conduct audits of facilities for compliance with mandatory and nonmandatory standards. Facilities are recommended for 3-year accreditation if they meet all mandatory and the majority of nonmandatory standards. The Mental Health in Corrections

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Consortium (www.forest.edu/mhcca/) provides consultation and training at annual conferences. The National Association of State Mental Health Program Directors (www.nasmhpd.org/forensic.cfm) provides information, promotes training, and has links to many other resources. The American Association for Correctional and Forensic Psychology (http://aa4cfp.org) publishes Criminal Justice and Behavior and has a quarterly newsletter, The Correctional Psychologist, in addition to sponsoring national debates and announcing workshops. The American Psychological Association’s Division 41, the American Psychology-Law Society (www.ap-ls.org), is somewhat broader in its forensic scope and publishes a newsletter three times a year. The Civic Research Institute (www.civicresearchinstitute.com) publishes the bimonthly Offender Programs Report, which provides information on innovative programs, management strategies, and legal developments in offender rehabilitation. The Haworth Press publishes the Journal of Offender Rehabilitation focusing on research in the area. A diplomate in forensic psychology is available through the American Board of Forensic Psychology (www.abfp.com). (This list is not exhaustive; no slight is intended to associations and publications not mentioned.) Opportunities for practica and internships, both predoctoral and postdoctoral, are likely to increase as correctional decision makers recognize the need for, and difficulty of finding, mental health professionals to work inside prisons. This need is driven by several factors. First, there is increasing recognition of the needs of mentally disordered offenders (American Psychiatric Association, 2004). Second, legislative emphasis (with modest funding) produced the Mentally Ill Offender Treatment and Crime Reduction Act of 2004 (Public Law 108-14). Third, concern at the state and local levels, as well as among advocacy groups (Human Rights Watch, 2003; National Alliance on Mental Illness, 2004) has led to increased monitoring and advocacy for the mentally ill (Council of State Governments, 2002). Fourth, the need to find more effective interventions than incarceration alone is demonstrated by the fact that most offenders will be released, the majority (67.5%) will be rearrested within 3 years, and many (51.8%) of those released will return to prison (Bureau of Justice Statistics, 2002). REMEMBER WHERE YOU ARE This admonition tends to become a mantra drummed into most new staff in corrections. It is no less salient for psychology interns. Although no two of the 5,000+ correctional facilities in the United States operate in exactly the same manner, commonalities will be found to some degree in most, if not all, of them. The baker’s dozen laundry list that follows briefly discusses some of the truisms. SECURITY COMES FIRST I am not aware of a corrections officer or administrator who was disciplined or fired for not making sure that an inmate got to therapy on time. I am aware of hundreds who were terminated for breaches of security. Most wardens can live with their ulcers if nobody is hurt and nobody is gone. Most wardens are also aware that “everybody is getting better” must be added to their list. This does not keep delayed movements, limited access, counts, and lockdown from interfering

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Clinical Supervision in Correctional Settings 385 with the psychologist doing his or her job. Assertive patience and joint problem solving with upper echelon staff tend to be an ongoing and necessary part of successful practice in prisons. CORRECTIONAL FACILITIES ARE PARAMILITARY ORGANIZATIONS Most wardens can live with staff that understand, respect, and follow the chain of command. Most security staff can find ways of isolating or undermining staff who do not. Mistrust is a common occurrence between security staff and both interns and new psychologists. Communications repair is a regular task needing attention. Any supervisee needs to know that the best safety and communication net involves “fitting in,” or at least being known as “not security, but okay.” CONFIDENTIALITY IS USUALLY AN ILLUSION The primary currency in the inmate population (besides mind-altering substances, green money, gambling slips, and tobacco) is information. Inmates gather, trade, and hoard information on staff and other inmates. The usual treatment confidentiality statement to inmates goes something like this: “I will not report what you say to people outside the mental health staff. However, if you tell me of your intention to hurt or kill someone else [Tarasoff v. Regents of the University of California, 1976], or engage in a disruptive activity that may result in people getting hurt, or do something to hurt or kill yourself, I will take action.” Assessments are under somewhat better control, as they are usually done in a one-on-one rather than group setting. Clear statements of limits of confidentiality do not seem to limit adverse revelations by most inmates. The supervisee needs to have considered the appropriate action if the offender discloses previously unsolved crimes or the location of a murder victim’s body. In any case, the supervisee needs to be clear on what the parameters of confidentiality are and express them honestly to the client. IT IS A DIFFERENT CULTURE FOR THE CLIENT The convict culture is tough, predatory, and often violent. Being seen as vulnerable is an invitation to being ridiculed, scorned, sought after as a receptacle for sex, used as a mule to hold or transport drugs, or physically hurt. Having unpaid debts, welching on bets, or messing with someone else’s punk regularly gets inmates threatened, shanked (i.e., stabbed or cut with a homemade weapon), beaten, and sometimes killed. Anyone dealing with inmates needs to be prepared to work through situations in which the inmate feels threatened or obliged by peer pressure to “be a man” (usually meaning “retaliate”) or to be sexually submissive to the stronger inmate and his or her friends. These types of client–therapist interactions need to be thought out in advance and even role-played with the supervisor. ADAPTIVE BEHAVIOR IS ACCORDINGLY DIFFERENT The inmate may view being paranoid, being hypervigilant, fashioning weapons, joining cliques or gangs, offering sex to an individual who can protect, lying, and acting tough as adaptive responses to a threatening environment. Talking to the

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police (guards, correctional officers) rather than shuckin’ and jivin’, distracting, jiggering for a buddy, manipulating, undermining, or seeking information is often viewed as a maladaptive behavior. Ways of encouraging the client to acceptably use prison staff resources need to be thought out in advance. These may include helping the inmate figure out which staff are likely to shrug off overtures and which are likely to be problem solvers. This gets to be a most delicate situation in that it is a safe assumption that anything said about staff that is even marginally negative is likely to get back to that person. FAIR, FIRM, AND CONSISTENT IN CORRECTIONS IS ALMOST THE EQUIVALENT OF PRIMUM NON NOCERE IN MEDICINE A reputation of being “easy” or a soft touch will provide the therapist with an endless stream of self-referrals accompanied by the ego-building “You’re the only one who really cares” or “You’re the only one who has really helped me” statements from inmates. A reputation of being a hard ass or a snitch shuts the therapist out of the loop and generates avoidance. Inmates tend to respect a member of staff who is straight and upfront so they know where they stand. Similarly, inmates tend to use and simultaneously denigrate someone who is easy. In many cases they will also try to find some way to “mess with” those who are messing with them, and this may include the therapist’s clients and peer counselors. (An old saying in corrections is “If you can’t get the man, get his convict.”) Even casual and vague statements (e.g., “I’ll look into that”) are regarded by inmates as promises to take action. Failures to follow through will not be forgotten or forgiven. Thus, the supervisee should be encouraged to be careful with casual conversations, avoid offering to do anything the inmate can do for himself or herself, and write down all commitments to do things before distractions drive them from mindfulness. UPHOLD THE SAFETY AND GOOD ORDER OF THE INSTITUTION No matter what other duties may be found in staff’s job description, this expectation is there. Helping professionals tend to see role conflict in writing up rule infractions, intervening in conflicts in the housing area, or taking administrative actions that they see as the role of a correctional officer. Look at the big picture: If one parent only disciplines and the other parent only nurtures, the whole family is going to suffer. The key is the preservation of the family in the one case, and the good order and safety of the institutional family in the other. This perspective needs to be balanced. Mental health staff are not “cops” and should never seek the role of the correctional officer or participate beyond that which is necessary to protect staff and inmates. If mental health professionals buy into playing the cops-and-robbers game, they will not be seen as trustworthy helping professionals. CORRECTIONAL OFFICERS ARE PEOPLE, TOO Staff in a prison setting are like those in any large operation. They have a range of personalities and styles. These range from overwhelmed to abusive of power, from too caring to despising, from ultraconservative to loose cannon, from ignorant to brilliant. Most experienced staff have developed some adaptation or

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Clinical Supervision in Correctional Settings 387 accommodation that allows them to survive in a correctional setting. In some cases, this may include maladaptive behavior such as abusing substances, trafficking and trading with inmates, or bullying. Each staff person contributes something to the culture of the facility, and each can provide insights. Being friends with any individual staff member is not required; showing respect and being able to work with him or her as a team player is. However, there will be those individuals whose maladaptive behavior threatens the good order and safety of the institution. A good clinical supervisor will help the supervisee to maintain a team perspective and determine the appropriate timing and method of bringing a staff member who threatens the team to the attention of a supervisor. NEW BEHAVIORS IN PRISON ARE RISKY Most professionals in corrections readily agree that inmates need to develop prosocial values and behaviors such as personal responsibility. However, the prison setting is so structured and rule bound that all inmates are expected to do the same things, at the same (or staggered) times, with the same people, in the same manner. Trying out a new behavior, being assertive with staff, or voluntarily admitting an inappropriate behavior outside of the therapy room can be a recipe for disaster if not carefully planned. The supervisee may find that good skills in cognitive-behavioral therapy and role-playing can offset this environmental limitation to some degree. THERAPISTS ARE PEOPLE, TOO The supervisee may easily overestimate his or her skills, training, position power, psychological power, or effectiveness in a correctional setting. Weighing one’s potency against the influence of people with whom an inmate lives 24 hours a day, 7 days a week, for months or years at a stretch, and the possibility of getting beaten, cut, or stabbed; having one’s colon ripped from a broomstick inserted rectally; or having one’s property destroyed or stolen is a necessary reality check for those who would be agents of change. This includes perceptions about the effectiveness of interventions. All too often the apparent treatment effects will be a fac¸ade to establish to the releasing authority that the inmate is rehabilitated. DON’T TRY THIS ALONE Although the term correction implies that people change for the better while incarcerated, the reality is questionable. Staff, even treatment staff who have been around for a while, are more impressed with the return of 40% to 50% of inmates to prison, the exchange of drug-cooking recipes, the “crime college” training in theft techniques, and the violence that is inherent in a crowded and frustrating environment. They come to believe that change is impossible for inmates and that any perceived change is illusory or a manipulation on the part of the inmate. It is helpful for anyone working in corrections to find staff who believe that “corrections” should “correct.” Chaplains often make good allies in an effort to support change. There are always some corrections officers who have managed not to become calloused or burned out who can be powerful allies in efforts to correct.

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NEVER UNDERESTIMATE THE ABILITY OF CORRECTIONAL OFFICERS TO PROVIDE IMPORTANT INFORMATION AND TO SUPPORT OR UNDERMINE TREATMENT EFFORTS Psychologists and psychiatrists too often dismiss the observations of correctional officers as not coming from those holding professional credentials. The second most influential aspect of the convict culture is the correctional officer. The officer also has the ability to make the inmate’s life uncomfortable, can undermine or enhance the credibility of other staff, and usually knows the inmate considerably better than treatment staff. Encourage supervisees to spend time with line officers in the areas in which the supervisees provide treatment services. This has the effect of both providing a window on the real life of the inmate and perhaps improving the correctional system by providing support and training for the correctional officer. Office-bound wardens and upper echelon staff (and psychologists) and correctional officers who avoid direct supervision of inmates tend to know that which gets passed up the chain, which may be what correctional officers think they want to know but is a sketchy and often inaccurate picture of what is really going on. Good wardens, upper echelon staff, and psychologists spend a lot of time in living quarters, in mess halls, and “standing mainline” (i.e., being in the hallways and accessible during times of meals or other movement). This is known as management by walking around and is the technique of effective staff at all levels. It is also wearing, frustrating, time consuming, an invitation to be manipulated, and a quick path to burnout. It is far easier for any staff member who is assigned an office to remain in that office, push papers, drink coffee, and wait to be needed.

FAMILIES ARE PEOPLE, TOO The toughest part of the job is likely to be dealing with families. It is helpful to have inmates sign a document at intake specifying with whom information about their physical and mental health may be shared. It is also important to have a clear understanding of the agency’s stand on sharing information with friends and relatives of inmates. Otherwise, worried mothers who have been told by the inmate to whom they are related (or by “a concerned but unnamed inmate”) that terrible things are being done to the one they love have to be told that the psychologist does not have a release to talk with them about their loved one. Mothers are often terrified or enraged that “you” would “do” or “let someone do” whatever terrible thing they have been told is happening to their son or daughter. I have never yet found one who responded well to being informed that her child is an adult who is playing to her fears and sympathies and has usually played the major role in creating the problem, if indeed one exists. It is helpful for a clinical supervisor to role-play an irate or terrified mother or outraged father with the supervisee and establish some parameters for family calls. (Hint: In my experience, a mother’s response to finding out that she has been misled by an inmate will most often be “Oh, no. He has never lied to me.” Quite often the discrepancy between the social history provided by the inmate and the mother who is adamant about thinking that she knows everything about her son or daughter’s life is huge.)

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Clinical Supervision in Correctional Settings 389 C O N S I D E R W H AT Y O U A R E D O I N G Each system is unique. Some systems provide forensic evaluations for courts. Some provide risk evaluations for releasing authorities. Some transfer seriously mentally ill inmates to mental health facilities operated by social service or medical agencies. Other systems house and treat seriously mentally ill inmates within correctional facilities. Some systems consider psychiatrists as medical staff; others include them as mental health staff. Some consider mental health services as a subset of medical services; others take a more behavioral model. Some include sex offender and drug and alcohol services as part of mental health, others separate them out. It is likely in some settings the opportunities for training will be quite broad indeed. In other more restricted settings, rotations outside of corrections will be needed to round out the supervisee’s skills. This chapter is limited to mental health assessment and treatment services for the general population and does not go into forensic or risk assessments for the courts or parole boards. Most prison settings are audited either by the American Correctional Association (ACA), the National Commission on Correctional Health Care (NCCHC), or both. Standards are provided by both organizations (ACA, 2002, 2003, 2006, 2008; NCCHC, 2003a, 2003b) that make a good framework for discussion of mental health tasks in corrections. Reference is made to these standards throughout the remainder of this chapter, as they require some activities by the therapist that are different from those in a community setting. Even if the individual being supervised is not subject to these standards, awareness of them can be instructive. The standards referred to in this chapter are for adult correctional institutions. There are some variations for jails, community corrections, juvenile facilities, and the like that must be reviewed if the supervisee’s placement is in something other than adult corrections. Effective intervention is often indirect and may include tasks that are not part of outpatient therapy in most settings. Most systems have some form of unit management in which many care and custody tasks and recommendations are assigned to the staff who spend most of their time in the housing areas and are responsible for a defined number of inmates. This is in lieu of decision making by committees of senior staff who see the inmate for a few minutes in formal circumstances on rare occasions. The psychologist is likely to find that his or her role in unit management operation demands time. But it can also pay dividends in that it allows for training, provides for impact on the culture of the facility, enhances communication with line staff, and provides information about individual inmates that can be helpful in diagnosis and treatment. SCREENING AND ASSESSMENT SCREENING ACA Standard 1-HC-1A-25 requires “screening for mental health problems on intake as approved by a mental health professional.” This is a requirement both for reception of newly committed inmates and for intersystem transfers. Screening is not necessarily done by the psychologist or psychiatrist but may be done by “adequately qualified staff” following written procedures and using a screening form.

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NCCHC Standard M-E-02 is somewhat more specific, requiring screening be done by “qualified health care professionals” and allowing “health trained correctional staff” in facilities housing fewer than 500 inmates. If subordinate staff are assigned this task, their training by the psychologist or psychiatrist must be documented and the screening forms reviewed periodically. In some systems, the term psychologist includes holders of master’s and bachelor’s degrees. Some jurisdictions do not require licensure for individuals employed by the state or federal government. This standard was tightened in 2004 (ACA, 2006, 1-HC-2A-05) to require compliance “with applicable state and federal licensure, certification, or registration requirements.” Thus, generally the licensure and supervision requirements in correctional facilities became the same as those in the community, and they may be stringently monitored if the correctional facility is accredited. The timing of this screening is not specified in the ACA standards but must occur prior to placement of the inmate into the general population. The NCCHC allows 14 days for screening to be complete. The simplest way to avoid deliberate indifference lawsuits is to screen as quickly as possible once custody and physical presence have been established. New commitments generally must be brought to the facility with Judgment and Commitment Orders or some other form of order from the court that authorizes the system to assume custody (and therefore responsibility) of the inmate. Many facilities have a “holding tank” or “fish tank” or separate housing facilities for placement of new arrivals out of the general population until screening has been completed, or longer if screening reveals problems. The concept is to prevent placement into the general population of inmates who are having severe problems or who might cause severe problems for themselves or other inmates or staff if they are not segregated and/or treated. Screening includes determination of mental status but does not require an in-depth appraisal, psychological testing, or a period of observation unless more serious problems are detected. Medical (and in some systems, mental health) staff are required to do screening of intrasystem transfers upon arrival, either at a new patient unit or while in transit (ACA, 1-HC-1A-21). Again, the concept is to prevent the overlooking of serious or urgent needs and the placing of dangerous individuals into the general population. Sometimes the move itself is stressful (e.g., greater distance from family, gambling debts, enemies not previously named in enemy alerts, loss of protection, sexual threats). At other times the classification committee at one facility has attempted to deal with problematic inmates by transferring them to another facility. The screening must include face-to-face visualization; questions about immediate needs, problems, or medications; and record review. It should include referral for mental health appraisal if any obvious problems are seen or reported. This may require the psychologist to train nurses in recognition of suicide threats and symptoms of serious mental illness. If a serious problem is detected, the inmate must be referred to the appropriate professional staff immediately. If a less urgent problem or treatment history is related by the inmate, this is noted in the screening and referred to qualified professional staff for assessment on a more routine basis. Serious problems (e.g., security threat group or gang affiliation, suicide risk, program needs) are fed into offender management systems where they reemerge as alerts or prompts for

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Clinical Supervision in Correctional Settings 391 periodic review. Offender management systems are transitioning (or, in some systems, have transitioned) to electronic-based systems. In the better systems, access permission to various types of information is limited to need to know. It is important for the supervisee to know what information will be published and who will have access to it. ASSESSMENT Screening is followed by “a comprehensive health appraisal” (ACA, 1-HC-1A-22) or “mental health evaluation” (NCCHC, M-E-04). Appraisal or evaluation, hereafter referred to as assessment, may not be required for inmates who have recently undergone the process. This is typically defined as “within the past ninety days” (ACA, 1-HC-1A-22). This assessment must be done within 14 days for inmates with serious problems and within 30 days for the remainder. The urgency of the problem dictates whether the assessment needs to occur sooner rather than later; the inmate (and the staff and population) should not be subjected to unnecessary risk. The assessment may have several levels. For example, screening for developmental disability or severe cognitive impairment may involve administration of a group intelligence test with follow-up individual testing such as Wechsler Adult Intelligence Scale, Vineland, or other adaptive scales for those suggested to have moderate to severe impairment. Mental illness may be screened with a social and mental health history interview (ACA, 1-HC-1A-28, 1-HC-1A-29; NCCHC, M-E05) that is followed up with standardized testing with psychometrics or diagnostic interview. Most systems have settled on a protocol for conducting assessments. Some systems may use instruments that were not well covered in the supervisee’s training and require some extra training and practice. There are usually psychologists on site who are willing to assist the supervisee in getting up to speed. It is important that the supervisee recognize that in an accredited facility, deadlines are externally imposed, and meeting them is crucial for the continued accreditation of the facility. CONFIDENTIALITY Most systems have established rules regarding confidentiality. Privacy must be afforded to the inmate when discussing problems and confidentiality of records maintained (ACA, 1-HC-3A-03; NCCHC, M-H-02). Although this sounds straightforward on paper or in the classroom, numerous factors complicate privacy and confidentiality in a prison setting. A maximum security or close custody setting often requires two officers to move an inmate from cell to interview room, and there are times when shifts are shorthanded or officers are tied up elsewhere. Conversely, inmates in lockdown or segregated housing will often report problems or request confidential interviews primarily in order to allow movement to relieve the prison version of cabin fever, to have the opportunity to talk to inmates in other cells, to enjoy private time with a staff member of the opposite sex, or to seek hope and sympathy for real or imagined problems. This makes some degree of cell-door screening necessary to triage problems. Quiet conversation may be

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possible through bar doors, but it is almost impossible with the solid doors that most facilities use to prevent dashing (i.e., throwing of liquid or solid waste), fishing (i.e., movement of messages or contraband), and assault on staff or passing inmates. There is also an often vaguely answered question as to what the correctional officers, the persons with most of the responsibility for managing the inmate, need to know about the risk and needs of that inmate. Any correctional officer will be justifiably concerned about not being notified about threat issues or about something as general as the heightened emotional state of an inmate “about to blow.” Some correctional officers tend to feel parent-like responsibilities and feel that inmates have only a small child’s right to confidentiality and privacy. It is important to be sensitive to any abuse or leaking of information by individual officers and to confront it directly, quickly, and privately. CRITICAL REVELATIONS The inmate may provide information on the location of victims’ bodies in unsolved crimes. He or she may make terroristic threats that seem a by-product of mental illness but are no less of interest to Homeland Security. These threats may be made to relieve the monotony through a visit from the Federal Bureau of Investigation, to gain notoriety, or in hopes of being removed from the correctional facility and taken to court. When specific targets of a threat are named, it is often difficult to determine whether or how a Tarasoff -type warning (Ewing, 2002) should be given. Warning an intended victim in a correctional setting may easily result in a preemptive strike by the named victim or the victim’s associates (friendships are rare and risky in prison settings; most offenders refer to associates) who may not even be known to the inmate making a threat. Similarly, it becomes a difficult issue if the inmate is doing many years and will not have an opportunity to carry forward the threat against an outside victim in the foreseeable future. TREATMENT PLANNING Treatment plans are expected to be individualized and present in all files of inmates assessed as being in need of treatment (ACA, 1-HC-4A-06; NCCHC, M-G-01). These assessments must be done by a licensed mental health professional (or in the case of an intern, co-signed) and usually involve some staffing mechanism so that the plan is not at the discretion of a single individual. Depending on the type and location of the facility to which an inmate may be referred for mental health treatment, certain due process may be required (ACA, 4-4404). This requirement usually flows from the decision in Vitek v. Jones (1980). S E G R E G AT I O N TYPES OF SEGREGATION Most facilities of any size will have segregation units. Perhaps the most common type of segregation is punitive segregation (punitive isolation, lockup, “the hole”),

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Clinical Supervision in Correctional Settings 393 which most systems use as a method of punishing the misbehavior of inmates found guilty in a due process (disciplinary court) hearing. This is the correctional version of time-out and usually requires a mental health review of inmates known or suspected to be mentally ill prior to sentencing to ensure that the behavior is not the product of “serious mental illness” (ACA, 1-HC-3A-07). Other facilities usually labeled maximum security, close custody, or supermax prisons may be predominantly segregation units. Housing units (barracks or cell blocks) may be established for administrative segregation, the purpose of which is primarily to keep violent and/or predatory inmates from harming others. Other housing units may be designated as protective custody and house vulnerable inmates, former police officers, and the like who are at risk for harm in the general population. MAKING ROUNDS For as long as an inmate remains in any type of segregation, his or her health must be monitored (ACA, 1-HC-3A-07; NCCHC, M-E-09), and he or she must have the same access to mental health services as an inmate in the general population. This requires that rounds be made in the segregation unit with a frequency of three to five times weekly (NCCHC, P-E-09). Segregation and lockdown units keep logs of who enters and exits. In some systems, psychologists sign in using a different color ink than chaplains, security, or medical staff. This facilitates checking, for audit or supervision purposes, that rounds have been made. Some systems require that the person doing rounds be licensed; others allow unlicensed correctional counselors to make rounds, triage needs, and make referrals to licensed personnel. Either method should result in some documentation that the inmate had access, the problem was recorded, and appropriate action was taken. This may be done in a log book, the mental health record, or both. Rounds may consist of the staff member announcing his or her presence in the area and being accessible to any inmate who submits a written request or makes a verbal request to be seen. Alternatively, the protocol established by the health authority may require that each inmate be contacted individually. Requirements vary with the type of housing, the classification of inmates, and the known needs and treatment plans of the inmates. The role of the psychologist may be life saving, as suicidal ideation, threats, gestures, and completed suicides tend to occur more frequently in inmates in isolation (Bonner, 2006). Rounds that consistently show only a few minutes spent in the housing area raise suspicions of perfunctory compliance with the standards (ACA, 1-HC-3A-07; NCCHC, M-E-09). However, rounds can eat up a great deal of time if inmates are allowed to control conversations with staff. Hope and empathy are rare and sought-after commodities in correctional settings. If a staff member develops a reputation among inmates as being supportive or caring, demands on his or her time tend to increase exponentially. This easily leads to overload, burnout, and callousness, or job change. It is incumbent on the part of the supervisee to develop and practice techniques of maintaining focused interactions without seeming dismissive or trivializing complaints. This may take the form of stating “If I were you, I would take this

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up with the unit manager [institution parole officer, chaplain, chief of security, sergeant on duty, nurse holding sick call].” It is easier and more common to say “That’s not my job.” That attitude undermines morale and tends to exacerbate rather than solve problems. It is better to encourage the inmate to make the contact and engage in effective problem solving than for the supervisee to take on the responsibility for doing it for the inmate. Problem solving requires knowing the roles of other staff and making effective suggestions to inmates. This requires good lines of communication with staff in all areas; developing these is possibly the best investment of time that someone new to the system can make. This is also important because inmates often firmly believe that the only way a problem will get solved is to “shotgun” or bring it to the attention of every staff member they can think of. Without good communication, several staff may work on the same problem, wasting resources and possibly working at cross purposes. PERIODIC ASSESSMENTS In addition to rounds, the standards and protocols of the facility may require periodic assessments of inmates on lockdown. ACA Standard 4-4253 requires a review of the status of inmates in administrative segregation every 7 days for the first 2 months and at least every 30 days thereafter. This is primarily an administrative and due process matter to determine whether the reasons for placement continue to exist. However, the psychologist may be asked to provide input, sit on a classification or review committee, or provide a written report. The psychologist should be monitoring the mental health, and the effects of segregation on the mental health, of the inmate to ensure that decompensation is not occurring and that adequate treatment can be provided in that setting. Usually it is best to work from documentation and report behavioral observations, including those gleaned from security and other staff, and express only evidencebased recommendations rather than to report clinical insights or express opinions regarding the correctness of the inmate’s placement. Wardens would like for assessment reports to contain definitive pronouncements as to whether an inmate is going to act out further or to comply with institutional rules. Sitting down and explaining actuarial versus clinical prediction or prediction of incidence of behavior in groups versus prediction of individual behavior is likely to be an exercise in frustration, especially in light of recent TV series showing a psychologist’s clairvoyance or individually predictive behavioral profiles, but it should be kept in mind by the supervisee. Although wardens do not like to hear the customary caveats, the psychologist who does not make clear the limitations of his or her insights and predictions is asking for trouble. ACA Standard 4-4256 requires that a mental health professional prepare a written report on any inmate in segregation for more than 30 days. Further reports are required at least every 3 months thereafter for as long as segregation continues. This can become a bureaucratic exercise of making sure the right paper is on file if the psychologist does not stay focused on the high risk isolation poses for the inmate.

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Clinical Supervision in Correctional Settings 395 The Commission on Safety and Abuse in American Prisons (2006) made the following recommendations with respect to minimizing the negative aspects of segregation: 1. Make segregation both a last resort and a more productive form of confinement. 2. Increase regular and meaningful human contact. 3. Protect the mentally ill through rigorous screening and assessment. None of this is new, but it provides a good summary regarding isolation.

SEGREGATING THE MENTALLY ILL The overrepresentation of mentally ill inmates in segregation units and the effects of isolation have been noted by a number of authors (Coid et al., 2003; Haney, 2003). However, this is a knotty problem in that Axis I and Axis II disorders often coexist, if not synergize each other. It is risky to place inmates who pose threats of danger and disruption in a mental health environment that often contains potential victims for them. It is just as problematic to keep these inmates in a segregated environment that exacerbates their Axis I disorders. The supervisee is likely to find the ethical landscape regarding conditions of confinement to be shrouded with fog and is likely to need support and guidance in working out issues surrounding segregation (Haag, 2006). In any case, mental disorders do have to be treated in segregation, or the inmate must be moved to a mental health setting. ACA Standard 4-4273 requires that inmates in administrative segregation and protective custody have access to the same array of programs and services as inmates in the general population. This also applies to inmates in punitive isolation for periods exceeding 60 days (ACA, 4-4255). Some systems avoid the necessity of providing programs and services in punitive lockdown areas by allowing for relief intervals of a day or two interspersed with continuation of punitive isolation.

PERSONALITY DISORDER The greatest challenge may be Axis II personality disorders and the culture they create, even if the inmate under consideration does not carry the diagnosis. This raises the question of treatment of Axis II disorders and antisocial personality processes. It is tempting to limit treatments to Axis I disorders and to consider Axis II disorders as untreatable problems to be addressed administratively. However, it is often Axis II disorders and associated behavior that cause the most pain and cost both to the client and to society. The majority of inmates in segregated areas are strongly tainted with antisocial personality or other Axis II traits. Many of them spend months or years in segregation as a result of their inability to adapt or accommodate, often extending sentences for years in systems that allow “good time” or credit earned against the length of the sentence for good behavior. Axis II disorders may cause major

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dysfunction and suffering (often inflicted on caretakers rather than experienced by the inmate). French and Gendreau (2006) conducted a meta-analysis of the effectiveness of correctional treatment in reducing misconduct. They reported that behavioral programs targeting criminogenic needs and having therapeutic integrity were the most effective in controlling misbehavior while in prison. Those programs also had the largest impact on recidivism after prisoners’ release to the community. Treatment of Axis II disorders (Cellini, Wood, Hinze, & Speaker, 2003; Walters, 2002) may increasingly become the focus of corrections as the “fires” or Axis I disorders are dealt with more effectively in corrections and as legislators and the general public become more aware of the failures of the correctional system to correct. Much of the failure has been due to a belief that treatment of Axis II disorders cannot be carried out effectively with the tools in the psychologist’s toolbox, and a perception that Axis II disorders are untreatable with any tools. Both of these are good reasons for research and careful discussions between supervisors and supervisees regarding what to treat and how to treat it in segregated areas. Provision of group services, although the most effective type of intervention, is nonexistent in the segregation areas of many systems due to the very factors that caused the inmate to be segregated. Individual therapy is costly and wearing on the provider, who may well find the inmate the better manipulator in the dyad. It often requires moving files and equipment to an area adjoining the segregation block; waiting on escort and movement of the inmate; dealing with concerns about an inmate of one gender being alone with a therapist of the other gender; contending with mechanical and inmate noises in the area; and accommodating interview to cramped, uncomfortable, and marginally private spaces. C R I S I S I N T E RV E N T I O N A N D S U I C I D E P R E V E N T I O N The suicide rate in confinement has declined dramatically since the 1980s. The rate in jails dropped from 129 per 100,000 in 1983 to 47 per 100,000 in 2002. The rate in prisons dropped from 34 per 100,000 to 14 per 100,000 (Bureau of Justice Statistics, 2005). The suicide rate in U.S. prisons overall is now closer to the 2002 rate of 11 per 100,000 (Centers for Disease Control and Prevention, 2005). The rate of suicide in prisons is down to nearly that of the country (free world). Even so, suicide is a behavior that prison systems consider a major issue and are required to address (ACA, 4-4373; NCCHC, M-G-05). The requirements include a written plan or protocol that may include the following:

r r r r r r r r

Documented and repeated training of staff in contact with inmates. Recognition of signs and symptoms. Methods for making referrals. Evaluation by professional staff. A system for triaging and setting levels of precautions. Specialized housing providing needed levels of observation. A protocol for notification of appropriate correctional staff. A schedule and documentation (logs and forms) of observation and checking of restraints, if used.

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Clinical Supervision in Correctional Settings 397

r A schedule of contact with professional staff. r Critical incident debriefing of staff and other inmates if suicide occurs. r Plans for follow-up once the immediate danger has resolved. Supervisees need to be well oriented to the written plan and be able to confidently role-play assessment and intervention with a supervisor taking the role of an inmate who has threatened or attempted suicide. RISK FACTORS For women, the presence of borderline personality disorder, mental illness (Borrill, Snow, Medlicott, Teers, & Paton 2005), history of abuse (Milligan & Andrews, 2005; Verona, Hicks, & Patrick, 2005), and lack of a support system suggest heightened risk for self-harm. Diagnosed depression, hopelessness (Palmer & Connelly, 2005), previous reliance on substance use, a lack of connectedness to family and friends (Adler & Adler, 2005), and a history of previous self-harm are strong risk factors in both genders. Most individuals who engage in self-harm do not die as suicides (fewer than 5% in a large-scale 5-year follow-up; Suominen, Isomets¨a, Haukka, ¨ & Lonnqvist, 2004). Nonetheless, a thorough assessment is protective of both the psychologist and the inmate. THREATS AND GESTURES Suicide prevention and intervention in the prison setting are complicated by inmates’ use of suicide threats and gestures for secondary gain. It is not uncommon for inmates who feel threatened physically or sexually, or who want a change in housing situation, to use suicidal threats or gestures to force the issue. These persons often fit into the description of alienated, frustrated, aggressive individuals with immature coping and poor impulse control mechanisms (Shea, 1993). Suicidal threats or gestures, whether real or manipulative, are not rare in correctional environments and are a challenge to handle because the tensions are complex and emotionally loaded. Manipulators may be perfectly content if they are successful at changing their environment and may no longer threaten or gesture suicide. At the same time, if a goal-directed behavior is successful, it is likely to be repeated. The psychologist hesitates to use suppression techniques (punishing or ignoring) with suicidal behavior, as those can lead to claims of deliberate indifference or neglect. It also appears cruel and callous if a disciplinary report is written on a suicidal gesture judged to be manipulative. At the same time, not to hold an individual accountable seems to undermine personal responsibility. APPROACHES TO PREVENTION AND INTERVENTION Although most correctional institutions have policies and protocols in place, it is worthwhile to stay aware of developments in the field. The National Center on Institutions and Alternatives puts out a quarterly newsletter on suicide and has published a guide (Hayes, 1995) to prevention. The National Institute of Corrections (2001) provided a lesson plan for departments of correction. Guidelines for

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line staff in the United Kingdom, which has recently had a more serious issue with self-harm (Fazel, Benning, & Danesh, 2005) than the United States, were published by Gough (2005). Also see Cox and Hayes (2003). Traditional approaches to management of suicidal behavior in prison have typically included three levels: (1) observation or suicide watch; (2) restriction or “strip cell”; and (3) restraints, ranging from securing to a gurney or bed with “D-rings” or hard (handcuffs and leg irons) or soft (leather or nylon) restraints, to molded specially designed restraint chairs, to straight jackets. All of these approaches are governed by standards (ACA, 1-HC-3A-12; NCCHC, M-1-01) and have limitations and drawbacks that raise issues for the psychologist.

Observation This first level of intervention also carries through succeeding levels and requires that the inmate be observed for self-harm behavior, usually in a location reserved for that purpose. Because lethal suicide attempts tend to occur primarily by hanging, architects have attempted to design suicide-proof cells with recessed or breakaway fixtures and mesh on ventilation too small to allow attachment of a homemade rope or clothing. Most observation cells include these features, but they are of limited utility because a successful hanging may occur by affixing an article of clothing to anything solid and leaning forward against the noose made of underwear. Even toilet paper can become a lethal tool for asphyxiation when wadded and jammed into the throat. Thus, observation is essential. Effective observation is based on human presence or contact more than on electronic means that often fail due to distraction or boredom on the part of the individual who is assigned to watch the monitor. Observation intervals are often set for 15 or 30 min, which is more than enough time for an inmate to asphyxiate. Effective observation requires full-time assignment of a member of staff, usually a corrections officer. In earlier times, another inmate was placed in a cell with the suicidal inmate and admonished of the dire consequences to him or her if the suicidal inmate succeeded in killing himself or herself. This approach has a newer version in which trained inmate observers assist with observation and intervention (Junker, Beeler, & Bates, 2005). Obviously this has to be done carefully. In my experience, inmates have assisted other inmates by pulling on their legs while they were hanging or cheered them on in their attempts. Usually it is up to the psychologist to specify the extent of observation and types of interaction between the observer and the inmate being observed. These specifications need to be part of an individualized treatment and management plan, balanced between reinforcing the behavior with attention and humane and appropriate observation. (One of my vivid memories is of asking in frustration “Why do you keep cutting on yourself?” The response that I received was “Because I know that someone from mental health will talk to me.”) However, most suicides occur in segregation areas that provide privacy and isolation. Isolation, even social isolation as subtle as lack of family support, can lead to increased despair and focus on how hard it is to go on living.

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Clinical Supervision in Correctional Settings 399 Restriction The second level of intervention is restriction or strip cell. Restriction may be associated with intensified observation and reflects an effort to deprive the inmate of the means of suicide. It is used for those inmates who are more acutely suicidal (or those who have worn the staff out with previous threats and gestures). This may involve removing only the items (sharp objects, belts, strings) that the inmates have focused on as a method, or it may range from removing all personal property to removing clothing, leaving the inmates in a suicide blanket or gown. It is never safe to conclude that a strip cell, a suicide gown, or even a padded cell is safe. Inmates have been known to rip steel from toilets, shred suicide gowns, and eat significant amounts of a padded cell when there was a break in observation. Observation in a restriction setting typically requires not only that correctional staff watch, but that mental health staff have frequent contact with the inmate. In a few cases, the inmate may feel grateful that the staff is trying to keep him or her alive. In many cases, restrictions are seen as degrading and punitive, often increasing alienation, frustration, and the desire to act out (“show you” or “beat the system”). In the case of some inmates (these tend to be primitive borderlines or individuals with deficient coping skills who repeatedly injure themselves), strip cell may require a body cavity search for items concealed in various orifices. In some systems, security officers may be trained to perform body cavity searches. However, it is usually considered to be a medical procedure and must be specified in the treatment plan. Medical staff see an ethical conflict in their involvement in forensic procedures but are ethically allowed to engage in treatment activities. Restraint Restraint is the third level of intervention. Restraints are used only when it is clear that less restrictive interventions have been ineffective or that the mental state of the inmate is such that a lesser intervention would place him or her at too much risk. In addition to requiring continuous observation by security and regular assessment by mental health professionals, the use of restraints puts demands on medical staff to check circulation. Maintenance in restraints for more than a couple of hours requires frequent exercises of each limb to prevent blood clots (ACA, 4-4405). Restraints can be amazingly ineffective with inmates bent on self-harm. Sutures can be ripped out by straining against restraints or wounds opened by rubbing them against the restraining straps or devices. Inmates have been known to bite themselves severely and to overturn restraint beds and chairs that were not well secured to the floor. In such cases, medical intervention is usually necessary. The smart psychologist will have established a prior relationship, or better yet a team approach to management, with the psychiatrist. A few inmates may request restraints to avoid self-harm, though such requests raise real questions about other pathology, such as a history of bondage, abuse, and/or posttraumatic stress disorder; overdependence on the therapist; self-dramatization; or the need for attention. Acquiescing to such requests may give inmates time to get back into control and the psychologist time to provide other interventions. It is also a symptom of a need to learn better coping strategies.

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Regardless of etiology, such requests become a nuisance for staff if inmates begin to enjoy the control exercised and the attention surrounding it. Restraints are to be applied only after less intrusive methods have been documented. Although this may be the expectation in the standards, a prudent psychologist will study the history of the inmate and skip levels if it seems to be necessary to protect the inmate. Rarely will a psychologist be successfully sued for taking prudent action to protect life. In many more cases, a wrongful death action will be filed when a successful suicide occurs. The other side of this balance is the tendency of security staff to overestimate the risk posed and underestimate the effectiveness of other interventions (Whittington, Lancaster, Meehan, Lane, & Riley, 2006). It is crucial that the decision reflect good clinical skills and judgment rather than bow to the wishes of correctional staff who have just been dashed with feces or had to go through a violent cell extraction process. This is followed by the question of how long to leave an individual in restraints. The staff inclination is “until he’s learned his lesson,” and there are often blurry lines between the use of restraints as punishment and as protection. Methods of living with staff while maintaining professional ethics are not taught in most academic programs and should be a topic of discussion with supervisees. The jurisdiction in which the correctional facility is located usually specifies who may authorize restraints. In some jurisdictions, this authority is limited to physicians; in many jurisdictions the psychologist also has that legal authority. In most systems, the psychologist will be expected to participate in the training of other staff who are likely to be involved in dealing with inmates in restraint status, if not expected to devise and provide that training. Standards require that a protocol be approved by the medical authority that delineates the specific authority, circumstances, methods, review, and documentation of restraint use (ACA, 4-4406; NCCHC, M-1-01). SELF-MUTILATION Sometimes an instance of deliberate self-harm is a single event, both shocking and frightening to the inmate, and is not likely to be repeated. Alternatively, selfmutilation may represent an attempt to extinguish the body’s natural pain avoidance and self-preservation reactions in a buildup to a lethal injury. Self-mutilation may be a manifestation of an established pattern of manipulation of staff and is much more difficult to treat and manage than self-mutilation that is symptomatic of an Axis I disorder. Hepp, Wittmann, Schnyder, and Michel (2004) provided a good review of treatment methodologies. There also are a number of “cutters” in most large systems who engage in self-mutilation to relieve tension or have control over their pain. This tends to be episodic; once tension is relieved, immediate risk is reduced but long-term risk increased. For individuals who need pain to relieve tension, the associated behaviors are quite different in that they are more persistent, long term, frequent, hidden, and often considered shameful by the person engaging in them. Self-mutilation often seems to be done in a dissociative state and can result in severe tissue damage, though there is no intention to cause death, at least not in the early episodes. There

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Clinical Supervision in Correctional Settings 401 are few well-studied therapies for self-mutilation, but a combination of medical treatment and cognitive-behavioral approaches (Muehlenkamp, 2006) holds some promise. As Nils Bohr, Nobel laureate in physics, noted, “Prediction is very difficult, particularly if it is about the future.” It is inevitable that any psychologist who handles suicidal ideation, gestures, or behavior on a regular basis is going to be wrong some of the time. The results can be devastating without preparation on the part of the supervisor for resources and methods for the supervisee to handle adverse outcomes (Kleespies, Penk, & Forsyth, 1993).

INDIVIDUAL AND GROUP THERAPY The effectiveness of treatment in a correctional setting has received warranted skepticism, culminating with the Lipton, Martinson, and Wilks (1975) review of outcome studies in correctional settings. Martinson’s (1974) pronouncements have been oversimplified as “nothing works.” It has taken psychologists some time to find which tools are both feasible and effective to use in the correctional environment. This remains an ongoing effort to which the supervisor and supervisee can contribute. There is a strong need for research and evidence-based practices in correctional psychology. I and others often describe prison management principles as “management by crisis,” despite lip service given to being proactive, much less gathering evidence for what works. To a large extent, time and resources spent putting out fires leaves little for therapy with the arsonists. Most settings have insufficient staff to attend to the requirements of making rounds in segregation, keeping up with crisis intervention, assessing inmates, and developing treatment plans to carry a caseload of clients in elective group and individual therapy, much less theorize, collect data, and do research. A number of authors (Blackburn, 2004; Coons, 2005) have noted the lack of good research on the effectiveness of correctional treatment. Even the definition of treatment varies greatly from setting to setting (Andrews, Bonta, & Hoge, 1990). When I started in corrections in 1976, I was told to report to the assistant warden for treatment. I asked the assistant warden what treatment was occurring and was informed that there was the kitchen, the laundry, and the infirmary. The definition of effective has similarly been a matter for debate, with recidivism being the most common outcome variable. Recidivism is a weak outcome measure. Much criminal behavior that could result in recidivism is unreported to police; if reported it does not result in arrest; if it results in arrest it is not prosecuted, thus does not result in recidivism.” This is particularly true among the incarcerated populations, as prosecutors place low priority on the prosecuting crimes of individuals who have already had their paroles violated or are doing time for other crimes.

EFFECTIVENESS Canadian psychologists took the early lead in research into what works. Andrews et al. (1990), Gendreau (1996), McGuire (2001), Andrews and Bonta (2003), and

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Gendreau, Goggin, French, and Smith (2006) laid out research-based principles for effective treatment. These include:

r The Risk Principle finds that providing treatment to low-risk inmates has little

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if any positive effect and may have negative effects. This principle steers treatment toward high-risk offenders with an emphasis on long-term and intensive treatment. Corrections has often taken the opposite approach. Treatment has traditionally been seen as a privilege to be earned by good behavior, like better jobs or less restrictive classifications, directing treatment at the more conforming and compliant inmates. The Need Principle focuses treatment on criminogenic needs, or those needs closely linked to, if not causal of, illegal behavior. Criminogenic needs may include substance abuse, anger management, and sexual deviance, among others. Needs related to anxiety, self-esteem, phobias, depression, and the like have often been the focus of treatment. Such treatment may only lead to criminals who are psychologically better adjusted and, in some cases, better able to carry on their criminal careers. The Responsivity Principle focuses on the offender and a determination as to what approaches are most likely to succeed given his or her personality, learning style, and receptivity. This principle calls for matching the therapist and program to the offender and individualizing treatment planning, typically with an emphasis on cognitive-behavioral treatment methods. The Professional Discretion Principle allows compensation for individual and group differences in classification for programs. Pedophiles, for example, score low on most recidivism risk instruments due to a large number of unreported victims and low rate of other types of criminal offenses, but some are known to engage in a high rate of undetected victimization. The Program Integrity Principle focuses on the need for a dedicated, enthusiastic staff following the first four principles, showing good interpersonal skills, and using effective modeling and positive reinforcement. Community-Based is not so much a principle as a finding that prison programs without follow-up in the community have little impact, and community-based programs show the strongest impact.

In my observations, although prison-based programs can be highly effective in helping inmates manage prison environment behaviors, there is too little transfer to life outside prison. The bottom line is that considerable time, money, and effort are likely to be wasted unless the psychologist establishes linkages with community programs that can work with the former inmate in the transition from prison life to the free world. This is particularly true for seriously mentally ill inmates (Lurigio, Rollins, & Fallon, 2004), who should not be released without provision for continuity of care. Often it takes coordination with community providers and leverage in the person of the parole or probation officer to ensure that former inmates keep the appointments that are made for them and have the resources to access any psychoactive medications they are taking at discharge.

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Clinical Supervision in Correctional Settings 403 McMurran and Ward (2004) provided strategies for motivating offenders to deal with criminogenic behaviors by finding acceptable ways to meet needs while avoiding situations likely to lead to relapse. It is somewhat telling that research in New Zealand (Skogstad, Deane, & Spicer, 2006) found inmates less likely to seek psychological help if they had had previous experience with a prison psychologist. Therapist characteristics have a major impact on the effectiveness of treatment. There is often a tendency to want to maintain emotional distance from depressed, angry, and hurting individuals. Although this may be more comfortable for the intervener and may be carried forward under the aegis of professionalism, management without concern that is clear to the inmate is likely to be ineffective (Huband & Tantam, 2004; Marshall & Serran, 2004). It also can set up the psychologist who comes across as unsupportive and uncaring is likely to harvest resentment rather than positive change. This balance needs to be a major focus of supervision in a correctional setting. The image of a swimmer being dragged under in a rescue attempt may be useful to convey to the supervisee. This needs to be balanced with the supervisor capitalizing on the enthusiasm of a supervisee to succeed with clients who have been previously labeled as not motivated for treatment. A related danger in correctional settings is the skill level many inmates with antisocial personality have at detecting weaknesses and playing them to gain favor. Comments such as “Wow, do you know how good looking you are!” directed at a female therapist who is some distance from supermodel status, “You sure do understand convicts,” “You are the first person that has helped me,” and “They don’t pay you enough, and sure don’t respect you” should always sound alarm bells that the recipient is being set up for manipulation. It takes 6 months, or more in some cases, to understand the culture and workings of a correctional facility. It usually takes longer to find one’s role and set proper boundaries; reality checks by the supervisor can facilitate this process. The supervisor can be a support and counselor during the adaptation period. Unfortunately, only the larger correctional environments provide the level of professional contact needed to support and the reality check providers. This, along with absence of a career ladder in many settings (but not all; see Hawk, 1997), tends to undermine the job satisfaction of the psychologist working in a correctional institution (Boothby & Clements, 2002). An outside support and counseling system may also be needed for those who stay past an internship. Other correctional psychologists best understand the stresses of working in corrections and may be able to provide reality checks and support. The risk is that dyads and groups within the work setting, no matter how well they start, may sink to the level of “bitch sessions” and telling “war stories.” It may be helpful to encourage supervisees to find some way to obtain support outside the corrections system to make sure that they continue to provide for their own mental health and avoid drug abuse, stress on family relations, and job burnout. Correctional treatment has followed the various political winds that blow funds into correctional settings. Substance abuse was an emphasis in the 1980s and early 1990s. Sex offender treatment has been a major emphasis more recently. Recent legislation pushes treatment for those who have been sexually victimized (Prison Rape Elimination Act of 2003) and for the mentally ill (Mentally Ill Offender

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Treatment and Crime Reduction Act, 2004). It remains up to the psychologist and the supervisor to seek out an evidentiary basis for programs in which the psychologist becomes involved and to seek best practices in the implementation of those programs. The majority of correctional facilities are located at considerable distances from professional labor pools. This has led to increased use of telepractice (Magaletta, Fagan, & Peyrot, 2000) to make better use of limited resources. Few psychology programs provide training in this technology, but many medical schools have telemedicine centers and may be able to provide some support. In my experience, the inmates raised on video games seem quick to adapt to talking to a TV set. This chapter has been heavy on pointing out conflicts and providing cautionary statements regarding practice in correctional settings. It is past time to point out some of the advantages:

r The extent and range of pathology. Correctional populations tend to have about

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double the prevalence of most Axis I diagnoses as free-world populations (Collins & Schlenger, 1983). There is much speculation as to why this is the case (the mentally ill being more predisposed to crime or more likely to wind up holding the bag for skilled criminals, deinstitutionalization of state hospitals, rarity of success of the insanity defense, greater difficulty of the mentally ill doing time). Regardless of the reason, the opportunity is there to treat a wide range of disorders. The depth of history and documentation available on inmates. Correctional institutions tend to collect and store masses of information, ranging from the obvious criminal history to medical records and information on family relations. Much more is known about inmates than is typically known about persons in the community. The presence of many additional observers able to provide input and feedback. Much official documentation as well staff are able to provide information about the inmate’s general adaptation and day-to-day behavior. Little goes unobserved in correctional institutions. The leverage, real or perceived, for inmates to participate in and stick with treatment regimens. Work supervisors, releasing authorities, and courts often value participation in treatment. Inmates definitely value looking good for those authorities. The ability to follow many inmates in prison and upon release to see what did or did not work. It is rare that an inmate drops out of treatment without the therapist being able to find out what is going on with him or her. A smart psychologist closely monitors the effects of interventions and learns what works. REFERENCES

Adler, P. A., & Adler, P. (2005). Self-injurers as loners: The social organization of solitary deviance. Deviant Behavior, 26, 345–378. American Correctional Association. (2002). Performance-based standards for correctional health care in adult correctional settings. Alexandria, VA: Author. Available from www.aca.org. American Correctional Association. (2003). Standards for adult correctional institutions. Alexandria, VA: Author. Available from www.aca.org.

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Clinical Supervision in Correctional Settings 405 American Correctional Association. (2006). 2006 standards supplement. Alexandria, VA: Author. Available from www.aca.org. American Correctional Association. (2008). 2008 standards supplement. Alexandria, VA: Author. Available from www.aca.org. American Psychiatric Association. (2004). Mental illness and the criminal justice system: Redirecting resources toward treatment, not containment. Washington, DC: Author. Retrieved from www.psych.org. American Psychology-Law Society, Graduate Programs. (n.d.). Clinical PhD/PsyD programs. Retrieved from www.ap-ls.org. Andrews, D. A., & Bonta, J. (2003). The psychology of criminal conduct (3rd ed.). Cincinnati, OH: Anderson. Andrews, D. A., Bonta, J., & Hoge, R. D. (1990). Classification for effective rehabilitation: Rediscovering psychology. Criminal Justice and Behavior, 17, 19–52. Ax, R. K., & Morgan, R. D. (2002). Internship training opportunities in correctional psychology: A comparison of settings. Criminal Justice and Behavior, 29, 332–347. Bartol, C. R., & Bartol, A. M. (2004). Introduction to forensic psychology. Thousand Oaks, CA: Sage. Bartol, C. R., & Bartol, A. M. (Eds.). (2006). Current perspectives in forensic psychology and criminal justice. Thousand Oaks, CA: Sage. Beck, A., & Harrison, P. (2005). Number of sentenced inmates incarcerated under state and federal jurisdiction per 100,000, 1980–2004. Washington, DC: Bureau of Justice Statistics. Retrieved from www.ojp.usdoj.gov/bjs/. Beck, A., & Maruschak, L. (2001, June). Mental health treatment in state prisons, 2000 (NCJ 188215). Washington, DC: Bureau of Justice Statistics. Retrieved from www.ojp.gov/bjs/. Blackburn, R. (2004). “What works” with mentally disordered offenders. Psychology, Crime, and Law, 10, 297–308. Bonner, R. L. (2006). Stressful segregation housing and psychosocial vulnerability in prison suicide ideators. Suicide and Life-Threatening Behavior, 36 (2), 250–254. Boothby, J. L., & Clements, C. B. (2000). A national survey of correctional psychologists. Journal of Criminal Justice and Behavior, 27, 716–732. Boothby, J. L., & Clements, C. B. (2002). Job satisfaction of correctional psychologists: Implications for recruitment and retention. Professional Psychology: Research and Practice, 33, 310–315. Borrill, J., Snow, L., Medlicott, D., Teers, R., & Paton, J. (2005). Learning from “near misses”: Interviews with women who survived an incident of severe self-harm in prison. Howard Journal of Criminal Justice, 44 (1), 57–69. Brandt, S. M. (2005). Correctional psychology: Looking beyond the bars. In R. D. Morgan, T. L. Kuther, & C. J. Habben (Eds.), Life after graduate school in psychology: Insider’s advice from new psychologists (pp. 151–165). New York: Psychology Press. Bureau of Justice Statistics. (2002, October 25). Reentry trends in the U.S. Washington, DC: Author. Retrieved from www.ojp.usdoj.gov/bjs/reentry/recidivism.htm. Bureau of Justice Statistics. (2005, August 21). State prison homicide rates down 93 percent jail suicide rates 64 percent lower than in early 1980s. Washington, DC: Author. Retrieved from www.ojp.usdoj. gov/bjs/pub/press/shspljpr.htm. Burton, A. (1948). Directory of clinical psychologists engaged in correctional psychology. Journal of Psychology: Interdisciplinary and Applied, 26, 19–23. Cellini, H. R., Wood, R. M., Hinze, T., & Speaker, T. J. (2003). Treatment and management of offenders with severe personality disorders. In B. K. Schwartz (Ed.), Correctional psychology: Practice, programming, and administration (pp. 10-1–10-17). Kingston, NJ: Civic Research Institute. Centers for Disease Control and Prevention. (2005, July 12). LCWK9. Deaths, percent of total deaths, and death rates for the 15 leading causes of death: United States and each state, 2002. Atlanta, GA: Author. Retrieved from www.cdc.gov/nchs/data/dvs/LCWK9 2002.pdf. Civil Rights of Institutionalized Persons Act, 42 U.S.C. ğ 1997a et seq. (1980). Coid, J., Petruckevitch, A., Bebbington, P., Jenkins, R., Brugha, T., Lewis, G., et al. (2003). Psychiatric morbidity in prisoners and solitary cellular confinement, II: Special (“strip”) cells. Journal of Forensic Psychiatry and Psychology, 14, 320–339. Coleman v. Wilson, 912 F. Supp. 1282 (E.D. Calif. 1995). Collins, J. J., & Schlenger, W. E. (1983, November). The prevalence of psychiatric disorder among admissions to prison. Paper presented at the annual meeting of the American Society of Criminology, Denver, CO. Commission on Safety and Abuse in American Prisons. (2006). Confronting confinement. New York: Vera Institute of Justice. Coons, W. H. (2005). Treatment in corrections: The view from the skeptical middle. Canadian Psychology, 22, 327–331.

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Correia, K. M. (2001). A handbook for correctional psychologists. Springfield, IL: Charles C Thomas. Council of State Governments. (2002). Criminal justice/mental health consensus project. New York: Author. Cox, J. F., & Hayes, L. M. (2003). A framework for preventing suicides in adult correctional facilities. In B. K. Schwartz (Ed.), Correctional psychology: Practice, programming, and administration (pp. 4-1–4-20). Kingston, NJ: Civic Research Institute. Darley, J. G., & Berdie, R. (1940). The fields of applied psychology: A survey report to the committee on professional employment of the American Association for Applied Psychology. Journal of Consulting Psychology, 4, 41–52. Ditton, P. M., & Beck, A. (1999, July). Mental health and treatment of inmates and probationers (NCJ 174463). Washington, DC: Bureau of Justice Statistics. Retrieved from www.ojp.usdoj.gov/bjs/ pub/ascii/mhtip.txt/. Estelle v. Gamble, 429 U.S. 97 (1976). Ewing, C. P. (2002). Tarasoff update: Psychotherapy threats alone provide no basis for criminal prosecution. Monitor on Psychology, 33 (2). Retrieved from www.apa.org/monitor/feb02/jn.html. Fagan, T. J., & Ax, R. K. (Eds.). (2003). Correctional mental health handbook. Thousand Oaks, CA: Sage. Fazel, S., Benning, R., & Danesh, J. (2005). Suicides in male prisoners in England and Wales, 1978–2003. Lancet, 366, 1301–1302. Federal Bureau of Prisons. (n.d.). Student information, psychology predoctoral internship program. Retrieved from www.bop.gov. French, S. A., & Gendreau, P. (2006). Reducing prison misconducts: What works! Criminal Justice and Behavior, 33, 185–218. Gendreau, P. (1996). The principles of effective intervention with offenders. In A. Harland (Ed.), Choosing correctional options that work: defining the demand and evaluating the supply (pp. 117–130). Newbury Park, CA: Sage. Gendreau, P., Goggin, C., French, S., & Smith, P. (2006). Practicing psychology in correctional settings. In I. B. Weiner & A. K. Hess (Eds.), The handbook of forensic psychology (3rd ed., pp. 722–750). Hoboken, NJ: Wiley. Gough, K. (2005). Guidelines for managing self-harm in a forensic setting. British Journal of Forensic Practice, 7 (2), 10–14. Gould, M. A. (2003). Issues of power and oppression. In B. K. Schwartz (Ed.), Correctional psychology: Practice, programming, and administration (pp. 1-1–1-30). Kingston, NJ: Civic Research Institute. Haag, A. M. (2006). Ethical dilemmas faced by correctional psychologists in Canada. Criminal Justice and Behavior, 33, 93–109. Haney, C. (2003). Mental health issues in long-term solitary and “supermax” confinement. Crime and Delinquency, 49 (1), 124–156. Hawk, K. M. (1997). Personal reflections on a career in correctional psychology. Professional Psychology: Research and Practice, 28, 335–337. Hayes, L. (1995, June). Prison suicide: An overview and guide to prevention. Mansfield, MA: National Center on Institutions and Alternatives. Retrieved from http://66.165.94.98/update/prisonsuicide.pdf. Hepp, U., Wittmann, L., Schnyder, U., & Michel, K. (2004). Psychological and psychosocial interventions after attempted suicide. Journal of Crisis Intervention and Suicide Prevention, 25 (3), 108–117. Hollin, C. R. (Ed.). (2001). Handbook of offender assessment and treatment. New York: Wiley. Huband, N., & Tantam, D. (2004). Repeated self-wounding: Women’s recollection of pathways to cutting and of the value of different interventions. Psychology and Psychotherapy: Theory, Research, and Practice, 77, 413–428. Human Rights Watch. (2003, September). Ill-equipped: U.S. prisons and offenders with mental illness. New York: Author. Retrieved from www.hrw.org/reports/2003/usa1003/. Junker, G., Beeler, A., & Bates, J. (2005). Using trained inmate observers for suicide watch in a federal correctional setting: A win-win solution. Psychological Services, 2 (1), 20–27. Kleespies, P. M., Penk, W. E., & Forsyth, J. P. (1993). The stress of patient suicidal behavior during clinical training: Incidence, impact, and recovery. Professional Psychology: Research and Practice, 24, 293–303. Levinson, R. (1984). The system that cannot say no. American Psychologist, 39, 811–812. Lindner, R. M., & Seliger, R. V. (Eds.). (1947). Handbook of correctional psychology. New York: Philosophical Library. Lipton, D., Martinson, R., & Wilks, J. (1975). The effectiveness of correctional treatment: A survey of treatment valuation studies. New York: Praeger Press. Lurigio, A., Rollins, A., & Fallon, J. (2004). The effects of serious mental illness on offender reentry. Federal Probation, 68 (2), 45–52.

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Clinical Supervision in Correctional Settings 407 Magaletta, P. R., Fagan, T. J., & Peyrot, M., F. (2000). Telehealth in the Federal Bureau of Prisons: Inmates’ perceptions. Professional Psychology: Research and Practice, 31, 497–502. Magaletta, P. R., & Verdeyen, V. (2005). Clinical practice in corrections: A conceptual framework. Professional Psychology: Research and Practice, 36, 37–43. Marshall, W. L., & Serran, G. A. (2004). The role of the therapist in offender treatment. Psychology, Crime, and Law, 10, 309–320. Martinson, R. (1974). What works? Questions and answers about prison reform. Public Interest, 35, 22–54. Mauer, M. (2003, June). Comparative international rates of incarceration: An examination of causes and trends. Retrieved from www.sentencingproject.org/pdfs/pub9036.pdf. McGuire, J. (2001). Treatment approaches for offenders with mental disorder. In L. Motiuk & R. Serin (Eds.), Compendium 2000 on effective correctional programming (pp. 122–134). Ottawa, Ontario, Canada: Correctional Service of Canada. McMurran, M., & Ward, T. (2004). Motivating offenders to change in therapy: An organizing framework. Legal and Criminological Psychology, 9, 295–311. Mentally Ill Offender Treatment and Crime Reduction Act (S. 1194) of 2004. (2004). Retrieved from www.consensusproject.org. Milligan, R., & Andrews, B. (2005). Suicidal and other self-harming behaviour in offender women: The role of shame, anger and childhood abuse. Legal and Criminological Psychology, 10, 13–25. Muehlenkamp, J. J. (2006). Empirically supported treatments and general therapy guidelines for nonsuicidal self-injury. Journal of Mental Health Counseling, 28, 166–185. National Alliance on Mental Illness. (2004, March). Spending money in all the wrong places: Jails and prisons. Retrieved from www.nami.org/Content/ContentGroups/Policy/Fact Sheets/jailsprisonsPFS.pdf. National Center on Institutions and Alternatives. (n.d.). Jail suicide/mental health update. Available from http://66.165.94.98/cjjsl.cfm. National Commission on Correctional Health Care. (2003a). Correctional mental health care. Chicago: Author. Available from www.ncchc.org. National Commission on Correctional Health Care. (2003b). Standards for health services in prisons. Chicago: Author. Available from www.ncchc.org. National Institute of Corrections. (2001). Prison health care: Suicide prevention. Longmont, CO: Author. Retrieved from www.nicic.org. Palmer, E. J., & Connelly, R. (2005). Depression, hopelessness and suicide ideation among vulnerable prisoners. Criminal Behaviour and Mental Health, 15, 164–170. Prison Litigation Reform Act, Ch. 21, subchapter I.-A. 42 U.S.C. ğ 1997e/. Prison Rape Elimination Act of 2003, Pub. L. No. 108-79. Retrieved from www.nicic.org. Schwartz, B. (Ed.). (2003). Correctional psychology: Practice, programming, and administration. Kingston, NJ: Civic Research Institute. Scott, C. L., & Gerbasi, J. B. (Eds.). (2005). Handbook of correctional mental health. Washington, DC: American Psychiatric Publishing. Shea, S. J. (1993). Personality characteristics of self-mutilating male prisoners. Journal of Clinical Psychology, 49, 576–585. Skogstad, P., Deane, F. P., & Spicer, J. (2006). Social-cognitive determinants of help-seeking for mental health problems among prison inmates. Criminal Behaviour and Mental Health, 16 (1/2), 43–59. Smith, R. R., & Sabatino, D. A. (1990). Roles and functions of psychologists in American correctional institutions. Journal of Offender Rehabilitation, 16 (1/2), 163–174. Steadman, H. J., & Ribner, S. A. (1980). Changing perceptions of the mental health needs of inmates in local jails. American Journal of Psychiatry, 137, 1115–1116. ¨ Suominen, K., Isomets¨a, E., Haukka, J., & Lonnqvist, J. (2004). Substance use and male gender as risk factors for deaths and suicide: A 5-year follow-up study after deliberate self-harm. Social Psychiatry and Psychiatric Epidemiology, 39, 720–724. Tarasoff v. Regents of the University of California, 17 Cal. 3d 425; 551 P.2d 334; 131 Cal. Rptr. 14 (1976). Teplin, L. (1984). Criminalizing mental disorder: The comparative arrest rate of the mentally ill. American Psychologist, 39, 794–803. Verona, E., Hicks, B. M., & Patrick, C. J. (2005). Psychopathy and suicidality in female offenders: Mediating influences of personality and abuse. Journal of Consulting and Clinical Psychology, 73, 1065–1073. Vitek v. Jones, 445 U.S. 480, No. 78–1155 (1980). Retrieved from http://laws.findlaw.com/us/ 445/480.html. Walters, G. D. (2002). Criminal belief systems: An integrated-interactive theory of lifestyles. Westport, CT: Praeger Press/Greenwood Press.

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Watkins, R. E. (1992). An historical review of the role and practice of psychology in the field of corrections. Ottawa, Ontario, Canada: Correctional Service of Canada. Retrieved from www.csc-scc.gc.ca/ text/rsrch/reports/r28/r28e e.shtml. Weiner, I., & Hess, A. K. (Eds.). (2005). The handbook of forensic psychology (3rd ed.). Hoboken, NJ: Wiley. Whittington, R., Lancaster, G., Meehan, C., Lane, S., & Riley, D. (2006). Physical restraint of patients in acute mental health care settings: Patient, staff, and environmental factors associated with the use of a horizontal restraint position. Journal of Forensic Psychiatry and Psychology, 17, 253–265.

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C H A P T E R 22

Teaching Interventions with the Sexually Disordered BARBARA K. SCHWARTZ

IN CONTEMPLATING what I might want a fellow professional planning on entering this field to consider, I was faced with the task of balancing the rewards with the numerous challenges in facing perhaps the least popular of all patient populations. The mental health professional contemplating specializing in treating sexually disordered individuals must first realize that this therapy requires a somewhat different mindset, and thus this chapter initially addresses specialized, training including specific differences from traditional treatment approaches. The myth that individuals with sexual problems cannot be treated successfully is addressed. Because the treatment of this population is multimodal, the different approaches are reviewed. Individuals with these types of problems come in many ages, both sexes, and with many comorbid conditions, and it will be necessary to decide what type of subpopulation(s) will become the target of one’s work. An important decision will be whether one wishes to work within a secure institution, so the pros and cons of different settings are explored. Finally, the dangers of working with this population are discussed. This field is much in need of qualified professionals, but only if these individuals enter this area forewarned of the frustrations, dangers, and need for special skills inherent in working with this population, as well as the rewards in helping to prevent further victimization.

C H A L L E N G E S O F T R E AT I N G T H I S P O P U L AT I O N Early tribal cultures had a variety of ways of dealing with the bizarre, deviant, and troublesome individuals in their midst. One approach was to take physical effects of the individual, such as hair and/or nail clippings; bake them into a loaf of bread; and give it to a specifically identified member of the tribe, who then consumed it. This person, known as the sin eater, and was chosen due to his or her 409

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personal and spiritual strength, which was supposed to be able to neutralize the negative forces that had been transferred into the physical items of the afflicted person. This then freed the afflicted community member from the evil influences responsible for the behavior. Although the sin eater was revered, he or she was also shunned for having contact with demonic factors. This person’s role in the community is not unlike that of the therapist who has chosen to treat sexually disordered individuals.1 The general public looks on this population with varying degrees of disgust, outrage, and fear. The public has great difficulty understanding why anyone would choose to devote his or her professional career to dealing with these “semi-human creatures” whom “everyone knows you can’t treat.” Before considering such a career, one is best advised to consider whether one wishes to constantly explain to family, friends, colleagues, and strangers why one has decided to follow this particular professional path. Alternatively, many of my colleagues have found it easier to make up some ambiguous response when asked about one’s vocation, such as “I treat men or women with issues.” Yet those of us who specialize in this population find it to be a tremendously rewarding endeavor. An old parable adopted by the sex offender treatment community tells of a man walking along a river bank who suddenly notices a large crowd gathered by the shore attempting to rescue dozens of children struggling against the current. He analyzes the scene and then begins to run upstream. The crowd calls to him to assist them in trying to rescue the children. However, he calls back that he is going to stop the person who is throwing them in. Professionals who work with the perpetrator are committed to stopping further victimization. Assisting sexually disordered individuals to stop their inappropriate behavior can save hundreds from being victimized.

SPECIALIZED TRAINING Unfortunately, students who are interested in pursuing specialized training in dealing with sexually disordered individuals will find few academic offerings addressing this population. Although training programs in psychology, social work, and counseling attempt to prepare their students to deal with most of the problems they will face in their professional careers, a negligible number offer courses in dealing with criminal behavior, although many mental health professionals will find employment in prisons, jails, and juvenile facilities. The only relevant training may be in substance abuse. Although specialized graduate programs are available in forensic psychology, these programs usually focus on the evaluation of competency or assessment of criminal responsibility and its relation to mental illness. Those interested in treating adults or children with sexually inappropriate behavior will either have to (a) find a program or a practitioner willing to provide a training experience through an internship, residency, or mentorship; or (b) attempt to acquire relevant skills in a piecemeal fashion by attending conferences, reading the relevant research, and joining national and statewide organizations.

1 The

term sexually disordered individuals refers to children, adolescents, and adults who engage in sexually inappropriate behavior regardless of whether they have been legally adjudicated.

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Teaching Interventions with the Sexually Disordered 411 Training materials may be available from the Center for Sex Offender Management,2 a division of the U.S. Department of Justice; or from the Safer Society Foundation,3 a Vermont-based nonprofit devoted to providing resources to those who treat sexually disordered individuals. D I F F E R E N C E S B E T W E E N T R A D I T I O N A L M E N TA L H E A LT H T R E AT M E N T A N D S E X O F F E N D E R T R E AT M E N T This lack of relevant training is particularly disconcerting because traditional mental health assumptions are often at odds with the assumptions of sex offender treatment. The mental health professional is typically prepared to work with individuals who are suffering from diagnosable conditions such as depression, psychoses, adjustment disorders, and some personality disorders—all ego-dystonic or personally distressing. The therapist does not make the assumption that patients are directly responsible for their condition. In fact, the focus is often helping the clients to understand how their condition has influenced their behavior. In contrast, a key component of sex offender treatment is to help one’s clients to understand that they are responsible for their conduct, directly and unequivocally. In a typical therapeutic relationship, the patient sets the agenda, decides when treatment begins and ends, expects the therapist to trust and believe him or her, and to respect his or her values. However, in treating the sexual abuser the therapist sets the treatment goals. External forces such as the criminal justice system usually initiate treatment, and it is the therapist, the structure of the treatment program, or the criminal sentence that determines when treatment concludes. The sex offender therapist does a grave injustice to the patient if he or she takes what the client says at face value. Sexually disordered individuals lie for many reasons, including fear of consequences, shame, a need to protect their family and embarrassment. The therapist should be wary of the offender who immediately acknowledges all of his or her deviance. This individual’s behavior may be ego-syntonic, indicating that sexual deviance is an accepted part of his or her self-concept. Fortunately, this type of sex offender is rare. Nevertheless, it will be an ongoing challenge for the therapist to constantly attempt to ferret out the truth. In many jurisdictions, the therapist and supervising agent rely on polygraphs to ascertain the full range of an individual’s deviance and to monitor his or her ongoing behavior. However, lacking this resource, the sex offender therapist needs to maintain a skeptical attitude and constantly be vigilant for signs of deception. At the same time, the treatment provider should remember that the client may misrepresent the truth for many complex reasons, probably least of all to deliberately mislead his or her therapist. Remembering that deception is part of deviance will help the therapist to refrain from personalizing this behavior. Sexually disordered individuals rarely believe that their behavior is justifiable. Yet at the same time they are able to rationalize their conduct through the use of cognitive distortions. It is the task of the treatment provider to discover and challenge those thinking errors that contribute to justifying the sexual abuse of others. 2 Center 3 Safer

for Sex Offender Management, Silver Spring, Maryland (www.csom.org). Society Foundation, Brandon, Vermont (www.safersociety.org).

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DEALING WITH GUILT AND SHAME Therapists working with a generic mental health caseload will spend much time addressing unwarranted guilt in their patients. Mothers feel guilty because their children are not happy. Adult children may feel guilty because they cannot alleviate the consequences of aging in their parents. Therefore, the task may be to help patients realize that they are not responsible for the problems of others. However, in the case of sexually disordered individuals who are responsible for the suffering of others, a primary goal of treatment may be to help clients accept the guilt that is legitimately associated with harmful behavior. I emphasize the term guilt rather than shame, the latter being an all-pervasive feeling that one’s being rather than one’s behavior is flawed. Marshall, Marshall, Serran, and Fernandez (2006) showed that shame interferes with the ability of sexually disordered individuals to take responsibility for their behavior and to develop empathy for their victims.

DEALING WITH CONFIDENTIALITY Additional differences between traditional mental health treatment and sex offender treatment include the limits on confidentiality and the basic overriding goals. Therapists treating offenders need to amend the strict limits on disclosure associated with the traditional therapist–client relationship. Typically offenders in treatment are either in an institutionally based program or in the community on probation or parole. Communication between professionals involved in this type of case is essential if the risk of reoffending is to be decreased. Therefore, confidentiality agreements in these cases must be clearly spelled out regarding what type of information will be disclosed, when it will be disclosed, and even whether offenders’ probation officer will be able to sit in on therapy sessions. These modifications of the therapeutic relationship exist because the basic reason for treating sexually disordered individuals is to enhance public safety. Whenever a decision must be made that appears to pit the interest of the clients against the interest of the community, therapists should err on the side of public safety. This does not mean that offenders should be kept in confinement because this would fully protect the community from these individuals. It means that when therapists are truly undecided about the best course of action, they should opt for notifying institutional personnel or the supervising agent of questionable behavior. In the long run, nothing that is not in the best interest of the community is in the best interest of offenders. Certainly, allowing offenders to remain in a high-risk situation or to reoffend will not be advantageous to them.

T R E AT M E N T E F F I C A C Y W I T H T H E A D U LT M A L E SEXUAL OFFENDER Before a professional elects to specialize in treating this subpopulation, he or she needs to understand several factors. First, the profession and lay communities consider sex offenders untreatable. There is a consequent isolation that the professional faces. One must understand what works, as briefly sketched below. Among the articles of faith one can rely on is the idea that various concatenations of people

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Teaching Interventions with the Sexually Disordered 413 and disorders are singularly lumped into a “sexual deviant” category as if all were uniform. This disregards the treatment efficacy literature. Why behaviors that are so varied should be regarded as intractable is not clear. However, research has consistently refuted this impression. Until the mid-1980s, the treatment of sexually disordered men was conducted primarily in civil commitment programs in a few state hospitals, in a few prisons around the country, and in scattered outpatient clinics. In 1984, the National Academy of Corrections used the cognitive-behavioral model to train teams from most of the 50 states to establish a uniform model of treatment in correctional institutions. Treatment models for adult men have not changed substantially over the past 20 years. Essentially, the same cognitive-behavioral relapse prevention model adopted in the early 1980s (Pithers, Marques, Gibat, & Marlatt, 1983; Schwartz & Cellini, 1988) continues, with revisions and adaptations (Laws, Hudson, & Ward, 2000). Perhaps the most significant change has been the increasing acceptance of the importance of medication as an adjunct to therapy. The pharmacological regimen includes three categories of drugs: (1) anti-androgens, with the agent of choice in the United States being medroxyprogesterone acetate (Provera); (2) selective serotonin reuptake inhibitors; and (3) gonadotropin-releasing hormone agonists (GnRH), with the agents of choice being two long-acting analogs of naturally occurring GnRH or luteining hormone-releasing hormone agonists (LH-RH; leuprolide [Lupron] and goserelin [Zoladex]). Measuring the effectiveness of these interventions is at once both simpler and more complex than measuring the efficacy of any type of psychotherapeutic intervention. All such research efforts are plagued with problems of controlling for individual differences among therapists regardless of the technique they may utilize, establishing adequate control groups, considering ethical issues such as denying treatment to patients, and measuring outcome criteria. The latter is usually defined as whether the individual has been either accused, charged, convicted, or incarcerated for another sex offense, although there remains the problem of undetected recidivism. Furthermore, it is difficult to compare studies to one another, as the definition of recidivism may be confounded with legal jurisdiction, duration of follow-up, offender characteristics, differences in attrition rate, differences in program integrity and amount of treatment, amount and quality of posttreatment supervision, and a host of other variables (Prentky, Lee, Knight, & Cerce, 1997). In an excellent paper on the critical role of base rates for recidivism in treatment outcome studies, Barbaree (1997) concluded, “Recidivism studies were found to be quite insensitive to the effects of treatment” (p. 111). The problem is a relatively simple one. As Barbaree noted, the base rates for sexual recidivism in most studies range from 10% to 40%. Sample sizes in most studies are generally small, rarely more than 200 offenders. With a low base rate and a small sample, the treatment effect would have to be quite large (>0.50) for one to observe significant differences between treated and untreated offenders. In other words, the difference in sexual recidivism rates between treated and untreated sexually disordered individuals would have to be 50% or more. It is quite unrealistic to expect treatment effects of that magnitude. Consequently, as Barbaree demonstrated, it is not surprising that the conventional treatment outcome studies of the past have failed to demonstrate significant treatment effects. However, he noted that the

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efficacy of sex offender treatment compares favorably with that of other types of interventions (e.g., chemotherapy with breast cancer) that are universally accepted as appropriate interventions. Yet the debate over sex offender treatment continues. Despite the challenges to research design inherent in studying the efficacy of psychotherapeutic techniques, numerous studies have attested to the ability of sex-offender-specific treatment to reduce recidivism or reoffense (McGrath, Cummings, Livingston, & Hoke, 2003; Nagayama Hall, 1995; Nicholaichuk, Gordon, Deqiang, & Wong, 2000; U.S. General Accounting Office, 1996; Zgoba, Sager, & Witt, 2003). The only longitudinal treatment outcome study with random assignment was California’s Sex Offender Treatment and Evaluation Project (Marques, Wiederanders, Day, Nelson, & van Ommeren, 2005). Conducted at Atascadero State Hospital, this project operated from 1985 to June 1995, with the final data panel collected in 2000. The most recent recidivism data indicated that, with an average of 8 years at risk, the 167 subjects who completed treatment did not have a lower sexual reoffense rate (22%) than the 225 volunteer control subjects (20%) or the 220 nonvolunteer controls (19%). Indeed it would appear that the treated group actually had a higher reoffense rate than the other groups. However, counted in the treated population were (a) participants who withdrew prior to receiving any treatment and (b) those who either quit or were removed from the program. Additionally, participants were allowed to remain in the program without making significant progress or even participating in the program. When the program participants were divided into the Got It group (defined as those who had successfully accomplished treatment goals) and the Did Not Get It group (those who had not completed treatment goals), the Got It group had a recidivism rate of 13.5% versus 27.2% for the Did Not Get It group, with the high-risk participants showing a reoffense rate of 10% in the first group compared to 50% in the second. Sample size was addressed by the Collaborative Outcome Data Project on the Effectiveness of Psychological Treatment for Sexually Disordered Individuals (Hanson et al., 2002). Hanson et al. reported on a meta-analysis of 43 studies with a total of 9,454 subjects (5,078 treated and 4,376 untreated). Although the average period at risk was 46 months, follow-up periods ranged from 12 months to 16 years. Averaged across all studies, the sexual recidivism4 rates were 12.3% for treated and 16.8% for untreated subjects. A microanalysis that selected only “modern” treatment studies, presumably those employing the relapse prevention model, found sexual recidivism rates of 9.9% for treated and 17.4% for untreated subjects. A similar pattern was found for general recidivism, although the overall rates were predictably higher (treatment, 27.9%; comparison, 39.2%; 30 studies). Current treatments (cognitive-behavioral, n = 13; systemic, n = 2) were associated with reductions in both sexual recidivism (from 17.4% to 9.9%) and general recidivism (from 51% to 32%). Given the sample sizes in the Hanson et al. study, there is little question at this point that treatment reduces sexual recidivism. 4 In

this chapter, the term recidivism is used to refer to any failure on the part of a subject in a study (including probation/parole violations), whereas the term reoffense is used to refer to a subsequent conviction of a crime.

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Teaching Interventions with the Sexually Disordered 415 T R E AT M E N T A P P R O A C H E S A review of the current research will show cognitive-behavioral treatment as the state-of-the-art or evidence-based approach to the treatment of this population. However, there is little consensus on what cognitive-behavioral treatment actually represents. Cognitive-behavioral treatment was first developed to treat depression (Beck, Rush, & Shaw, 1979) and traditionally targets the thoughts that elicit emotions and behaviors. Samenow (1984) in writing Inside the Criminal Mind elucidated how certain thoughts that reflect certain ways of viewing the world perpetuate antisocial behavior. By addressing the thoughts that reflect underlying values and schemas, the therapist may be able to intervene in the subsequent criminal conduct. The evidence that intrusive thoughts and urges may be the by-products of neurological pathology related to disorders of the neurotransmitters or hormonal system and thus responsive to medication may challenge the assumption that dysfunctional conduct is the product of distorted cognitions. Other emerging therapies such as Dialectical Behavioral Therapy (DBT), developed by Linehan (1993), are much more focused on teaching the patient to modulate emotional overresponsiveness. Thus, although cognitive-behavioral treatment has proven to be helpful in reducing recidivism, it has not been systematically compared to other contemporary treatments. Furthermore, treatment programs that purport to be cognitive-behavioral in nature often offer a variety of approaches. Treatment that is offered in a comprehensive, institutionally based program where offenders may receive up to 20 hours a week of treatment is significantly different from 90 minutes of group therapy a week in an outpatient setting. The former program may include a therapeutic community, experiential therapies, dialectical behavioral treatment, Eye Movement Desensitization and Reprocessing (EMDR) (U.S. Department of Veterans Affairs and Department of Defense, 2004), and a wide range of adjunct approaches, whereas outpatient therapy may be limited to the basics, which usually include challenging cognitive distortions and developing a relapse prevention plan. Many of these multimodal programs identify themselves as being “integrated” or “integrative” in nature. Thus, they may incorporate biological, cognitive-affective, interpersonal, familial, societal, and even spiritual approaches into the rehabilitation program.

BIOLOGICAL During my career, a number of mental illnesses that I was initially taught were the by-products of psychological forces such as family dysfunction were subsequently recognized as biological in origin. For example, 30 years ago schizophrenia was hypothesized to be caused by schizophrenogenic mothers who gave their children “double messages.” Autism was thought to emerge when children were raised by emotionally cold parents. Today we recognize that these conditions are not caused by pathological parenting but by neurological factors that are not yet fully understood. In reviewing the domains that may contribute to sexually inappropriate behavior, the role of organic factors must not be overlooked. Research has shown that attention-deficit/hyperactivity disorder may contribute to hypersexuality

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and increased impulsiveness, distinguishing the individual whose sexual behavior may be excessive and personally troublesome from the person whose sexual conduct violates the law (Kafka & Hennen, 2002). The success of the use of selective serotonin reuptake inhibitors suggests a biological basis for some aspects of sexual compulsivity such as irresistible urges and intrusive fantasies (Kafka, 1991). Fascinating research is demonstrating that early abuse can actually change the structure of the brain, resulting in a number of cognitive and behavioral problems (Teicher, 2000, 2002). Sexually disordered individuals have often come from abusive families, as do other types of criminals. There may be neurological bases for the poor judgment, emotional dysregulation, and impulsivity underlying a variety of types of antisocial conduct. COGNITIVE There are two basic approaches to addressing the cognitive domain in the treatment of sexual abusers. The first is the traditional cognitive-behavioral approach that was alluded to earlier. Core beliefs or schemas produce an inner dialogue that can then lead to related emotions and subsequent actions. For example, if one holds a belief that one is inherently a flawed human being and that no one would want to associate with him or her, this belief produces a set of self-statements such as “I am a creep. No one will ever be my friend,” which leads to negative emotions and also to certain behaviors such as social isolation. Core beliefs and their associated thoughts also lead to justifying, rationalizing, minimizing, and excusing the maladaptive behaviors that one might adapt to escape negative emotional states or to simply indulge one’s appetites. Everyone has experienced the urge to engage in some activity that may not be in one’s best interest. However, the pleasure of immediate gratification may compromise delay of gratification and its benefits. To relieve oneself of conflict, one might use a rationalization (e.g., “I deserve it”) or a justification (e.g., “This will help me get through this stress”), or a minimization (e.g., “Just this once”). Having found an excuse, it is then easier to dismiss one’s better judgment. Thus, much of sex offender treatment is devoted to identifying the core beliefs, schemas, and cognitive distortions that have initially allowed and then perpetuated the sexual abuse of others. These distortions certainly range from the sublime to the ridiculous (e.g., “She wanted it” or “I wanted her to learn about sex from someone who cared about her—like her father”). A standard technique that almost defines sex offender treatment is relapse prevention. First designed by Marlatt and Gordon (1985) for the substance abuse field, relapse prevention addresses the commonly held belief that if an alcoholic had one drink, he or she had fallen off the wagon (i.e., one drink would inevitably lead to a full relapse). In reality, one can quit after having one drink; a major binge is not preordained. Having one drink would be defined as a lapse. This concept was adapted for use with sexually disordered individuals by Bill Pithers and Janice Marques when they were doing their internships at Atascadero State Hospital, which housed civilly committed sexually disordered individuals in California. Certain adjustments to the concepts had to be made. Obviously, if a sex offender commits another offense, this is not a lapse from which he or she can recover and begin again. The concept of what a lapse is needed to be refined to

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Teaching Interventions with the Sexually Disordered 417 include warning signs such as indulging in sexually deviant fantasies. Participants in sex-offender-specific treatment are asked to develop a relapse prevention plan that identifies triggers and high-risk situations that lead to negative emotional states that eventually lead to offending behavior. Additionally, participants have to devise interventions that will abort the cycle. Recently, several theorists (Yates & Kingston, 2006) have challenged the presumption that relapse among sexually disordered individuals is triggered by highrisk situations that are associated with stressors that overwhelm the offender and lead him or her to try to escape into deviant sexual fantasies and behaviors. They present an alternative model, which they have dubbed the pathways model, that hypothesizes four paths to offending: 1. Wanting to avoid the behavior and needing to learn new ways to cope with stress. 2. Wanting to avoid the behavior but making mistakes in choosing the appropriate intervention. 3. Automatically slipping into one’s old offending mode. 4. Wanting to engage in sexually offending behavior and having no interest in intervening. A well-developed relapse prevention plan is a blueprint for recovery that lists warning signs and how to deal with them. It is meant to be shared with members of the offender’s support group as well as his or her therapist and supervising agent.

TEACHING COGNITIVE SKILLS The other treatment approach to addressing the cognitive domain of sexual abusers addresses basic cognitive skills such as decision making, problem solving, and information analysis. It appears to be fairly obvious that regardless of one’s sexual arousal pattern, one could conclude that gratifying deviant sexual impulses can lead to major problems in one’s life, including lifelong incarceration. Additionally, if one accepts the theory that many sexually disordered individuals act out in response to stressors that they cannot handle, then it is apparent that sexually abusing other people is not an effective way of dealing with problems such as financial or family problems. Failing to think through the consequences of one’s behavior is not unique to sexually disordered individuals. Prisoners in general are notorious for failing to consider the consequences of their conduct. Recognizing that many imprisoned individuals have poor cognitive skills, Canadian psychologists Ross, Fabiano, and Ewles (1988) developed a program called Reasoning and Rehabilitation that teaches basic thinking skills. If one does not naturally think through one’s behavior, then perhaps one can be taught to do it. The program focuses on social skills development and on the work of DeBono (1982), who outlined thinking tools such as Consider All Factors and Positive–Negative–Interesting. The program is now in widespread use both inside and outside of prisons.

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AFFECTIVE A common question about sexually disordered individuals is the following: How could anyone do such a thing to another person? One of the explanations is that many sexually disordered individuals are so emotionally blocked that they have no feelings for their victims, just as they have no feelings for themselves. Until fairly recently, even therapists questioned whether a significant number of sexually disordered individuals had themselves been abused. Studies of sexually aggressive youths have revealed that the majority of these children had been abused, and because of the abuse the majority of sexually disordered adults report that they started abusing as adolescents (Abel, Mittleman, & Becker, 1985). Thus, a significant number of adult offenders were either physically, psychologically, or sexually mistreated during their childhood to a degree to which many suffer from posttraumatic stress disorder, one symptom of which is affective numbing. A traditional goal of sex offender treatment is to help individuals develop empathy for their victims and others in their environment. However, empathy is an emotion, and if offenders are emotionally blunted, it is unlikely that simply discussing the impact of sexual abuse on others will affectively awaken them. However, experiential therapies that tap into the right hemisphere are often useful in breaking through the wall that offenders have built up around their feelings. I have observed drama, art, music, and dance therapies making a tremendous impact on offenders. Surveys done with treatment participants have confirmed the efficacy of these therapies with offenders, reporting that drama therapy had the greatest impact of all the treatment modalities used in a cognitive-behavioral therapeutic community (Schwartz & Baker, 1997). The treatment of an offender’s own trauma may allow him or her to be able to identify with the pain of past victims and thus arouse a commitment to abstain from reoffending. Techniques developed to deal with trauma, including eye movement desensitization and reprocessing and dialectical behavioral therapy, may be tremendously useful as adjunct therapies for this population. The field awaits well-controlled efficacy studies in this regard.

INTERPERSONAL Sexual offenses, with the possible exception of some Internet offenses, are crimes that are interpersonal in nature. They involve the interplay between a perpetrator and a victim. Sexually disordered individuals are tremendously sensitive to rejection, a problem of which the new sex offender therapist will quickly become cognizant. Many child molesters are intimidated by adults. They have such low self-concepts that only by associating with children can they feel accepted. The classic pedophile relates to children as peers, peers with whom he or she can have sexual contact. Other child molesters can only feel powerful when controlling children, as they feel that they could never control an adult. Rapists are also hypersensitive to rejection. However, they respond to perceived rebuffs with anger. Many voice the sentiment that they are not being seen or acknowledged by the females in their world. Thus, they choose a crime in which they are literally “in the face” of their victims.

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Teaching Interventions with the Sexually Disordered 419 The student might benefit from knowing that both child molesters and rapists may invite social rejection through their lack of social skills. Additionally, they may ease their social anxiety through the use of drugs or alcohol. Inversely early substance abuse may have impaired the acquisition of appropriate tools to interact with others, exercise appropriate boundaries, manage anger, and handle stress. Thus emerge individuals who want to relate to others but perceive themselves as being unable to make effective connections with others, especially in the sexual realm. A basic component of sex offender treatment is to improve these basic social skills. This is one of the reasons that the group process can be so useful—by providing a laboratory for learning to relate to others. The offenders can recognize that they are not the only ones with this pathology. Helping others with their problems may assist them in dealing with their own issues, and being given feedback by those who have walked in their shoes may be much more effective than being advised by a therapist who has never faced these issues. FAMILIAL Although sexually disordered individuals are a highly heterogeneous group and come from all types of personal and socioeconomic backgrounds, few come from truly stable family backgrounds. Recently there has been a great deal of interest in attachment disorders among treatment professionals of both adult and adolescent offenders. Ward, Hudson, and Marshall (1996) studied attachment styles among sexually disordered individuals and found that child molesters tend to have a preoccupied insecure attachment style that predisposes them to seek relationships with children whom they can control and who will admire and approve of them rather than attempting to gain admiration and approval from an adult peer. Dealing with early familial issues is often necessary in order to uncover the origins of the schemas and cognitions that are the foundation for the cognitive distortions that provided excuses and justification for the abuse of others. To treat a rapist who hates women, one must understand the roots of that hatred. Most often the origin is a dysfunctional family system. This is not to blame the families of sexually disordered individuals for their inappropriate conduct. However, it is vital to understand which situations may incubate cognitive distortions. Although the therapist needs to explore family-of-origin issues, the sexually disordered individual may also have issues within his or her current family that deserve attention. Every offender can greatly benefit from an informed support network. Whether the support network is actively involved with the offender who is living in the community, or whether the members visit the offender in an institution, the family and friends who are committed to helping the offender in his or her recovery must be fully informed of the offender’s past behavior and of his or her relapse prevention plan. They must pledge themselves to warning the offender if they perceive that he or she is in the “deviant cycle.” This may involve informing a parole or probation officer of the offender’s high-risk behavior. Because in many cases sexually disordered individuals have aggressed against members of their own families, reunification will emerge as a major therapeutic issue. Many wives do stay with husbands who have abused their children.

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Additionally, women with children may become involved with men who have previously sexually assaulted children. Can these men ever live with families containing children? Initially these offenders must not have unsupervised contact with underage individuals. However, over time the family may reach a point where the offender can again live in the family if a number of criteria can be met. For one thing, the original offense should have been situational or opportunistic in nature. In other words, the offender should not have been a pedophile who has shown preferential sexual arousal to children. The offender must have made outstanding progress in treatment. The spouse must fully understand the relapse prevention plan. Most important, the children must be totally informed about the issue and capable of protecting themselves. If some of the children were the victims, then their therapist should be fully involved in the plans for reunification. SOCIETAL Unfortunately, societal factors may contribute to the perpetuation of sexual offenses. Beginning in the 1970s with Susan Brownmiller’s (1975) book Against Our Wills, feminists have argued that rape of both women and children is one of society’s ways of bringing the vulnerable under the control of the more powerful male. Rape is not viewed as the pathology of an individual but as the natural outcome of the way males are socialized in this society. Ethnobiologists hypothesize that males are genetically programmed to attempt to spread their genes into the gene pool by any means at their disposal (Thornhill & Thornhill, 1983). That might mean fathering numerous children by a single woman, having affairs with multiple women, or raping. Our culture encourages the objectification of females in a variety of ways, including through the marketing of various products. Women’s bodies are draped over cars, suggesting that owning a certain brand of automobile will result in sexual gratification. Calvin Klein has been criticized for depicting young adolescents as sexual objects. Even young children, such as the child portrayed in the film Little Miss Sunshine, have been dressed in seductive ways in advertisements. Advertising is not the only channel for exploiting and perpetuating sexual images. Movies have long reinforced stereotypical myths about sexuality. Gone with the Wind contains a blatant rape scene that suggests that women crave the “caveman” approach. One can even purchase a music box depicting the rape scene from this film. Other famous rape scenes that depict women being aroused by brutal assaults include those in Last Tango in Paris, Dog Day Afternoon, and Duel in the Sun. Sexual activity with children was romanticized in Lolita, Pretty Baby, and Taxi Driver. Additionally, depictions of older women seducing adolescent boys to their mutual benefit or as self-sacrificing acts of kindness are portrayed in Tea and Sympathy, My Tutor, and Summer of ‘41. Society has many myths and stereotypes that contribute to dysfunctional relations. Cultures that endorse inequality of the sexes, sexual entitlement for men, and power differentials have higher rates of sexual abuse. The sex offender therapist will need to confront and challenge these beliefs. This is an example of a situation in which the therapist does not abide by the traditional mental health ethic of not challenging the values of a patient.

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Teaching Interventions with the Sexually Disordered 421 SPIRITUAL Few therapies other than pastoral counseling address the spirituality of their patients. However, in this field this may be unavoidable. The public’s attention has been riveted on the phenomenon of the pedophile priest, and Catholics do not hold a monopoly on the sexual abuse of children by their clergy. If one is to treat sexually disordered individuals, one will eventually treat a member of the clergy. There are a variety of hypotheses about why individuals who molest children are found in a field dedicated to serving God and His children. Certain religions are associated with repressive attitudes toward sexuality in general that engender guilt and shame over a normal human activity. Other creeds focus on the “sin” of homosexuality, which can distort one’s natural sexual preference. Spirituality can greatly enhance a sex offender’s recovery as long as he or she does not use it as an excuse to keep from dealing with his or her issues. I have had many offenders tell me that they need not deal with their past offending behavior because they are born again or because it is a sin to discuss sexual issues. Therefore, therapists may find themselves in the awkward situation of having to challenge the patient’s religious beliefs in order to help him or her develop a healthier outlook on the sexual aspect of his of her personality. Therapists working in institutions will find that the chaplain and religious volunteers can be a tremendous help or hindrance. In prisons, sexually disordered individuals often find that the religious programs are the only ones that accept them, and additionally that affiliating with the religious activities offers them a degree of physical safety from the more predatory criminals who target child molesters. It is therefore mandatory that sex offender therapists try to develop good working relationships with institutionally based clergy and church-affiliated volunteers.

THERAPIST SKILLS Sex offender treatment has in many respects modeled itself on substance abuse treatment. Both fields deal with the compulsive behaviors of involuntary patients. One could track the developments in the sex offender field by looking at what is happening in the chemical dependency arena. Relapse prevention was developed to treat alcoholics. Motivational interviewing (Miller & Rollnick, 2002), (see Chapter 19) which is becoming increasingly popular among sex offender treatment providers, was also originally developed for use with substance abusers. The 1970s saw the use among addicts and alcoholics of highly confrontational therapeutic styles. The theory that one needed to totally break down the personality of the offender and build it up from scratch was prevalent. Although this was successful with some, many other individuals either rejected treatment altogether or became so cowed that they just said anything that they thought the therapist wanted to hear. The substance abuse field eventually began to move away from this highly confrontational approach and has now largely embraced motivational interviewing (Miller & Rollnick, 2002). This approach seeks to create internal motivation in the patient rather than intimidating him or her into looking motivated. Marshall and associates (2006) were able to gain access to hundreds of taped sex offender therapy sessions made in sex treatment programs in England. They

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rated therapists according to their styles, classifying them as confrontational, unchallenging, or motivational. Subsequently they followed up on the reoffense rate of patients treated with different styles. Their findings reflected the efficacy of the motivational approach. The successful sex offender therapist is warm, empathic, and genuine and is able to understand the offender’s perspective and be flexible. Coincidently, these are the same traits that characterize a good therapist regardless of specialty or theoretical approach. The successful treatment provider is like a good coach—positive and affirming, but never settling for less than the patient is capable of accomplishing. Of course, with this population the stakes are frighteningly high. Inadequate treatment can result in horrible consequences, although reoffending can rarely be directly attributed to inadequate therapy, even though the therapist may be blamed. Being able to tolerate the consequences of the inevitable failure of these patients is another trait that the sex offender treatment provider must acquire. Other therapists must deal with treatment failures, even suicides, but rarely will they find themselves on the national news being held responsible for the death of an innocent woman or child. This is a possibility for the sex offender specialist. S U B S P E C I A L I Z AT I O N Although most specialists in the field of treating sexually disordered individuals deal with adult men, there are a growing number of subspecialties, including male and female adolescents and children, developmentally disabled and mentally ill individuals, personality disordered individuals, and individuals with autism spectrum disorders. Some professionals prefer to deal with relatively low-risk individuals including those who may never have been convicted of a crime (although they may have committed criminal acts) and those on probation. Others choose to work at the other end of the continuum with incarcerated or civilly committed individuals. One might assume that those doing outpatient treatment would be safer than those working in high-security situations. However, of the assaults that have been perpetrated against therapists by their sexually aggressive clients, probably as many have occurred in the community as within institutions. The choice of what type of setting the professional offering services to this population chooses probably has more to do with whether he or she can tolerate the often rigid and sometimes openly hostile environment of a prison or the insecurity of maintaining a private practice. The choice between working with children or adolescents may be based on whether one can tolerate working with the many dysfunctional families that may have generated and sustained the child’s deviant sexual behavior or may care more about maintaining family secrets than helping the child recover. I have had mothers directly tell their children who were in treatment for serious inappropriate sexual behavior never to tell me the truth. T R A N S F E R E N C E A N D C O U N T E RT R A N S F E R E N C E Choosing to work with sex offenders is to invite the majority of one’s family members, friends, and professional colleagues to constantly confront one with the

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Teaching Interventions with the Sexually Disordered 423 question “How can you stand to work with those people?” Indeed, dealing with sex offenders can present a significant challenge to one’s professional objectivity. Countless personal issues may intrude upon the therapeutic relationship, including the possibility that the therapist has been sexually abused, had a close relationship with a victim, or is influenced by the depiction of the sex offender in the media. However, one of the main goals of treatment is to overcome any personal agendas. Freud (1912) talked about the role of transference neurosis in the therapeutic relationship, such that the patient may superimpose the identity of significant others in his or her life onto the therapist so that the patient responds to the therapist as if he or she were the patient’s adored mother or hated father. This is helpful in the psychoanalytic process where these interactions are analyzed in depth. This is a helpful concept to keep in mind in all treatment situations, but especially in those with sexually disordered individuals who may react in extreme ways to even the most casual encounter with staff. It also provides much grist for the therapeutic mill as one helps the offender to understand the origins of his responses to others. A more problematic situation is when the therapist begins to superimpose unresolved relationships on the sex offender. This dynamic is known as positive or negative countertransference, depending on the valence of the emotional response. The mental health professional who has been sexually abused may respond to the sex offender patient as if he or she was the therapist’s abuser. Indeed, some individuals have consciously chosen to enter this field in order to have a context in which to express their anger toward the offender while cloaking this in the guise of treatment. When highly confrontational therapy styles were the rage, therapists could more readily disguise their anger and disgust with their patients. Countertransference may be directed toward whole classes of patients (e.g., incest offenders) or may be focused on a single individual who, for whatever reason, evokes the old relationship. Negative countertransference destroys the therapeutic relationship because the patient becomes invisible. The therapist is responding to someone else. Unfortunately, the therapist’s interactions and decisions may cause real harm to the sex offender, who is already hypersensitive to rejection, causing him or her to become increasingly confused and frustrated. This therapist may also have tremendous power over the course of the patient’s life, being able to recommend against a parole or for civil commitment. Of course, the therapist is the individual with the power in this relationship, regardless of the background or characteristics of the patient. This is the case in any sexual acting out between the therapist and the patient. Watkins (1985) identified two kinds of negative countertransference: rejecting and hostile. The rejecting type often involves “a view of the client as dependent and needy” (p. 358). The therapist then responds with fear either that the client will overburden the therapist with demands or that the therapist will have to be responsible for the client’s welfare. The therapist may respond in a passive-aggressive or outright aggressive manner by using the information gathered from the patient against him or her or by communicating in a sharp or distancing manner. According to Watkins, this leaves the patient to flounder in fear and rejection, feeling distanced, alienated, and rejected, and it may evoke panic, depersonalization, and derealization.

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Watkins (1985) also discussed the hostile brand of countertransference, in which the therapist believes that he or she is “being infected by the patient’s disturbing behavior” (p. 358). He stated: A counselor-counselee interaction of this type tends to be sadomasochistic in nature, with the [counselor] manifesting the sadistic qualities and the later playing out the role of the masochistic. The emotional ramifications of this are dire for the client. Counseling then works only to reinforce and further entrench preexisting structures and behavior patterns. Thus therapy becomes negative and deteriorative in effect rather than positive and constructive. (p. 359)

The supervisor must watch closely for tendencies on the part of supervisees to project their attitudes onto their patients. Some new therapists may be misinformed and may believe that hostile approaches are simply a form of confrontation that may be helpful to the patient. The supervisor can then educate students as to more effective techniques. However, there are individuals who enter this field to avenge their own abuse. This may not even be a conscious reason. In this case, supervisees should be guided toward another type of specialization until they can resolve that issue. Some of the most effective therapists I have worked with are survivors of sexual assault who have reconciled their personal histories of abuse with their work with perpetrators. At the other extreme, the therapist may develop positive countertransference, which refers to positive feelings for the offender based again on unresolved relationships. For example, a female therapist who is leading a lonely, isolated life may project her romantic fantasies onto a sex offender on her caseload. She falls in love with a romantic delusion. The offender, who may be a master at grooming and manipulating others for his own needs, can easily recognize and take advantage of this vulnerability. I have seen therapists be seduced into planning escapes, smuggling guns into institutions, and being sexually assaulted or murdered. Yet it remains the responsibility of the therapist to confront any inappropriate advances and hopefully use them as therapeutic grist for the mill. The supervisor cannot overemphasize the danger of this pitfall. The trainee must be able to recognize the warning signs and be open in discussing these with the supervisor. It may appear to be overly cautious to be reminding professionals not to become romantically involved with their clients. However, in every residential program for sexually disordered individuals with which I have ever been connected highly respected mental health professionals became involved with (and in several cases married) the incarcerated offenders with whom they were working. The vast majority of these relationships dissolved either before or shortly after the release of the inmate from custody. However, in some cases the involved parties are still together years later. Professionals must comply with the American Psychological Association (2002) guidelines with respect to relations with patients. Other types of dysfunctional therapeutic relations may involve the therapist becoming overly protective of the client. Tamer (1981) stated: The therapist . . . must clearly recognize that there is a difference between helping and saving and must be sensitive to both the patient’s and one’s own fantasy of being the parent the patient never had. (p. 13)

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Teaching Interventions with the Sexually Disordered 425 Watkins (1985) has described benign countertransference, which is commonly found among therapists who have a fear either of being rejected by the client or of being harmed by the client. Thus, the therapist creates a bland, benign, colorless therapeutic atmosphere. If the therapist is afraid of the client, one way to deal with this situation is to become the patient’s “friend.” The therapist begins to chat and self-disclose, and the therapy session becomes a social visit. Tamer (1981) referenced the “you are who you treat” brand of countertransference, in which the counselor derives his or her self-esteem from the status of the clients. If the patients are viewed as low on the social totem pole, the therapist may react with hostility and rejection and quick burnout (p. 16) or may become a “swashbuckler” who can go into the lion’s den of sex offenders and emerge to tell tales to colleagues and friends. How can a therapist recognize that countertransference is affecting his or her relationship with a patient? The following questions might offer some clues:

r Does the individual evoke behavioral or emotional triggers based on physical r r r r r r

traits, behaviors that are similar to those of a significant figure in the therapist’s life, tone of voice, similar lifestyle, or history? Does the therapist treat the individual differently, either more critically or more permissively, than other patients? Does the supervisor or other staff members notice that the therapist is treating the patient differently? Does the therapist evaluate the individual’s progress in treatment in a significantly different way from other therapists? Does the therapist describe the individual as “different” from other patients? Does the therapist talk about this individual outside of the work setting? Does the therapist disproportionately allot time to this individual?

Both positive and negative countertransference can have devastating effects on a therapist’s career or personal life. A negative reaction may suggest some type of past unresolved relationship, possibly but not necessarily repressed sexual abuse. Positive countertransference may result in romantic involvement with an individual who may prey on this vulnerability. I have repeatedly seen offenders convince naive staff members who believe that they have found a soul mate to smuggle money, drugs, or weapons into a prison. These women may end up serving long criminal sentences or die as a result of this behavior. If one suspects that one is developing countertransference, one must immediately share this with one’s supervisor or with a trusted professional. To reduce the likelihood of the development of countertransference, the student should follow these guidelines:

r Clearly separate his or her professional life from his or her private life. r If the students maintains personal friendships with his or her professional colleagues, try to focus these friendships on interests other than work.

r Constantly watch out for a tendency to satisfy his or her emotional needs through work.

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r Be willing to immediately talk to his or her supervisor about any client relationship that he or she is tempted not to talk about. In all cases, the student and the supervisor must scrutinize for this so that when it does occur, the situation and remediation is normalized so that the student does not necessarily get punished. r Follow the advice that he or she gives clients about handling stress. Additionally, the therapist who has developed either negative or positive countertransference may produce feelings of rejection in a client who belongs to a group that is already exquisitely sensitive to rejection. The hostile therapist may make the patient angry and resentful. However, this may actually be less dangerous than if the therapist becomes involved in even a covert romance and then backs out. The scorn of the proverbially scorned woman is nothing compared to the scorn of a sex offender—especially one with a history of violently attacking women. V I C A R I O U S T R A U M AT I Z AT I O N When therapists listen day in and day out to descriptions of sexual assault and victimization, they may be susceptible to developing a condition known as secondary or vicarious traumatization. This condition was first identified by McCann and Pearlman (1990), who noted the impact that working with sexual abuse survivors can have on therapists. Through empathetic connection to their clients’ trauma, mental health professionals may experience changes in their worldviews, self-identities, and cognitive schemas (McCann & Pearlman, 1990; Pearlman & Saakvitne, 1995). Many researchers have reported that sex offender therapists can experience disruptions in affect regulation and expression, interpersonal relationships, and sexuality as well as experiencing nightmares and intrusive imagery (Ellerby, 1998; Farrenkopf, 1992; Jackson, Holtzman, Barnard, & Paradis, 1997; Kearns, 1995; Layton, 1988; Mitchell & Melikian, 1995; Polson & McCullom, 1995). Rich (1997) asked therapists working with survivors and perpetrators of sexual abuse to identify whether they believed that they were suffering from vicarious traumatization. In all, 62% replied in the affirmative and reported that they experienced difficulty in coping with stress at work, intrusive images, discouragement, anxiety, and feeling at odds with the world. It is helpful to be able to use the supervisor to provide inoculation and a venue for processing these experiences. Emerick (2006) has conducted research with first responders in child sexual abuse cases, which include the sex offender treatment specialist. He coined the term silent injuries to describe the possible adverse emotional, social, and sexual consequences to the professionals dealing with these cases. Of interest is that in his research sample 48% of the female professionals and 22% of the male professionals indicated that they themselves had a history of being the victim of childhood sexual abuse. The sample was given a questionnaire that measured (a) sexual response cycle injury, (b) secrecy and social challenges, (c) negative self-appraisal, and (d) silent injuries. Certain circumstances were identified as being particularly toxic. They included (a) having to reject a case because there was a social relationship with the offender, (b) being exposed to confiscated pornography, and (c) experiencing

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Teaching Interventions with the Sexually Disordered 427 sexual arousal while performing work-related activities. Those professionals who were exposed to these toxic experiences reported (a) higher rates of insomnia and secrecy and social challenges and (b) an increase in personal faults such as being irritable with the family, speeding, and so on. They also had a higher silent injury score. Therapists who had difficulty communicating with their partners reported that their work had disrupted their own sexual response cycle and reported a significant correlation between toxin exposure and negative self-appraisal. The effects of this work on the personal lives of treatment providers can be mitigated by maintaining a healthy lifestyle and by acquiring knowledge of both the field in general and the possible personal effects. Additionally, certain employment can decrease the negative impact of this career. The supervisor should be willing and able to discuss the trauma involved with this work. The supervisor should show an active concern with therapists’ health and well-being. The professional setting should value quality over quantity. The effects of politics on agency decision making should be minimal. Specific self-care techniques that were shown to minimize silent injuries were the following:

r r r r r

Maintaining an exercise program. Following a healthy diet. Having healthy outside interests (e.g., religion, hobbies). Nurturing intimate relationships. Scheduling and taking vacations.

DEALING WITH COUNTERPRODUCTIVE PUBLIC POLICY Therapists who work for social service agencies are often frustrated by funding problems. Therapists who are in private practice face difficulties in dealing with insurance companies. Those employed by governmental agencies may face yearly budget battles. However, few mental health professionals have to deal with the public fear and hostility that are engendered by sexually disordered individuals and the misguided public policy that consequently ensues. For example, over the past 7 years in Massachusetts public registration has been instituted that currently contains individuals as young as 10 years of age. Civil commitment of individuals identified as sexually dangerous was reinstituted despite the fact that several years previously civil commitment had been declared to be ineffective. Sentences have been expanded. “Predator-free zones,” which would severely restrict housing options, have been proposed. Zoning ordinances have even been suggested that would limit where sex offender treatment providers could locate their offices. Recent federal legislation has established a national registry that will place the pictures of most sexually disordered individuals (including juveniles) on an Internet site. In other states, legislatures have tried to mandate chemical castration. Although effective means of diminishing the rate of reoffense through appropriate therapy and supervision have been identified and widely disseminated through the Center for Sex Offender Management, a division of the U.S. Department of Justice, few politicians have consulted this research. Consequently, the therapist who chooses to work with sexually disordered individuals will face the constant

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frustration of seeing his or her patient lose his job because someone found his picture on the Internet and consequently losing the money he needs for treatment or having the offender’s family face eviction from their home. Therapists in Maine saw two of their patients murdered by a man who found their pictures and addresses on the Internet. Research has consistently shown that recidivism is lowered by facilitating employment and housing opportunities, educating the offender’s support system, and making treatment accessible and affordable (Petersilia, 2003). Additionally, the containment approach, which stresses close networking between the treatment provider, supervising officer, and polygrapher, has proven effectiveness (English, Pullen, & Jones, 1996). Continued therapy can facilitate reentry and enhance public safety. Public safety could be significantly enhanced if even a fraction of the money spent on civil commitment or public notification could be devoted to providing treatment and other social services to offenders. CONCLUSION Sexual abuse can be one of the most devastating of all traumas. One of the ways to counter this tragedy is to treat offenders, thus preventing future victimization. However, sexually disordered individuals currently rank among the most detested individuals in this society. Professionals who choose to provide therapy to them may be viewed as apologists for their behavior. However, providing appropriate therapy to this population has been shown to effectively reduce recidivism, thus eliminating scores of possible victims. For each offender treated, the potential benefit to society goes far beyond that one person. Thus, treating this population can be tremendously rewarding. However, it can also be tremendously challenging. This has less to do with the offenders themselves than with the settings in which treatment is offered, the public policies that are becoming more and more draconian, and the never-ending fight to justify humane and effective approaches to managing this population. One of the first challenges to the individual who wishes to deal with this group will be to find appropriate training. Classes in rehabilitating any type of offender are few and far between. Thus, the graduate student or the seasoned professional interested in this specialty will have to find conferences, mentors, or programs that offer internships in the treatment of individuals with inappropriate sexual behavior. Therapists should not begin offering this type of treatment prior to obtaining a sophisticated supervisor and a solid background in the techniques and core principles, which are often quite different from traditional mental health assumptions and approaches. The novice therapist should also do some serious soul searching prior to beginning this professional pursuit. Is one able to remain grounded and objective in the face of exposure to the most traumatic material? Can one maintain a professional relationship with a patient who is attempting to mislead, manipulate, seduce, and even physically harm the therapist? Is one cut out to attempt to conduct a treatment program in an environment that may be openly hostile to one’s mission? Answering these questions can be facilitated with the help of a trusted supervisor.

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Teaching Interventions with the Sexually Disordered 429 Fortunately, an increasing number of sex offender treatment professionals are available to offer support and encouragement to their colleagues. State and national organizations offer conferences and other resources. Part of maintaining one’s sanity in this arena is to surround oneself with a strong support system that understands the particular stresses of this specialty. Although the frustrations are great, the rewards, in my opinion, are greater. Not only is there the satisfaction of knowing that successful treatment equates to fewer victims, but there is the pleasure of seeing most of one’s patients transform from dangerous individuals into functional human beings who take responsibility for the harm they have caused and are committed to not reoffending. Another positive aspect of this field is that it is constantly adapting and evolving as new treatment techniques emerge. Thus, it is open to creative approaches. For the therapist open to challenges, eager to make a significant impact on society, and with the courage to deal with multiple systemic frustrations, this specialization may well be an ideal match. Individuals in this field tend to either decide quickly that it is not a match or commit to it for the duration of their career. Attending an international conference, one will see many psychologists, social workers, and counselors who have more than 3 decades of work exclusively with this population and who are still as excited as ever about their work.

REFERENCES Abel, G. G., Mittleman, M., & Becker, J. V. (1985). Sexual offenders: Results of assessment and recommendation for treatment. In H. H. Ben-Aron, S. I. Huckers, & C. D. Webster (Eds.), Clinical criminology: Current concepts (pp. 191–205). Toronto, Ontario, Canada: M. M. Graphics. American Psychological Association. (2002). Ethical principles of psychologists. Washington, DC: Author. Barbaree, H. E. (1997). Evaluating treatment efficacy with sexual offenders: The insensitivity of recidivism studies to treatment effect. Sexual Abuse: Journal of Research and Treatment, 9, 111–128. Beck, A. T., Rush, A. J., & Shaw, B. F. (1979). Cognitive treatment of depression. New York: Guilford Press. Brownmiller, S. (1975). Against our wills. New York: Simon & Schuster. DeBono, E. (1982). Dr. DeBono’s thinking course. London: British Broadcasting. Ellerby, L. A. (1998). Providing clinical services to sexually disordered individuals: Burnout, compassion fatigue and moderating variables. Dissertation Abstracts International, 59(10-B), 5575. Emerick, R. (2006). Silent Injuries Questionnaire. Available from www.silentinjuries.com/ questionnaire.html. English, K., Pullen, S., & Jones, L. (1996). Managing sex offenders: A containment approach. Lexington, KY: American Probation and Parole Association. Farrenkopf, T. (1992). What happens to therapists who work with sexually disordered individual. Journal of Offender Rehabilitation, 18, 217–223. Freud, S. (1912). International lectures on psychoanalysis (Vol. 1). New York: Penguin Freud Library. Hall, G. C. N. (1995). Sexual offender recidivism revisited: A meta-analysis of recent treatment studies. Journal of Consulting and Clinical Psychology, 63, 802–809. Hanson, R. K., Gordon, A., Harris, A. J. R., Marques, J. K., Murphy, W., Quinsey, V. L., et al. (2002). First report of the Collaborative Outcome Data Project on the Effectiveness of Psychological Treatment for Sexually Disordered Individuals. Sexual Abuse: A Journal of Research and Treatment, 14, 169–194. Jackson, K. E., Holtzman, C., Barnard, T., & Paradis, C. (1997). Working with sexually disordered individuals. The impact on clinicians. In S. B. Edmunds (Eds.), Impact: Working with sexual abusers (pp. 61–73). Brandon, VT: Safer Society. Kafka, M. P. (1991). Successful antidepressant treatment of non-paraphilic sexual addictions and paraphilias in men. Journal of Clinical Psychiatry, 52, 60–65. Kafka, M. P., & Hennen, J. (2002). A DSM-IV Axis I comorbidity study with males (n = 120) with paraphilias and paraphilia-related disorders. Sexual Abuse: A Journal of Research and Treatment, 14, 349–366.

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Kearns, B. (1995). Self-reflection in work with sexually disordered individuals: A process not just for therapists. Journal of Child Sexual Abuse, 4, 107–110. Laws, D. R., Hudson, S. M., & Ward, T. (2000). Remaking relapse prevention with sex offenders. Thousand Oaks, CA: Sage. Layton, J. C. (1988). The countertransference phenomenon with therapists who work with sexually disordered individuals. Unpublished doctoral dissertation, University of Pittsburgh, PA. Linehan, M. M. (1993). Cognitive-behavioral treatment. New York: Guilford Press. Marlatt, G. A., & Gordon, J. R. (1985). Relapse prevention: A self-control strategy for the maintenance of behavioral change. New York: Guilford Press. Marques, J. K., Wiederanders, M., Day, D. M., Nelson, C., & van Ommeren, A. (2005). Effects of relapse prevention program on sexual recidivism: Final results from California’s Sex Offender Treatment and Evaluation Project (SOTEP). Sexual Abuse: A Journal of Research and Treatment, 17, 79–107. Marshall, W. L., Marshall, L. E., Serran, G. A., & Fernandez, Y. M. (2006). Treating sexual offenders: An integrated approach. New York: Routledge. McCann, L. & Perlman, M. (1990) Vicarous traumatization: A framework for understanding psychological effects of working with victims. Journal of Traumatic Stress, 3, 1–15. McGrath, R. J., Cummings, G., Livingston, J. A., & Hoke, S. E. (2003). Outcome of a treatment program for adult sexually disordered individuals. Journal of Interpersonal Violence, 18(1), 3–17. Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press. Mitchell, C., & Melikian, K. (1995). The treatment of male sexually disordered individuals: Countertransference reactions. Journal of Child Sexual Abuse, 4, 87–93. Nagayama Hall, G. (1995). Sexual offender recidivism revisited: A meta-analysis of recent treatment studies. Journal of Consulting and Counseling Psychology, 63, 802–809. Nicholaichuk, T., Gordon, A., Deqiang, G., & Wong, S. (2000). Outcome of an institutional sexual offender program: A comparison between treated and matched untreated offenders. Sexual Abuse: Journal of Treatment and Research, 14, 139–155. Pearlman, M., & Saakvitne, R. (1995) Trauma and the therapist. New York: Norton. Petersilia, J. (2003). When prisoners come home: Parole and prisoner reentry. New York: Oxford University Press. Pithers, W. D., Marques, J. K., Gibat, C. C., & Marlatt, G. A. (1983) Relapse prevention: with sexual aggressives: A self-control model of treatment and maintenance of change. In J. G. Greer & I. R. Stuart (Eds.), The sex aggressor (pp. 214–234) New York: Norton. Polson, M., & McCullom, E. (1995). Therapist caring in the treatment of sexual abuse offenders: Perspectives from a qualitative case study of one sexual abuse treatment program. Journal of Child Sexual Abuse, 4, 21–43. Prentky, R. A., Lee, A. F. S., Knight, R. A., & Cerce, D. (1997). Recidivism rates among child molesters and rapists: A methodological analysis. Law and Human Behavior, 21, 635–659. Rich, K. D. (1997). Vicarious traumatization: A preliminary study. In S. B. Edmunds (Ed.), Impact: Working with sexual abusers (pp. 75–88). Brandon, VT: Safer Society. Ross, R., Fabiano, E., & Ewles, C. (1988). Reasoning and rehabilitation. International Journal of Offender Therapy and Comparative Criminology, 32, 29–35. Samenow, S. (1984). Inside the criminal mind. New York: Crown. Schwartz, B. K., & Baker, D. K. (1997). Reported effectiveness of various treatment modalities at the Massachusetts Treatment Center. Unpublished manuscript. Schwartz, B. K., & Cellini, H. R. (1988). Treating the incarcerated male sex offender. Washington, DC: U.S. Department of Justice. Tamer, J. S. (1981). Countertransference issues in the psychotherapy and management of substance abusers. Unpublished manuscript. Teicher, M. H. (2000, Fall). Wounds that time won’t heal: The neurobiology of child abuse. Cerebrum, The Dana Forum on Brain Science, 50–67. Teicher, M. H. (2002, March). Scars that won’t heal: The neurobiology of child abuse. Scientific American, 286(3), 68–75. Thornhill, E. S., & Thornhill, N. W. (1983). Human rape: An evolutionary perspective. Ethnology and Sociobiology, 4, 137–173. U.S. Department of Veterans Affairs and Department of Defense. (2004). Clinical practice guideline for the management of post-traumatic stress. Washington, DC: Author. U.S. General Accounting Office. (1996, June). Sex offender treatment (Report to the chairman, Subcommittee on Crime, Committee on the Judiciary, U.S. House of Representatives). Washington, DC: Author.

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Teaching Interventions with the Sexually Disordered 431 Ward, T., Hudson, S. M., & Marshall, W. L. (1996). Attachment style in sex offenders: A preliminary study. Journal of Sex Research, 33, 17–26. Watkins, C. E. (1985). Countertransference: Its impact on the counseling situation. Journal of Counseling and Development, 63, 356–364. Yates, P. M., & Kingston, D. A. (2006). The self-regulation model of sexual offending: The relationship between offense pathways and static and dynamic sexual offence risk. Sexual Abuse: A Journal of Research and Treatment, 18, 249–259. Zgoba, K. M., Sager, W. R., & Witt, P. H. (2003). Evaluation of New Jersey’s sex offender treatment program at the Adult Diagnostic and Treatment Center: Preliminary results. Journal of Psychiatry and Law, 10, 25–45.

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C H A P T E R 23

Psychotherapy Supervision and Angry, Hostile, and Violent Patients ALLEN K. HESS

Who is mighty? He who subdues his passions as it is said, He who is slow to anger is better than the mighty, and he that ruleth over his spirit than he that taketh a city. —Ben Zoma, in The Sayings of the Fathers (Hertz, 1945, p. 67)

PSYCHOTHERAPISTS NEED to learn about managing aggressive, angry, hostile, and violent clients for three reasons. First, maladjustment characterizes the caseload of virtually all clinicians (Mowrer, 1964). Anger and resentment over some slights and even some major intrusions in the client’s life are the foundations for many presenting complaints. This turmoil may result from the frustration of not getting promoted when one perceives that one’s work excels but is unrewarded, from being abused and beaten by alcoholic or disturbed parents (Wood, 1987), or from the world simply not seeming to make sense. Stricker (1983) found that passive aggression “is rarely the reason that the patient is brought to our attention” (p. 8) because the patient presents as superficially cooperative and affable. Only as psychotherapy is found to be a safe place for expressing feelings or a source of frustration as the patient replicates his or her conflicts does the patient express lability, stubbornness, irritability, and self- and other-defeating patterns. The presenting complaint fades in importance, replaced by the resentment of being small and ineffective in a big world. This leads to resistance to change and

I thank Steven Elias, Sigrid A. Hess, Bettina Schmidt, and Steven Walfish for their commentary.

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Psychotherapy Supervision and Angry, Hostile, and Violent Patients 433 seething anger, emotions that arouse feelings in the psychotherapist that might require processing by a consultant or supervisor. Second, an increasing number of psychologists find employment in correctional and other forensic settings (see Chapters 18 and 21). Also, military and veteran facilities have a great need for psychologists to help with clientele who were selected and trained to break things and kill people and who perform under constant threat of death—a violence-prone group if ever there were one. Third, increasingly people find themselves in overwhelming situations, situations that often involve losses. Events such as employment termination or child custody loss are devastating and appear to have no resolution. These situations often provoke violence even in seemingly nonviolent people. Thus, fully trained professionals need to be taught to identify and intervene with violent people and evocative situations. And supervisors may well be negligent if they are not prepared to supervise students who might treat violent populations or confront violent situations in seemingly ordinary psychotherapy proceedings. Walfish, Marlyere, and Zielke (2008) found that 13% of a sample of psychologists had a client reveal a murder, 33% had a client reveal an unprosecuted sexual assault, 69% reported at least one revelation in the consultation room of an unprosecuted physical assault, and 64% reported feeling inadequately prepared in their graduate training to manage client reports of violence. The balance of this chapter (a) reviews types of angry, aggressive, hostile, and violent people; (b) identifies situations that may escalate into violence; and (c) addresses specific steps in educating students to become adept at identifying and using the client’s energies to refocus the client in more healthy directions.

TYPES OF PEOPLE ANGRY PEOPLE Distress drives people to psychotherapy, be it experienced by the person (e.g., depression); by the people around the patient who are being distressed and distressing; or even by the legal system, which might refer a person to a clinician. Can a supervision or a training program be complete without a focus on anger and its treatment? Anger provides an opportunity for the supervisor to educate on several levels. On the cognitive level, understanding anger provides the chance to engage the student in theoretical discourse. That is, the supervisor can ask how the student understands anger. If the student needs guidance, the supervisor can review several theorists and assign readings so the student can learn the maps or cognitive structures by which anger has been conceptualized. For Sullivan (1951), anxiety (or his term, insecurity) underlays all anger. When a person feels insecure, he or she tends to narrow his or her focus, which limits fight-or-flight options. When flight is not an option, then striking out becomes the default. One can often hear in the aftermath of family destruction: “If I cannot have [her] [the children], then no one can.” This loss of control over one’s destiny and the sense of the catastrophic collapse of one’s world as underlying sudden eruptions of anger is an important insight or map provided by Sullivan. In reviewing cases in supervision, the student

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and supervisor can then see how well the various maps or theoretical models fit the terrain or the psychotherapy case the supervisor and supervisee are reviewing. Then the supervision dyad can plan on how uncovering what is making the patient insecure can relieve the torrent of anger. Or whether a sense of security and hope can serve as a foundation upon which the patient can temporize or see that the world will not end in the immediacy of his or her feelings of an imploding world. AGGRESSIVE PEOPLE Kelly (1955) distinguished aggression from hostility in a useful fashion. Aggression for him was the active elaboration of one’s construct system. That is, the person who asserts himself or herself in trying out different behaviors is being aggressive but is not necessarily harming others. However, when a person does not take feedback and use it adaptively but persists in imposing his or her own view of the world as the only view worth considering, then aggression becomes fused with hostility to create harm. Hostility is the extortion of validational evidence where it does not exist. Thus, a parent who beats a child and tells the child that it is for the child’s own good and tells himself or herself that it is the best way of providing love is cloaking rampant hostility in rationalization. As mentioned previously, passive aggression is the exercise of hostility with little to no overt physical expression. The supervisor familiar with a variety of theories about aggression, anger, hostility, and violence can use the literature or experience the student brings to psychotherapy as a way of having the student explain the clinical phenomena he or she is witnessing. The supervisor can then best serve as a teacher, mutually exploring with the student ways to understand or see the phenomena. From these explorations, perhaps fortified by the supervisor suggesting some scholarly resources to the student, the supervisor takes a more collegial role in planning interventions and seeing what works and what does not work for this student.

Case 23.1 M, a capable third-year doctoral student, was assigned an inpatient group psychotherapy as part of his assistantship in a delinquency center. The first group session proceeded in total chaos. Before M uttered his first words, people began to argue and fight. He tried to establish order by telling the teens to sit down and shut up. A gentle person, he began quietly and then ratcheted up until he was yelling as loudly as the rest of the group. He threatened that they would spend the rest of the session in silence or receive disciplinaries. He came to his first supervision session totally defeated. The supervisor asked about a graduate class that M was taking with the professor: How did the professor establish control over the rowdy bunch of 20 graduate students? They discussed the professor standing in silence; the professor paying attention to the several orderly students; and the professor addressing a question to the rowdiest of students, or even telling a particularly disruptive student that he may be excused from the class. Respectively, they discussed the concepts that the professor was the acknowledged authority figure by degree, by appointment, by knowledge of the material, by dispensing of assignments, by calling on people to recite or answer questions, by the grading process, and even by expelling students from class. They discussed the various powers that the student had in the group psychotherapy setting,

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Psychotherapy Supervision and Angry, Hostile, and Violent Patients 435

despite his difficulty seeing himself as powerful. His age, knowledge, verbal facility, positional power, ability to bestow attention on one or the other resident, ability to leave the facility, and imputed ability to “write good paper” about the youths were discussed and role-played. In effect, the supervisor spent the time empowering and building confidence in the student. Then they discussed other settings in which M was the leader and had used authority successfully in the past. The session ended with the supervisor suggesting that M use some of the techniques they had discussed. M wryly opined that he could hardly do worse than he had in the previous group session; both laughed and implicitly the supervisor engaged in permission giving, a vital part of psychotherapy supervision. The supervisor gave M the permission to try and to succeed or fail, and to bring the results into supervision the next time without blame, but with mutual respect for the attempt and the courage of the student in bringing this situation to supervision. The next psychotherapy session began with M imposing order by greeting the group members by name and taking his seat and clearing his throat while they came to order. He asked a member a question and then asked one who had not quite come to order what the other person had said. M told the group that getting respect is important, just as giving respect is important. He then asked the first person to repeat herself to the then-quiet and attentive group.

Often the supervisor would do well to draw upon and remind students of their experiences and strengths. The group members were attention-seeking, aggressive and undisciplined. They were not necessarily hostile or angry, but they were in need of structure, support, and direction in terms of finding productive ways to make their needs known. Too often neglected youth who wind up in delinquency centers are more in need of charm school and parental care, concern, and attention rather than (more) punishment. Students learning psychotherapy may be a novices, but they do come to the supervisor with rich sets of experiences: Some are strengths, and some are scar tissues from wounds inflicted earlier in their lives. They often misinterpret delinquent behaviors and communications. The skillful supervisor uses these experiences as building blocks in teaching psychotherapy.

Case 23.2 Ron was the son of a police sergeant. As loud as the sergeant was and as much space as he occupied, Ron, taller than his major professor, always seemed to be short and tried to occupy as little space as possible, as if making himself a smaller target. The faculty played favorites and used scapegoating with students and colleagues alike. At the semiannual student evaluations, they moved to drop Ron from the graduate program for being “schizoidal.” The major professor supported Ron, asking whether they conflated “shy” with schizoidal. The motion was tabled. Ron and the professor were engaged in prison research at a medium- to maximum-security facility for hardcore criminals. Ron was scared. The professor said they would run subjects together. He gave Ron a white laboratory coat. They set up a darkroom for vision research and blindfolded subjects for 10 minutes to adapt them to the dark. During this time the professor had Ron chat with the inmates. They ran the first inmate subject together. Ron ran the second with the professor in the room and the third by himself. When they took a brief break between subjects, the professor informed Ron that he had (Continued)

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run two murderers and an armed robber, all sentenced and serving at least 10 years. The professor told him he would never work with a more difficult client population and hugged Ron’s shoulder. Ron shook and then changed visibly into a person with erect posture and self-possession. At one time he had wondered aloud about his personal competence to engage clients. After a number of trips to the prison, during which he practiced engaging the worst of the felons, his physical appearance changed and he spoke of himself as a skilled professional. When he began his practicum with other faculty, he earned the highest ratings and went on to a stellar career of service in the military. This is an excellent example of scaffolding (see Chapter 10) one’s experience in a setting to the demands of another setting or, an alternative construal, of building efficacy in the student.

HOSTILE PEOPLE Hostile people can pose more danger and be more refractory than angry or aggressive people. They extort their views from reality, sometimes at a cost of their sense of reality and well-being. Exploring the sources of their fixed views and working to change them calls on the resources and talents of the most seasoned psychotherapist and the support of an able supervisor.

Case 23.3 Hal was both helpful and caustic at the same time. He knew the psychotherapist socially and was almost overly attentive when the psychotherapist became ill, offering his vast knowledge of medical sciences to opine about treatments. Yet he chided the psychotherapist as being a fraud in that “psychotherapists have no skills but merely parrot back to the patient whatever the patient said,” caricaturing client-centered psychotherapy. Yet when his daughter got in trouble with the law for shoplifting, Hal was quick to contact the psychotherapist to take his child into counseling to show the courts the problem was being addressed, which led to the charges being dropped. When Hal’s wife attempted suicide, he brought her to the psychotherapist for couple’s counseling when it was determined he was a major player in her despondency. Over the course of a year and a half, she showed remarkable progress, seeming to lose about 10 to 15 years off her previously haggard appearance. However, Hal remained the same, though his criticisms of her abated somewhat (and she no longer took these criticisms as being about her but as being his problem, which was a large part of her progress in treatment). During a family session, after all the children and the wife said what they had to work on, they turned to Hal as the last to speak. He pointed to each of them and said, “You have this problem and you have that problem, but I have no problem.” They all turned on him and began telling him of his problems and how unrelenting caustic comments impacted them over the years. After each had worked on his or her problems (the children in individual sessions, Hal and his wife in marital sessions) and Hal’s wife had improved, she and the psychotherapist again turned to him. He again resisted. Finally, Hal began to move a bit by telling of a few harrowing flashbacks in his dreams of childhood abuse experiences that had startled him awake. All the while he became more hostile to the psychotherapist, accusing him of fraud by taking people’s money and not doing anything. As more memories arose, the accusations became fiercer and more torrential. This pierced a soft spot in the psychotherapist, who had been raised to give more than a dollar’s worth of effort for any dollar he earned.

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Finally one day, in the face of a particularly vicious attack, the psychotherapist asked Hal if he would care for a refund for the sessions if he felt that strongly about the psychotherapist’s incompetence and inability to help. Hal looked stunned. He said that he trusted the psychotherapist as the only one with whom he would and could act this way without reprisals and with whom he trusted his family members—in what other setting and with what other professional could he express his anger and rage and feel safe? At home his acidic comments cost his family’s well-being while at work it cost him any hope of promotions and raises.

In this case, the psychotherapist learned an important lesson and redoubled his effort to have Hal explore the sources of his hostility and the impact of his rages on those around him. Eventually, some of Hal’s repressions lifted and allowed him to express his feelings of helplessness and hostility, particularly with regard to women. However he never could confront his core problems. The chronic childhood abuse had taken a number of victims. The psychotherapist learned about how he needed to examine his assumptions about his values with respect to the value of his services and his ability to manage transference. Family life can be a hotbed of hostility, in its germination, its expression and its refractory nature.

Case 23.4 A man was hospitalized due to a coma induced by metabolic syndrome. He had diabetes, chronic heart disease, arthritis, and gall bladder pathology. A family acquaintance, a psychologist colleague of his daughter, visited him and his daughter and wife. Despite the presence of a guest who had met the family only one time before, the family, a pseudo-hostile type, launched into combat that made the psychologist flinch. The father began berating them for his misery and said they were ungrateful for his support all these years; that if they were kind to him they would listen to his needs. These needs included their sneaking him candy snacks, thus thwarting his hospital diet. The mother and daughter kept upbraiding him for not adhering to good health practices. Then, to the psychologist’s astonishment, the wife opened her purse and snuck her husband a variety of sugar-laden candy bars. He munched them while the wife and daughter lowered their heads in defeat. The wife and daughter then proceeded to launch another verbal assault on him, with a whiny quality to their voices. With the family only able to relate in the most hostile and destructive ways, the psychologist wished them well and removed himself from the hospital room.

The adept supervisor would help the student identify the nature of hostility, schizotypal attachment styles, and homeostasis on the part of the parties and link this to the interesting literature on the pseudo-hostile family in both Schizophrenia (Alanen, 1997; Wynne, Ryckoff, Day, & Hirsch, 1958) and unbalanced parent–child relationships (Shulman & Knafo, 1997; von der Lippe & Moller, 2000). This concept identifies the family as one in which hostility is ladled out with the premise being “we are truly family for no one else would tolerate this kind of abuse and intimacy.” These families stick together through a hell from which any reasonable person would flee, because the fear of change and loss of acceptance for bizarre behavior is riskier than the continued abuse that comes with stability and acceptance.

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Case 23.5 My wife and I were moving into a newly purchased home. The seller, a woman in her 60s, lived with her recovering alcoholic son. She turned to him and told him he could help earn his worth by packing the remaining items in the living room in the boxes she had just brought—from the liquor store. She told him how his helping her was part of their love for each other. Yet she had brought only bourbon, scotch, and whiskey bottle boxes for him to use in packing, surely something not recommended by any psychotherapy program for recovering alcoholics. She cloaked this hostility in the guise of a loving relationship.

Recognizing and gauging hostility, planning psychotherapeutic strategies, and supporting the student as various reactions are aroused in him or her will provide plenty of grist for the supervisory mill. Hostility invariably involves manipulation, deceit, and cruelty, even when the person is “doing it for X’s own good” and might even believe that line as he or she utters it. The effects of this hostility and manipulative harm on even seasoned psychotherapists are soul-shaking—and they are so much more so for students who will need to process these events in supervision (Gediman & Lieberman, 1996). VIOLENT PEOPLE Despite the nightly diet of gore on television, violence-saturated movies and videogames, and newspapers featuring local crime on page 1, violence is a relatively low base-rate phenomenon. For all the human interactions each of us has, few are violent. This complicates the prediction of violence (Litwack, Zapf, Groscup, & Hart, 2006; Nussbaum, 2006). One distinction useful in predicting violence is that of static and dynamic factors. Static factors, the focus for the balance of this section, are those that are more trait-like and enduring. They accompany one’s status or being and are typically seen via the diagnostic nomenclature. Dynamic factors often serve as triggers to violent acts. They are recent in that they are provoked. Sometimes, the person is easily provoked, and hence, a violence-prone individual. Events such as brain tumors, job loss after repeated disciplinary warnings, or unfavorable child custody or alimony awards in divorce cases serve as dynamic factors or factors due to the situation, which interact with static factors. Although the stigma of the association between mental illness and violence is a common stereotype, there are categories in which people prone to violence are more prevalent. Types of Violent People Three factors interact to produce expressive violence as opposed to instrumental violence (in the latter case, seizing property or intimidation for gain is the goal). First, in expressively violent people there is often an exaggerated and quite vulnerable sense of psychological self coupled with the need to be in control. Second, when the inflated self is punctured or there is a weakening of executive control (e.g., with drugs and alcohol, stress, or central nervous system compromise as with aging), violence is potentiated. Third is the lack of empathic regard or the lack of

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Psychotherapy Supervision and Angry, Hostile, and Violent Patients 439 a sense of the other. These three factors are found in various combinations in the following types of people. Persons with Paranoias and Delusions I shot Andy Warhol. I had to. He had too much control over my mind. —Valerie Solanas

The first major constellation of violence-prone individuals are those in the paranoid conditions. There are five such paranoid conditions: states, personalities, schizophrenia, cultural and delusional psychosis. Paranoid states more frequently occur in paranoid personalities but can be manifest in anyone. Having the sense of being followed by a police car, being caught in a bad audit by the Internal Revenue Service, or being vulnerable to employment “retrenchments” or firings when one is financially dependent on a job are all examples of conditions that make one interpersonally hypersensitive and distrusting. Paranoid personalities have this sense on a recurrent if not constant basis. Severely mentally ill include people whose perceptions are not consensual with others’, who cannot “get” the punch line of a joke but see the rest of the gathering roaring with laughter, and whose common communications seem endowed with special meanings that are not shared by others. Sinking into paranoid psychoses, they might think there are conspiracies or cabals targeting them. Seeking revenge or a lashing out to settle scores then seems the only right thing to do. Their isolation and then contrived explanations for social estrangement—a paranoid and delusional construction—seem understandable. Teenagers, blacks, and especially black teenagers find themselves followed around by mall security as potential shoplifters, trouble-makers, and gangsters. These groups are subject to cultural paranoia, or the normal response to an abnormal situation. It is not that they think mall security is following them; mall security is following them. And if one is a criminal, then indeed he or she belongs to a criminal underculture in which paranoia is the modus vivendi. Police are (and should be) attending to them. The only culture more paranoid than that of the prison inmate is that of the spy and conspirator. This later culture both selects and trains people for paranoia. The unsuspecting person in this culture is unprepared and is likely to perish; the adaptive ones are like coiled springs. The clinician working with people who have one (or more) of these conditions characterized by a profound sense of distrust of others ought to be aware of the potential for brief, sudden, focused, and seemingly unpredictable violent expressions. The key sign may come in the form of certain obsessions that blend into delusional thinking. The obsessions become operative with the more psychotic individuals when they take the form of command hallucinations, and these hallucinations seem more driven, compelling, and controlling. The sense of control is passed to the imagined other or commander of the hallucination, with the sense of executive control being severely compromised. Other people who are trying to control people prone to violence often become part of the target to be obliterated. The supervisor needs to help the student build the ability to convey a sense of trust to the patient. In these cases, the student must be attuned to the patient’s

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ability to maintain distance while approaching as this ability allows. In inpatient cases, coordination with staff about patients who are “about to go off” is essential. Any confrontations ought to be done in the first third of a session to allow for working through the conflict. The student must know that “blowing someone out of the water is easy, but giving them a place to land,” or working through the emotions and building new structures in handling conflict, is the key to effective psychotherapy. Confrontations must be managed most carefully in sessions and must be both planned and reviewed in supervision. Manics. Manics, or bipolars, to use the current terminology, are people who, by dint of genetics, faulty nurture, or pharmaceutical agents such as amphetamines, might be prone to outbursts of energy. These people are more likely to have diffuse outbursts, be they geographical, ideological, temporal, or physical. That is, these outbursts seem to effect no particular financial or status gain (instrumental emotion) except primary gain or emotional release (expressive emotion). For example, a patient in east Alabama decided to have caf´e au lait and beignet in the French Quarter and sped through the night to New Orleans (geographical), lectured to people in Jackson Square (ideological), sped back to stay up the day at work (temporal), and became combative when people at work tried to quiet him. Of course, fraternity members have pulled the same prank, so one must use judgment before deeming someone manic. Yet manics typically have an unfocused and spontaneous flurries of energy that tends to be expressed violently. This is particularly so when they perceive their freedom of movement and expression is constricted. Psychotherapist and staff safety become primary concerns during such outbursts. If manic flurries last long enough and occur in situations that cannot ensure patient and staff safety, then civil commitment of outpatients and isolation and restraint of inpatients might be needed for the protection of patients and those around them. These events need to be carefully choreographed, even by experienced psychotherapists, and carefully supervised when a student-psychotherapist is involved. In outpatient treatment, one must consider threats to third parties. Invoking a Tarasoff warning can abort any trust built in the psychotherapy and ought to be done only when the violent situation is imminent, palpable, and uncontrollable and when a known third party is at risk. Commitment, isolation and restraint, and invoking Tarasoff can be traumatic for all concerned, especially the student, and ought to be planned for, if possible, and processed afterward in supervision. Persons with Brain Syndromes. Organic brain syndromes and retardation are characterized by compromises in executive control. The irony is that unlike the paranoid and manic conditions, in which there is a surfeit of energy, brain syndromes are similar to vehicles without brakes. One need only be going a at moderate speed and one will still crash. In some perverse calculus, and unlike those of persons with paranoid and manic conditions, the victims of the attacks of brain syndrome patients are likely to be weak or inferior—other infirm people in the ward, children too young to defend themselves, and the disabled. For example, an elder suffering from dementia, with a spotless history at the age of 65, might lack the control to rein in aggression or sexuality. He might select a target, such as a 6-year-old grandchild, who is incapable of warding off the assault. A retarded teen is unlikely to aggress against another teen but rather find a kindergarten-age

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Psychotherapy Supervision and Angry, Hostile, and Violent Patients 441 child a more successful target. Thus, a person may seem mild-mannered in the presence of a professional and toward others in power positions but may become aggressive or violent with those in vulnerable positions. In terms of victim selection and grooming, even though these two examples were not determined to have brain syndromes, Ted Bundy chose teenage women and handcuffed them, whereas Jeffrey Dahmer intoxicated his victims, rendering them harmless and wholly vulnerable. Assessing violent people must involve assessing their attitudes toward the weak and vulnerable. Failure to assess the potential classes of victims will lead to false negatives in predicting violence among patients with brain dysfunction. Substance Abusers. Although mentioned above in the section on manics, substance abusers compose a distinct class of violent people. Although drugs energize people to act impulsively and violently, they can also be depressing to the point of actuating suicidal ideation and action. This is particularly the case during drug withdrawal, be it under medical supervision or ad lib in the street. Menninger (1963) implicated the wish to kill, the wish to die, and the wish to kill oneself as the fatal trio that actuates suicide. There is the phenomenon in which a person kills his or her family and often turns the firearm upon himself or herself, completing a murder–suicide. Such is the lability of the impulse to destroy—others or oneself. Drugs compromise functions of the frontal lobe and cerebral cortex, where executive function or judgment is said to reside (Walsh, 1978). But further increasing their potential for violence, substance abusers frequent places such as nightclubs, bars, and other places where drugs are bought and sold and where things tend to be less socially structured, lethal weapons are present, there is a changing clientele with no established social order, and where violence is the coin of the realm. Also, in order to obtain funds, addicts are likely to employ instrumental violence as they rob, burgle, and mug their way to funding their habits. It is hard to overestimate the potential for violence among substance abusers. Psychopaths. Psychopaths do not necessarily have a high drive to aggress. More typically, they employ few executive controls to hinder their need for stimulation. This need for stimulation is coupled with a profound lack of empathic regard, such that they see others as objects to trifle with for their own gain or amusement. Whereas the manic might not regard the other person during the manic flurry, the psychopath just does not care about others whatsoever. One organized crime figure, nominally employed as a union representative, calmly cut off finger after finger of a business owner until the entrepreneur capitulated and signed a contract favorable to the union. That is primary psychopathy sin its pure form. Psychotherapy Strategy with Violent Patients The goals of psychotherapy with the violent ought to be threefold: (1) Can the patient recognize the damage he or she is perpetrating? (2) To what extent does the patient have the capacity to control his or her aggression and violence? (3) If the patient cannot develop such internal controls or maintain a pharmaceutical control by taking medicines when needed, then what external controls are required to avert harm from the patient and others? If need be, the psychotherapist may have to engage in difficult processes such as civil or criminal commitment, loss of the patient’s parental rights, loss of the patient’s civil autonomy, and appointment of guardianship.

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The supervisor must attend to two critical realities. The first is the safety of the student psychotherapist. The supervisor must know about violence, its prediction, and its precipitants. Assessing the working environment for security and examining the agency’s policies and the administration’s integrity are essential. Assessing the student’s social competence is quintessential.

Case 23.6 Doug was about to run his dissertation in the medium-security prison. His professor noted that the administration had cultivated a snitch system of informants (which creates extreme levels of tension among inmates), the warden’s arrest for driving under the influence on Christmas Eve was featured in the town newspaper, the bulletproof glass in the windows was easily penetrated by stones from the lawnmowers (and hence was not bulletproof), and not all doors were locked punctually due to staff shortages and absenteeism. The professor placed his student at another facility. A few months later, the national news featured this prison as the seat of a week-long riot.

The second issue is how and when to invoke a Tarasoff warning. This is one of the most difficult decisions to make, as it will harm, often irreparably, the trust level between the psychotherapist and the patient, as mentioned above. An inherently distrusting patient comes in to work on anger, hostility, and violence problems, which involves placing a great degree of trust in the psychotherapist. But when the patient reveals these feelings and even fantasies that can appear as plans, his or her trust might be violated by the psychotherapist. The current norms are to be safe, but Max Siegel (1976, 1979), immediately following the Tarasoff decision, admonished psychotherapists not to concede privilege, noting the breach of trust that it involves. Rather, psychotherapists ought not undertake psychotherapy lightly and ought to be well trained in managing dangerous patients. This tension between ensuring third-party safety and protecting a strong version of privilege must be discussed in supervision and in psychotherapy.

T Y P E S O F V I O L E N T S I T U AT I O N S As illustrated earlier, the static–dynamic distinction of viewing the prediction of violence is but a heuristic, as violent people will more likely find themselves in a violent situation (or structure a current situation into a violent one) than will nonviolent people. This interactional and escalating pattern is similar to the finding that violent people not only will have watched more violent television during their first 18 years of life but that they prefer such fare. Nonetheless, certain situations precipitate violence, and the student and the supervisor might do well to notice and discuss these. These situations are characterized by a sense of loss and a sense of anomie or lack of structure.

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Psychotherapy Supervision and Angry, Hostile, and Violent Patients 443 FAMILY The family is the primary social structure into which we are born; through which we are socialized; and through which we are inculcated into a world of particular language, mores, and standards of thinking, feeling, and behaving. In short, the family is the world or its representation to the young. As we grow, these internalizations are the benchmarks by which we judge most of life’s events and characters; relate to authorities and social structures; view our marital partners and subsequent patterns of interactions; and raise our children and, almost genetically, pass down the patterns we learned. It should come as no surprise, then, that when one’s sense of family is disrupted, the potential for violence is elevated. Police report that domestic violence calls, frequent as they are, carry a high risk of sudden violence. Similar are anecdotal observations of violent court confrontations that often occur in divorce and child custody cases. The words “If I cannot have her, then no one can,” are frequently reported in cases of domestic murder and are often accompanied by the perpetrator’s suicide. Anyone handling these cases needs to be aware of this seething, barely subliminal, structural violence.

SEXUALITY Sexuality is, by its nature, arousing. Arousal compromises deliberative judgments, increasing impulsivity. In the hands of manipulative and immature women who are heavily represented in some clinical populations, sexuality elevates the risk of male violence. Sexuality, in their world, offers instrumental opportunities. Simply put, making suitors compete with one another can offer entertainment, whereas arousing the man might provide for financial and psychic gain. Ethologists are quick to show the link between dominance, sexuality, and territoriality (Eibl-Eibesfeldt, 1975). The expression of sexuality is tied to dominance; the dominant male wins the fertilization rights. In group psychotherapy with youths, for example, the student or clinician can make this issue a focus of the group’s attention to help both the boys and girls learn to manage their sexuality as opposed to having it serve as a lever for others to control them. The loss of a sexual partner and the accompanying unnerving feeling are a brew that can potentiate violence. Perhaps nowhere else in the delinquent’s life can someone educate these children about their options. In our society, power can take many forms and modes of expression such as music, art, sports, and academics rather than brute power.

WORK With so many waking hours occupied by work, one’s sense of self or identity is heavily influenced by one’s job and associates. Some patients are loners and may be further isolated and even harassed in the work situation. When retrenchment comes, their work is found wanting; they have no political support from peers or supervisors; and they are more likely to be passed over for promotions, demoted, and fired. One consequence of the sudden loss of employment status is workplace sabotage or even workplace violence. Often this becomes obvious only after the fact. A second and less obvious source of violence in the workplace, albeit violence

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that is internally directed, are cases of promotion neurosis. Some promotions cause a person to become depressed and even suicidal. Faced with increased demands of the new position, and shorn of the support of one’s old buddies over whom supervisory authority is now vested, the promoted person can be left feeling isolated. The astute clinician and supervisor are attuned to the emotional tone of the patient, particularly during times of loss of position, esteem, and support. PLACES AND TIMES Places with few social controls potentiate violence. The workplace is highly structured to the point that employment manuals detail the levels of offenses and corresponding disciplinary responses, and dress and even language codes constrain behavior. In contrast, night clubs, bars, and sporting venues have transient populations with fewer established relationships among patrons and are highly emotionally charged. In these relatively unstructured places and in light of the different norms in particular venues (e.g., in some bars chatting with someone else’s date is acceptable, whereas in other bars it can be fatal), insults are quick to trigger violence. Sporting events have the same dynamics as bars. There is a shifting audience, an absence of status insignia (e.g., military ranks or business suits and name tags), alcohol use, and a highly charged emotional setting. At soccer games, one’s national identity and prestige may be at stake. Even youth leagues are seeing increases in parental violence, with parental pride at stake. That the looser structure of holidays and weekends leads to violence is well known to police and evident in arrest records. The clinician assessing violence and intervening to help the client better manage himself or herself is well advised to ask the client (and to reflect when making predictions) the degree to which the client’s lack of internal controls makes the weakening of social structure a real violence potentiator. IDENTITY, ALIENATION, AND COLLAPSING DEFENSES As seen above, erosion of one’s sense of self, deindividuation, and the inability to access defenses lead to violence. The person who is belittled tends to engage in a fight-or-flight response. If the person struggles with the loss of self-esteem (Baumeister, Bushman, & Campbell, 2000), he or she can become a neighborhood tough or chronically assaultive type (Megargee, 1966). If the person continually flees when cornered or at the end of his or her rope, he or she might become Megargee’s overcontrolled hostile type. This type of individual tends to be mild mannered and aloof and is often described as “nice, kept to himself, polite, and the last person you would have thought to do this.” Sudden spree or one-time group attack murders, such as that perpetrated among the Amish in Lancaster County, Pennsylvania, in October 2006, typify this dynamic. Whether the erosion of a man’s identity as a father and fully functioning human being triggered this brutal and wholly unholy attack on these Amish school girls continues to puzzle most observers and many professionals. Attacks on one’s identity, including compromises in one’s family, work, and sexual relations, contribute to the senses of loss and anomie that stoke the fires of violence.

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Psychotherapy Supervision and Angry, Hostile, and Violent Patients 445 Clinicians who make premature interpretations and fail to assess the limits of a patient’s ability to access defense mechanisms between sessions can potentiate violence. Violent tendencies then have fewer barriers to overcome. A student who pridefully recognizes pathology and then removes the symptom that is seemingly causing the disorder may send the client from the session with compromised defenses. In this way, supervision faces a dual challenge: that of making the student ready to withhold his or her hard-won insights from the client, and that of making sure the student’s interventions are of such a graduated form that the patient finds them beneficial and digestible. The same issues arise with inpatients, though there is support staff to help the clients between sessions. The supervisor will find this an opportune moment to help the student learn to coordinate psychotherapeutic efforts with staff members. Teaching a student to be a professional in inpatient settings involves informing the staff of a risky patient or inmate situation. In return, a collegial staff can provide a wealth of information that nurses or correctional officers might have by virtue of their 24/7 in situ observations. Staff interactions with clients provide a plethora of information about the clients for the clinician who takes the time to cultivate relationships with nursing, correctional, and custodial staff members. The key, then, is for the supervisor to assess the interpersonal skills that the student shows in working with the staff and to assess what rough edges need refining. Some researchers are quick to point out the limitations of clinical prediction, especially with regard to violence. In fact, when Meehl (1954) issued his clarion call for actuarial methods over clinical prediction, there were two caveats. First, in reviewing the literature he weighted the studies or assigned different levels of importance according to his clinical judgment—an irony surely not lost on Meehl, as he did it. Second, he did not exclude clinical data, just critiqued how it was combined. What the overinterpretation of Meehl’s caveat accomplished was to denigrate many important data sources, such as the clinician’s observations of the client’s muscle tension, eye glances, body posture, pitch of voice, and other nonverbal, paraverbal, and verbal information. In addition to these points, interactionism leads us to summarize this section as a matrix. Thus, the Person × Time × Situation interaction effects result in a matrix that eludes our current research base, leaving the clinician to make the best judgments he or she can. Because clinicians do not have the luxury of waiting for the next generation’s research base, they must glean from current theory and research to make predictions of violence. As these predictions provide feedback, a new source of research becomes available. T E A C H I N G A S T H E E S S E N C E O F S U P E RV I S I O N Supervising is much like reading a map. The supervisor knows the student learned about various theories and research during coursework and reading assignments. The supervisor then helps the student apply these maps to the clinical phenomena the student might be seeing but not connecting to the research and theory. For example, the supervisor can introduce concepts such as expressive and instrumental aggression (Buss, 1961) and expressive and instrumental emotion (Hess & Handler, 2008) in deciding whether a patient is simply blowing off steam in expressing anger or trying to intimidate the student or members of a psychotherapy group. The supervisor has an excellent opportunity to help the student assess the

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client’s motivation: whether the expressed anger is due to lack of internal controls (expressive emotion) or whether the anger or threat of violence is being used to extort the client’s will upon someone else (instrumental use of emotions and violence). That is, whether one is facing an anxious patient or a manipulative one can be the difference between a successful or a failed and dangerous case. Additionally, the integration of the literature and the phenomena the student confronts, the ability to get an arm’s-length perspective when immersed in the ebb and flow of an angry display by the client, and the support of a supervisor in conceptualizing beneficial responses can help build the student’s psychotherapist identity. Or one can examine John B. Watson’s (1962) two fundamental sources of insecurity: the sudden loss of support and loud noises. Watson performed his research on small children, but the loss of control underlies both phenomena. When a person’s world seems beyond control, anger becomes a predominant response. Consider a person for whom the masculine role of supporting one’s family is primary and the need for social status as the breadwinner dominates. The loss of a job can trigger anger and even violence, directed either outward or inward. In the former case, workplace violence is often perpetrated by one who was fired or who lost out on a promotion or another benefit one thought was his or her due. In the latter case, professionals and middle-level managers who lose status through a professional misdeed (e.g., an accusation or conviction of embezzlement, sexual harassment, or other wrongdoing) or through the realization that the top positions have passed them by, might turn to self-destruction. The key point for the supervisor is that he or she can best connect the rich theoretical, research, and clinical literature with the phenomena that confront the student psychotherapist. Here again, let us look at a reconceptualization of the delinquency literature concerning self-esteem. Conventional wisdom holds that people who have low self-esteem tend toward violence. However, both theoretically and empirically, those who suffer from loss of esteem are more likely to become angry and violent than those with chronic low self-regard. Horney (1950) held that those for whom self-esteem is an issue are vulnerable to psychopathology, even if they regard themselves highly, for when high self-esteem is unstable, then violent outbursts occur. Horney found that those who simply live with little regard for the constant examination of their self-regard have an elevated sense of being. Baumeister et al. (2000) provided a plethora of laboratory and field research supporting this view that inflated egoism, in their words, makes people vulnerable to self-esteem losses. Helping the student learn these maps and then identify the field, or what he or she is seeing in the consulting room with the patient, is of immeasurable value. Of course, these maps from the literature will resonate with the maps the student (and supervisor) learned early in their lives. These complexes will evoke rich responses and blind spots as to what is happening in the student’s psychotherapy sessions and the supervision sessions. E M O T I O N A L L E A R N I N G A S T H E E S S E N C E O F S U P E RV I S I O N Naturally, when someone is angry, the target of that anger tends to be threatened, a virtual tautology. Even being in the presence of an angry person is taxing. With angry clients, the supervisor has a golden opportunity to teach the student about the student’s emotional state and about how to respond therapeutically. The stance of the effective psychotherapist is to realize that the anger is not directed at the person

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Psychotherapy Supervision and Angry, Hostile, and Violent Patients 447 of the psychotherapist but rather represents the inability of the patient to tolerate a stressor. Interpersonal psychologists stress the notion of “unhooking” or not taking the complementary position to the angry person but maintaining a demeanor of control over one’s emotions. Internalizing this idea of not personalizing a verbal attack (termed maintaining one’s psychoanalytic incognito by psychodynamic theorists; Brenner, 1973) is critical if one is to keep the client from escalating and then allow the client to examine his or her angry reactions. Eagle (2000) critically evaluated Heinrich Racker’s prescient treatment of hard and soft forms of countertransference. Racker’s recognition of countertransference as providing a basis for empathic understanding of the patient radically expanded the traditional view as countertransference as solely a distorting influence. Eagle discussed the complexities of concordant and complementary identification. The effective supervisor links theoretical and experimental literature on emotions, particularly that of suppressing or managing one’s reactions in emotionally charged situations, to the student’s experiences. Emotional regulation or management addresses a core quality in the effective psychotherapist and supervisor. Gelso and Hayes (2001) discussed countertransference management as having five components: self-insight, self-integration, anxiety management, empathy, and conceptualizing ability. The ability to exercise these components characterizes the excellent psychotherapist (Van Wagoner, Gelso, Hayes, & Diemer, 1991). There are costs to this emotional labor (Gross & Levenson, 1997; Mann & Cowburn, 2005). Richards (2004) described the cognitive and physiological costs (Richards & Gross, 2000), yet this research yields a supervisory heuristic. The student and supervisor can assess the student’s emotional responses and readiness to examine the emotional labor and the type of exhaustion, or burnout, the student is experiencing. A student with a caseload of child sexual victims bears a great emotional load. The supervisor might do well to allow a place for the student to decompress. The ability to assess and discuss countertransferential feelings or psychological flexibility allows the supervisory dyad to determine the amount of confrontation the student is able to use and can provide a good template for the student to use with the client. This template involves being able to recognize the emotional processes as well and calibrate the amount of material that can be metabolized during a session. Of course, this probing into the student’s emotions ought to be done solely with the goal of developing student competence and not with the goal of doing psychotherapy with the student. The effective, ethical, and judicious supervisor has to judge the readiness for the student and the quality of the supervisory relationship in gauging the superficiality or depth to which the student is able to engage before proceeding. The effective supervisor might let the student engage in theoretical discourse, knowing full well that the issues are resonating in the student on some level. And when that student feels safe in the supervision, the issues can be related to personal development. This approach both mimics psychotherapy at its best when it readies the client for the next step in personal exploration and distinguishes supervision from psychotherapy in that the goal is not to resolve the student’s conflicts. The goal is to allow the student to function more freely as a psychotherapeutic agent. This centers on developing the student’s personal strengths and resolving obstacles to learning. The student ought to be prepared by the supervisor to invite the supervisor to offer observations on personal style. Case 23.7 shows a student’s eventual reduction in paralyzing anxiety.

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Case 23.7 A first-year graduate student was learning the Minnesota Multiphasic Personality Inventory (MMPI). The program was highly competitive, and students were told that two of every three would fail and be terminated from the program. Students were terrified. The professor, who was also the department head, offered the students the chance to take the MMPI before they learned about it so they could experience it without the contamination of having learned it. He offered, for those who wished, to interpret the protocol. The student figured there were any number of reasons not to reveal his code type to the professor, but then who better than this expert to interpret his MMPI? With trepidation he offered his protocol. The professor, in keeping with good practice, looked at the validity scales and said, “You tend to use denial.” Thereupon the student tore the protocol from the professor’s hands, saying, “I do not!” and marched away while the professor had an amused grin on his face. It was only 2 to 3 years later, in reviewing the protocol, that the student started laughing as he realized the professor’s wisdom in his interpretation, its instant validation, and mostly his forbearance in not forcing an interpretation.

SUPERVISOR AND SUPERVISEE QUALITIES Working with violent clients and situations draws heavily on the resources, energies, and past histories of the clinician. Is there anyone who has not had an encounter with violence? U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics (1987) revealed that five of six U.S. citizens are victims of felonies at some point in their lives. Three of six, or 50%, are victims of multiple crimes. The unreported victimization is geometrically higher. Thus, it is the rare psychologist who has not encountered violence, intimidation, or aggression in one of its myriad forms at some point in his or her life and practice. The real question remains: What is the residue of that experience on the way the person structures subsequent experiences? Some become aggressive when they are top dog. Others are “wounded healers” (Wood, 1987), seeking to rescue others from a fate from which they themselves were not rescued—an enduring, career-long undoing. Although all clinicians need supervised experience in detecting and working with aggressive, angry, hostile, and violent clients, those who are skilled and self-assured in working with this population might find an exciting and useful contribution to society in refining this skill. Let each man pass his days in that endeavor wherein his gift is greatest. —Prospectius

REFERENCES Alanen, Y. O. (1997). Schizophrenia: Its origins and need-adapted treatment. London: Karnac. Baumeister, R. F., Bushman, B. J., & Campbell, W. K. (2000). Self-esteem, narcissism, and aggression: Does violence result from low self-esteem or from threatened egotism? Current Directions in Psychological Research, 9, 26–29. Brenner, C. (1973). An elementary textbook of psychoanalysis. New York: International Universities Press. Buss, A. H. (1961). The psychology of aggression. New York: Wiley.

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Psychotherapy Supervision and Angry, Hostile, and Violent Patients 449 Eagle, M. N. (2000). A critical evaluation of current conceptions of transference and countertransference. Psychoanalytic Psychology, 17, 24–37. Eibl-Eibesfeldt, I. (1975). Ethology: The biology of behavior (2nd ed.). New York: Holt, Rinehart and Winston. Gediman, H. J., & Lieberman, K. S. (1996). The many faces of deceit: Omissions, lies and disguise in psychotherapy. North Vale, NJ: Aronson. Gelso, C. J., & Hayes, J. A. (2001). Countertransference management. Psychotherapy, 38, 418–422. Gross, J. J., & Levenson, R. W. (1997). Hiding feelings: The acute effects of inhibiting negative and positive emotions. Journal of Abnormal Psychology, 106, 95–103. Hertz, J. H. (1945). The sayings of the fathers. New York: Behrman House. Hess, T. H., & Handler, L. (2008, March). Using emotion: Development and validation of the Instrumental Use of Emotion Inventory. Paper presented at the Society for Personality Assessment, New Orleans, LA. Horney, K. (1950). Neurosis and human growth. New York: Norton. Kelly, G. A. (1955). The psychology of personal constructs (Vols. 1 & 2). New York: Norton. Litwack, T. R., Zapf, P. A., Groscup, J. L., & Hart, S. D. (2006). Violence risk assessment: Research, legal and clinical considerations. In I. B. Weiner & A. K. Hess (Eds.), The handbook of forensic psychology (3rd ed., pp. 487–533). Hoboken, NJ: Wiley. Mann, S., & Cowburn, J. (2005). Emotional labour and stress within mental health nursing. Journal of Psychiatric and Mental Health Nursing, 12, 154–162. Meehl, P. E. (1954). Clinical versus actuarial prediction: A theoretical analysis and a review of the evidence. Minneapolis: University of Minnesota Press. Megargee, E. I. (1966). Undercontrolled and overcontrolled personality types in extreme antisocial aggression. Psychological Monographs, 80(3, Whole No. 611). Menninger, K. (1963). Man against himself. New York: Harcourt, Brace. Mowrer, O. H. (1964). Does psychoanalysis encourage sociopathy? In O. H. Mowrer (Ed.), The new group psychotherapy (pp. 181–214). Princeton, NJ: Van Nostrand. Nussbaum, D. (2006). Recommending probation and parole. In I. B. Weiner & A. K. Hess (Eds.), The handbook of forensic psychology (3rd ed., pp. 426–483). Hoboken, NJ: Wiley. Richards, J. M. (2004). The cognitive consequences of concealing feelings. Current Directions in Psychological Science, 13, 131–134. Richards, J. M., & Gross, J. J. (2000). Emotional regulation and memory. Journal of Personality and Social Psychology, 79, 410–424. Shulman, S., & Knafo, D. (1997). Balancing closeness and individuality in adolescent close relationships. International Journal of Behavioral Development, 21, 687–702. Siegel, M. (1976). Confidentiality. Clinical Psychologist, 30(1) 23. Siegel, M. (1979). Privacy, ethics and confidentiality. Professional Psychology, 10, 249–258. Stricker, G. (1983). Passive-aggressiveness: A condition especially suited to the psychodynamic approach. In R. D. Parsons & R. J. Wicks (Eds.), Passive-aggressiveness: Theory and practice (pp. 5–24). New York: Brunner/Mazel. Sullivan, H. S. (1951). The interpersonal theory of psychiatry. New York: Norton. U.S. Department of Justice, Office of Justice Programs, Bureau of Statistics. (1987). Lifetime likelihood of viticmization (BJS, NCJ-10427, March). Washington, DC: Author. Van Wagoner, S. L., Gelso, C. J., Hayes, J. A., & Diemer, R. A. (1991). Countertransference and the reputedly excellent therapist. Psychotherapy, 28, 411–421. von der Lippe, A. L., & Moller, I. U. (2000). Negotiation of conflict, communication patterns, and ego development in the family of adolescent daughters. International Journal of Behavioral Development, 24, 59–67. Walfish, S., Marlyere, K., & Zielke, R. (2008, March 19). “Doc. there is something I have to tell you”: Patient self-disclosure of unprosecuted murder and other violence to their psychotherapists. Unpublished manuscript. Available from [email protected]. Walsh, K. W. (1978). Neuropsychology: A clinical approach. New York: Churchill Livingstone. Watson, J. B. (1962). Behaviorism. Chicago: University of Chicago Press. Wood, B. (1987). Children of alcoholism. New York: New York University Press. Wynne, L. C., Ryckoff, I., Day, J., & Hirsch, S. (1958). Pseudomutuality in families of schizophrenics. Psychiatry, 1, 205–250.

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C H A P T E R 24

Supervision in Medical Settings C. DON MORGAN, DANA K. SOETAERT, and ROBIN J. HEINRICHS

TRADITIONAL PSYCHOTHERAPY with its 50-minute therapy hour and weekly sessions occurs infrequently in medical settings. Although some clinicians in medical settings do utilize the more traditional verbal psychotherapies, sessions tend to be brief and highly focused. For clinicians in medical settings (especially those in primary care), the extent of their contact with patients is quite brief and may well consist of three to five sessions of 15- to 30 minute-duration. Regardless of the approach or format, the overarching goals are to provide education and other interventions intended to treat the medical consequences of unhealthy lifestyle, to prevent illness, and to foster health. A few decades ago, much of this work was being done under the descriptor of behavioral medicine. A 1980 article described behavioral medicine as “a robust and growing area of professional endeavor” (Swan, Piccione, & Anderson, 1980, p. 339). These authors also noted the paucity of training programs and the absence of training guidelines needed to train psychologists in this interdisciplinary field. In the decades since this article was written, much has changed; the specialties of health psychology and clinical health psychology have evolved greatly, and more than 65 programs now offer training in health psychology (American Psychological Association, Division of Health Psychology, 1995, as cited in Resnick & Rozensky, 1996). This specialized field requires that clinicians possess skills not emphasized in traditional training programs; the differences are such that the Boulder model, which has served as the training model gold standard for many programs, has been described, in a minority position, as inadequate for meeting these new training needs (Snyder & Elliott, 2005). As clinicians become increasingly involved in general health care, new demands are placed upon training programs and supervision. Effective supervision complements the didactics in academic programs by giving clinicians the opportunity to practice these new interventions while also providing the knowledge needed to succeed in the nontraditional culture of medical settings. Accordingly, this chapter reviews the evolution of this relatively new area, describes the necessary skills 450

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and attitudes required to succeed, and moves then to the process of supervision in medical settings. The chapter also considers professional behavior and ethical and malpractice issues that merit supervisory attention and concludes with a review of administrative concerns. The intent is to provide both practical and theoretical information that will be of use to supervisors and supervisees. As we are psychologists, the chapter reflects such an orientation. However, other professions are also involved in this work: The American Association for Marriage and Family Therapy, for instance, offers graduate training in family therapy in medical settings (Gawinski, Edwards, & Speice, 1999), and we hope that allied professionals find this chapter relevant and useful. EVOLUTION OF THE FIELD Several disciplines, including psychology, social work, and nursing, have a long and honorable tradition of providing psychotherapy to those afflicted with mental illness. Although members of these professions continue to be heavily engaged in this endeavor, the past few decades has seen a virtual sea change in the work settings and range of services provided by professionals in these fields. In increasing numbers, these professionals are involved in providing care in hospitals and primary care clinics where they provide a full range of clinical and health promotion services. The causes and extent of these substantial changes in the behavioral health-care delivery system have been well documented in numerous excellent reviews (Gray, Brody, & Johnson, 2005; Schulte, Isley, Link, Shealy, & Winfrey, 2004; Thompson, 1991). Briefly stated, the impetus behind these changes includes managed care and its attempt at cost containment, and the subsequent emergence of managed behavioral health care. As the health care market has become increasingly competitive, there is increasing focus on value. As a result, capitated systems, which provide care to a defined group of patients at a fixed monthly cost, currently dominate the market. The effect of these forces is an increasing integration of the organization and delivery of health care: “Thus, the traditional lines separating hospitals, providers, and insurers have begun to blur” (Newman & Reed, 1996, p. 16). Consequently, professions historically associated with the provision of services for those with mental disorders are now also providing patient care in numerous medical settings including primary care, pediatrics, internal medicine, and surgery. A partial list of medical disorders for which these clinicians provide direct care and interventions includes noncompliance, chronic pain, cancer, anxiety disorders, diabetes, hypertension, coronary artery disease, obesity, smoking cessation, functional gastrointestinal disorders, asthma, and stress (Belar & Deardorff, 1995; Haas, 2004; Sweet, Rozensky, & Tovian, 1991). These new work settings are unlike the relative predictability of a traditional mental health clinic; they are fast paced, highly varied, and technical. They require not only sound psychotherapy skills and expertise with the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (American Psychiatric Association, 1994) but also extensive knowledge regarding medical disorders and disease, medications, and the ability to engage patients in highly structured 15- to 30-minute sessions while complying with detailed administrative procedures such as charting and documentation. Also essential are sound collaborative skills and the ability to provide clear and concise feedback

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to physicians (Belar & Deardorff, 1995; Frank, McDaniel, Bray, & Heldring, 2004; Gatchel & Oordt, 2003; James & Folen, 2005). Psychology has been strongly affected by and responsive to these changes in the behavioral health-care delivery system. Millon (1982) maintained that psychology has been especially involved as this discipline has demonstrated unique treatment skills not available from other medical specialties. There is also increased recognition of the effect of lifestyle and habits on health, and a need for more practical interventions than have been historically available. Health-care economics (i.e., the recognition that psychological interventions effectively lower health-care costs), advances in technology, and societal forces have also contributed to psychology’s increased involvement and the subsequent development of the specialties of health psychology and clinical health psychology. However, some argue that “most of all it grew as a result of the apparent inadequacy of traditional medical models to explain, prevent, or manage chronic illness” (Baum, Perry, & Tarbell, 2004, p. 12). T H E E M E R G E N C E O F C L I N I C A L H E A LT H P S Y C H O L O G Y Although efforts to incorporate psychological principles into the education of medical students so that they might provide more integrated care began in the early 1900s, it was not until the 1960s that the number of psychologists in medical schools began increasing. Although this was initially within psychiatry departments, by the 1970s psychologists were increasingly involved in general health care (Millon, 1982), and the past 30 years has seen a substantial increase in the number of psychologists working throughout medical schools. In the mid-1970s there were 2,336 psychologists employed in 115 U.S. medical schools (Lubin, Nathan, & Matarazzo, 1978, as cited in Hong & Leventhal, 2004), but by 1998 this number had grown to 4,598 (Williams, Wicherski, & Kohout, 1998, as cited in Hong & Leventhal, 2004). Hong and Leventhal (2004), in their survey of psychologists in medical schools, found that psychiatry was the home department for 56% of psychologists, 9.3% were employed by pediatrics, neurology 4.6%, family medicine 4.5%, internal medicine 3.5%, physical medicine 3.2%, surgery 1.7%, and anesthesiology 1.3%. Although the number of psychologists in medical schools has increased, they continue to represent a small percentage of total faculty (Hong & Leventhal, 2004); however, the number of psychologists in departments other than psychiatry would seem to confirm increasing involvement in nonpsychiatric areas of medicine. Interest in these new applications of psychology and the need for professionals adequately trained in these nontraditional areas fueled the formation of several specialties and organizations. Specialization of health psychology took root in 1978 with the charter meeting of the Society of Behavioral Medicine and the establishment of the Division of Health Psychology of the American Psychological Association. The demand for professionals skilled in these specializations resulted in board certification in the mid-1980s. By 1993, the American Board of Health Psychology was formally recognized by the American Board of Professional Psychology as a specialty practice area (Belar & Deardorff, 1995). Millon (1982) noted that various labels including psychosomatic medicine, medical psychology, behavioral medicine, and health psychology have been used to describe this field. Although the term health psychology remains popular, Millon cogently argued that the term

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clinical health psychology is the most accurate descriptor for this recently evolved specialty. He defined it as follows: The application of knowledge and methods from all substantive fields of psychology to the promotion and maintenance of mental and physical health of the individual and to the prevention, assessment, and treatment of all forms of mental and physical disorder in which psychological influences either contribute to or can be used to relieve an individual’s distress or dysfunction. (p. 9)

Health psychology technically refers to a specialty with a focus on research, whereas clinical health psychology describes a specialty composed of research and clinical training (Baum et al., 2004). Nevertheless, the terms are often used interchangeably and, descriptor selection aside, the field is clearly a substantial change of focus in that it is concerned primarily with helping mentally healthy people cope with illness, preventing psychopathology, and promoting health and resilience (Baum et al., 2004). Given this emphasis on the promotion and maintenance of health as opposed to the treatment of mental illness, it comes as no surprise that “it is an interdisciplinary model, often more closely aligned with medicine, surgery, pediatrics, or other medical specialties than with psychiatry” (Baum et al., 2004, p. 15). A recent development that exemplifies such an interdisciplinary approach and the utility of the biopsychosocial model is the integration of the clinician into the primary care setting. Within psychology, this new subspecialty (termed primary care psychology) is indicative of the increased recognition of psychology as a health-care profession. A recent search of books available from the American Psychological Association found more than 100 under the heading of health psychology (American Psychological Association, n.d.). An American Psychological Association Task Force found that psychologists in primary care settings serve both treatment and consultant roles, function as generalists, and work with families and patients of all ages. They are expected to provide interventions for lifestyle issues as well as a host of medical problems. Furthermore, while they are expected to have the ability to assess and treat mental disorders, this is not their principal focus (Frank et al., 2004). In general, clinical health psychologists work in a variety of medical settings and utilize a wide range of interventions including supportive work, behavioral interventions, the various verbal therapies (in brief formats), as well as provide information and education. Primary care psychologists work closely with primary care providers and, depending on the setting, may need additional training in order to successfully adapt to the specialized primary care environment (Belar & Deardorff, 1995; Gatchel & Oordt, 2003). Primary care settings may “require unique skills and a different philosophy of care because the psychologists must function as primary care providers” (Gatchel & Oordt, 2003, p. 11). These skills include the ability to conduct brief, structured assessments and focused interventions; the ability to be available on short notice; and tolerance for the loss of some autonomy, as treatment is guided by the primary care physician (Gatchel & Oordt, 2003). This overview of the field might seem excessively detailed. However, it is important that the reader be aware of these extensive changes in the behavioral health-care system, as they have important implications for both training and

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supervision. It is of note that, despite the increasing popularity of this field (i.e., more training programs and postdoctoral training opportunities), several authorities have noted training deficits. James and Folen (2005), for instance, stated that although most programs emphasize psychosocial issues, training in biological aspects receives insufficient attention. Other experts have also described deficits and provided recommendations for training in clinical health psychology and primary care psychology (Belar & Deardorff, 1995; McDaniel, Hargrove, Belar, Schroeder, & Freeman, 2004; Tovian, Rozensky, & Sweet, 2003). In sum, “At this point there are few organized, sequential experiences that enable psychologists to learn the information and gain the skills necessary for working in primary care settings” (McDaniel et al., 2004, p. 63). It is these skills and attitudes that receive inadequate emphasis in many training programs and subsequently little supervisory attention, which are essential for success in medical settings. The regrettable consequence of inadequately trained clinicians was clearly stated by Belar and Deardorff (1995): We have, on numerous occasions, heard stories about health-care units being “spoiled” for entry by new psychologists because of previous experiences with traditionally trained (and, in our view, insufficiently trained) clinical psychologists or health psychologists who lack training in applied professional practice. (p. 20)

The authors added that although these deficits may reflect inadequate knowledge or technique, they often are caused by inappropriate clinician conduct or attitudes fueled by a lack of understanding of the medical culture. Supervision plays a crucial role in helping clinicians acquire the professional identity, skills, and knowledge needed to succeed. In this regard, Watkins (1998) stated, “Psychotherapy supervision has long been regarded as a key means by which therapist trainees learn to become effective psychotherapists” (p. 93). Given this, we maintain that the deficits in current training experiences along with the knowledge, skills, and attitudes needed to succeed in these specialized settings place even greater importance on the role of supervision. Our position seems confirmed by Baum et al. (2004), who stated that the complexity of the field necessitates more systematic teaching and added that “most often the depth of skills required to function as a competent clinical health psychologist is acquired on the job” (p. 22). What, then, are these nontraditional skills and attitudes that clinicians must possess in order to deliver state-of-the-art care and collaborate effectively with physicians? Table 24.1 provides a partial listing, and the following section describes how these issues may be addressed in the course of supervision.

S U P E RV I S I O N PRELIMINARY ISSUES Although most supervisors have no training in supervision and have essentially learned by doing (Hess & Hess, 1983; Peake, Nussbaum, & Tindell, 2002; Watkins, 1995), much is known about what constitutes a good supervisor, and this would seem an appropriate place to begin. Good supervisors approach their supervisees with respect and empathy and are able to consistently track their supervisees’

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Table 24.1 Differences in Mental Health Care and Clinical Health/Primary Care Psychology Dimension

Mental Health Care

Model

Generally focused on treating the individual.

Assessments

Extensive psychometric testing with option of lengthy objective and projective testing.

Time efficiency/interventions

50-min session with in-depth exploration of relevant issues. May include long-term work and exploration of patient–therapist relationship. Frequent use of long-term follow-up. Clinician and patient agree on goals and treatment plan, which are generally provided in an individual format. High levels of clinician autonomy.

Autonomy

Scheduling

Generally under control of clinician.

Knowledge base

Extensive knowledge of nonpsychiatric medical disorders/medications not generally needed.

Collaborative skills

Coordinates care with primary care physician or other physicians involved in care by phone or letter.

Administration

Progress note following each session.

Clinical Health Psychology and Primary Care Psychology Focused on improving the health of the clinic population (population health model). Less use of lengthy assessment measures and increased use of rapidly scored brief checklists or rating scales that target specific symptoms. Generally one to three visits of 15- to 30-min duration timed with primary care visits. Clinician is a consultant who educates and encourages home-based practice. Infrequent use of long-term follow-up. Clinician works in close coordination with primary care provider/physician, who is in charge of care. Clinician must function as a team member and tolerate a hierarchical system. Clinician has less control and must be available on very short notice. Prompt response to consults may require after-hours work. Must have thorough knowledge of medical diseases, terminology, biological basis of behavior, and medications. Frequent direct contact with primary care or consulting physician. Needs to briefly communicate practical information without psychological jargon. Must be aware of professional protocol in the medical community. Must comply with medical requirements regarding abbreviations, charting, and documentation.

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concerns. They are genuine, self-disclose as appropriate, and avoid combining psychotherapy and supervision. Furthermore, goals are clearly set and feedback is systematic, timely, and direct (Carifio & Hess, 1987; Shanfield, Matthews, & Hetherly, 1993). Good supervisors are viewed by their supervisees as being skilled, experienced, and trustworthy; in a finding with high applicability to supervision in medical settings, both supervisors and supervisees prefer supervisors to dominate supervision and provide high levels of structure when supervising new skills. As much of the work with medical patients is structured, it is also relevant that the literature shows that compliance with treatment protocols is enhanced if supervisors pose specific learning tasks, ask questions regarding therapists’ thought processes, and reinforce desirable therapist behaviors (Henry, Schacht, Strupp, Butler, & Binder, 1993, as cited in Neufeldt, Beutler, & Banchero, 1997). Watkins (1995) aptly summarized good supervision: It would truly appear that supervision, if it is to have a beneficial effect, needs to be infused with supervisor support, respect, skill, clarity, and teaching/education. Where those are lacking, any beneficial effect that supervision might have would seem to be sorely compromised. (p. 573)

It is also relevant to review the characteristics of good supervisees. Desirable characteristics include psychological-mindedness, interpersonal curiosity, initiative, and the ability to make decisions. Also relevant is being prepared for supervision; having an interest in the welfare of the client; and having personal, theoretical, and clinical flexibility with openness to supervisor suggestions (Swain, 1981, as cited in Hess, 2001; Whitman, 2001). As medical settings are characterized by a rapid pace and a relative lack of control over scheduling or types of patients seen, initiative and flexibility would seem especially desirable. Belar and Deardorff (1995) noted that because the medical setting offers little external reinforcement, those with high needs for recognition and external validation do not do as well as those motivated by internal belief systems. Also, clinicians who dislike structured, directive supervision and prefer high levels of autonomy tend to chafe in medical settings. Attitudes toward the medical field are also of relevance: Prior to beginning formal supervision, it is advisable to assess potential supervisees’ attitudes toward physicians and the medical model. Henderson (1999) stated, “Supervision of counselling in general practice is not for those . . . who wish to challenge the medical model or be heroic subversives within it” (p. 85). As this is obviously true for supervisees as well, it is advisable to thoroughly evaluate for attitudes that are incompatible with working in a medical setting. One cause of such attitudes is family-of-origin issues: The first author recalls one supervisee whose parent was a physician who was highly critical of the supervisee, and this affected this supervisee’s attitude toward the physicians with whom the supervisee interacted. Other sources of negative attitudes include training programs that are excessively biased against medications and the medical model, as well as supervisees or family members having had an unpleasant experience with physicians in the course of illness or injury. This issue merits further clarification. We are not encouraging overidentification with the medical model; in our interactions with physicians, we are persistent advocates of the biopsychosocial model. However, some physicians

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either are not familiar with the model or are skeptical of what psychology has to offer. For supervisees to interact with these physicians in a way that is influenced by their past needlessly complicates the interaction and does patients (and psychology) a disservice. Related issues of professionalism in medical settings receive considerable attention in a subsequent section. THE PROCESS Review of several clinical health psychology books found relatively infrequent reference to the issue of supervision. This may be attributable to the relative newness of the field, as well as the observation that the supervision literature has historically focused more on theories and models per se than on the process of providing supervision for clinicians working with specific populations. Nonetheless, we can glean some direction from the literature. The following quote sets the stage for this section: “Insomuch as supervision often parallels the therapeutic process, supervisors must also be brief and direct in this changing health-care climate” (Peake et al., 2002, p. 114). Certainly in many settings, clinicians and supervisors are utilizing briefer approaches. However, in a mental health clinic, it is still commonplace for a clinician to use several 50-minute sessions utilizing primarily a single form of psychotherapy as the intervention (e.g., cognitive-behavioral therapy with a depressed patient). Such a scenario is unlikely in medical settings, where fewer sessions and multiple, specific interventions are used. General and broad-based techniques are rejected in favor of several interventions with multiple and specific targets: “In fact, the empirical support for some procedures has been established only within the context of a multistrategy treatment program” (Belar & Deardorff, 1995, p. 78). It is beyond the scope of this chapter to provide a comprehensive list of the interventions utilized; however, a partial list includes placebo, supportive counseling, individual and family approaches, support groups, education and information, verbal therapies (analytic, cognitive-behavioral, rational-emotive, directive, and systems oriented), crisis intervention, relaxation training (diaphragmatic breathing, progressive muscle relaxation, autogenic relaxation training), imagery (guided imagery, covert sensitization), hypnosis, biofeedback, systematic desensitization, modeling, skills training and behavioral rehearsal, contingency management, selfmonitoring and use of cues, cognitive strategies, and paradoxical strategies (Belar & Deardorff, 1995; Haas, 2004). Belar and Deardorff stated when selecting an intervention, “the clinician should consider issues of treatment efficacy, efficiency, durability, generality, convenience, cost, side effects, and clinician competence” (p. 77). Essentially, clinicians must select interventions that are individualized to meet the needs of patients while, as much as possible, complying with what is known about empirically validated treatments, and they must learn to do this in a medical culture that is unfamiliar to most clinicians (Belar & Deardorff, 1995). We concede the psychotherapy scenario in the mental health clinic was rather simplistic, and we are certainly not implying that mental health work is less complex or demanding than work in medical settings. The first author of this chapter has a good number of years of experience with the former and can readily attest to its complexity. The different settings do, however, have relevance for the approach used in supervision. There are two key points in this regard. First, although brief

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and traditional verbal therapies are often utilized in medical settings, these are used for fewer sessions and are typically one component of a multistrategy intervention that addresses biological, affective, cognitive, and behavioral domains (Belar & Deardorff, 1995). Accordingly, psychotherapy-based models of supervision are utilized, but not in the near-exclusive way seen in many mental health settings. Second, as medical settings are characterized by the need to tailor multistrategy interventions and also require extensive knowledge regarding medical issues and protocol, a highly structured and skills-based approach to supervision is desirable, especially in the early to middle stages of supervision. The issue of structure in medical settings merits attention as beginning supervisors may, due to personality or training, be reluctant to be as directive or structured as the setting requires. A recent article by primary care psychologists who train predoctoral interns is instructive and would seem to justify such a supervisory style. The authors described the following difficulties experienced by new interns: difficulty with time management, excessive use of techniques such as empathic and reflective statements more appropriate to traditional mental health settings, inappropriate selection of interventions, unclear conceptualizations, overdocumentation, and providing feedback to physicians that has mental health jargon or is excessively lengthy. Dobmeyer, Rowan, Etherage, and Wilson (2003) described these deficiencies in detail and provided useful corrective supervisory actions. Gordan (1996), a psychodynamic supervisor, argued that the supervision method must reflect the aims and goals of the supervision and described the supervision models shown in Table 24.2. A review of Table 24.2 shows that relationship/therapist focused models of supervision closely fit what most would consider to be traditional psychodynamic supervision. The patient-focused approach is, however, intriguing in its applicability to medical settings. According to this model, the chief skill required of the supervisor is a knowledgeable and skilled teacher who imparts specific information regarding treatment and provides direct feedback to students: Table 24.2 Supervision Models Supervision Goal or Focus Goal Focus

Patient-Focused (Instruction Oriented) Teach technical skills/theoretical knowledge. Focus is on the patient and the specific skills/knowledge needed to intervene successfully.

Relationship/Therapist Focused (Experience Oriented) Help the student develop as a therapist. Relationship and interaction between student–patient and student–supervisor, transference, countertransference, and parallel processes are addressed.

From Psychotherapy Supervision in Education, Clinical Practice, and Institutions (p. 6), by K. Gordan, 1996, Northvale, NJ: Jason Aronson. Copyright 1996 by Jason Aronson. Adapted with permission.

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The supervisor who prefers this method in therapeutic work is first of all the guardian of the patient and his needs. The supervisee’s needs and reactions take second place. Discussions of symptoms, diagnosis, and concrete treatment measures are in the foreground. (Gordan, 1996, p. 7)

Not surprisingly, the hierarchical teacher–student relationship in the patientfocused approach is characterized by considerable emotional distance between the supervisor and supervisee. In medical settings, the use of a patient-focused approach has several advantages: It keeps the focus of supervision on the patient and allows for maximum efficiency when there is a need to communicate large amounts of information (e.g., history, intervention techniques, medications, medical protocol) in a short period of time. Furthermore, maintaining focus on the patient is consistent with medical culture and is also advisable given the high risk of malpractice suits in medical settings. (Malpractice and other legal issues are addressed later in this chapter.) We wish to assure the reader that we are not advocating a heavy-handed approach to supervision; it is possible and necessary to conduct this style of supervision in the empathic and supportive manner characteristic of good supervision. Also, the use of a structured approach is not inconsistent with the literature. The reader is reminded of the literature earlier cited that found that, when learning new skills, both supervisee and supervisor prefer the supervisor dominate, and the finding that compliance with treatment protocols is enhanced if supervisors structure the supervision (Henry et al., 1993, as cited in Neufeldt et al., 1997). Having advocated for a structured and skills-based approach to supervision, let us now state our concerns. First, so little has been published on the patient-focused model that it might be more accurately described as an approach or style rather than a model. Second, the model is inflexible and inadequate in its consideration of developmental issues in supervision. In this regard, research has not investigated the long-term effects of such a supervisory style on supervisee development, and “whether such moment-to-moment control leads to the long-term ability of the therapist to conceptualize about clients, accurately estimate the effects of their interventions on the client, and develop as a therapist is unknown” (Holloway & Neufeldt, 1995, as cited in Neufeldt et al., 1997, p. 519). Thus, although the patientfocused model has practical applicability in medical settings, its deficiencies are such that it should be considered more of a supervisory style to be used when a high degree of structure is necessary. As the chief goals of supervision are to protect the patient as well as to develop competent therapists, a comprehensive model that is sensitive to the issue of supervisee development and also informs and directs the supervision process is necessary. In this regard, consideration must be given to the use of developmental models of supervision. Such models assume the supervisee passes through a sequence of developmental stages, each of which has specific developmental issues that must be addressed in the course of supervision. It is expected that the supervisor will tailor the supervision to the supervisee’s level of development. There are numerous developmental models, “. . . and the developmental paradigm has come to dominate current supervision thinking and research like no other” (Watkins, 1995, p. 571). The research clearly makes a compelling case for the use of developmental

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models of supervision, and researchers have stated “there is support for general developmental models, perceptions of supervisors and supervisees are consistent with developmental theories, the behavior of supervisors changes as counselors gain experience, and the supervision relationship changes as counselors gain experience” (Stoltenberg, McNeill, & Crethar, 1994, p. 419). Whereas earlier models were noted as being simplistic, recent models are increasingly complex and, in the opinion of this chapter’s first author, are sufficiently detailed that supervisors may well need training in order to obtain maximum supervisory benefit from their use. One popular, comprehensive, and well-researched developmental model is the integrated developmental model. The model is rather complex, but “although more simple models are more readily comprehensible, they lack the elegance to capture important aspects of the process” (Stoltenberg & McNeill, 1997, p. 187). The model consists of three levels of development (Level 1 to Level 3, with Level 3 being highly experienced) and eight domains (Intervention Skills, Assessment Techniques, Interpersonal Assessment, Client Conceptualization, Individual Differences, Theoretical Orientation, Treatment Goals and Plans, and Professional Ethics). The supervisor then evaluates and monitors supervisees on each domain using three structures: Self and Other Awareness, Maturation, and Autonomy (Stoltenberg & McNeill, 1997). The model is highly individualized and has as a strength its recognition that supervisees may be functioning at different developmental levels across domains. Also, the domains correspond nicely with the knowledge and skills applicable to medical settings. Another characteristic of this model that makes it useful in medical settings is its recognition of the need for a higher degree of structure with less experienced trainees. Regarding this issue, the developers of the model have noted that the literature consistently indicates that skills training and structure are necessary in the early stages of training. As trainees move to Level 3 (which typically occurs in at least a few domains during the predoctoral internship), they are increasingly autonomous but have the ability to seek direction when needed. However, as medical settings are characterized by the need to communicate a large volume of information such as history, diagnosis, and behavioral assessments, it may well be necessary to use more structure than is usually required by relatively experienced therapists. This is not inconsistent with the model, and it is expected that experienced therapists who are at Level 3 in most other domains would, because of their maturity and motivation, fairly rapidly acquire the necessary skills and knowledge (B. McNeill, personal communication, January 30, 2007). It is, of course, essential that the supervisor form and maintain a strong supervisory alliance. Although the model is somewhat complex, a few hours of reading will provide a fairly thorough orientation, which is nicely met by Stoltenberg and McNeill’s chapter in Watkins’s (1997) Handbook of Psychotherapy Supervision. The most exhaustive source of information about the model is the book IDM Supervision: An Integrated Developmental Model for Supervising Counselors and Therapists (Stoltenberg, McNeill, & Delworth, 1998), which includes detailed information on the model, the three levels, the supervisory relationship, supervisor development and training, ethical and legal issues, and other relevant topics.

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Overholser (2004) proposed a brief and highly practical model that addresses the need for structure as well as the importance of considering developmental issues. The model is composed of the following four strategies: Positive Collaboration, Socratic Exploration, Directive Guidance, and Individual Customization. Although the model was developed for use in a mental health setting, it appears readily adaptable to the medical environment. Model selection aside, supervisors must demonstrate the same flexibility they expect from supervisees. The work pace in medical settings and the rapidity with which clinical and treatment decisions must be made are inconsistent with supervision that occurs exclusively (or even chiefly) in the course of a 1-hour scheduled weekly supervision. Interruptions for rapid and informal consultations among colleagues are characteristic of this setting, and just as colleagues are available to one another, so too must supervisors be available to their supervisees. Supervisors must be available on an as-needed basis and should develop mechanisms (pager, phone, e-mail, or simply door knocking) by which their supervisees can reach them when needed. Although the supervisees’ use of these mechanisms will decrease as they gain skill and confidence, this use should be normalized, as a degree of this is inherent to the setting. Supervisors are cautioned not to allow these as-needed supervision contacts to substitute for the scheduled weekly supervision meetings. Because the as-needed supervision contacts tend to address skills and knowledge issues (and thus tend to be highly directive and focused), the scheduled weekly supervision meetings allow time for addressing ongoing developmental concerns (e.g., providing feedback and evaluation and listening to the supervisees’ concerns). To summarize, supervisors will certainly spend some time supervising verbal psychotherapies; there are, for instance, medical settings in which cognitivebehavioral therapy is a routinely utilized intervention. However, this would rarely be used exclusively and would, instead, be one component of a multistrategy intervention. This requires that supervisors have the ability to provide psychotherapy-based supervision as well as the knowledge and ability to help the supervisee learn to formulate, develop, and conduct these multistrategy interventions. In addition, supervisors must address a host of issues, such as those described in Table 24.1, that are unique to medical settings. Accomplishing these supervisory tasks will involve the use of higher levels of structure for a longer period of time than some beginning supervisors are comfortable with. There is no evidence that high levels of structure (if appropriate to the setting or task, and when occurring within a positive and collaborative supervisory relationship) are detrimental to supervisee development. This, however, is not enough; supervisors must accomplish this while being constantly mindful of developmental issues. Learning to effectively provide the high levels of necessary structure while simultaneously monitoring and addressing ongoing supervisee developmental issues is a major developmental task faced by new supervisors. As stated earlier, relatively little has been written about psychotherapy supervision in medical settings. The documented effectiveness of psychology’s involvement in reducing health-care costs (Resnick & Rozensky, 1996) will hopefully spur research that investigates supervision issues unique to medical settings. The next section addresses a host of professional issues that may affect a clinician’s success as a psychotherapist.

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Recall the earlier quote from Belar and Deardorff (1995) describing the harmful effect of inappropriate attitudes and conduct by clinicians caused by failure to understand the medical culture. An example might be the clinician whose therapy and intervention skills are adequate but whose inability to communicate with physicians is such that physicians are reluctant to refer. In this vein, Belar (1991), in a thorough and highly useful chapter titled “Professionalism in Medical Settings,” stated, “It is well recognized that there is more to being a competent professional psychologist than specific knowledge and skills in the discipline of psychology and the delivery of psychological services” (p. 81). Medical settings certainly have many such concerns that are considered here.

PROFESSIONAL BEHAVIOR Earlier in this chapter the importance of the supervisor evaluating the supervisee for attitudes inconsistent with working in medical settings was discussed. Although such beliefs may be caused by the kind of family history described earlier, there are other causes of problematic attitudes among supervisees. These include discontent over the loss of autonomy long prized by psychologists, as well as difficulty accepting the hierarchical structure that is the reality in medical settings. The supervisee needs to be reminded that the lone practitioner is increasingly rare and, although there has been some loss of autonomy, medical settings are an opportunity to showcase psychology’s strengths; when done properly, everybody (most important, the patient) benefits. The hierarchical structure of medical settings in which physicians are responsible for and coordinate care is an obvious necessity that must also be accepted (Belar & Deardorff, 1995). Although the supervisee will encounter physicians who are hostile to psychology, most physicians value psychology’s contributions and especially appreciate help with their difficult patients (Belar, 1991; Belar & Deardorff, 1995). Many of these patients have personality disorders that complicate treatment. The psychologist’s ability to diagnose these disorders and then make specific recommendations regarding treatment is appreciated by most physicians. Harper’s (2004) book provides useful techniques for treating personality-disordered patients with common medical conditions. Also, medical settings can be somewhat impersonal, and the supervisee who expects or needs a good amount of appreciation from physicians, patients, or staff is likely to be disappointed. Physicians tend to be more focused on diagnosing and treating than on addressing interpersonal issues or needs, and the nurses and staff are generally quite busy. Also, contact with patients tends to be structured, quite brief, and inconsistent with the type of therapist–client interactions that the supervisee may be expecting. The supervisor’s task in such instances is to help the supervisee adjust and “get along well on a thin schedule of external reinforcement” (Belar, 1991, p. 82), to validate the supervisee, and to reconcile the situation’s harsh demands with the trainee’s sensitivities. The supervisee’s ability to accept and work with issues of death, trauma, physical disfigurement, and chronic illness rapidly becomes relevant in medical settings. These issues are common to medical settings, and the new clinician must be aware

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of his or her personal issues related to body image, death, and disability. It is especially important to avoid communicating discomfort when working with these patients (Belar, 1991; Belar & Deardorff, 1995). These issues merit frequent supervisory attention in the early stages of supervision to help the supervisee acclimate to the setting (Haley et al., 2004). The supervisor is reminded that these developmental concerns are best addressed in regularly scheduled, weekly supervision meetings. It is also worthwhile for the supervisor to address how to effectively interact with physicians and patients, as they tend to prefer direct and practical feedback. Patients “may be frustrated with mental health clinicians’ indirectness and quasi-socratic questioning style” (Searight, Price, & Gafford, 2004, p. 25). Likewise, physicians want an objective, brief, and clear statement of the problem and specific, research-based treatment recommendations. This can require a period of adjustment for the supervisee, who may be accustomed to communicating in a fashion that is more indirect (Belar & Deardorff, 1995; Haley et al., 2004). Also, medical settings can have an “immersion” quality: The clinician often works long hours; is surrounded by physicians, nurses and staff; and attends events such as grand rounds that have a medical focus. It is important that the supervisee not respond to these experiences by overidentifying with medicine and thereby compromising the autonomy of the psychological treatment model (Belar, 1991; Belar & Deardorff, 1995). Just as overidentification with medicine is to be avoided, supervisees should not allow their new environment to intimidate them and respond by becoming excessively passive. Psychologists should honestly evaluate their knowledge base, be honest about gaps, and eagerly acquire relevant knowledge. However, supervisees must learn to trust that their knowledge in research and psychological aspects of health is a unique contribution to patient care, and they must adapt to the more challenging interpersonal style often used by physicians: Psychologists should not allow themselves to be bullied by the occasional overly brusque physician who may not be accustomed to having a PhD, PsyD, or EdD as a colleague. In most cases, collaboration that is based on mutual respect can be developed. (Haley et al., 2004, p. 107)

Belar and Deardorff (1995) noted the need to avoid being aggressive or defensive in interactions with difficult physicians and added that a degree of conflict is routine and ongoing even among the different medical specialties. These authors emphasized the need to avoid unrealistic enthusiasm about a technique and added “we believe it important not to be fanatical in our beliefs about the importance of the biopsychosocial model. Nor should we be wedded to any single treatment technique” (p. 34). Ruddy and Schroeder (2004), in a highly useful chapter on collaboration, described the need to avoid working in a frantic, overzealous way that offends medical providers. Their sound advice, which should be integrated into supervision at the outset, is that clinicians new to the setting should be curious, be respectful, and focus more on helping (as opposed to teaching) medical providers. Also, “a psychologist entering a medical setting needs to keep an open mind and allow for time to understand this new culture” (p. 158).

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There is much here for the supervisor to monitor. The supervisor must, early on, begin to get a sense of how the clinician will make the adjustment to this new setting and supervise as appropriate. Those who seem a bit thin-skinned will need to be shored up and encouraged, whereas those who are highly assertive will need to be taught how to stand their ground in a way that does not cause unnecessary tension and conflict. Although the need for high levels of supervisory structure to expand the clinician’s skill and knowledge base has been previously emphasized, the supervisory need here is clearly different. These are key developmental issues that affect supervisees’ professional identity, their ability to collaborate with other professionals, and ultimately, their success as psychologists. The ability of the supervisor to address these issues in an ongoing, proactive, and respectful fashion goes to the heart of effective supervision. Belar (1991) and Belar and Deardorff (1995) offered much useful information about professional behavior that merits supervisory attention, and Haley et al. (2004) provided several practical tips to facilitate clinician adjustment to the medical setting. PSYCHOLOGICAL ASSESSMENT Certainly one of the chief contributions made by psychologists to the health-care team is their knowledge and skill in psychological testing. “Although a number of providers offer treatment services, psychology has specialized, uniquely, in formal assessments that are quantitatively based; a requirement increasingly important in the future” (Rozensky, Sweet, & Tovian, 1997, p. 273). In medical settings, this knowledge is demonstrated in a host of ways ranging from the relatively simple task of helping physicians select a screening instrument, to testing for psychological factors that are complicating treatment, to conducting detailed and elaborate presurgery or neuropsychology assessments. It is well beyond the scope of this chapter to delve deeply into this topic, and several thorough references are available (Belar & Deardorff, 1995; Linton, 2004; Rozensky et al., 1997; Sweet, 1991). However, the large amount of time devoted to assessments, the important role testing results can have for treatment, and the increased risk of malpractice suits justify this area receiving considerable supervisory attention. As therapists tend to practice as they were trained, the supervisor should understand that his or her influence in this important area will likely be long lasting. In general, supervisees will need direction in at least four areas: (1) how to select the appropriate instrument; (2) how to accurately interpret the data and integrate it into the intervention; (3) how to communicate test results to physicians in a brief, meaningful way; and (4) how to accomplish the above while complying with unstated medical protocol described later in this section. The assessment measures most frequently used in medical settings consist of broadband instruments such as the Minnesota Multiphasic Personality Inventory–2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) and more narrowly focused measures that are either checklists or rating scales that gauge specific symptoms or traits such as depression or anxiety. Psychologists are often approached by allied professionals regarding locating and selecting a narrowfocus measure. Morgan and Bober (2005) described the numerous narrow-focus measures and offered methods to facilitate selection.

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Supervisees must become knowledgeable about the assessment issues unique to medical settings. These include the risk of interpretive errors, as many of the measures used were normed on psychiatric populations, the inappropriate use of tests to rule out medical conditions; and the risk of allied professionals inappropriately using test data and results (Belar, 1991; Belar & Deardorff, 1995). The process of responding to assessment consults occurs at a fast pace: Consults that involve an interview and narrow-focus measures are typically completed in 24 hours, whereas those that require broadband or additional testing are completed within a few days. Some less experienced clinicians who are accustomed to seeing a patient several times before diagnosing and formulating a treatment plan may be uncomfortable with the rapidity of this process. Supervisors can facilitate adjustment by reminding clinicians that, in medical settings, diagnoses and treatment plans are based on current information, are provisional, and are routinely modified as additional information becomes available. Although conclusions must be sound and reflect the issues and history unique to each patient, “Those who are uncomfortable in pressing ahead without a thorough exploration of every aspect of a patient’s life, past and present, will not be well suited for primary care work” (Gatchel & Oordt, 2003, p. 14). Most reports should be no longer than one page; many supervisees will need a good bit of teaching to learn how to identify and address only relevant information in a logical and sequential fashion. The report should concisely address the referral question and be free of jargon. If the referral questions are unclear, new clinicians must be taught how to tactfully obtain clarification. Physicians will, on occasion, specify what psychological test is to be done; whereas some have sufficient knowledge to select the appropriate test, most do not. In such cases, the first author of this chapter generally responds to such requests by contacting the referring physician and diplomatically stating that the referral question may be better addressed by the use of different instrument(s), and that allowing the psychologist to select the instrument(s) is the most efficient way to get the information needed by the physician. This typically occurs when dealing with physicians who view psychologists as “ancillary care providers,” and supervisees need to be taught how to appropriately deal with these situations. Also, some physicians order consults without informing the patient; this is uncomfortable for both the patient and psychologist, and physicians should be advised that informing the patient in advance will result in a higher level of patient cooperation and a better consult (Belar, 1991; Belar & Deardorff, 1995). Supervisors need to familiarize new clinicians with the unstated protocol that exists around the process of responding to consults. As an example, a serious breach of protocol would occur should the psychologist refer a patient on whom he or she had been consulted to another physician without first obtaining agreement from the referring physician (Belar, 1991). Protocol violation would also occur should the psychologist, in the course of a consult, provide excessive feedback to the patient. Clinicians need to learn how to respond professionally to patient questions with an explanation of their role as a consultant and advise the patient that it is the physician who is coordinating care and who will be communicating results and the recommended treatment. To summarize, assessment is a major activity for psychologists in medical settings. The process of instrument selection, the proper use of the instrument, report

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writing, and adherence to protocol unique to medical settings will require ongoing supervisory attention. Assessment is a skill unique to psychologists, and nowhere is it more crucial than in medical settings. These are complex skills learned over time, and supervisors must closely track supervisees’ progress. Close attention must be paid to helping supervisees learn the unstated protocol associated with assessment that, if violated, can harm the collaborative environment. Close supervisory attention is also necessary as “an increased risk of successful malpractice suits is present in this area if the psychologist is not attentive to these issues” (Belar, 1991, p. 87). The reader is reminded that the references cited earlier provide much useful information on the issue of assessment. The following section addresses ethical and malpractice issues, many of which are associated with assessment. ETHICAL AND MALPRACTICE ISSUES Although psychologists receive extensive training in ethics, “because of the special settings and patient populations encountered, the practice of clinical health psychology brings with it unique ethical issues” (Belar & Deardorff, 1995, p. 137). Gatchel and Oordt (2003) described ethical issues relevant to primary care settings that include the need to practice within the boundaries of one’s competence. In medical settings it is not uncommon for psychologists to be approached for advice that is clearly medical, and supervisees must be reminded to maintain their professional boundary. Similarly, Belar (1991) cautioned against practicing medicine without a license, which could occur should psychologists diagnose medical conditions or offer advice about medications. Supervisees should be clear with patients about their role and should openly and clearly explain to patients their areas of expertise. Similarly, psychologists should ensure that patients are referred to the health-care providers who can best meet their needs. For instance, Gatchel and Oordt (2003) noted that patients with more extensive and severe psychiatric histories would be best served by referral to a mental health clinic. The issue of confidentiality is an important and ongoing concern. In the course of a diagnostic interview and testing, much detailed and personal patient information is obtained. Supervisees must be reminded to confine talk about the patient to members of the treatment team and to limit the discussion to only relevant information. Also, as the patient’s medical chart is available to a host of other health-care personnel, supervisees must be taught to include only necessary information in reports and progress notes (Gatchel & Oordt, 2003). Supervisors are reminded of their liability, as supervisees are considered to be extensions of supervisors (Belar, 1991). Also, supervisors obviously must co-sign reports but should also regularly co-sign (and thereby show agreement with) progress notes and treatment plans. In the early stages of supervision, supervisors should carefully review all supervisee entries in the patient chart to ensure adequacy and compliance with hospital policy and ethical and legal guidelines. The supervisor must ensure that the supervisee’s and patient’s needs are both addressed in supervision and must also provide the amount of supervision needed (Belar, 1991; Belar & Deardorff, 1995). In addition, the quality of the supervisory relationship must be monitored. This is of concern, as supervisory relationships of poor quality are associated with higher rates of nondisclosure by supervisees

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(Ladany, Hill, Corbett, & Nutt, 1996; Yourman & Farber, 1996). Nondisclosure seems routine, and “supervisors should be aware that there is significant information that supervisees do not disclose about themselves, their work with clients, and the supervision relationship” (Ladany et al., 1996, p. 22). As a supervisee is understandably invested in presenting himself or herself in a favorable light, a degree of nondisclosure is thus expected and likely appropriate. However, nondisclosure of important information can affect patient care as well as increase the legal risk faced by supervisors and supervisees. Ladany et al. concluded that nondisclosure is associated with supervisor style and supervisee satisfaction; they suggested that supervisors discuss their own growth and mistakes and remind the supervisee that an honest and open discussion of mistakes will not harm their view of the supervisee. Supervisors should be open and collaborative, and the goals of supervision should be agreed upon and clearly defined. The supervisee’s views of the supervisory relationship should be regularly discussed, and the emotional climate should allow for the supervisee to offer different opinions (Yourman, 2003). The brevity of this section does not do justice to the importance or complexity of this topic. Although it is possible to discuss only a few of the most salient topics, we hope to have emphasized that supervisors must exercise a high degree of vigilance regarding these issues. Supervisors are encouraged to acquire the necessary reference materials and to consult them regularly. Belar (1991) and Belar and Deardorff (1995) cited several useful references. A key task for supervisors is to help those they supervise learn to proactively anticipate and address legal and ethical concerns as a matter of routine. ADMINISTRATIVE AND ORGANIZATIONAL ISSUES Most psychologists who work in medical settings will spend some time in hospitals performing assessments or the types of interventions described earlier. Hospitals, especially those in large urban areas, have complex organizational structures and a plethora of detailed regulations and procedures. Even those psychologists who will spend only a small amount of time in hospitals need to become familiar with the structure, organization, and regulations of the hospital in which they will work. This information helps psychologists learn their way around the hospital, as well as acquire a sense of how psychologists fit into the hospital structure. Review of the hospital’s policies will also provide information about dress codes, charting, documentation, and other practical information. Early in the process of supervision, the supervisor should provide the supervisee with this information and discuss the most salient points. Although much of this will involve discussion of formal structures, procedures, and lines of authority, hospitals also have informal hierarchies (often involving nursing and support staff) about which the supervisee should be informed. Fortunately, there are reference materials that provide detailed and thorough information on these issues. A chapter by Bonecutter and Harrow (1991) titled “The Structure and Authority of Hospitals” provides a wealth of information including the procedures typically involved in obtaining privileges. The book by Belar and Deardorff (1995) is useful, and other resources include Practicing Psychology in Hospitals and Other Health Care Facilities (American Psychological Association Practice Directorate, 1998) and a chapter by

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Papas, Belar, and Rozensky (2004) on the practice of health psychology. Most medical settings have a library nearby; these are typically well staffed and have computers to conduct literature searches and access journals. However, the supervisor can assist by orienting the supervisee to relevant reference materials; these include medical dictionaries such as Dorland’s Illustrated Medical Dictionary (2003), which provides descriptions of most diseases, as well as relevant and timely journals and articles. Knowledge of academic organizations that influence medical education and hospital policy is helpful and is available in a recent article by Garcia-Shelton and Leventhal (2005). In terms of membership in professional organizations, the supervisor should model professional behavior by belonging to and encouraging supervisee membership in appropriate state and national organizations. The Association of Psychologists in Academic Health Centers is especially relevant for psychologists working in medical settings.

CONCLUSION As psychology’s role in health care is increasingly recognized, demand grows for psychologists who are trained to practice in the areas known as clinical health psychology and primary care psychology. The deficits in training programs and the need to ensure psychologists have the skills and knowledge required to succeed in this nontraditional environment place increased importance on supervision. In general, the nature of medical settings requires that both the supervisor and supervisee be comfortable with higher levels of structure than are required in nonmedical settings. However, it is important that the rapid work pace and the intensity of the setting not distract the supervisor from monitoring and proactively addressing developmental issues crucial to professional development. The setting requires much specialized knowledge, an understanding of medical culture, and the ability to collaborate with physicians and staff. Also, the high risk of malpractice suits necessitates close supervisory attention and guidance regarding legal and ethical issues. For the supervisor, there is clearly much to do, and we hope to have provided useful guidance.

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Papas, R. K., Belar, C. D., & Rozensky, R. H. (2004). The practice of clinical health psychology: Professional issues. In T. J. Boll, R. G. Frank, A. Baum, & J. L. Wallender (Eds.), Handbook of clinical health psychology: Vol. 3. Models and perspectives in health psychology (pp. 203–319). Washington, DC: American Psychological Association. Peake, T. H., Nussbaum, B. D., & Tindell, S. D. (2002). Clinical and counseling supervision references: Trends and needs. Psychotherapy: Theory, Research, and Practice Training, 39, 114–125. Resnick, R. J., & Rozensky, R. H. (1996). Introduction. In R. J. Resnick & R. H. Rozensky (Eds.), Health psychology through the life span: Practice and research opportunities (pp. 1–6). Washington, DC: American Psychological Association. Rozensky, R. H., Sweet, J. J., & Tovian, S. M. (Eds.). (1997). Psychological assessment in medical settings. New York: Plenum Press. Ruddy, N. B., & Schroeder, C. S. (2004). Making it in the real world: Diverse models of collaboration in primary care. In R. G. Frank, S. H. McDaniel, J. H. Bray, & M. Heldring (Eds.), Primary care psychology (pp. 149–168). Washington, DC: American Psychological Association. Schulte, T. J., Isley, E., Link, N., Shealy, C. N., & Winfrey, L. L. (2004). General practice, primary care, and health service psychology: Concepts, competencies, and the combined-integrated model. Journal of Clinical Psychology, 60, 1011–1025. Searight, H. R., Price, J. W., & Gafford, J. (2004). Establishing and maintaining a psychological practice in primary care. In L. J. Haas (Ed.), Handbook of primary care psychology (pp. 21–33). New York: Oxford University Press. Shanfield, S. B., Matthews, K. L., & Hetherly, V. (1993). What do excellent psychotherapy supervisors do? American Journal of Psychiatry, 150, 1081–1084. Snyder, C. R., & Elliott, T. R. (2005). Twenty-first century graduate education in clinical psychology: A four level matrix model. Journal of Clinical Psychology, 61, 1033–1054. Stoltenberg, C. D., & McNeill, B. W. (1997). Clinical supervision from a developmental perspective: Research and practice. In C. E. Watkins (Ed.), Handbook of psychotherapy supervision (pp. 184–202). New York: Wiley. Stoltenberg, C. D., McNeill, B. W., & Crethar, H. C. (1994). Changes in supervision as counselors and therapists gain experience: A review. Professional Psychology: Research and Practice, 25, 416–449. Stoltenberg, C. D., McNeill, B., & Delworth, U. (1998). IDM supervision: An integrated developmental model for supervising counselors and therapists. San Francisco: Jossey-Bass. Swan, G. E., Piccione A., & Anderson, D. C. (1980, April). Internship training in behavioral medicine: Program description, issues and guidelines. Professional Psychology, 339–346. Sweet, J. J. (1991). Psychological evaluation and testing services in medical settings. In J. J. Sweet, R. H. Rozensky, & S. M. Tovian (Eds.), Handbook of clinical psychology in medical settings (pp. 291–313). New York: Plenum Press. Sweet, J. J., Rozensky, R. H., & Tovian, S. M. (Eds.). (1991). Handbook of clinical psychology in medical settings. New York: Plenum Press. Thompson, R. J. (1991). Psychology and the health care system: Characteristics and transactions. In J. J. Sweet, R. H. Rozensky, & S. M. Tovian (Eds.), Handbook of clinical psychology in medical settings (pp. 11–25). New York: Plenum Press. Tovian, S. M., Rozensky, R. H., & Sweet, J. J. (2003). A decade of clinical psychology in medical settings: The short longer view. Journal of Clinical Psychology in Medical Settings, 10(1), 1–8. Watkins, C. E. (1995). Psychotherapy supervision in the 1990s: Some observations and reflections. American Journal of Psychotherapy, 49, 568–581. Watkins, C. E. (Ed.). (1997). Handbook of psychotherapy supervision. New York: Wiley. Watkins, C. E. (1998). Psychotherapy supervision in the 21st century: Some pressing needs and impressing possibilities. Journal of Psychotherapy Practice and Research, 7(2), 93–101. Whitman, S. M. (2001). Teaching residents to use supervision effectively. Academic Psychiatry, 25(3), 143–147. Yourman, D. B. (2003). Trainee disclosure in psychotherapy supervision: The impact of shame. Journal of Clinical and Consulting Psychology in Session, 59, 601–609. Yourman, D. B., & Farber, B. A. (1996). Nondisclosure and distortion in psychotherapy supervision. Psychotherapy, 33, 567–575.

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PART SEVEN

RESEARCH DEVELOPMENTS

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C H A P T E R 25

State of the Art in the Assessment, Measurement, and Evaluation of Clinical Supervision MICHAEL V. ELLIS, NADIA D’IUSO, and NICHOLAS LADANY

ASSESSMENT, WHICH includes measurement and evaluation, is an essential and ubiquitous component of clinical supervision (Bernard & Goodyear, 2004). In fact, many argue that it is the evaluative component of the supervision relationship that distinguishes clinical supervision from therapy, teaching, and consultation (e.g., Bernard & Goodyear, 2004; Leddick & Bernard, 1980). That is, it is the ethical responsibility of the supervisor to assess and evaluate supervisees to determine if they will proceed to the next step in their professional development, such as attaining a degree, credentialing, or licensure, or retaining a job (e.g., Association for Counselor Education and Supervision, 1995). Even though assessment broadly defined is inescapable in clinical supervision, less has been written about it relative to other aspects of clinical supervision (cf. the major textbooks in clinical supervision). The recent years, however, have witnessed increasing attention to evaluation, especially for assessing therapist–supervisee competencies (e.g., American Association for Marriage and Family Therapy, 2004; Hatcher & Lassiter, 2007; Kaslow, 2004; Kaslow & Roberts, 2007) and supervisor competencies (e.g., American Association for Marriage and Family Therapy, 1990; Falender et al., 2004; Getz, 1999; Milne & James, 2002). Nevertheless, the lack of psychometrically sound measures available for clinical supervision practitioners and researchers continues to be a pervasive problem (Ellis & Ladany, 1997; (Ellis, Ladany, Krengel, & Schult, 1996; (Russell, Crimmings, & Lent, 1984; Vonk & Thyer, 1997). The purpose of this chapter is to discuss the emerging issues in assessment, We gratefully acknowledge Lauren Morere, Shaina Bernardi, and Heidi Robinson for their assistance with the quantitative variables and Erica R. Ellis for insightful comments on earlier drafts of the chapter.

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measurement, and evaluation of clinical supervision and to update our review of measures specific to clinical supervision (i.e., Ellis & Ladany, 1997). We conclude with recommendations to advance sound assessment in supervision. In this chapter, we review current psychometric standards and apply them to clinical supervision assessment. We present both quantitative and qualitative findings from our review of measures specific to supervision, we review current evaluation questionnaires, and we delineate what we need to do in the future to build a more sound basis for evaluating supervision. As a caveat, our presentation focuses on what we consider to be the most compelling issues confronting assessment (broadly defined) in supervision. Thus, some issues we may oversimplify; some issues we may overemphasize to make our point more compelling. Our bias is to advocate for conceptual and methodological rigor in any form of assessment. Finally, one of our basic premises is that multicultural and diversity perspectives should be systematically infused in any contemplation of assessment, measurement, and evaluation pertaining to clinical supervision. DEFINITIONS To bring some conceptual clarity to our presentation, we begin by defining the principal concepts. First, to set the overall context for our discussion, we differentiate between clinical supervision, case management, and administrative (managerial) supervision. Nevertheless, we recognize that in many applied settings, a supervisor may function in one or more of these three types of supervision (see Chapter 1 of this volume). We then define the terms assessment, measurement, and evaluation. Throughout our presentation, we interchangeably use the terms counselor- (therapist)-in training, therapist, and counselor when referring to the supervisee. Furthermore, clinical supervision can entail individual (i.e., one-on-one) and group supervision of individual, couple, family, and group interventions for mental health clients. CLINICAL SUPERVISION, CASE MANAGEMENT, AND ADMINISTRATIVE (MANAGERIAL) SUPERVISION We adopt Bernard and Goodyear’s (2004) definition of mental health clinical supervision: An intervention that is provided by a senior member of a profession to a 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 junior member(s), monitoring the quality of professional services offered to the clients she, he, or they see(s), and serving as a gatekeeper for . . . the particular profession. (p. 8)

Hence, clinical supervision serves as a quality control function with the goals of ensuring that (a) supervisees do not harm clients or others, (b) clients receive an acceptable level of care, (c) supervisees acquire and maintain sufficient clinical skills, and (d) supervisees whose skills are deficient or whose behaviors may put clients at risk receive remediation (e.g., Watkins, 1997).

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State of the Art in the Assessment, Measurement, and Evaluation 475 We differentiate clinical supervision from case management and administrative (managerial) supervision for two reasons. Although overlapping, each of these three types of supervision entails different roles, goals, foci, content, and tasks. Furthermore, some view them as distinct disciplines (e.g., Bernard & Goodyear, 2004; Falvey, 1987; Lindbloom, TenEyck, & Gallon, 2003; Powell & Brodsky, 2004). Case management emphasizes administrative, clinical, and evaluation activities that bring the client, treatment services, community agencies, and other resources together (Lindbloom et al., 2003). That is, case management focuses on broader treatment logistics such as monitoring progress through treatment modalities, adhering to documentation protocols, advocating for the client, coordinating treatment referral services, and acting as a liaison with community resources. Typically, it does not focus on the supervisee’s professional development or clinical skills, especially the supervisee’s in-session behaviors. In contrast to clinical supervision, administrative (managerial) supervision focuses mainly on organizational structure; work environment; and agency logistical, personnel, policy, legal, and fiscal issues (Bernard & Goodyear, 2004; Falvey, 1987). Service delivery (e.g., client outcome, counselor professional development and therapeutic skills, and client specific interventions) and coordination of clinical care are generally not a priority for administrative supervision. ASSESSMENT, MEASUREMENT, AND EVALUATION IN CLINICAL SUPERVISION We define assessment such that it subsumes measurement, rating protocols, evaluation, and clinical assessment. Most broadly defined, assessment facilitates the generation, testing, and selection of tenable inferences (Bellack & Hersen, 1998). That is, assessment entails gathering data in order to make inferences about some phenomenon of interest. Here, inferences pertain to clinical supervision. Assessment involves collecting data and making inferences about the supervisee, the supervisor, or the supervisory relationship or dyad, in the context of individual or group supervision. A fundamental principle of assessment warrants exposition. Following Pepinsky and Pepinsky (1954), we differentiate between what one can observe and the inferences one makes from his or her observations (i.e., we distinguish observations and inferences). Observations refer to that which is given by immediate sensory experience (visual, auditory, kinesthetic) (Pepinsky & Pepinsky, 1954). Inferences refer to tentative conclusions based on observational data; they are abstractions about reality (Pepinsky & Pepinsky, 1954). Of course, the process of using words to describe what one experiences through the senses is inherently inferential (words are abstractions) and value laden. Nevertheless, one can distinguish between that which one observes (sees, hears, touches, or measures) and the inferences one makes from these observations (experiences, behavioral ratings, or scale scores). It is important to understand that inferences are not reality, they are tentative, and they are subject to cultural biases and values. The separation of observations and inferences is crucial to generating and testing hypotheses about clients, supervisees, and the supervisory relationship. We take the position that assessment necessarily entails separation of observations and inferences as well as awareness and consideration of multicultural and diversity issues.

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For the purposes of our presentation, we use the terms tests, scales, and measures interchangeably, even though technically there are often differences. Measures, scales, and tests refer to objective quantitative measurement using standardized procedures. More specifically, measurement consists of establishing unambiguous rules for assigning numbers to represent attributes of people (Nunnally, 1970). As is evident in Nunnally’s definition, measurement separates observations (numbers or scale scores) from the inferences one makes from the numbers or scores (attributes). To judge the viability of a measure for assessing a given construct, context, and target population in supervision, it is essential to establish empirically the psychometric properties of the scale scores. Rating protocols refers to classification taxonomies and rating systems that are typically employed by an observer (Bellack & Hersen, 1998; Cone 1998). The classification systems are objective and generally involve rating, classifying, or categorizing behaviors. The psychometric properties of the ratings are important, even though many researchers are uninformed about the procedures to test them empirically (e.g., generalizability theory; Hoyt & Melby, 1999; Shavelson & Webb, 1991) outside of interrater reliability and agreement (Cone, 1998). Evaluation entails assessing the congruency between what is expected and what actually occurs (e.g., Chen, 1990). Evaluation can range from formal to informal quantitative or qualitative, written or verbal (or both), and formative (ongoing) or summative (e.g., performed at the conclusion of a supervision experience). As with rating protocols, procedures to test empirically the psychometric properties of evaluation scores exist, but they are not well known (Chen, 1990). The good news is that, generally speaking, traditional statistical procedures for testing the psychometric properties of scale scores also apply to evaluation scores. Finally, clinical assessment refers to less formal observations of supervisors, supervisees, and clients and is typically not fully standardized or quantitative. Clinical assessment may focus on one or several aspects of therapy or supervision (e.g., see Hawkins & Shohet, 2000, for seven foci of supervision). For example, after viewing a few of the supervisee’s therapy sessions, the supervisor identifies the tendency for the supervisee to change topics whenever the client becomes emotional (assessing supervisee skills). Given these definitions and terms, we turn our attention to the established view of measurement. THE MODERN VIEW OF MEASUREMENT In part, the blessing and curse of conducting research in clinical supervision is that the field is relatively wide-open and fertile ground for empirical investigations. That is, investigators of clinical supervision are often conducting leading-edge research where a dearth of established measures exists, constructs are often not well known or defined (e.g., lack of empirical data about dimensionality, and known confounds), large databases and item banks do not exist, and large samples (N > 300) are onerous to attain. Thus, researchers (and practitioners) must either create new measures or adapt existing ones from other domains such as therapy (e.g., Working Alliance Inventory; Horvath & Greenberg, 1989). One common error supervision researchers make is believing that an existing measure with good psychometric properties can be adapted to a new context or population, or

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State of the Art in the Assessment, Measurement, and Evaluation 477 modified (e.g., substituting “supervisee” for “therapist”) without having to reestablish empirically the psychometric properties of the new scores (e.g., reliability and validity). One of the major limitations of classical test theory is that one cannot change virtually anything about a measure and continue to apply the psychometric data to the scores (e.g., Embretson & Reise, 2000; Hambleton, Swaminathan, & Rogers, 1991; Messick, 1995). Although completing the series of psychometric studies for a new or adapted measure is compulsory, it is a burdensome and time-consuming task. Another common mistake is that many clinical supervision researchers apparently have not been trained in or are largely uninformed about the evolution of measurement theory (i.e., Anastasi & Urbina, 1997; Ellis & Blustein, 1991a, 1991b; Messick, 1995). On the basis of our previous reviews (Ellis & Ladany, 1997; Ellis et al., 1996), many researchers adopted the position that developing and validating a measure is somehow different from traditional hypothesis-testing research (see Landy, 1986). Minimal attention is given to accepted standards of conceptual and methodological rigor for research (e.g., Kerlinger & Lee, 2000; Shadish, Cook, & Campbell, 2002; Wampold, Davis, & Good, 1990) or to the dominant view that theory-derived constructs are being measured even if the researchers did not explicate the theorizing or the underlying construct being investigated (e.g., Messick, 1989, 1995). The prevailing view among measurement specialists and psychometricians is that scale construction and investigations of the psychometric properties of a measure are traditionally theory-driven, hypothesis-testing research endeavors (e.g., Landy, 1986; Messick, 1995). That is, the modern approach to test theory is predicated on theory-driven, hypothesis-testing research. This has rather profound implications for clinical supervision: How researchers approach assessment, measurement, and evaluation needs to be reframed. Clinical supervision researchers who develop new scales (measures, rating protocols, evaluations) or adapt existing scales from other content domains (e.g., therapy, social psychology) need to adhere to established criteria of scientific rigor. That is, researchers need to explicate the underlying theorizing of the study (e.g., Serlin, 1987; Tracey & Glidden-Tracey, 1999), including clearly defining the constructs under investigation (Ellis & Blustein, 1991a, 1991b; Serlin, 1987); to identify and sample from the target population and context (Messick, 1995); to consider and address multi- and cross-cultural and diversity issues systematically; to articulate a compelling, reasoned argument for the study (Tracey & Glidden-Tracey, 1999); to delineate falsifiable, unambiguous research hypotheses (Wampold et al., 1990); to methodically rule out or control the most plausible threats to the validity of the study (e.g., see Shadish et al., 2002, for 37 threats to validity; Kerlinger & Lee, 2000, for the MAXMINCON principle; Wampold et al., 1990, for four threats to hypothesis validity); and to use confirmatory statistical procedures (e.g., confirmatory factor analysis [CFA]) rather than exploratory procedures in the major analysis. In addition, it is essential that the theorizing, research hypotheses, research design-methods-procedures, statistical hypotheses, and statistical analyses create a logically coherent and internally consistent study (e.g., Serlin, 1987; Tracey & Glidden-Tracey, 1999; Wampold et al., 1990). To ensure that scales and scale scores generalize to other samples from the target supervision population, researchers need to cross-validate any new or adapted scale (Messick, 1989, 1995).

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As said previously, creating psychometrically and conceptually sound measures is a meticulous and arduous task; nevertheless, we strongly advocate that to advance the field it must be done. With the modern view of measurement in mind, we conducted a quantitative review study of published measures in clinical supervision since 1995 (see Ellis, 1991). That is, investigated the extent to which any new measures had emerged in the clinical supervision literature in the 10 years since our last review and assessed the extent to which researchers adopted a theory-driven, hypothesis-testing approach to scale development and validity. We also include in our review of the literature psychometric investigations of existing measures specific to clinical supervision. We hypothesized that measures published since Ellis and Ladany (1997) and Ellis et al. (1996) would have better psychometric properties and fewer threats to validity. METHOD We replicated the methods and procedures from our prior methodological critiques to update the review of measures specific to clinical supervision (cf. Ellis & Ladany, 1997; Ellis et al., 1996). That is, the methods presented here essentially duplicate those of our previous writings. We use the term article to refer to a published journal article, book chapter, or book that reports one or more empirical investigations of the psychometric properties of a new or existing supervision measure. The term study refers to a separate empirical investigation (e.g., qualitative, quantitative, or a combination thereof) reported in a published article, chapter, or book. Because none of the reviewed articles reported more than one study, we use the terms study and article interchangeably henceforth. SAMPLE Search Procedures We used Bernard and Goodyear’s (2004) definition of clinical supervision to circumscribe the review search procedures. Per Cooper (1998), we identified the empirical articles by using the ancestry approach (reference lists of previous and current articles), searching Psychological Abstracts and related databases (e.g., PsycINFO and ERIC [the Education Resources Information Center]), and examining journals that publish research pertaining to the assessment of supervisory processes (e.g., the supervisory relationship and variables that enhance satisfaction within supervision). The journals included Clinical Supervisor, Counselor Education and Supervision, Counseling Psychologist, Journal of Counseling and Development, Journal of Counseling Psychology, Professional Psychology: Research and Practice, Psychological Assessment, Psychotherapy, Rehabilitation Counseling Bulletin, and Training and Education in Professional Psychology. Inclusion–Exclusion Criteria The inclusion criteria were the following: (a) the main focus of the study was clinical supervision or the supervisory process; (b) the article was empirically based and was published in the literature since our last review (i.e., from June 1995 to June

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State of the Art in the Assessment, Measurement, and Evaluation 479 2007); (c) the article focused on measures or methods of assessing clinical supervision, supervisors, supervisees, and/or group supervision; (d) the article needed to describe the development of the measure and its psychometric properties, not simply present a theoretical framework; and (e) the article presented further psychometric data about an existing measure for clinical supervision. The exclusion criteria were the following: (a) The article did not discuss the measurement of supervision; (b) the research involved anecdotal case studies, supervision of group therapy or speech pathology, teacher supervision, or prepracticum training; or (c) the article was unpublished (e.g., doctoral dissertation paper). Recommended or Not Recommended Criteria The criterion for judging whether a new or existing scale was recommended for use for practice and as a dependent measure in research was whether it demonstrated acceptable psychometric properties. In particular, the psychometric properties we assessed were the following: (a) reliability coefficients exceeding .80, (b) scale discrimination validity, scale scores intercorrelated less than approximately .7 and items not correlating highly on more than one scale/factor, (c) scores demonstrating acceptable properties (i.e., no profound ceiling or floor effects), (d) scale scores cross-validated in at least one additional sample, (e) samples being reasonably large and representative of the target population and context, (f) presence of evidence provided for convergent and divergent construct validity of scores, (g) appropriate use of confirmatory statistical procedures, and (h) sufficient information and data provided to evaluate the psychometric properties of the measure. Sample Description The sample consisted of seven articles that described and included an assessment scale or measure for supervision. Six of the seven articles included sufficient information to be used for the purposes of this review (Herbert, Ward, & Hemlick, 1995; Lehrman-Waterman & Ladany, 2000; McHenry & Freeman, 1997; Meier, 2000; Vespia, Heckman-Stone, & Delworth, 2002; White & Rudolph, 2000). The excluded article (Rudolph, Craig, Leifer, & Rubin, 1998) did not provide sufficient information for the quantitative critique (e.g., insufficient data were presented on either the development or psychometric properties of the Trainee Process Evaluation Form rating scale). Broken down by journal, three articles were published in the Clinical Supervisor, and one article was found in each of the following journals: Journal of Counseling Psychology; Psychotherapy: Theory, Research, Practice, and Training; and Rehabilitation Counseling Bulletin. METHODOLOGICAL EVALUATION VARIABLES We evaluated the scientific rigor of each study on the basis of 37 potential threats to the validity of the results. Specifically, we used Cook and Campbell’s (1979) four types of threats to validity (i.e., statistical conclusion validity, internal validity, construct validity, and external validity; see also Shadish et al., 2002) in combination with Wampold et al.’s (1990) four threats to hypothesis validity. Each threat or methodological limitation was rated “yes” if a threat definitely applied, “maybe” if not enough information was provided to evaluate whether the threat

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applied, and “no” if the threat did not apply. A description of the 37 threats and the methodological variables follows. Hypothesis Validity According to Wampold et al. (1990), hypothesis validity pertains to the interrelations among theory, research hypotheses, and statistical hypotheses. The four threats to hypothesis validity are (1) inconsequential hypotheses (the extent to which the hypotheses fail to corroborate one theory and falsify others), (2) ambiguous hypotheses (hypotheses are not delineated; if provided, the conditions under which hypotheses succeed or fail are not specified), (3) noncongruence of research and statistical hypotheses (e.g., statistical procedures do not test or are inconsistent with the research hypotheses; improper statistical tests are used), and (4) diffuse statistical tests (at least one of the following: use of multiple statistical tests per hypothesis, use of omnibus tests with subsequent follow-up or post hoc tests, or incorporation in the statistical analyses of extraneous variables that are not specified in the hypotheses). Statistical Conclusion Validity Cook and Campbell’s (1979) statistical conclusion validity addresses the validity of inferences from the statistical data to the covariation of independent and dependent variables (i.e., are the variables related to one another?). Cook and Campbell outlined seven threats to statistical conclusion validity. These threats are the following: 1. Low statistical power (e.g., the probability of detecting a true effect; determined by the population effect size, per-comparison alpha, and N). 2. Violation of the assumptions of statistical tests (e.g., nonnormality, heterogeneity of variances). 3. Uncontrolled type I error (e.g., multiple statistical tests using α = .05). 4. Use of unreliable measures (reliability coefficients below .80 or measures with unknown reliability in a supervision context). 5. Unreliable treatment implementation (lack of standardization between and within treatment conditions). 6. Random irrelevancies in the experimental setting (extraneous sources within the setting that induce error variance). 7. Random heterogeneity of respondents (e.g., failing to control for supervisee developmental level). Internal Validity Internal validity refers to the relationship between the variables and the extent to which the changes to the dependent variable relate to the manipulation of the independent variable (Cook & Campbell, 1979; Shadish et al., 2002). The 13 threats to internal validity are the following: 1. History (events occurring between pretest and posttest cause changes in the dependent variable). 2. Maturation (e.g., differential developmental changes in the participants between pre- and posttest).

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State of the Art in the Assessment, Measurement, and Evaluation 481 3. Testing (e.g., familiarity with a measure used multiple times improves scores at posttest). 4. Instrumentation (e.g., ceiling or floor effects; change in instrumentation or experience level of the observer between pretest and posttest). 5. Statistical regression (regression to the mean accounts for changes in the preand posttests). 6. Selection (biases that result from the nonrandom selection of participants and/or their assignment to different treatment conditions, resulting in nonequivalent groups). 7. Mortality (differential dropout among the treatment conditions changes the composition of the groups at posttest). 8. Interactions with selection (e.g., selection bias interacts with maturation, history, or instrumentation). 9. Ambiguity concerning the direction of causality (i.e., unclear whether the independent variable influences the dependent variable or vice versa). 10. Diffusion of treatments (e.g., participants in the control group learn about the experimental interventions). 11. Compensatory equalization of treatments (e.g., supervisors try to better the conditions for supervisees in less desirable treatments). 12. Compensatory rivalry by respondents receiving less desirable treatments (e.g., participants in the control group change their behavior to compensate for the perceived advantage of the members of the other groups). 13. Resentful demoralization of respondents receiving less desirable treatments (e.g., control group members become aware of the other treatment groups’ advantages and negatively change their behavior).

Construct Validity Construct validity pertains to generalizations from the data and results to latent variables and constructs and encompasses issues of confounding (Cook & Campbell, 1979; Shadish et al., 2002). The 10 construct validity threats are the following: 1. Inadequate preoperational explication of constructs (constructs that are integral parts of the theory and study are not sufficiently defined). 2. Mono-operation bias (e.g., only one measure is used to operationalize a construct). 3. Mono-method bias (only one method is used to operationalize a construct; e.g., via self-report). 4. Hypothesis guessing within the experimental condition (participants become aware of the experimenter’s expectations and respond accordingly, thereby biasing the results). 5. Evaluation apprehension (e.g., supervisees’ responses are affected by their own apprehension and anxiety about being evaluated). 6. Experimenter expectancies (e.g., raters inadvertently favor one of the experimental conditions or group of supervisees). 7. Confounding constructs and levels of constructs (e.g., dichotomizing of a continuous variable).

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8. Interaction of different treatments (e.g., treatments combine to produce a synergetic effect). 9. Interaction of testing and treatment (e.g., supervisees respond to pretreatment testing). 10. Restricted generalizability across constructs (e.g., the operational definition of constructs are too narrowly defined, limiting their generalizability to related constructs). External Validity External validity pertains to the generalizability of the observed relationship between the variables of the study to and across different people, different times, and different settings. Cook and Campbell’s (1979) three external threats are the following: 1. Interaction of selection and treatment (e.g., limited generalizability of effects to and across different samples or populations of supervisees or supervisors). 2. Interaction of setting and treatment (limited generalizability of findings to and across different supervisory settings). 3. Interaction of history and treatment (limited generalizability to and across time). Supplemental Evaluation Criteria Consistent with Ellis and Ladany (1997) and Ellis et al. (1996), we incorporated additional evaluation criteria. The supplemental criteria included assessing whether the investigators explicitly tested theory (or models), explicated research hypotheses, used measures with established reliability and validity data in a clinical supervision context, tested developmental inferences using cross-sectional data (vs. over time), controlled type I and type II error rates, and acknowledged the limitations of their research. We also evaluated the consistency among the stated purposes of the study; the research hypotheses; the methods, design, and procedures; and the data analyses. RATERS AND RATING PROCEDURES The three of us were the raters. Two are Caucasian male counseling psychologists with approximately 15 and 22 years of postdoctoral experience. The Caucasian female rater is a second-year doctoral student in counseling psychology. Raters received training until achieving 90% agreement on all rating variables including the screening criteria (approximately 5 hours). Potential articles were first screened for inclusion on the basis of the abstract. Once screened, the full articles were then evaluated according to the inclusion and exclusion criteria. Pairs of judges used the methodological variables to rate each accepted study in a random order. Rater discrepancies were resolved by consensus. Interrater agreement was assessed by the average interrater unanimous agreement (100%) per study, the agreement between each rater and the final consensus ratings (average rater–final agreement), and kappas. For both types of interrater

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State of the Art in the Assessment, Measurement, and Evaluation 483 agreement, we calculated agreement across the 37 threats within each study and then averaged across studies. The average interrater agreement was high (Mdn = 83.3%, M = 75.0%, SD = 18.9%; kappas: Mdn = .57, M = .58, SD = .29). The average rater-final agreement rate was 87.4% (Mdn = 83.3%, SD = 16.3%; kappas: Mdn = .67, M = .73, SD = .27). The lack of variability among several of the threats necessarily limited the values of kappa at minimum and often prohibited computing kappa (see Table 25.2 shown later in the Methodological Variables section). That is, the kappas reported herein represent lower bound estimates of interrater agreement. STATISTICAL VARIABLES Following Ellis et al. (1996) and Ellis and Ladany (1997), we computed several statistical variables whenever sufficient statistical data were presented by the original authors. Specifically, for each statistical analysis and for each study we computed or ρ |2 ), post report sample size (N), sample (η2 ) and estimated population effect size (|
hoc (1 − βPC (η2 ) ) and a priori (1 − βPC (
ρ 2 ) ) statistical power, and per-comparison and experimentwise type I (α PC and α EW ) and type II error rates (β PC and β EW ). Each statistical analysis as a separate entity. The statistical variables were averaged for each study. For a detailed presentation of computational procedures for the statistical variables, see Ellis et al. (1996) or Ellis and Ladany (1997). PROCEDURES We evaluated the studies using the 37 threats to validity plus the computed statistical variables. We critiqued each study individually to consider the methodological strengths and limitations according to the criteria outlined. The raters then examined the studies collectively and consensus was reached regarding validity and methodological strengths and weaknesses. Finally, a consensus decision was made about recommending or not recommending each measure. Q U A N T I TAT I V E R E S U LT S STATISTICAL VARIABLES One of the six reviewed studies did not provide enough statistical information to compute the statistical variables (Vespia et al., 2002). The remaining five studies reported a total of 293 statistical tests with sufficient information to compute the statistical variables. In Table 25.1, we presented the quantitative data averaged across the 293 adequately reported statistical tests. Also, we first averaged some quantitative data within each study then averaged these data across the five studies. Because most of the variables evidenced skewed distributions, we focused on the medians. We presented means, medians, standard deviations, standard error of the mean, and 95% confidence intervals about the medians in Table 25.1. METHODOLOGICAL VARIABLES The results of the methodological variables were presented in Table 25.2. We examined the frequency percentages for the 37 methodological threats aggregated

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Table 25.1 Medians, Means, Standard Deviations, Standard Errors, and 95% Confidence Intervals about the Median for Statistical Variables

Mdn

M

SD

SE

95% CI Mdn

Averaged across 293 Statistical Tests N per analysis Sample effect size (η2 ) Estimated population effect size (
ρ2 ) Post hoc power (1 − βPC (η2 ) ) A priori power (1 − βPC (
ρ2 ) ) Type II error (βPC (η2 ) )

123.00 .128 .116

111.21 .186 .172

82.796 .190 .187

4.84 .011 .011

113.32–132.68 .106–.150 .094–.138

.958

.701

.371

.022

.914–1.00

.931

.662

.397

.023

.885–.997

.031

.317

.470

.192

0.00–.223

Averaged across Six Studies (Sufficient Information Presented) Statistical tests per study Number of tests nonsignificant Number of tests significant Experimentwise Type I error (αEW ) Experimentwise Type II error (βEW )* Number of threats per study (of 37) * Estimated

109.0

159.83

151.03

61.65

0.0–232.3

36.0

100.17

130.10

53.11

0.0–142.22

39.0

60.00

52.43

21.40

0.00–81.80

.963

.843

.300

.122

.972

.733

.410

.168 0.636–1.00

21.0

23.67

7.12

2.91

.719–1.00

15.18–26.82

on the basis of observed post hoc statistical power.

across the six studies. In terms of hypothesis validity, all four types of threats were consistently problematic. Seven threats were applicable to all six studies: 2 of the 7 threats to statistical conclusion validity (unreliability of measures and heterogeneity of participants); 3 of the 10 threats to construct validity (hypothesis guessing, confounding and limited levels of constructs, restricted generalizability across constructs); and all three threats to external validity. The data from the supplemental evaluation criteria revealed that none were fully internally consistent (i.e., there were mismatches among the theorizing, hypotheses, design, and analyses) and authors made developmental inferences from cross-sectional data. Eighty-three percent did not test theory or explicate research hypotheses, did not attempt to control experiment-wise type I or II error rates, and used measures with poor psychometric properties. Complete results for qualitative variables are available from M. Ellis.

QUANTITATIVE DISCUSSION Due to small sample sizes (low statistical power, ns ≤ 7), we chose not to perform any statistical tests comparing the results observed here with those found by Ellis et al. (1996) and Ellis and Ladany (1997). Our rationale was that any statistically

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State of the Art in the Assessment, Measurement, and Evaluation 485 Table 25.2 Percentages, Interrater Agreement, and Kappas for Methodological Threats across Six Studies Threat Hypothesis Validity Inconsequential hypotheses Ambiguous hypotheses Noncongruence of research and statistical hypotheses Diffuse statistical hypotheses and tests Multiple tests per hypotheses Omnibus and follow-up tests Tests with extraneous independent variables Statistical conclusion validity Low statistical power Violated assumptions of statistics Error rate problems Unreliability of measures Unreliability of treatment implementation Irrelevancies of experimental setting Heterogeneity of participants Internal Validity History Maturation Testing Instrumentation Statistical regression Selection Mortality/attrition Interactions with selection Ambiguity of direction causal influence Diffusion of treatment Compensatory equalization of treatment Rivalry by participants Resentful demoralization Construct Validity Inadequate preoperational explication Mono-operation bias Mono-method bias Hypothesis guessing within treatment Evaluation apprehension Experimenter/expectancy (not blind) Confounding and limited levels of constructs

Not a Insufficient Definitely Interrater Threat Information a Threat Agreementa Kappab 50.0 16.7 33.3

0.0 0.0 0.0

50.0 83.3 66.7

1.00 .83 1.00

1.00

16.7

0.0

83.3

.67

.33

16.7 33.3 16.7

0.0 0.0 0.0

83.3 66.7 83.3

.83 1.00 .83

.57 1.00 .57

33.3 0.0 16.7 0.0 83.3

0.0 16.7 0.0 0.0 0.0

66.6 83.3 83.3 100 16.7

.83 1.00 1.00 .83 .33

.57 1.00 1.00

33.3

0.0

66.6

.33

0.0

0.0

16.7 83.3 16.7 16.7 16.7 50.0 100 100 33.3

0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

83.3 16.7 83.3 83.3 83.3 50.0 0.0 0.0 66.6

.83 .83 .83 .83 .67 .67 .83 1.00 .50

83.3 33.3

0.0 0.0

16.7 83.3

.67 .67

100 83.3

0.0 0.0

0.0 16.7

.83 .83

33.3

0.0

66.6

.83

.57

33.3 33.3 0.0

0.0 0.0 0.0

66.6 66.6 100

.33 .83 .33

.08 .11

33.3 16.7

0.0 0.0

66.6 83.3

.67 .67

.46 .33

0.0

0.0

100

100

1.00

.09

.67 .60 .60 .60 .60 .33 .40 .57 1.00

.67 (continued)

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RESEARCH DEVELOPMENTS Table 25.2 (Continued ) Threat

Interaction of treatments Interaction of testing and treatment Restricted generalizability across constructs External Validity Interaction of selection and treatment Interaction of setting and treatment Interaction of history and treatment

Not a Insufficient Definitely Interrater Threat Information a Threat Agreementa Kappab 50.0 33.3 0.0

0.0 0.0 0.0

50.0 66.6 100

.83 .83 .50

0.0

0.0

100

.83

0.0 0.0

0.0 0.0

100 100

.83 .67

.57 .57

a Unanimous

agreement in percentages. blank field occurs where kappa was not computable. Note: Numbers are the percent of six studies rated per category for that methodological threat (criteria). bA

significant results would be clearly visible without a statistical test, and the probability of failing to detect one or more effects in the population would be essentially 1.0. Several findings seem noteworthy. For data averaged across the 293 statistical tests, the statistical power was high (i.e., authors had about a 93% chance of detecting a true difference if one in fact existed in the population). The average sample ρ | = .116, respectively, see and population effect sizes were large (η2 = .128 and |
Haase, Ellis, & Ladany, 1989), which was not consistent with the medium effect ρ |2 = .048, respectively). In adsizes Ellis and Ladany found (i.e., η2 =.073 and |
dition, the value of the post hoc power across the 293 statistical tests (.958) was substantially larger than Ellis and Ladany found reported (.432). The larger effects and greater statistical power seems consistent with psychometric investigations seeking to establish construct validity. The samples used in the studies reviewed here were twice as large as those from Ellis and Ladany (Mdn N = 123.0 vs. 51.0), which results in much greater statistical power. Also, we expected new scales to be strongly correlated with similar constructs. What can we infer from the quantitative results? We propose three inferences. First, researchers continue to develop and adapt new measures specific to clinical supervision. Given the dearth of psychometrically sound measures appropriate for clinical supervision, this is a welcome finding. Second, there is some evidence that researchers are beginning to implement more stringent criteria when designing and testing validity inferences about new or exiting measures. Third, most of the research was scientifically unrigorous, evidencing numerous threats to the validity of the findings. Several important limitations exist for these inferences. Quantitative Limitations Mirroring the limitations articulated in Ellis et al. (1996) and Ellis and Ladany (1997), there are three major limitations to the quantitative review. First, the 37 threats to validity (Cook & Campbell, 1979; Wampold et al., 1990) were not all inclusive (longitudinal inferences from cross-sectional data, cohort effects), and

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State of the Art in the Assessment, Measurement, and Evaluation 487 no variability was observed on 5 of the threats. Second, the interrater agreement ranged from excellent (100%) to poor (33%). The specific threats with poor interrater agreement should be viewed cautiously. Because chi-square tests require a minimum of five observations per cell, we chose not to conduct statistical tests comparing the quantitative results observed here with those from the two previous reviews due to the limited number of scale development and validation studies published over the past 27 years (e.g., six studies here and seven in Ellis & Ladany, 1997). The resulting type I and type II error rates (and low statistical power) would have egregiously compromised meaningful inferences from the results. Finally, the data presented here are most likely favorably biased, representing an overly optimistic perspective. We deduce this due to the fact that (a) 50% of the studies did not report sufficient information to conduct the quantitative review; (b) full statistical data were reported for significant findings rather than nonsignificant findings, which were underreported or not fully reported so that we were unable to compute the statistical variables; and (c) the published research represents the best research in the field inasmuch as nonsignificant and methodologically flawed studies do not tend to get published (e.g., Cooper, 1998). Thus, the statistical variable results most likely overestimate the effect sizes and statistical power and underestimate the per-comparison and experimentwise error rates. With the quantitative results and these limitations in mind, we turn to the qualitative review of the six studies and the measures they investigated. Q U A L I TAT I V E R E V I E W RECOMMENDED MEASURES Evaluation Process within Supervision Inventory The Evaluation Process within Supervision Inventory (EPSI) was developed by Lehrman-Waterman and Ladany (2000) to assess the evaluative components within supervision. The 21-item EPSI is composed of two scales: Goal Setting and Feedback. The authors employed a rigorous theory-driven approach to construct the EPSI, tested the content validity and initial differential construct validity of the item pool, tested the clarity of the instructions and item format and wording, used CFA procedures with an adequate-size sample from the target population, and tested convergent and divergent validity inferences about the EPSI scale scores using multivariate procedures and controlled experimentwise type I and II error rates. Using the Working Alliance Inventory (Bahrick, 1990), there was strong evidence of convergent validity of the EPSI scale scores. Evidence of divergent validity of EPSI scores was demonstrated by testing hypothesized relations with self-efficacy (Self-Efficacy Inventory; Friedlander & Snyder, 1983), supervisee satisfaction (Supervisee Satisfaction Questionnaire; Ladany, Hill, Corbett, & Nutt, 1996), and supervisee training level. Given that cross-sectional data were used (no longitudinal data), inferences from scores pertaining to trainee developmental level are questionable. We recommend the EPSI tentatively with the proviso that the EPSI may be suitable only for clinical and counseling psychology supervisees and that it has not been cross-validated, for example with a more heterogeneous sample of mental health therapists (such as paraprofessionals, postdoctoral candidates,

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social workers, substance abuse counselors, and psychiatrists). The median statistical values for this study were as follows: N = 131, 134 tests, of which 126 were ρ |2 = .119, 1 − βPC (η2 ) = .996, significant; median statistical values were: η2 = .126, |
1 − βPC (
ρ 2 ) = .995, βPC (η2 ) = .004, α EW = .999, β EW = .383, 10 threats. MEASURES NOT RECOMMENDED Supervisory Styles Inventory and Supervision Questionnaire—Revised Herbert et al. (1995) set out to cross-validate and assess the interrelationships between the Supervisory Styles Inventory (SSI; Friedlander & Ward, 1984) and the Supervision Questionnaire—Revised (SQ-R; Worthington, 1984; Worthington & Roehlke, 1979), both of which were reviewed by Ellis and Ladany (1997). Both the SSI and SQ-R were subjected to CFA to test their hypothesized item-scale structure, however with an inadequate-size sample (N = 124; e.g., see Quintana & Maxwell, 1999). The CFA results suggested that neither the SSI nor SQ-R data fit their hypothesized structure. The CFA more closely approximating the original analyses for the SSI (Friedlander & Ward, 1984) evidenced an acceptable fit. However, the scales were highly interrelated (rs = .64–.85). These findings considered with those of Herbert and Ward (1989, 1990) suggest that for rehabilitation counseling supervision, the SSI scales may not demonstrate sufficient discriminant validity. Thus, for a rehabilitation counseling context, the SSI is recommended with caution. Because Herbert et al. based their conclusions on an exploratory factor analysis of the SQ-R using an inadequately small sample, they included single-item “scales,” and only 2 of the 13 SQ-R scales achieved adequate reliability (>.80), their SQ-R results are not credible. Thus, we do not recommend the use of the SQ-R for other than informal descriptive purposes (see Ellis & Ladany, 1997). Supervisor Emphasis Rating Form-Revised Building on previous work (Lanning, 1986; Lanning & Friedman, 1994; Lanning, Whiston, & Carey, 1994), McHenry and Freeman (1997) investigated the construct validity of the 60-item Supervisory Emphasis Rating Form—Revised (SERF-R; Lanning & Friedman, 1994). Because the SERF-R evaluates supervisors and thus was not reviewed by Ellis and Ladany (1997), a more in-depth presentation follows here. The SERF and SERF-R, which were based on Bernard’s (1979) discrimination model, consist of four scales: Professional Behavior Skills, Process Skills, Personalization Skills, and Conceptualization Skills. To address the psychometric inadequacies of the SERF (Lanning et al., 1994), Lanning and Friedman revised the SERF using an innovative method: an ingenious application of ipsative scoring. Items from each of the four original 15-item scales were organized into 15 sets (i.e., each set had 1 item from each of the four scales). Respondents (supervisees or supervisors) rank order the four items in each set. This is important because the SERF-R yields ordinal (ranked) data (vs. interval data), and scale scores (computed by summing the ranks across the 15 items per scale) do not take into account the ipsative nature of the data. Both of these may violate the assumptions underlying the statistical tests. Internal consistency reliability coefficients ranged from .66 to .80 (Lanning & Friedman, 1994), yet no other validity data were reported for this new measure.

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State of the Art in the Assessment, Measurement, and Evaluation 489 Using a multimethod–multitrait design to test inferences about the construct validity of the SERF-R, McHenry and Freeman (1997) incorporated three selfreport measures, the Supervisor and Supervisee Forms of the Supervisory Work Alliance Inventory (Efstation, Patton, & Kardash, 1990) and the SSI (Friedlander & Ward, 1984), and a content analysis of videotaped clinical supervision sessions. Obtaining supervisee–supervisor pairs willing to provide a videotape of their supervision sessions was ambitious and a major strength of the study. The results were mixed, providing partial support for and partial disconfirmation of inferences regarding constructs the SERF-R is purported to measure. This, in combination with the lack of cross-validity data, the small sample size (15 pairs), and use of new and untested criterion measures (author-created content analysis rating measures corresponding to the four SERF-R scales, with no validity data) severely limits the interpretability of the results. Until further psychometric data are available, we recommend the Supervisor and Supervisee forms of the SERF-R only for research on the psychometric properties of the scores. Group Supervisory Behavior Scale White and Rudolph (2000) investigated the psychometric properties of the Group Supervisory Behavior Scale (GSBS). Their study represents one of the few to assess the behaviors of supervisors in groups, an inherent strength. Their sample consisted of graduate students in a program in the Midwest accredited by the American Psychological Association. However, no demographic information was provided about the participants, nor were participants randomly selected, limiting the generalizability of the findings. When taking a closer look at the psychometric data, the reliability of the subscales seems promising, as four out of the six demonstrate good reliability (i.e., αs = .83–.94). The validity data, however, seem to cast doubt on the effectiveness of the GSBS in measuring supervisor group behaviors (i.e., all criterion validity coefficients were below the acceptable level of .80). In essence, though the authors introduced a measure that can shed some light on supervisory processes in groups, the weaknesses in the psychometric properties of the GSBS need to be addressed. Furthermore, a more rigorous design needs to be in place to control for the potential confounds that can limit the interpretation of the findings (e.g., homogenous sample, small N). Supervision Utilization Rating Form Vespia et al. (2002) designed the Supervision Utilization Rating Form (SURF) to assess specific behaviors and characteristics that describe supervisees who are able to get the most out of supervision. Specifically, the authors sought to develop both a list and new measures of effective supervisee behaviors at different supervisee developmental levels. They attempted to define effective supervisee behaviors from both the supervisor and the supervisee perspectives. Strengths of the study included employing a qualitative approach to generating items, using a random sampling procedure that attained a moderate response rate, obtaining importance ratings of the 52 items, and controlling type I error rates for some analyses. Given that neither the implicit theorizing nor research hypotheses were explicated, the scales were “rationally” derived based on importance ratings (implicit theorizing and no statistical tests were done), statistical power was inadequate, studywise

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type II error rates were uncontrolled, few significant findings were observed (likely due to poor statistical power), cross-sectional data were used to make longitudinal inferences, and no additional psychometric data about the scores were presented or tested, we cannot recommend the SURF as a viable measure. The SURF may be appropriate for cautious use as an aid to facilitate discussions in supervision, but we believe the other uses recommended by Vespia et al. are premature without substantive psychometric and validity data regarding the items, scale scores, and measure. Meier’s 11 New Scales of Trainee Development Meier (2000) illustrated the use of change-sensitive item analyses to identify counselor developmental constructs in supervisees. Specifically, using an implicit theorizing, data-driven nomothetic approach, he sought to identify items that demonstrated the largest changes in self-efficacy (i.e., the Counselor Self-Estimate Inventory; Larson et al., 1992) and counseling-related skills (i.e., the CounselorEvaluation Rating Scale; Myrick & Kelly, 1971) of neophyte-level supervisees during their first semester of counseling practicum. From the 105 items he constructed post hoc 11 new scales. On the plus side, Meier collected data over 5 years to attain a relatively large sample and utilized a nomothetic approach to assessing change. Other than assessing change score data and internal consistency reliability, however, he provided no other psychometric or validity data. Only 1 of the 11 scales consistently demonstrated reliability above .80, and most scale scores demonstrated interdependence (did not demonstrate discriminant validity). There was no theoretical basis, rationale, or hypothesis to provide a context for the scale scores, especially for making developmental inferences. Hence, the scores from Meier’s 11 new scales are uninterpretable and not recommended for use. Assessment Interview Skill Deployment Inventory, the Global Impressions of the Diagnostic Interview—Revised, and The Seminar Process Evaluation Form—Revised Rudolph et al. (1998) reported pilot data on the development of three new generic scales to assess trainee competency in diagnostic interviews: Assessment Interview Skill Deployment Inventory, the Global Impressions of the Diagnostic Interview—Revised, and the Seminar Process Evaluation Form—Revised. The first two are rating protocols used to classify and then evaluate the quality of the trainee’s skills. Other than reporting interrater reliability (specific type not indicated), the authors provided no data regarding validity or the psychometric properties of the rating scores. No data were reported for the Seminar Process Evaluation Form—Revised. In fact, there was such a dearth of information about the development and pilot studies for these three measures as to prohibit a quantitative review of the article. We commend Rudolph et al. for attempting to develop rating scales and measures of diagnostic interview competency; however, considerable psychometric work is required before these scales can be recommended for use. Untested Measures Some authors constructed their own measures or adapted measures from other contexts to clinical supervision (e.g., Ladany et al., 1996). However, creating these new measures were an incidental part of the study. Consequently, meager if any

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State of the Art in the Assessment, Measurement, and Evaluation 491 psychometric data specific to a supervision context were presented. More important, these measures have not been subjected to systematic attempts to test the psychometric properties and construct validity of the scores. Hence, we do not recommend their use as major variables in research (other than testing their psychometric properties) or their use in practice. QUALITATIVE DISCUSSION Of the new measures reported in the seven studies reviewed here, we recommend only one: the EPSI (Lehrman-Waterman & Ladany, 2000).* It appears that most supervision researchers beset with the difficult task of developing a new scale or testing an existing one often did not follow modern psychometric procedures and guidelines (e.g., Messick, 1995). We suspect that one contributing factor is the prevailing misconception among supervision researchers that scale development and validity is not traditional theory-testing research (see Ellis & Ladany, 1997). Researchers appear uninformed as to accepted criteria for evaluating the rigor and quality of the research for developing and establishing validity data for new measures. In addition, journal editors continue to accept substandard studies for publication, specifically those reporting the development of new measures and investigations of the psychometric properties of existing measures for clinical supervision. We need to better inform journal editors and editorial board members about the current state of measurement in clinical supervision and the need for more rigorous research that complies with accepted standards for scale construction and validation. Although we did not recommend the SERF-R, we applaud McHenry and Freeman (1997) for their efforts to attain bona fide videotaped supervision sessions and data from supervisee–supervisor pairs. We know how difficult this is to do. We highly recommend that researchers use a multimethod–multitrait investigation to test validity inferences about scores. With the exception of Lehrman-Waterman and Ladany (2000), authors did not provide descriptive data about the cultural diversity of their sample (e.g., racial or ethnic identity, socioeconomic status, religious identity). This further restricts the utility of the measures inasmuch as consumers cannot assess the extent to which the scales may be applicable to nontraditional therapist supervisees. We strongly advocate that researchers routinely consider multicultural and diversity issues in any investigations of new and existing measures. E VA L U AT I N G A P P R O A C H E S T O E VA L U AT I O N A perusal of the major textbooks in clinical supervision reveals a host of measures to evaluate the supervisee, supervisor, and supervision (e.g., Bernard & Goodyear, 2004; Borders & Brown, 2005; Bradley & Ladany, 2000; Falender & Shafronske, 2004; Neufeldt, 2007; Studer, 2007). Unfortunately, none of these evaluation tools * We note that studies were reviewed as blindly as possible, that raters assiduously adhered to the rating protocols and criteria, and that Dr. Ladany was not a reviewer for his article. Nevertheless, experimenter bias remains a concern.

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or measures has undergone psychometric investigations of the scores. Hence, there continues to be a paucity of psychometrically valid and reliable instruments from which supervisors can choose to evaluate trainees or for trainees to evaluate their supervisors (Ellis & Ladany, 1997; Inman & Ladany, this volume). Whenever new evaluation measures are created and put forward by researchers and clinicians, guidance is needed to assist professionals to determine the adequacy of these evaluation approaches. This seems especially relevant given recent endorsements of assessing and evaluating competencies in therapy and in supervision (e.g., American Association for Marriage and Family Therapy, 1990, 2004; Hatcher & Lassiter, 2007; Kaslow, 2004; Kaslow & Roberts, 2007). Ladany and Muse-Burke (2001) proposed a set of criteria that could be used to determine the adequacy of an evaluation approach. These criteria are detailed and expanded upon here. In essence, the utility of each evaluation instrument or approach can be determined based on the extent to which it attends to each of the following 12 components. First, the mode of psychotherapy should be identified. Specifically, does the approach attend to individual, group, family, or other forms of psychotherapy? Presumably, a measure would be hard-pressed to consider more than one of these modes. Second, what is the domain of the trainee’s behavior being assessed? In particular, is it about work in psychotherapy, supervision, or agency behaviors? Third, the competence area must be articulated. For example, the measure should clearly indicate specific competencies such as helping skills, conceptualization skills, and assessment skills. Fourth, the method used to obtain the behavioral sample should be indicated, such as trainee self-report, case notes, audiotapes, or videotapes. Fifth, what is the proportion of caseload (e.g., number of clients, one client) that was examined? Sixth, what is the segment of the experience (e.g., one session, the first part of a session, or the last five minutes of a session)? Seventh, the time period in which the evaluation takes place, such as late in the client treatment, or late in the training experience should be considered. Eighth, who is the evaluator (e.g., supervisor, trainee, client, objective observer)? Ninth, is the level of proficiency being evaluated based on a cohort group (i.e., developmental rating) or is it based on a minimum criterion? The tenth component is the reliability of the measure and the eleventh is the validity of the measure using standard means for assessing reliability and validity. The twelfth component is format, meaning the extent to which the evaluation is based on a quantitative and/or qualitative review. To be sure, no evaluation approach can attend to all of these components. In all likelihood, any one approach could address only a subset of these components. However, when recommendations are made about a trainee’s competence, it is imperative that the precise components to which that approach attends is indicated. Moreover, the more serious the evaluation result (i.e., termination of the trainee as the most serious), the greater the number of components that should be addressed in order to ensure the adequacy of the evaluation result. RECOMMENDED STEPS IN SCALE CONSTRUCTION In an effort to promote more rigorous and psychometrically sound measures applicable to clinical supervision, we offer the following guidelines for developing and

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State of the Art in the Assessment, Measurement, and Evaluation 493 constructing a new measure and establishing empirical evidence of the psychometric properties of the scores in addition to supporting inferences from the scores. In short, these are best practices approaches to measuring construction and validity (see Blustein, Ellis, & Devenis, 1989). Interested readers are referred to Anastasi and Urbina (1997), Cone (1998), Chen (1990), Messick (1989, 1995), Jackson (1970), and Ellis and Blustein (1991a, 1991b) for more detailed presentations. Our presentation is not limited to measures and includes rating protocols (classification systems, taxonomies, behavior rating systems) and evaluation measures.

THEORIZING, CONSTRUCTS, AND SUPERVISION CONTEXT Although it is somewhat obvious, the investigator should start by identifying the phenomenon of interest. This could be done via qualitative research, practical experience, and drawing from the existing literature and theory. Once the phenomenon is identified, the researcher then explicates the constructs of interest and the theorizing that underlies the constructs and how they interrelate. During this phase of designing a measure, we believe it is essential to consider diversity, cross-cultural, cross-national, and multilanguage issues. That is, the researcher is responsible for delineating systematically the potential effects of cross-cultural, diversity, and cross-national issues. If the researcher intends the measure to be used broadly in clinical supervision, he or she needs to consider and tailor specifically the theorizing, constructs, and measure to be appropriately suitable for the diversity of supervisors and supervisees (e.g., ethnic, cultural, language, and gender differences), supervision contexts (e.g., types of settings, types of supervision, pedigree, or postlicensure), and clientele (e.g., ethnic, culture, socioeconomic status, and focus of treatment).

ITEM POOLS Once the theorizing, constructs, target supervision context, and target supervision population are initially established, items need to be written to tap the full range of the construct domains and continuum. Composing items consists of selecting the form of the items, type of items, and item responses (e.g., specifying the rating scale and anchors: 1 = not at all, 7 = totally). The process of explicating the theorizing and defining the constructs and target supervision population (and context) to be measured is often an iterative one, especially as one begins to develop an item pool. That is, attempts to operationalize the construct (e.g., generate items) often result in revisiting and revising the theorizing and definitions of the key constructs as well as the target supervision population and context. If item development is used in conjunction with a qualitative approach (i.e., focus groups and interviews of supervisees and supervisors who give ongoing feedback on the theorizing, construct definitions, items, and item wording and readability), the process of developing an item pool is both time consuming and iterative. This approach is worth the investment of time and resources, as it will ultimately yield a better measure, especially if the “consulting group” represents the target supervision population and context in terms of diversity, ethnoculture, and settings.

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CONTENT VALIDITY DATA Once the item pools are set, the next step is to gather content validity data. Specifically, this may entail having a sample of experts in clinical supervision (N ≈ 30) rate each item on the extent to which it taps each of the key constructs (e.g., using a Likert-type rating scale of 1 = totally and 7 = not at all). Each item is tested to see if lower ratings are obtained on the hypothesized construct than the other constructs. Items that fail to discriminate are dropped or revised. This is another opportunity to receive feedback from experts on the items (wording, structure) and construct definitions. Depending on the feedback received, the researcher should make revisions as necessary. If substantial changes are made, additional content validity data may be needed before proceeding.

DERIVATION SAMPLE Items that make it through the screening and content validity processes are subjected to a full psychometric investigation on a large sample (N > 200) from the target supervision population and context. The purpose of the study is to gather initial data to conduct an item analysis and establish initial psychometric properties of, and validity data for, the scores. The researcher should build in initial construct validity at the item level (see Anastasi & Urbina, 1997; Jackson, 1970). Specifically, items that correlate substantively with social desirability (rs > .25) would be dropped. Likewise, two or three measures that would help establish convergent and divergent validity data are correlated to each item. Items that do not correlate as expected with these constructs would be eliminated. In fact, the item analysis should entail examining several pieces of information concurrently: item distributions, item-to-total-score correlations, CFA goodness-of-fit criteria plus results of target and nontarget factor loadings and factor correlations, correlations with initial construct validity measures (e.g., social desirability), and the theoretical importance of the item to the construct (e.g., item redundancy, and ensuring that the full domain of the construct is being assessed across items). After the item analysis is done and once the scales are established, scores could be tested to determine if they correlate as hypothesized with applicable demographic variables so as to establish initial convergent and divergent construct validity for the scores. It is vital that the sample correspond to the target clinical supervision population and context for the measure.

CROSS-VALIDITY SAMPLE A well-established criterion for any measure is that it has been tested in a new sample (cross-validity; e.g., Messick, 1995). Essentially, cross-validity entails assessing the extent to which the item analysis and initial psychometric properties of the measure and scores are maintained with a new sample of participants drawn from the target supervision population and context. One of the best statistical procedures is a two-group CFA in combination with a replication of the item analysis procedures used when initially developing the measure (e.g., using the same criteria for dropping and retaining items as that used to develop the initial measure).

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State of the Art in the Assessment, Measurement, and Evaluation 495 Typically there will be fluctuations in factor loadings and item-to-total-score correlations in the new sample that may result in dropping or adding items. Often in conjunction with a cross-validity study, researchers will include additional measures to further test the convergent and divergent construct validity of the scores. In addition, tentative norms are often developed during this phase of measure development. DIVERSITY AND CROSS-CULTURAL SAMPLES If cross-cultural and diversity constructs and issues were not systematically addressed in the cross-validity study, the researcher is obligated to provide evidence that the scores are applicable to subgroups or subpopulations of supervisees (or supervisors). Likewise, if there is a desire to use the measure in different supervisory contexts or settings than those for which it was originally developed, these inferences need to be tested empirically. We submit that how one defines culture and cultural differences is a theoretical question (as is supervision context and setting). Hence, these issues should be well thought out and attended to a priori. One of the more rigorous methods for establishing the cross-cultural (or crosssetting or cross-context) viability of a measure is to test systematically measurement invariance (e.g., Reise, Widaman, & Pugh, 1993; Steenkamp & Baumgartner, 1998). Measurement invariance tests the extent to which psychometric properties of scores hold across different populations, contexts and settings. Measurement invariance seeks to answer four questions: to what extent can a construct be conceptualized equivalently across cultures? to what extent is the same construct being measured equivalently across cultures? to what extent can mean scores be compared equivalently across cultures? to what extent can measures of association (correlations) be compared equivalently across cultures? Measurement invariance consists of seven progressively more restrictive levels: configural invariance, metric invariance, scalar invariance, factor variance invariance, factor covariance invariance, error variance invariance, and full measurement invariance. Generally speaking, we are talking about using an existing supervision scale or measure with or in another culture, language, or country. Multigroup CFA is the statistical procedure of choice to test measurement invariance, that is unless the measure was developed using item response theory (IRT), in which case IRT and generalized IRT are better suited (e.g., Reise et al., 1993). We should note that testing measurement invariance across cultures requires sophisticated knowledge of multigroup CFA and the attendant software (Steenkamp & Baumgartner, 1998). Assessing measurement invariance entails imposing a series of constraints in the CFA across the cultural groups (or supervision contexts or settings). For detailed step-by-step procedures for testing measurement invariance, we refer readers to Steenkamp and Baumgartner (1998). They also provide a clearly articulated decision-making flow chart. FURTHER CONSTRUCT VALIDITY INVESTIGATIONS If not part of the cross-validity study, subsequent investigations are performed to test inferences about the construct validity of the scores. Depending on the

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construct under investigation and the underlying theorizing, these may include assessing the stability of the scores over a period of time consistent with the construct (i.e., test–retest reliability), employing a multimethod–multitrait investigation (e.g., McHenry & Freeman, 1997), testing inferences about predicting various criterion constructs, and testing inferences about classification accuracy. We expect that the next two decades will witness increasing application of IRT (see Embretson & Reise, 2000; Hambleton et al., 1991; Harvey & Hammer, 1999) to applied psychology, including clinical supervision. Of particular importance have been recent developments in IRT applications to attitudinal data and the corresponding software (e.g., rating scale data; Ostini & Nering, 2006; http://work.psych.uiuc.edu/irt/main tutorial.asp). These statistical models are called graded response IRT. In its most basic form, IRT is a statistical theory (not a psychological or substantive theory) that describes the relation between a person’s magnitude on a construct to his or her probability of making a particular response to an individual item. IRT represents a major advancement in test construction, validation, and application. In part this is due to the ability to rank both people and items on the underlying construct of interest. In terms of utility and applications of IRT, researchers can create shorter tests with stronger psychometric properties that have interchangeable items (or parallel forms) than by traditional testing methods. Computer-adaptive testing is perhaps the quintessential example of the strengths of IRT. The limitations for clinical supervision are: (a) graded response IRT requires that researchers have to first go through the rigorous steps outlined above to develop the scale, which is then subjected to IRT, (b) relatively large sample sizes are required (between 300 and 500) for both scale derivation and cross-validation, and (c) graded response IRT is a sophisticated statistical procedure with scant references that are consumable by the average supervision researcher. Due to the need for large, diverse samples of supervisees and supervisors, cross-discipline research endeavors will likely become increasingly vital for advancement of the field, especially in terms of psychometrically sound measures for clinical supervision. To this end, more efforts such as the annual International Interdisciplinary Conference on Clinical Supervision (see www.socialwork.buffalo.edu/csconference/) are needed. CONCLUSION We initiated this chapter with the intent to assess the state of the art of assessment in clinical supervision and, given the results, make recommendations for the future of scale development and validation. To this end, we found that researchers and editors continue to use or endorse substandard procedures to construct and test the validity of new and existing measures for clinical supervision. There is evidence of improvement in adopting and applying customary standards for establishing the psychometric properties of measures (e.g., Lehrman-Waterman & Ladany, 2000; McHenry & Freeman, 1997). From an optimistic perspective, the field of clinical supervision continues to evolve and mature (cf. Ellis & Ladany, 1997). We suspect that advances in assessment and measurement in clinical supervision over the next 15 years will yield steady improvements as well as unexpected evolutionary leaps. We look forward to what will unfold in the coming decades.

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State of the Art in the Assessment, Measurement, and Evaluation 499 Neufeldt, S. A. (2007). Supervision strategies for the first practicum (3rd. ed.). Annapolis Junction, MD: American Counseling Association. Nunnally, J. C., Jr. (1970). Introduction to psychological measurement. New York: McGraw-Hill. Ostini, R., & Nering, M. L. (2006). Polytomous item response models. Thousand Oaks, CA: Sage. Pepinsky, H. B., & Pepinsky, P. N. (1954). Counseling: Theory and practice. New York: Ronald Press. Powell, D. J., & Brodsky, A. (2004). Clinical supervision in alcohol and drug abuse counseling: Principles, models, methods (2nd. ed.). New York: Lexington Books/Macmillan. Quintana, S. M., & Maxwell, S. E. (1999). Implications of recent developments in structural equation modeling for counseling psychology. Counseling Psychologist, 27, 485–527. Reise, S. P., Widaman, K. F., & Pugh, R. H. (1993). Confirmatory factor analysis and item response theory: Two approaches for exploring measurement invariance. Psychological Bulletin, 114, 552–566. Rudolph, B., Craig, R., Leifer, M., & Rubin, N. (1998). Evaluating competency in the diagnostic interview among graduate psychology students: Development of generic scales. Professional Psychology: Research and Practice, 29, 488–491. Russell, R. K., Crimmings, A. M., & Lent, R. W. (1984). Counselor training and supervision: Theory and research. In S. D. Brown & R. W. Lent. (Eds.), Handbook of counseling psychology (pp. 625–681). New York: Wiley. Serlin, R. C. (1987). Hypothesis testing, theory building, and the philosophy of science. Journal of Counseling Psychology, 34, 365–371. Shadish, W. R., Cook, T. D., & Campbell, D. T. (2002). Experimental and quasi-experimental designs for generalized causal inferences. New York: Houghton Mifflin. Shavelson, R. J., & Webb, N. M. (1991). Generalizability theory: A primer. Newbury Park, CA: Sage. Steenkamp, J. E. M., & Baumgartner, H. (1998). Assessing measurement invariance in cross-national consumer research. Journal of Consumer Research, 25, 78–90. Studer, J. R. (Ed.). (2007). Supervising the school counselor trainee: Guidelines for practice. Annapolis Junction, MD: American Counseling Association. Tracey, T. J. G., & Glidden-Tracey, C. E. (1999). Integration of theory, research design, measurement, and statistics: Toward a reasoned argument. Counseling Psychologist, 27, 299–324. Vespia, K. M., Heckman-Stone, C., & Delworth, U. (2002). Describing and facilitating effective supervision behavior in counseling trainees. Psychotherapy: Theory, Research, Practice, and Training, 39, 56–65. Vonk, M. E., & Thyer, B. A. (1997). Evaluating the quality of supervision: A review of instruments for use in field instruction. Clinical Supervisor, 15(1), 103–113. Wampold, B. E., Davis, B., & Good, R. H., III. (1990). Hypothesis validity of clinical research. Journal of Consulting and Clinical Psychology, 58, 360–367. Watkins, C. E., Jr. (Ed.). (1997). Handbook of psychotherapy supervision. New York: Wiley. White, J. H. D., & Rudolph, B. A. (2000). A pilot investigation of the reliability and validity of the Group Supervisory Behavior Scale (GSBS). Clinical Supervisor, 19(2), 161–170. Worthington, E. L., Jr. (1984). Empirical investigation of supervision of counselors as they gain experience. Journal of Counseling Psychology, 31, 63–75. Worthington, E. L., Jr., & Roehlke, H. J. (1979). Effective supervision as perceived by beginning counselors-in-training. Journal of Counseling Psychology, 26, 64–73.

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C H A P T E R 26

Research: The State of the Field ARPANA G. INMAN and NICHOLAS LADANY

S U P E RV I S I O N R E S E A R C H Since the publication of the first edition of this Handbook, research on psychotherapy supervision has seen some growth both in its theoretical and research focus. For instance, the 1980s had a total of 185 articles (97 theoretical, 28 dissertations, and 60 empirical) addressing psychotherapy supervision, whereas the 1990s saw an increase in publications by approximately 60% (i.e., a total of 291 articles—190 theoretical, 29 dissertations, and 72 empirical). It is interesting that since 2000, there has been only a 4% increase in psychotherapy-based supervision articles (i.e., a total of 303 articles—191 theoretical, 32 dissertations, and 80 empirical). Although research in the 1980s began addressing aspects such as supervision models, supervisee variables, parallel process in supervision, and the impact of psychotherapy supervision on client outcome, a great many articles focused on theoretical and conceptual issues in supervision. By the 1990s, an important change had occurred within the American Psychological Association’s (1996, 2000) Committee on Accreditation. Supervision was deemed to be a crucial area of training and identified as one of the top five activities for psychologists (Robiner & Schofield, 1990). This era of research saw an expansion of theoretical literature on supervision and a greater research focus on supervisory process, supervisee and supervisor characteristics and development, legal and ethical issues in supervision, supervision in special settings, and cultural issues and competencies in supervision (Peake, Nussbaum, & Tindell, 2002). This emerging literature highlighted supervision as a distinct area of study. Although this focus has continued into the present, there continue to be a greater number of theoretical articles as opposed to

We would like to thank Amanda Busby and Sarini Ettigi for their superb assistance with the literature review.

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Research: The State of the Field 501 research-based articles on psychotherapy supervision. Empirical articles on psychotherapy supervision continue to increase at a slow rate. Although the reasons for the slow state of output have never been examined, it is likely a result of several factors. First, a comprehensive examination of supervision involves assessing the experiences of supervisors, supervisees, and their clients, a task that is not easily achieved (e.g., Ladany, Walker, Pate-Carolan, & Gray, 2008). Despite the recognition of the importance of the supervisor’s role, a majority of the research has focused on the supervisee’s experience (Watkins, 1997), with some attention to client outcome (Freitas, 2002). Attention to the supervisory role has been lagging. A second and related factor is that engaging in such quality research can be difficult due to sampling difficulties and methodological rigor (e.g., few reliable assessment instruments; Ellis, Ladany, Krengel, & Schult, 1996). Finally, few researchers are engaged in a systematic program of research, resulting in a smattering of supervision research resulting in the ability to draw only tentative conclusions. In light of this, for our review we included research from across disciplines (e.g., social work, counseling psychology, marriage and family therapy) to obtain a more comprehensive view of psychotherapy research. We attempted to focus on variables that have some history of investigation. In addition, we clustered studies in order to draw some conclusions. We also included empirical research on some collateral dimensions of supervision that have been supported by theoretical literature as meaningful to the practice of supervision. Thus, we clustered studies that reflect supervisory process; supervisee variables; client outcome; supervisor variables; and collateral dimensions such as multicultural competencies, ethics, and areas of specialization. S U P E RV I S O RY P R O C E S S THE SUPERVISORY RELATIONSHIP In the 1980s and early 1990s, a series of articles examined the supervisory relationship. During this period, the conceptualization of the supervisory relationship was based on social influence theory (e.g., Efstation, Patton, & Kardash, 1990; Heppner & Handley, 1981), the reconceptualization of the therapeutic working alliance (Bordin, 1983), the structure of the supervisory relationship (Holloway, 1982; Holloway & Wampold, 1983), and client-centered conditions (Schacht, Howe, & Berman, 1988, 1989). Few investigations examined the supervisory relationship from an atheoretical perspective (see Ellis & Ladany, 1997, for a review). Although some studies (Chen & Bernstein, 2000) have been conducted using Efstation et al.’s conceptualization of the alliance, the efficacy of the measure is confounded by its psychometric and theoretical problems (Ellis & Ladany, 1997). It is interesting that of the different conceptualizations, Bordin’s reconceptualization of the therapeutic working alliance has garnered the most attention both theoretically and empirically. Bordin’s (1983) model of the supervisory working alliance is made of up of three components: agreement on goals of supervision, agreement on tasks of supervision, and an emotional bond between the supervisee and the supervisor. With all three components, the concept of mutuality is noted to be critical. In relation to the goals, Bordin described eight areas of focus: (1) mastering specific skills, (2) expanding one’s conceptual understanding of clients, (3) increasing one’s awareness of

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therapeutic process issues, (4) increasing awareness of self and its impact on the therapeutic process, (5) identifying and overcoming personal and intellectual obstacles in learning to engage in the psychotherapeutic process, (6) deepening one’s understanding of theoretical concepts, (7) providing an avenue for research, and (8) maintaining ethical standards of practice. Corresponding to these goals, Bordin identified a series of mutually agreed-upon tasks. Although the tasks were perceived to shift based on the goals, in general Bordin identified tasks that included observation of the supervisee’s clinical work through self-reports, audiotape, and videotape recordings; provision of critical feedback on reports; identification of supervisee strengths; exploration of supervisee feelings in the clinical setting; and development of alternative hypotheses. Furthermore, in speaking of the third component of the working alliance, Bordin proposed that the strength of the emotional bond is reflected in the extent to which there is mutual trust, likability, and care between the supervisee and supervisor. Additionally, Bordin identified the need for the supervisor to empathize with the supervisee and to actively diffuse the hierarchical relationship inherent in supervision to help strengthen the alliance. Bordin’s model has been tested empirically using a measure developed by Bahrick (1990). The measure was adapted from the Working Alliance Inventory, a measure originally intended to assess the therapeutic alliance (Horvath & Greenberg, 1986). Findings from the various studies indicate that a stronger supervisory working alliance is related to goal setting and feedback (Lehrman-Waterman & Ladany, 2001), trainee satisfaction (Inman, 2006; Ladany, Ellis, & Friedlander, 1999), greater supervisor attractiveness and interpersonal sensitivity (Ladany, Walker, & Melincoff, 2001), supervisor self-disclosure (Ladany & Lehrman-Waterman, 1999), and supervisor and supervisee being at advanced stages of racial identity (Ladany, Brittan-Powell, & Pannu, 1997). Conversely, a weaker supervisory alliance relates to greater trainee role conflict and ambiguity (Ladany & Friedlander, 1995), poorer supervisor adherence to ethical behaviors (Ladany, Lehrman-Waterman, Molinaro, & Wolgast, 1999), and lower supervisor multicultural competence (Inman, 2006). One tentative but important conclusion that can be drawn from these studies is that supervisory working alliance is at the heart of effective supervision (Ladany et al., 2005). Although Bahrick’s measure has demonstrated good reliability and validity, there are still some concerns related to the measure. For instance, because of the multicollinearity among the three factors of the scale, it is speculated that perhaps the scale should be used as a single-score measure rather than a three-subscale measure (Inman, 2006). Furthermore, given that Bordin’s model is adapted from an aspect of therapy (i.e., therapeutic alliance), it is limited in its scope. For instance, there are conceptual gaps in the theoretical model related to specificity among the goals and tasks identified. Furthermore, the model does not address how supervision may differ from psychotherapy (e.g., involuntary nature and evaluation). Thus, future research is needed to consider the effectiveness of Bordin’s model to the supervisory relationship. EVALUATION Apart from being involuntary, one aspect that distinguishes counseling from supervision and adds complexities to the supervisory relationship is its evaluative

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Research: The State of the Field 503 nature. Evaluation has been conceptualized as having two functions: goal setting and feedback (Lehrman-Waterman & Ladany, 2001). Despite the fact that setting goals and providing feedback are integral parts of the evaluative process in supervision, knowing which processes constitute effective evaluation is a challenging task. Researchers have used different approaches to examine varying aspects of the evaluative process in order to get to the heart of this question. For instance, some attention has been given to the use of audiotapes and videotapes to evaluate supervisees’ clinical work. It is interesting that Ladany and colleagues (Ladany & Lehrman-Waterman, 1999; Ladany, Lehrman-Waterman, et al., 1999) found that supervisors rely minimally on audiotapes (60%) and videotapes (40%) to assess trainees’ clinical work. In fact, research has revealed that use of one-way mirrors, audiotaping, and videotaping has negligent effects on supervisees (Ellis, Krengel, & Beck, 2002). Conversely, supervisors tend to predominantly rely on supervisee self-report to assess the latter’s clinical work. Russell, DuPree, Beggs, Peterson, and Anderson (2007) found that marriage and family therapy supervisors strongly uphold their role as gatekeepers. Although the more serious consequences such as probation or dismissal are used for issues related to dishonesty or lack of personal integrity, the supervisors assessed in this study considered talking with their supervisee as an important step to fully assessing student performance and problems. In fact, the evaluation literature indicates that trainees are often evaluated qualitatively (Norcross & Stevenson, 1984). Furthermore, supervisors tend to have a leniency bias (Gonsalvez & Freestone, 2007) in that evaluations are influenced by how much supervisors like trainees (Carey, Williams, & Wells, 1988; Dodenhoff, 1981). These issues bring up questions related to supervisors’ appropriate, reliable, and ethical evaluation of their supervisees (Cormier & Bernard, 1982; Ladany, Lehrman-Waterman, et al., 1999). Other studies have examined specific components of evaluation. For instance, in examining the role of feedback in supervision, Chur-Hansen and McLean (2006) found that formative feedback (i.e., ongoing throughout supervision) as compared to summative feedback (i.e., more formal review, typically at the middle and end of an academic semester) was seen as more important for good supervision among psychiatry trainees and their supervisors. In another qualitative study, Hoffman, Hill, Holmes, and Freitas (2005) examined the reasons why supervisors gave easy, difficult, or no feedback. Easy feedback that was typically given for clinical problems was provided directly and positively received by supervisees who were open to the supervisory process. Conversely, difficult feedback related to clinical, personal, and professional issues; was likely provided indirectly; and involved supervisees who were not open to the supervisory process. Finally, no feedback was given when issues typically pertained to personal concerns on the part of supervisees. Lehrman-Waterman and Ladany (2001) noted the overall effectiveness of evaluations and found that supervisees’ perceptions of effective evaluation (including goal setting and feedback) were related to the supervisory working alliance, supervisee self-efficacy, and satisfaction. Although these studies provide some important information, the findings also reveal some of the challenges related to the evaluative process. Furthermore, although the bulk of the evaluation tends to be qualitative and verbal, several evaluation instruments currently exist in the field. However,

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researchers (Ellis & Ladany, 1997; Lambert & Ogles, 1997) have found that no one measure is superior to any other because measures are either outdated or psychometrically unsound. Furthermore, not using multiple sources of evaluation that focus on specific trainee behaviors creates a monomethod bias (Campbell & Fiske, 1959). Thus, additional research is needed to assess the effectiveness of supervisee evaluation instruments. To assist with this, Ladany and Muse-Burke (2001) provided a theoretical framework that identifies several different components to assessing the efficacy of the evaluative process. These components include (a) mode of counseling, (b) domain of supervisee behavior, (c) area of competence, (d) approach to assessment, (e) proportion of caseload, (f) segment of experience, (g) particular time period in treatment, (h) evaluator, (i) proficiency level, (j) reliability, (k) validity, and (l) format. Although we recognize that it may be challenging to include all of these components in one measure, it may be helpful to develop multiple strategies and measures that target specific behaviors to assist in this process. PARALLEL PROCESS Parallel process is a powerful three-person interaction wherein interpersonal dynamics experienced in the therapeutic relationship may be unconsciously carried over to the supervisory relationship and vice versa (Ekstein & Wallerstein, 1972; McNeill & Worthen, 1989). Thus, parallel process can be upward (i.e., therapy to supervision) or downward (i.e., supervision to therapy; Doehrman, 1976). Although parallel process has a long history and is widely used, there is little empirical evidence for its existence (Mothersole, 1999). What little evidence does exist is limited to case study research (Alpher, 1991; Caligor, 1981; Doehrman, 1976; Friedlander, Siegel, & Brenock, 1989) and one survey (Raichelson, Herron, Primavera, & Ramirez, 1997). Although these studies suggest that parallel process can occur and has significant value in the supervisory relationship, the specificity or the manner by which it occurs is unclear. Thus, further research is needed in this area. CONFLICTUAL SUPERVISION Recent research has examined the role of conflictual experiences in supervision, noting that supervision is not always a safe place for learning. In fact, just as supervision can foster growth in the supervisee, it can also cause psychological harm to the supervisee. The impact of such harm is likely to vary depending on the supervisee’s developmental level and the strength of the working alliance (Ramos-S´anchez et al., 2002). Using a qualitative methodology, researchers (Gray, Ladany, Walker, & Ancis, 2001; Magnuson, Wilcoxon, & Norem, 2000; Nelson & Friedlander, 2001) examined the influence of conflictual experiences in supervision. Similar themes evolved across investigations that reflected supervisor roles and supervisee experiences. For instance, studies revealed that when conflictual supervision occurred, supervisory style was depicted as being unsupportive, disrespectful, and blaming. Conversely, supervisees reported not having clarity in their roles and expectations, with conflict

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Research: The State of the Field 505 resulting in negative feelings and decreased self-efficacy. Furthermore, it was noted that under such circumstances, supervisees sought help from others (e.g., peers) in the form of support and more appropriate supervision. It appears that these situations also allowed supervisees to become knowledgeable about what effective and ineffective supervision may look like. Based on these investigations, Veach (2001) extended a model with eight dimensions that can be used to classify conflictual events in supervision: (1) type of event, (2) focus of content, (3) intentionality, (4) covert versus overt, (5) intensity, (6) frequency, (7) timing in relationship, and (8) recency of event. Furthermore, because conflicts can occur in multiple ways within supervision and one cannot underscore their effects, Ellis (2001) recommended five areas for future research: (1) harmful supervisory behaviors, (2) training issues for supervisors, (3) supervisees’ contributions to the conflictual experience, (4) pervasiveness of the phenomenon, and (5) ethical practice (e.g., training sites having a Supervisee Bill of Rights).

S U P E RV I S E E VA R I A B L E S DEVELOPMENT Historically, supervisee development has received the most attention in the supervision literature. Broadly defined, supervisee development has been explored in terms of developmental level (Borders, 1990; Fisher, 1989), level of awareness or reflexivity (Neufeldt, Karno, & Nelson, 1996; Tryon, 1996), cognitive complexity (Lovell, 1999), and developmental model (Krause & Allen, 1988), to name a few. Reviews on the empirical work on supervisee development (Ellis & Ladany, 1997; Holloway, 1982; Stoltenberg, McNeill, & Crethar, 1994; Watkins, 1995b; Worthington, 1987) seem to share some thoughts about the viability of developmental processes for supervisees. In particular, the bulk of the studies suggest some support for a developmental process operating in supervisees. Furthermore, the research shows that supervisees not only need different types of guidance (e.g., there is a greater need for structure on the part of beginning vs. advanced supervisees), but also show a developmental increase in both personal (e.g., reflectivity) and intellectual (e.g., cognitive complexity) aspects of their growth. These reviews suggest that both supervisors and supervisees perceive supervisees differently as supervisees gain experience. Furthermore, self-assessments, expression of expectations, and role adoption have been considered important trainee attributes for engaging in psychotherapy supervision (Rodenhauser, Rudisill, & Painter, 1989). On a related note, one area that has received some attention in recent years is supervisees’ ability to engage in self-supervision. An aspect of self-supervision is to self-regulate one’s behaviors in counseling (e.g., reflect, monitor, manage, and critique behaviors; Dennin & Ellis, 2003). Some preliminary evidence suggests that self-regulation training increases supervisees’ ability to use metaphors but does not affect their use of empathy (Dennin & Ellis, 2003). However, given that a majority of studies have relied on self-reports and have shown significant methodological issues, these conclusions are tenuous. Clearly, more work is needed to test specific developmental hypotheses in a theoretically consistent manner.

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SEXUAL ATTRACTION TOWARD CLIENTS AND USE OF SUPERVISION A major taboo for supervisees is the discussion of sexual attraction, and this topic is perhaps the most difficult for supervisees to talk about in supervision (Ladany, Hill, Corbett, & Nutt, 1996; Ladany, O’Brien, et al., 1997; Pope, Sonne, & Greene, 2006). In fact, despite the frequency with which sexual attraction may occur, surveys have shown that fewer than 10% of graduate training programs address this topic (Bernsen, Tabachnick, & Pope, 1994). However, preliminary results examining the discussion of sexual attraction within the context of supervision suggest that supervisees believe that their sexual attraction toward clients does influence counseling process and outcome, and it is interesting that it is the supervisor who is reluctant to talk about it in supervision (Ladany, O’Brien, et al., 1997). NONDISCLOSURE One area of research that has attracted much attention in recent years is that which supervisees do not disclose to their supervisors. Four studies have examined supervisee nondisclosure (Ladany et al., 1996; Webb & Wheeler, 1998; Yourman, 2003; Yourman & Farber, 1996). Both Ladany et al. (1996) and Yourman and Farber’s studies revealed that 90% of the time, supervisees tend to withhold important information from their supervisors. Typically, these nondisclosures occur when supervisees experience shame in supervision (Yourman, 2003). For instance, supervisee nondisclosures were frequently related to fear of being judged negatively for clinical mistakes. Nondisclosures also occurred when supervisees had negative reactions toward their supervisors. These nondisclosures were noted to negatively influence the supervisory working alliance (Webb & Wheeler, 1998). Furthermore, although nondisclosures occurred within all modalities, supervisees were more likely to engage in nondisclosures in group supervision rather than in individual supervision (Webb & Wheeler, 1998). Given that covert experiences are perhaps more significant than overt experiences, greater attention needs to be given to this supervisee variable. CLIENT OUTCOME Although psychotherapy supervision is conducted to promote trainee development, the ultimate effect of supervision is intended to influence client outcome (Freitas, 2002). However, given that client outcome is at least one step removed from supervision work, it is possible that supervision may have limited influence on it. Assessing the influence of supervision on client outcome entails significant methodological complexities due to the difficulties in obtaining data on triadic samples (client–counselor–supervisor; Ladany et al., 2008). That being said, there has been a diverse set of approaches to studying supervision and client outcome, with at least 18 studies conducted since the 1980s. Despite the fact that these studies have been criticized for their methodological flaws, poor psychometric properties, and research design (Ellis & Ladany, 1997; Freitas, 2002), these investigations provide a general sense of how supervision can be used to influence client outcome. Specifically, counselors can alter the course of treatment if they receive information about poor client progress (Lambert, Hansen, & Finch, 2001). Providing supervision closer to the trainee’s therapy session with his or her client (Couchon & Bernard,

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Research: The State of the Field 507 1984; Kivlighan, Angelone, & Swafford, 1991) and focusing on a particular skill or content area in supervision may not only help the trainee alter the skill or address the issue in counseling (Bambling, King, Raue, Schweitzer, & Lambert, 2006) but also lead the client to view the session more positively (Kivlighan et al., 1991). In the end, given the complexities inherent in the supervisor–supervisee–client triadic experience, the influence of supervision on client outcome may present significant challenges for researchers wishing to demonstrate the efficacy of supervision.

S U P E RV I S O R VA R I A B L E S DEVELOPMENT Whereas a majority of the research from 1980 to 2007 focused on supervisee development, we were able to find only four empirical articles addressing supervisor development (i.e., Ellis, 1991; Ellis & Dell, 1986; Glidden & Tracey, 1992; Steven, Goodyear, & Robertson, 1998). These studies revealed that not only are there fewer supervisor development models, but many of these models lack empirical support (Watkins, 1995a). Furthermore, given the methodological issues related to the limited research on supervisor development, Watkins (1995a) suggested that future research use both qualitative and quantitative approaches. He also encouraged researchers to engage in longitudinal research by separating developmental level from experience level, examining the interactional effects of variables, and studying self-reflection or criticality as an important component of supervisor development. Finally, he suggested that the research on supervisee–supervisor relationship be the impetus for research on supervision development as well as supervision training. As noted previously, the 1990s saw a significant shift relative to supervisor training. The American Psychological Association’s (1996, 2000) Committee on Accreditation deemed supervision to be a critical area of training (Robiner & Schofield, 1990), and states began to require psychologists engaged in supervision practice to obtain supervisor training. Following this mandate, Scott, Ingram, Vitanza, and Smith (2000) examined the status of supervisor training and found that in comparison to clinical psychology programs, counseling psychology programs were more likely to offer supervision training. In a related fashion, counseling center internships were more likely than any other internship sites to include supervision training. Steven et al. (1998) examined the influence of time served as supervisor and formal training on supervisory stance, supervisory emphases, and self-efficacy. Their findings revealed that experience alone does not influence supervisor development, however the type of training that supervisors receive does influence the stance they take in supervision (e.g., more supportive, less critical and dogmatic). Conversely, both experience and training seem to be positively related to supervisors’ sense of self-efficacy. These findings provide some preliminary support for the provision of supervisor training in the development of the supervisory role.

COUNTERTRANSFERENCE Supervisor countertransference, also known as supertransference (Teitelbaum, 1990), has been pantheoretically defined as “an exaggerated, unrealistic, irrational, or distorted reaction related to a supervisor’s work with a trainee” (Ladany, Constantine,

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Miller, Erickson, & Muse-Burke, 2000, p. 111). These authors conducted a study exploring supervisor countertransference in supervision and noted that countertransference occurs in the form of thoughts, feelings, or behaviors “in response to both the trainee’s interpersonal style and the supervisor’s unresolved personal issues and may also be in response to trainee-supervision environmental interactions, problematic client-trainee interactions, trainee-supervisor interactions, or supervisor-supervision environment interactions” (p. 111) and can influence supervision outcome.

SELF-DISCLOSURE Similar to supervisee nondisclosure, some attention has been given to supervisor disclosure in supervision. For example, Ladany and Walker (2003) developed a model of supervisor self-disclosure. This model proposes that the content (i.e., personal material, professional experiences, therapy experiences, supervision experiences, and reactions to the trainee’s clients) and the personalization (i.e., discordant to congruent, nonintimate to intimate, and in the service of the supervisor or trainee) of the self-disclosure can to varying degrees create shifts in the supervisory working alliance, supervisee disclosure, and supervisee ability to learn. To date, preliminary evidence suggests that supervisor self-disclosure, particularly about counseling struggles, is related to the supervisory working alliance (Ladany & Lehrman-Waterman, 1999). Furthermore, Ladany & Lehrman-Waterman’s study revealed that supervisors engage in two types of nondisclosures: those that should not have been disclosed and those that should have been disclosed. Nondisclosures that should have been kept to oneself included those related to personal issues, negative supervisor self-efficacy, and attraction to the trainee; nondisclosures that merited disclosure were related to positive or negative reactions to the trainee’s counseling or supervision work. Clearly, this research suggests that what is not verbalized is perhaps more revealing than what is verbalized. Thus, more work is needed to determine how these nondisclosures influence supervision outcome.

C O L L AT E R A L D I M E N S I O N S O F S U P E RV I S I O N MULTICULTURAL ISSUES With multiculturalism being identified as the fourth force in the field of counseling (Pedersen, 1990), research on multicultural training has steadily increased (Goodyear & Guzzardo, 2000). However, this same commitment has not been as evident in the theoretical or empirical work on supervision. Although the bulk of the research has examined discussion of multicultural issues in general and the role of race in supervision, other cultural constructs have received less attention. For instance, several researchers have found that trainees value the discussion of multicultural issues in supervision (Burkard et al., 2006; Dressel, Consoli, Kim, & Atkinson, 2007; Duan & Roehlke, 2001; Fukuyama, 1994; Hird, Cavalieri, Dulko, Felice, & Ho, 2001; Killian, 2001; Kleintjes & Swartz, 1996; Lawless, Gale, & Bacigalupe, 2001). In fact, authors have investigated the difference between culturally responsive supervision and culturally unresponsive supervision. In culturally

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Research: The State of the Field 509 responsive supervision, supervisors are aware, open, and sincere in creating a space for explicit discussion of culture-specific issues and to show their vulnerability by sharing their own struggles. Furthermore, when supervisors focus trainees on race in a conceptualization, it leads supervisees to include racial issues in the conceptualization (Ladany, Inman, Constantine, & Hofheinz, 1997). Conversely, in culturally unresponsive supervision, supervisors engage in gender bias and racial microaggressions such as ignoring or discounting cultural issues, not being sensitive to supervisees’ nonverbal cues, stereotyping cultural explanations for psychological difficulties, and lacking interpersonal awareness within the supervisory relationship (e.g., Constantine & Sue, 2007; Dressel et al., 2007; Fong & Lease, 1997; Killian, 2001; Lopez, 1997; Priest, 1994; Remington & DaCosta, 1989). Furthermore, supervisees of color experience culturally unresponsive supervision more frequently than their White counterparts (Burkard et al., 2006). Using a blend of qualitative and analog methodology, Utsey, Hammar, and Gernat (2005) found that their sample of White supervisees was uncomfortable discussing their own racial issues in a focus group. In sum, these studies shed light on complex perspectives regarding cultural responsiveness in supervision and racial issues in particular. For an extended discussion on racial and cultural issues in psychotherapy supervision, see Chapter 28. In order to address race and racial issues in supervision, studies have been conducted on the influence of racial matching in supervision (Cook & Helms, 1988; Hilton, Russell, & Salmi, 1995; McRoy, Freeman, Logan, & Blackmon, 1986). Although findings from these studies have been mixed, the construct of racial identity has proven to be more promising (Bhat & Davis, 2007; Killian, 2001; Ladany, Brittan-Powell, et al., 1997). Specifically, supervisors with higher racial consciousness and a genuine interest in other cultures or similar cultural experiences as their supervisees seem better equipped to bring up these issues in supervision, thus creating a culturally receptive environment and a stronger working alliance. Early studies of gender matching in relation to supervisory process and outcome also demonstrated mixed results (Goodyear, 1990; Putney, Worthington, & McCullough, 1992; Schiavone & Jessell, 1988; Stenack & Dye, 1983; Worthington & Stern, 1985). However, investigations exploring the effects of gender on supervision have revealed that the extent to which a supervisor is task oriented or relationship oriented and displays power messages varies by the gender of the supervisor and supervisee (Nelson & Holloway, 1990; Robyak, Goodyear, & Prange, 1987; Robyak, Goodyear, Prange, & Donham, 1986; Sells, Goodyear, Lichtenberg, & Polkinghorne, 1997). Recent research on gender and supervision has moved beyond mere nominal variables (e.g., biological sex) to understand the complexities inherent in the social construction of gender. For instance, in a recent study examining the relationship between feminist identity and supervision practices, Szymanski (2005) found that a feminist identity that includes a critical examination of traditional gender roles and sexism, connection with women’s communities, and activism was related to feminist supervision practices. In a related fashion, Walker, Ladany, and Pate-Carolan (in press) studied gender-related events in supervision from the perspectives of women supervisees. A gender-related event was identified as relating to the gender of either the trainee or client, or to stereotypes about gender roles and the social construction of gender. Findings revealed that approximately half of

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the supervisees identified events that were supportive in nature (e.g., helping the supervisee conceptualize a case using a gendered perspective, processing genderrelated feelings in supervision, integrating gender information into professional development discussions), whereas approximately half of the supervisees identified unsupportive events (e.g., making stereotypical comments about the trainee or a client, discounting gender, engaging in inappropriate behavior toward the supervisee). These studies not only highlight the reality that gender issues continue to influence the supervision process but urge researchers to move beyond considering mere nominal variables. With regard to sexual orientation and supervision, there continues to be a noticeable gap in the empirical literature. We found only one study that considered sexual orientation in supervision. Sherry, Whilde, and Patton’s (2005) study revealed that although sexual orientation issues were discussed in practicum and supervision experiences, the specifics regarding how this was done were beyond the scope of their survey. Clearly, more empirical work is needed in this neglected area. For an extended discussion about sex and gender issues, please see Chapter 29. We find a similar gap in the literature with regard to religion. This is not surprising, given the controversial nature of this construct in the field of counseling psychology. The one study that we found highlighted these issues clearly. Gubi (2007) explored the supervision experience of mainstream counselors integrating prayer in supervision. His findings suggest that counselors are hesitant to bring up the use of prayer in supervision for several reasons: fear of being misunderstood, reaction to a culture closed to the use of religion or prayer in counseling, fear of being judged by the supervisor, and fear of dismissing an important aspect of a trainee’s experience or identity. Although these latter investigations extend the work in multicultural supervision, the findings tend to create binary identities, denying the multiplicity of cultural identities. Thus, more research is needed to understand the complex nuances inherent in multicultural issues in supervision. To this end, Ancis and Ladany (2001) offered a theoretical framework for conceptualizing multicultural identity issues as well as multicultural supervision competencies. As part of their heuristic model of nonoppressive interpersonal development for supervisors and supervisees, they propose a model that focuses on conceptualizing multicultural identities (i.e., gender, race, sexual orientation, ethnicity, disability, and socioeconomic status) in the client–counselor–supervisor triad. Although this model mimics other identity models (e.g., Helms, 1990) by defining similar phases of identity development (i.e., adaptation, incongruence, exploration, and integration) and supervisory interpersonal relationship types (progressive, parallel advanced, parallel delayed, and regressive), it takes into account the whole individual without the need to essentialize identities. In effect, it takes the perspective of identity development as evolving from both socially oppressed (e.g., female) and socially privileged (e.g., White) groups, aspects that exist in individuals. This model not only brings to the forefront the intersection of identities but also defines multicultural competencies across six domains (i.e., supervisor-focused personal development, superviseefocused development, conceptualization, skills and interventions, process, and outcome and evaluation). Inman (2006) adapted this model and developed a

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Research: The State of the Field 511 measure that provides an important avenue for exploring supervisor multicultural competence. However, further research is needed to validate this measure. ETHICS Although all mental health professions (e.g., social work, marriage and family, counseling psychology) have created ethical guidelines for supervision, little empirical attention has been given to ethical behaviors in supervision. For instance, Henderson, Cawyer, and Watkins (1999) found that issues of evaluation, ethics, and adaptability were key features of the supervisory experience in the perception of effective practicum experiences. Ladany, Lehrman-Waterman, et al.’s 1999) study revealed that 51% of their trainee sample reported that their supervisor did not adhere to an ethical approach to supervision, with inadequate performance evaluation, confidentiality issues, ability to work from alternative perspectives, and respectful treatment being cited as the most frequently violated supervisory guidelines. Clearly, these statistics warrant greater attention to this variable. AREAS OF SPECIALIZATION The bulk of supervision has attended to supervisees working with individual clients in general mental health settings. However, specialized forms of supervision for specialized populations, clinical problems, and counseling work continue to need attention. These areas include psychotherapy-based supervision (Rosenbaum & Ronen, 1998; Slavin, 1998); group supervision of individual coun¨ seling (Ogren, Jonsson, & Sundin, 2005; peer group supervision (Bernard & Goodyear, 2004); postdegree supervision (King & Wheeler, 1999); and supervision of family counseling (Liddle, Becker, & Diamond, 1997), couples counseling (Stratton & Smith, 2006), career counseling (Bronson, 2001), assessment (Handler & Hilsenroth, 1998; Prieto & Stoltenberg, 1997), counseling children and adolescents (Neill, 2006), counseling in the military (Ball & Gingras, 1991), counseling in rehabilitation settings (Strutts, 1991), working with HIV patients (Bor, Scher, & Salt, 1992; Pugh, Ramsay, & Catalan, 1994), international trainees (Nilsson & Anderson, 2004; Nilsson & Dodds, 2006), and school counseling (Magnuson, Norem, & Bradley, 2001). CONCLUSION The strongest conclusion that we can make about psychotherapy supervision is that it continues to be a path less traveled. Although the existing research is encouraging, the complex and interrelated roles of the supervisor, supervisee, and client challenge researchers’ ability to assess the relevant issues that influence the supervision process and outcomes in psychotherapy. This certainly highlights the disconnect that exists in theory, research, and practice. Furthermore, although researchers have developed some important insights into specific supervision variables (e.g., supervisory process, supervisee characteristics), supervisor experiences continue to receive little attention. This is surprising, given that the supervisor is integral to counselor development. Additionally, despite the fact that there is more

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research on supervisees, the small sample sizes of these studies create significant difficulties necessitating the use of alternative research and statistical methods. We hope that the state of research highlighted in this chapter provides meaningful pathways for engaging in a more comprehensive and thoughtful research program on the practice of psychotherapy supervision. REFERENCES Alpher, V. S. (1991). Interdependence and parallel processes: A case study of structural analysis of social behavior in supervision and short-term dynamic psychotherapy. Psychotherapy: Theory, Research, Practice, and Training, 28, 218–231. American Psychological Association. (1996). Office of program consultation and accreditation guidelines and principles for accreditation of programs in professional psychology. Washington, DC: Author. American Psychological Association. (2000). Office of program consultation and accreditation guidelines and principles for accreditation of programs in professional psychology. Washington, DC: Author. Ancis, J., & Ladany, N. (2001). Multicultural supervision. In L. J. Bradley & N. Ladany (Eds.), Counselor supervision: Principles, process, and practice (3rd ed. , pp. 63–90). Philadelphia: Brunner-Routledge. Bahrick, A. S. (1990). Role induction for counselor trainees: Effects on the supervisory working alliance. Dissertation Abstracts International, 51(3-B), 1484. Ball, J. D., & Gingras, T. (1991). Psychotherapy and its supervision in the U.S. military. Clinical Supervisor, 9(1), 115–134. Bambling, M., King, R., Raue, P., Schweitzer, R., & Lambert, W. (2006). Clinical supervision: Its influence on client-rated working alliance and client symptom reduction in the brief treatment of major depression. Psychotherapy Research, 16, 317–331. Bernard, J. M., & Goodyear, R. K. (2004). Fundamentals of clinical supervision (3rd ed. ). Needham Heights, MA: Allyn & Bacon. Bernsen, A., Tabachnick, B. G., & Pope, K. S. (1994). National survey of social workers’ sexual attraction to their clients: Results, implications, and comparison to psychologists. Ethics and Behavior, 4, 369–388. Bhat, C. S., & Davis, T. E. (2007). Counseling supervisors’ assessment of race, racial identity, and working alliance in supervisory dyads. Journal of Multicultural Counseling and Development, 35(2), 80–91. Bor, R., Scher, I., & Salt, H. (1992). Supervising professionals involved in the psychological care of people infected with HIV/AIDS. Counselling Psychology Quarterly, 5, 95–109. Borders, L. D. (1990). Developmental changes during supervisees’ first practicum. Clinical Supervisor, 8(2), 157–167. Bordin, E. S. (1983). Supervision in counseling: Pt. II. Contemporary models of supervision—A working alliance based model of supervision. Counseling Psychologist, 11, 35–42. Bronson, M. K. (2001). Supervision of career counseling. In L. J. Bradley & L. Nicholas (Eds.), Counselor supervision: Principles, process, and practice (3rd ed. , pp. 222–244). New York: Brunner-Routledge. Burkard, A. W., Johnson, A. J., Madson, M. B., Pruitt, N. T., Contreras-Tadych, D. A., Kozlowski, J. M., et al. (2006). Supervisor cultural responsiveness and unresponsiveness in cross-cultural supervision. Journal of Counseling Psychology, 53, 288–301. Caligor, L. (1981). Parallel and reciprocal processes in psychoanalytic supervision. Contemporary Psychoanalysis, 17(1), 1–27. Campbell, D. T., & Fiske, D. W. (1959). Convergent and discriminant validation by the multitraitmultimethod matrix. Psychological Bulletin, 56, 81–105. Carey, J. C., Williams, K. S., & Wells, M. (1988). Relationship between dimensions of supervisor influence and counselor trainees’ performance. Counselor Education and Supervision, 28, 130–139. Chen, E. C., & Bernstein, B. L. (2000). Relations of complementarity and supervisory issues to supervisory working alliance: A comparative analysis of two cases. Journal of Counseling Psychology, 47, 485–497. Chur-Hansen, A., & McLean, S. (2006). On being a supervisor: The importance of feedback and how to give it. Australian Psychiatry, 14, 67–71. Constantine, M. G., & Sue, D. W. (2007). Perceptions of racial microaggressions among Black supervisees in cross-racial dyads. Journal of Counseling Psychology, 54, 142–153. Cook, D. A., & Helms, J. E. (1988). Visible racial/ethnic group supervisees’ satisfaction with crosscultural supervision as predicted by relationship characteristics. Journal of Counseling Psychology, 35, 268–274.

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Research: The State of the Field 513 Cormier, L. S., & Bernard, J. M. (1982). Ethical and legal responsibilities of clinical supervisors. Personnel and Guidance Journal, 60, 486–491. Couchon, W. D., & Bernard, J. M. (1984). Effects of timing of supervision on supervisor and counselor performance. Clinical Supervisor, 2(3), 3–20. Dennin, M. K., & Ellis, M. V. (2003). Effects of a method of self-supervision for counselor trainees. Journal of Counseling Psychology, 50, 69–83. Dodenhoff, J. T. (1981). Interpersonal attraction and direct-indirect supervisor influence as predictors of counselor trainee effectiveness. Journal of Counseling Psychology, 28, 47–52. Doehrman, M. J. (1976). Parallel processes in supervision and psychotherapy. Bulletin of the Menninger Clinic, 40, 3–104. Dressel, J. L., Consoli, A. J., Kim, B. S. K., & Atkinson, D. R. (2007). Successful and unsuccessful multicultural supervisory behaviors: A Delphi poll. Journal of Multicultural Counseling and Development, 35(1), 51–64. Duan, C., & Roehlke, H. (2001). A descriptive “snapshot” of cross-racial supervision in university counseling center internships. Journal of Multicultural Counseling and Development, 29(2), 131–146. Efstation, J. F., Patton, M. J., & Kardash, C. M. (1990). Measuring the working alliance in counseling supervision. Journal of Counseling Psychology, 37, 322–329. Ekstein, R., & Wallerstein, R. S. (1972). The teaching and learning of psychotherapy (Rev. ed.). Oxford, England: International Universities Press. Ellis, M. V. (1991). Critical incidents in clinical supervision and in supervisor supervision: Assessing supervisory issues. Journal of Counseling Psychology, 38, 342–349. Ellis, M. V. (2001). Harmful supervision, a cause for alarm: Comment on Gray et al. (2001) and Nelson and Friedlander (2001). Journal of Counseling Psychology, 48, 401–406. Ellis, M. V., & Dell, D. M. (1986). Dimensionality of supervisor roles: Supervisors’ perceptions of supervision. Journal of Counseling Psychology, 33, 282–291. Ellis, M. V., Krengel, M., & Beck, M. (2002). Testing self-focused attention theory in clinical supervision: Effects on supervisee anxiety and performance. Journal of Counseling Psychology, 49, 101–116. Ellis, M. V., & Ladany, N. (1997). Inferences concerning supervisees and clients in clinical supervision: An integrative review. In C. E. Watkins (Ed.), Handbook of psychotherapy supervision (pp. 447–507). New York: Wiley. Ellis, M. V., Ladany, N., Krengel, M., & Schult, D. (1996). Clinical supervision research from 1981 to 1993: A methodological critique. Journal of Counseling Psychology, 43, 35–50. Fisher, B. L. (1989). Differences between supervision of beginning and advanced therapists: Hogan’s hypothesis empirically revisited. Clinical Supervisor, 7(1), 57–74. Fong, M. L., & Lease, S. H. (1997). Cross-cultural supervision: Issues for the White supervisor. In Multicultural counseling competencies: Assessment, education and training, and supervision (pp. 387–405). Thousand Oaks, CA: Sage. Freitas, G. J. (2002). The impact of psychotherapy supervision on client outcome: A critical examination of 2 decades of research. Psychotherapy: Theory, Research, Practice, and Training, 39, 354–367. Friedlander, M. L., Siegel, S. M., & Brenock, K. (1989). Parallel process in counseling and supervision: A case study. Journal of Counseling Psychology, 36, 149–157. Fukuyama, M. A. (1994). Critical incidents in multicultural counseling supervision: A phenomenological approach to supervision research. Counselor Education and Supervision, 34, 142–151. Glidden, C. E., & Tracey, T. J. (1992). A multidimensional scaling analysis of supervisory dimensions and their perceived relevance across trainee experience levels. Professional Psychology: Research and Practice, 23, 151–157. Gonsalvez, C. J., & Freestone, J. (2007). Field supervisors’ assessments of trainee performance: Are they reliable and valid? Australian Psychologist, 42(1), 23–32. Goodyear, R. K. (1990). Gender configurations in supervisory dyads: Their relation to supervisee influence strategies and to skill evaluations of the supervisee. Clinical Supervisor, 8(2), 67–79. Goodyear, R. K., & Guzzardo, C. R. (2000). Psychotherapy supervision and training. In S. Brown & R. W. Lent (Eds.), Handbook of counseling psychology (3rd ed. , pp. 83–108). New York: Wiley. Gray, L. A., Ladany, N., Walker, J. A., & Ancis, J. R. (2001). Psychotherapy trainees’ experience of counterproductive events in supervision. Journal of Counseling Psychology, 48, 371–383. Gubi, P. M. (2007). Exploring the supervision experience of some mainstream counsellors who integrate prayer in counselling. Counselling and Psychotherapy Research, 7(2), 114–121. Handler, L., & Hilsenroth, M. J. (1998). Teaching and learning personality assessment. Mahwah, NJ: Erlbaum. Helms, J. E. (1990). Black and White racial identity: Theories, research, and practice. Westport, CT: Greenwood Press.

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Henderson, C. E., Cawyer, C. S., & Watkins, C. E., Jr. (1999). A comparison of student and supervisor perceptions of effective practicum supervision. Clinical Supervisor, 18(1), 47–74. Heppner, P. P., & Handley, P. G. (1981). A study of the interpersonal influence process in supervision. Journal of Counseling Psychology, 28, 437–444. Hilton, D. B., Russell, R. K., & Salmi, S. W. (1995). The effects of supervisor’s race and level of support on perceptions of supervision. Journal of Counseling and Development, 73, 559–563. Hird, J. S., Cavalieri, C. E., Dulko, J. P., Felice, A. A. D., & Ho, T. A. (2001). Visions and realities: Supervisee perspectives of multicultural supervision. Journal of Multicultural Counseling and Development, 29(2), 114–130. Hoffman, M. A., Hill, C. E., Holmes, S. E., & Freitas, G. F. (2005). Supervisor perspective on the process and outcome of giving easy, difficult, or no feedback to supervisees. Journal of Counseling Psychology, 52, 3–13. Holloway, E. L. (1982). Interactional structure of the supervision interview. Journal of Counseling Psychology, 29, 309–317. Holloway, E. L., & Wampold, B. E. (1983). Patterns of verbal behavior and judgments of satisfaction in the supervision interview. Journal of Counseling Psychology, 30, 227–234. Horvath, A. O., & Greenberg, L. S. (1986). The development of the Working Alliance Inventory. In L. S. Greenberg & W. M. Pinsof (Eds.), The psychotherapeutic process: A research handbook (pp. 529–556). New York: Guilford Press. Inman, A. G. (2006). Supervisor multicultural competence and its relation to supervisory process and outcome. Journal of Marital and Family Therapy, 32, 73–85. Killian, K. D. (2001). Differences making a difference: Cross-cultural interactions in supervisory relationships. Journal of Feminist Family Therapy, 12(2/3), 61–103. King, D., & Wheeler, S. (1999). The responsibilities of counsellor supervisors: A qualitative study. British Journal of Guidance and Counselling, 27, 215–229. Kivlighan, D. M., Angelone, E. O., & Swafford, K. G. (1991). Live supervision in individual psychotherapy: Effects on therapist’s intention use and client’s evaluation of session effect and working alliance. Professional Psychology: Research and Practice, 22, 489–495. Kleintjes, S., & Swartz, L. (1996). Black clinical psychology trainees at a “White” South African university: Issues for clinical supervision. Clinical Supervisor, 14(1), 87–109. Krause, A. A., & Allen, G. J. (1988). Perceptions of counselor supervision: An examination of Stoltenberg’s model from the perspectives of supervisor and supervisee. Journal of Counseling Psychology, 35, 77–80. Ladany, N., Brittan-Powell, C. S., & Pannu, R. K. (1997). The influence of supervisory racial identity interaction and racial matching on the supervisory working alliance and supervisee multicultural competence. Counselor Education and Supervision, 36, 284–304. Ladany, N., Constantine, M. G., Miller, K., Erickson, C. D., & Muse-Burke, J. L. (2000). Supervisor countertransference: A qualitative investigation into its identification and description. Journal of Counseling Psychology, 47, 102–115. Ladany, N., Ellis, M. V., & Friedlander, M. L. (1999). The supervisory working alliance, trainee selfefficacy, and satisfaction with supervision. Journal of Counseling and Development, 77, 447–455. Ladany, N., & Friedlander, M. L. (1995). The relationship between the supervisory working alliance and trainees’ experience of role conflict and role ambiguity. Counselor Education and Supervision, 34, 356–368. Ladany, N., Friedlander, M. L., & Nelson, M. L. (2005). Critical events in psychotherapy supervision: An interpersonal approach. Washington, DC: American Psychological Association. Ladany, N., Hill, C. E., Corbett, M., & Nutt, L. (1996). Nature, extent, and importance of what therapy trainees do not disclose to their supervisors. Journal of Counseling Psychology, 43, 10–24. Ladany, N., Inman, A. G., Constantine, M. G., & Hofheinz, E. (1997). Supervisee multicultural case conceptualization ability and self-reported multicultural competence as functions of supervisee racial identity and supervisor focus. Journal of Counseling Psychology, 44, 284–293. Ladany, N., & Lehrman-Waterman, D. E. (1999). The content and frequency of supervisor selfdisclosures and their relationship to supervisor style and the supervisory working alliance. Counselor Education and Supervision, 38, 143–160. Ladany, N., Lehrman-Waterman, D. E., Molinaro, M., & Wolgast, B. (1999). Psychotherapy supervisor ethical practices: Adherence to guidelines, the supervisory working alliance, and supervisee satisfaction. Counseling Psychologist, 27, 443–475. Ladany, N., & Muse-Burke, J. L. (2001). Understanding and conducting supervision research. In L. J. Bradley & N. Ladany (Eds.), Counselor supervision: Principles, process, and practice (3rd ed. , pp. 304–329). Philadelphia: Brunner-Routledge.

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Research: The State of the Field 515 Ladany, N., O’Brien, K. M., Hill, C. E., Melincoff, D. S., Knox, S., & Petersen, D. A. (1997). Sexual attraction toward clients, use of supervision, and prior training: A qualitative study of predoctoral psychology interns. Journal of Counseling Psychology, 44, 413–424. Ladany, N., & Walker, J. A. (2003). Supervisor self-disclosure: Balancing the uncontrollable narcissist with the indomitable altruist. Journal of Clinical Psychology, 59, 611–621. Ladany, N., Walker, J., & Melincoff, D. S. (2001). Supervisee integrative complexity, experience, and preference for supervisor style. Counselor Education and Supervision, 40, 203–219. Ladany, N., Walker, J. A., Pate-Carolan, L., & Gray, E. L. (2008). Experiencing counseling and psychotherapy: Insights from psychotherapy trainees, their clients, and their supervisors. New York: Taylor & Francis. Lambert, M. J., Hansen, N. B., & Finch, A. E. (2001). Patient-focused research: Using patient outcome data to enhance treatment effects. Journal of Consulting and Clinical Psychology, 69, 159–172. Lambert, M. J., & Ogles, B. M. (1997). The effectiveness of psychotherapy supervision. In C. E. Watkins, Jr. (Ed.), Handbook of psychotherapy supervision (pp. 421–446). New York: Wiley. Lawless, J. J., Gale, J. E., & Bacigalupe, G. (2001). The discourse of race and culture in family therapy supervision: A conversation analysis. Contemporary Family Therapy, 23(2), 181–197. Lehrman-Waterman, D., & Ladany, N. (2001). Development and validation of the Evaluation Process within Supervision Inventory. Journal of Counseling Psychology, 48, 168–177. Liddle, H. A., Becker, D., & Diamond, G. M. (1997). Family therapy supervision. In C. E. Watkins, Jr. (Ed.), Handbook of psychotherapy supervision (pp. 400–418). New York: Wiley. Lopez, S. R. (1997). Cultural competence in psychotherapy: A guide for clinicians and their supervisors. In C. E. Watkins, Jr. (Ed.), Handbook of psychotherapy supervision (pp. 570–588). New York: Wiley. Lovell, C. (1999). Supervisee cognitive complexity and the Integrated Developmental Model. Clinical Supervisor. 18(1), 191–201. Magnuson, S., Norem, K., & Bradley, L. J. (2001). Supervising school counselors. In L. J. Bradley & N. Ladany. (Eds.), Counselor supervision: Principles, process, and practice (3rd ed. , pp. 207–221). New York: Brunner-Routledge. Magnuson, S., Wilcoxon, S. A., & Norem, K. (2000). A profile of lousy supervision: Experienced counselors’ perspectives. Counselor Education and Supervision, 39, 189–202. McNeill, B. W., & Worthen, V. (1989). The parallel process in psychotherapy supervision. Professional Psychology: Research and Practice, 20, 329–333. McRoy, R. G., Freeman, E. M., Logan, S., & Blackmon,(1986). Cross-cultural field supervision: Implications for social work education. Journal of Social Work Education, 22, 50–56. Mothersole, G. (1999). Parallel process: A review. Clinical Supervisor, 18(2), 107–121. Neill, T. K. (2006). Helping others help children: Clinical supervision of child psychotherapy. Washington, DC: American Psychological Association. Nelson, M. L., & Friedlander, M. L. (2001). A close look at conflictual supervisory relationships: The trainee’s perspective. Journal of Counseling Psychology, 48, 384–395. Nelson, M. L., & Holloway, E. L. (1990). Relation of gender to power and involvement in supervision. Journal of Counseling Psychology, 37, 473–481. Neufeldt, S. A., Karno, M. P., & Nelson, M. L. (1996). A qualitative study of experts’ conceptualizations of supervisee reflectivity. Journal of Counseling Psychology, 43, 3–9. Nilsson, J. E., & Anderson, M. Z. (2004). Supervising international students: The role of acculturation, role ambiguity, and multicultural discussions. Professional Psychology: Research and Practice, 35, 306–312. Nilsson, J. E., & Dodds, A. K. (2006). A pilot phase in the development of the International Student Supervision Scale. Journal of Multicultural Counseling and Development, 34(1), 50–62. Norcross, J. C., & Stevenson, J. F. (1984). How shall we judge ourselves? Training evaluation in clinical psychology programs. Professional Psychology: Research and Practice, 15, 497–508. ¨ Ogren, M.-L., Jonsson, C.-O., & Sundin, E. C. (2005). Group supervision in psychotherapy: The relationship between focus, group climate, and perceived attained skill. Journal of Clinical Psychology, 61, 373–388. Peake, T. H., Nussbaum, B. D., & Tindell, S. D. (2002). Clinical and counseling supervision references: Trends and needs. Psychotherapy: Theory, Research, Practice, and Training, 39, 114–125. Pedersen, P. (1990). The multicultural perspective as a fourth force in counseling. Journal of Mental Health Counseling, 12(1), 93–95. Pope, K. S., Sonne, J. L., & Greene, B. (2006). What therapists don’t talk about and why. 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Prieto, L. R., & Stoltenberg, C. D. (1997). The supervision of psychological assessment: Toward parsimony and empirical evidence for developmental supervision theory. Professional Psychology: Research and Practice, 28, 593–594. Pugh, K., Ramsay, N., & Catalan, J. (1994). Supervision groups for health advisers working with patients with HIV disease. Counselling Psychology Quarterly, 7, 359–366. Putney, M. W., Worthington, E. L., & McCullough, M. E. (1992). Effects of supervisor and supervisee theoretical orientation and supervisor-supervisee matching on interns’ perceptions of supervision. Journal of Counseling Psychology, 39, 258–265. Raichelson, S. H., Herron, W. G., Primavera, L. H., & Ramirez, S. M. (1997). Incidence and effects of parallel process in psychotherapy supervision. Clinical Supervisor, 15(2), 37–48. Ramos-S´anchez, L., Esnil, E., Goodwin, A., Riggs, S., Touster, L. O., Wright, L. K., et al. (2002). Negative supervisory events: Effects on supervision and supervisory alliance. Professional Psychology: Research and Practice, 33, 197–202. Remington, G., & DaCosta, G. (1989). Ethnocultural factors in resident supervision: Black supervisor and White supervisees. American Journal of Psychotherapy, 43, 398–404. Robiner, W. N., & Schofield, W. (1990). References on supervision in clinical and counseling psychology. Professional Psychology: Research and Practice, 21, 297–312. Robyak, J. E., Goodyear, R. K., & Prange, M. (1987). Effects of supervisors’ sex, focus, and experience on preferences for interpersonal power bases. Counselor Education and Supervision, 26, 299–309. Robyak, J. E., Goodyear, R. K., Prange, M. E., & Donham, G. (1986). Effects of gender, supervision, and presenting problems on practicum students’ preference for interpersonal power bases. Journal of Counseling Psychology, 33, 159–163. Rodenhauser, P., Rudisill, J. R., & Painter, A. F. (1989). Attributes conducive to learning in psychotherapy supervision. American Journal of Psychotherapy, 43, 368–377. Rosenbaum, M., & Ronen, T. (1998). Clinical supervision from the standpoint of cognitive-behavior therapy. Psychotherapy: Theory, Research, Practice, and Training, 35, 220–230. Russell, C. S., DuPree, W. J., Beggs, M. A., Peterson, C. M., & Anderson, M. P. (2007). Responding to remediation and gatekeeping challenges in supervision. Journal of Marital and Family Therapy, 33, 227–244. Schacht, A. J., Howe, H. E., & Berman, J. J. (1988). A short form of the Barrett-Lennard Relationship Inventory for supervisory relationships. Psychological Reports, 63, 699–706. Schacht, A. J., Howe, H. E., & Berman, J. J. (1989). Supervisor facilitative conditions and effectiveness as perceived by thinking- and feeling-type supervisees. Psychotherapy: Theory, Research, Practice, and Training, 26, 475–483. Schiavone, C. D., & Jessell, J. C. (1988). Influence of attributed expertness and gender in counselor supervision. Counselor Education and Supervision, 28, 29–42. Scott, K. J., Ingram, K. M., Vitanza, S. A., & Smith, N. G. (2000). Training in supervision: A survey of current practices. Counseling Psychologist, 28, 403–422. Sells, J. N., Goodyear, R. K., Lichtenberg, J. W., & Polkinghorne, D. E. (1997). Relationship of supervisor and trainee gender to in-session verbal behavior and ratings of trainee skills. Journal of Counseling Psychology, 44, 406–412. Sherry, A., Whilde, M. R., & Patton, J. (2005). Gay, lesbian, and bisexual training competencies in American Psychological Association accredited graduate programs. Psychotherapy: Theory, Research, Practice, and Training, 42, 116–120. Slavin, J. H. (1998). Influence and vulnerability in psychoanalytic supervision and treatment. Psychoanalytic Psychology, 15(2), 230–244. Stenack, R. J., & Dye, H. A. (1983). Practicum supervision roles: Effects on supervisee statements. Counselor Education and Supervision, 23, 157–168. Steven, D. T., Goodyear, R. K., & Robertson, P. (1998). Supervisor development: An exploratory study in changes in stance and emphasis. Clinical Supervisor, 16(2), 73–88. Stoltenberg, C. D., McNeill, B. W., & Crethar, H. C. (1994). Changes in supervision as counselors and therapists gain experience: A review. Professional Psychology: Research and Practice, 25, 416–449. Stratton, J. S., & Smith, R. D. (2006). Supervision of couples cases. Psychotherapy: Theory, Research, Practice, and Training, 43, 337–348. Strutts, M. L. (1991). Supervision in comprehensive rehabilitation settings: The traveler and the terrain. Clinical Supervision, 9, 33–58. Szymanski, D. M. (2005). Feminist identity and theories as correlates of feminist supervision practices. Counseling Psychologist, 33, 739–747. Teitelbaum, S. H. (1990). Supertransference: The role of the supervisor’s blind spots. Psychoanalytic Psychology, 7(2), 243–258.

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Research: The State of the Field 517 Tryon, G. S. (1996). Supervisee development during the practicum year. Counselor Education and Supervision, 35, 287–294. Utsey, S. O., Hammar, L., & Gernat, C. A. (2005). Examining the reactions of White, Black, and Latino/a counseling psychologists to a study of racial issues in counseling and supervision dyads. Counseling Psychologist, 33, 565–573. Veach, P. (2001). Conflict and counterproductivity in supervision: When relationships are less than ideal: Comment on Nelson and Friedlander (2001) and Gray et al. (2001). Journal of Counseling Psychology, 48, 396–400. Walker, J., Ladany, N., & Pate-Carolan, L. (2007). Gender-related events in psychotherapy supervision: Female trainee perspectives. Counselling and Psychotherapy Research, 7, 12–18. Watkins, C. E. (1995a). Psychotherapy supervisor and supervisee: Developmental models and research nine years later. Clinical Psychology Review, 15, 647–680. Watkins, C. E. (1995b). Researching psychotherapy supervisor development: Four key considerations. Clinical Supervisor, 13(2), 111–118. Watkins, C. E., Jr. (1997). The ineffective psychotherapy supervisor: Some reflections about bad behaviors, poor process, and offensive outcomes. Clinical Supervisor, 16(1), 163–180. Webb, A., & Wheeler, S. (1998). How honest do counsellors dare to be in the supervisory relationship? An exploratory study. British Journal of Guidance and Counselling, 26, 509–524. Worthington, E. L. (1987). Changes in supervision as counselors and supervisors gain experience: A review. Professional Psychology: Research and Practice, 18, 189–208. Worthington, E. L., & Stern, A. (1985). Effects of supervisor and supervisee degree level and gender on the supervisory relationship. Journal of Counseling Psychology, 32, 252–262. Yourman, D. B. (2003). Trainee disclosure in psychotherapy supervision: The impact of shame. Journal of Clinical Psychology, 59, 601–609. Yourman, D. B., & Farber, B. A. (1996). Nondisclosure and distortion in psychotherapy supervision. Psychotherapy: Theory, Research, Practice, and Training, 33, 567–575.

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PART EIGHT

PROFESSIONAL ISSUES

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C H A P T E R 27

Ethical and Legal Considerations in Psychotherapy Supervision ALLEN K. HESS

Do what is right Because it is right. —Chiune Sugihara1

HUMANS ARE valuing creatures. From birth, we learn what is beneficial and what brings harm. Certain berries and certain people bring nourishment, whereas others bring sickness and malady. When we attach values to objects, axiologists (or philosophers of values) tell us, we are speaking of aesthetics. When we value human actions, we are engaged in ethics. Because we build social structures and endow certain people within their professional roles with rights and privileges, there is a need to detail the parameters of those roles. For example, we endow certain people with the ability to take the lives of other citizens. Thus, we have strict rules of engagement and review boards for police officers who discharge their weapons. Similarly, physicians, financial advisors, and hairdressers are subject to licensing boards and standards of care or practice within their professions. Because legislators do not have the expertise to adjudicate proper from improper practice, they delegate regulatory and administrative functions to various licensing, review, or ethics boards or committees. The boards typically rely on professional associations to promulgate standards, ethical principles, and codes of conduct. These take the form of minimal standards of practice and of aspirational or best practice 1 Chiune

Sugihara was the Japanese Consul General in Kaunas, Lithuania, in 1939 when thousands of Jews fled German-occupied Poland. From July 31 to August 28, 1940, with his wife Yukiko’s encouragement and assistance, he worked 18 to 24 hours per day writing some 300 visas a day (a month’s worth), saving between 2,000 and 10,000 people. His career was ruined and Japan sent him to the Soviet heartland, separating him and his family for 16 years.

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models. Legislators also rely on the expertise of boards to act in a quasi-judicial role, empowering such boards to enforce their codes and regulations. In a growing number of cases, individual complainants or defendants, who are licensed by the professional association have to go through the administrative system before being permitted entry into the courthouse. This chapter (a) describes the functions of ethical standards and a system of ethical decision making, (b) reviews the literature, and (c) discusses the legal implications of professional decision making—all with particular application to psychotherapy supervision. Before I begin, though, the reader of this or any other work on ethics needs to be warned. The literature focuses on what happens when authentic meeting between people fails. It captures none of the joy of seeing a student when he or she recognizes denial in a patient, the exuberance when the student is able to wait until the patient is ready to accept an interpretation delivered in a dose that the patient can assimilate, or the satisfaction when the supervisor sees the student bring materials to a supervisory session that the student read on his or her own initiative to help polish the student’s technique. Sadly, chapters on ethics are necessary because one or both parties does not see the other’s interests, values, or being. F U N C T I O N S O F E T H I C A L S TA N D A R D S Professional codes regulate, educate, and inspire practitioners (Frankl, 1989). Frankl found that codes provide a number of functions. They provide a moral compass; expectations of standards of practice for the public; a source of pride, power, and prestige; a sense of allegiance to shared values; an induction of public trust; a sense of identity; a deterrence to behavior flaunting the profession’s values; support for controversial stances; and a place for the adjudication of conflicts. Such codes can express minimal standards of practice or be aspirational. They can express deontological or teleological values. Deontological approaches invoke basic principles such as Immanuel Kant’s two moral imperatives: Treat people equally, and treat people as ends and not means to an end (Durant, 1933). Teleological approaches view consequences of actions as essential and find expression in thinkers such as Jeremy Bentham, John Mill and his son John Stuart Mill who weighed different outcomes in terms of benefit and harm. The American Psychological Association’s (APA; 2002) Ethical Principles of Psychologists and Code of Conduct expresses deontological principles: beneficence and nonmalfeasance, fidelity and responsibility, integrity, justice, and respect for people’s rights and dignity. They also present outcomes, principally negative, that describe minimal standards for practice. The reader is encouraged to become familiar with this document and with Knapp and VandeCreek (2003), who reviewed the changes between this code and its predecessor (APA, 1992) as well as this team’s work on legal issues in supervision (Harrar, VandeCreek, & Knapp, 1990). Ethical Standard 7 (Education and Training) features major changes and recognizes psychotherapy supervision explicitly. Programs ought to provide education and experiences to meet goals expressed by those programs (7.01). Program descriptions should be timely and available (7.02) and accurate (7.03). Students cannot be compelled to produce personal materials (e.g., their history of sexual abuse or neglect, family relations, or treatment) unless this is a clear requirement of the program or is needed to help an impaired student (7.04). Any required

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Ethical and Legal Considerations in Psychotherapy Supervision 523 psychotherapy experience must be provided by professionals unaffiliated with the program (7.05). Psychotherapy supervision must provide a timely and specific feedback process, to the student that is described at the onset of supervision (7.06). Finally, sexual relations between evaluating psychologists and students or interns within their purview are forbidden (7.07). Both student trainees and supervisors are responsible for knowing the other standards (e.g., competence, informed consent, and conditions for the release of information) that informs practice. As the reader will see, the essential factor in ethical decision making is knowing which values guide the ethics codes; what inquiries have been made into a professional’s actions that have been investigated by various bodies such as legislatures, courts, or quasi-judicial agencies; and, when there is a conflict, what is the effective controlling mechanism. That is, demonstrating an ethical sense, a knowledge of the relevant codes, and a knowledge of the literature that has established standards of practice within a field ought to help a professional make ethically sound decisions. These decisions then have a better chance of surviving scrutiny. Ethics codes can be used as blunt instruments to inflict damage to professionals who do practice ethically. Even a successfully defended inquiry can inflict financial, reputational, and emotional costs. Clearly one of the costs of ethics codes is their use for retaliation for real or imagined wrongs. Within child custody cases, attorneys and parents on both sides—not merely the side opposing the one hiring the expert—use the filing of ethics complaints to impeach testimony they do not like, to intimidate professionals into rendering favorable testimony, and to punish the expert if that side loses the case. Both the chilling and the protective effects of ethics codes can be seen in forcing defensive practices on the one hand and in helping a falsely accused professional on the other. At this point, it may be most helpful to review the literature on the ethical practice of supervision. T H E L I T E R AT U R E Newman (1981) presented a clear pr´ecis that ought to be required reading for all supervisors. She documented the importance of supervision in the student’s education. In fact, one might opine that supervision is one of the central points in forming a psychologist’s professional identity. What follow are the various considerations that people need to keep in mind in making ethically driven decisions.

MULTIPLE RELATIONS Newman (1981) described the inequality of the participants as a feature of supervision. This is important because of several factors. First, supervisor and supervisee roles are close in status, as contrasted with the role of the first-year student, the undergraduate student (who might receive supervision when performing tasks such as history gathering), or the patient. Supervisor and supervisee roles often are part of multiple relations, such as research collaborators, which further blurs boundary distinctions and power inequities. Second, the perception of power inequities varies dramatically depending on whether one is the dominant or subordinate party (Fiske, 1993). The person who is dependent always scrutinizes the more powerful person to satisfy or placate him or her in securing rewards and avoiding opprobrium. A superordinate person often ignores major parts of

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the subordinate’s being, focusing instead on his or her own superiors. Thus, if the reader takes anything from this chapter, it should be to understand the difference in perception of the relationship. What the supervisor thinks is a collegial invitation to play tennis can be seen as a superior’s command by the student. Case 27.1 The director of an internship, a former professional boxer, saw himself as a highly skilled athlete, even as he aged. The student lettered in two sports in college and had similar vanities. In December, the director invited the student to play tennis. The director wore white, whereas the student wore a striped shirt and plaid shorts. Indeed, their cultures clashed just as their garb did. The student toyed with the director on the court and was suspended for poor writing skills in January. No doubt the hours the student spent with the director rewriting psychological assessment reports were well spent, but doubts lingered as to the motivation behind the suspension.

When a supervisor plays tennis or dines with a student, other students might suspect favoritism, even in its absence. Or they might be sufficiently secure to know there is a reason for such an appearance of favor that will not impact adversely upon them. Here the perception of inequity might be an unforeseen consequence. The literature is replete with caveats of the negative consequences of multiple or dual-role relationships (e.g., Gottlieb, Robinson, & Younggren, 2007). Nonetheless, human relations are complex. Depending upon the totality of the role relationship, there might be absolutely nothing wrong in socializing, in playing sports, in hiking with each other’s families, and even in vacationing together. Although multiple relationships can compromise any role relationship (consider how going into business with family members is fraught with peril), ignoring the larger circumstances is both unrealistic and needlessly rigid. Having mentioned the drawbacks of multiple or dual-role relations, I would be remiss not to focus on the bleaching of humanity that some admonishments effect. That is, if someone is interested in wines, cooking, or racquetball, and so is another person in the work environment, then it is perfectly natural for those similarly interested people to engage each other. Propinquity is the single biggest factor in establishing human relations. To ignore the similarity of values and interests among people in a psychology department or a clinic is to run counter to nature. In fact, social and sports relationships that supervisees engage with their supervisors could affirm their value as humans and colleagues in their supervisors’ eyes. We ought not criminalize human relations between people who might simply enjoy each other’s company.

Case 27.2 Bob and his student were interested in group psychotherapy, a course taught by Bob. They began playing tennis and chatted about many issues, including developing the student’s term paper into a group psychotherapy research study together. This relationship resulted in several publications that helped boost the careers of both. The student felt a special status and bond; felt accepted as a professional who had something collaborative to offer; and went to his first APA convention, where Bob

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served as a role model. Bob and the student copresented, and Bob introduced the student to several luminaries in the field. Practicing defensive psychology, like defensive medicine, may prevent problems, but the costs can be great enough to compromise the meeting ground that is social as well as professional and that the student needs. Rather than offer a “white-line” demarcation as to when multiple relations are beneficial, the practitioner needs to be sensitive to the threat to parity in the nonsupervision relationship that supervision can present while not missing opportunities to effectively supervise the new professional.

SUPERVISION AS THERAPY Perhaps it is because supervisors are trained as psychotherapists, and perhaps because training in supervision is a rara avis, and perhaps because we are trained to see pathology rather than learning problems that this issue arises at all. With so much to do in supervision, the effective supervisor wonders how others can even indulge in the thought of doing psychotherapy in lieu of supervision with time to review cases in such short supply. Consider how much there is to do in teaching child psychotherapy: how to deal with violent clients, how to care for aged clients or domestic abuse victims. Consider, too, how many cases the student brings to the single supervision session; there is simply no time to conduct psychotherapy in the valuable supervision time. Yet this issue arises so often that it occupies a sizable portion of the writings on supervision. In some cases personal self-revelation, the attitudes and experiences of a student might be central to a case and its supervision, and pose severe problems in learning unless the student’s personal history is addressed, in contrast to the mandate of APA Ethical Standard 7.04.

Case 27.3 W was a talented student who was assigned to the Veterans Affairs hospital for a practicum rotation. She went to her supervisor to tell him she could not engage in this rotation. The supervisor, who also served as her dissertation director and her “study buddy” in a book club, asked why. W closed the door and swallowed hard. She asked that this information be held confidential and received such assurance. Thereupon she told him that she was a twin and that her sibling had been in and out of institutions since age 8 for severe depression and strange behavioral outbursts and had eventually committed suicide at age 16. W was paralyzed with fear about going into the hospital, breaking down, being found out, and never leaving, as she knew quite well the high concordance rates for psychotic depression in identical twins. She harbored fears for decades, waiting for decompensation to break through. The supervisor asked W whether she thought he was skilled in diagnosis, specifically with problems in thought and speech pathognomonic for depression. W said, “Of course.” The supervisor asked how long they had known each other, to which W replied, “Since I entered this program 3 years ago.” The supervisor said, “And have I seen you operate under considerable stress?” to which W replied affirmatively. The supervisor said, “I have not seen a single sign of inappropriate feelings, thoughts, or speech; nor behavioral or emotional control problems; nor any sign of depression in the years I have known you.” He wryly commented, “I can give you a certificate of (Continued)

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sanity if you wish so you can get in and out of the hospital each day,” to which they both roared with laughter—W’s sounding cathartic. The supervisor assured W she would be fine and she had the supervisor’s home phone number if she needed it, to which they both chuckled again. W, as usual, performed superbly on the rotation. Since then, she has spent decades in successful practice in institutions and private outpatient work.

For such an exchange to occur as in Case 27.3, there must be interpersonal trust. For a student to grow and be free from deeply driven and preverbally formed fear, and to be able to work with the severely disturbed, quite personal revelation was essential. If a patient faces a clinician who has unresolved attitudes, the patient will sense this and freeze up. Sullivan (1953) termed this transference jam. The more severely disturbed the patient, the more such a psychotherapist jams the patient, or shuts him or her down. The patient’s trust cannot be commanded by virtue of one’s credentials but must be earned. Nothing was mentioned to anyone else (i.e., faculty, director of clinical training) about W’s case (27.3 above), nor should it have been. This recounting here is its first revelation. The legalistic minimalist approach would have every interaction subject to informed consent, and this can have bizarre results. For example, one graduate handbook states that the student is obliged to be open and honest with his or her feelings, and that failure to be open and honest will result in dismissal from the rotation. The reader can judge the absurdity of that command—sort of like “Relax, I command you.” SUPERVISOR QUALIFICATIONS Newman (1981) asks, is the supervisor qualified to supervise? Here the competencies are twofold: The supervisor ought to be facile with the type of problem and patient, and be qualified to supervise. These competencies can be gained by reading, continuing education, supervised practice, and peer consultation, as well as by more formal means. Although education, training, and experience are the usual touchstones of competence, perhaps skills and knowledge or clinical judgment are even more central to effective and ethical supervision, as Case 27.3 illustrates. SUPERVISOR RESPONSIBILITIES Is the supervisor willing to accept the responsibilities that are part of supervision? APA Ethical Standard 7.06 and several articles in the literature are devoted to this question. At the inception of supervision, all of the formal aspects ought to be clarified. These issues include which cases from which rotations are within the supervision; when and how long are the supervisory meetings are to occur; whether the supervisor is available for emergencies; how vacations and absences, both from supervision and client sessions, are to be handled; the supervisory method to be used (e.g., taping, free-floating associations as discussed in Chapter 9; how much self-revelation the supervisor expects); the formal and informal evaluation mechanisms to be used; and how the supervision will be terminated. Chapter 1 explicates the various roles that are typically included in the overarching definition of supervision. Each role has consequences for how much control the

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Ethical and Legal Considerations in Psychotherapy Supervision 527 supervisor has or does not have. With less control, less liability accrues. So “curbside consultation” carries less of a burden than paid case consultation, which carries less of a burden than overseeing paperwork. Case monitoring carries less of a burden than individual case supervision by a supervisor who controls the department’s onsite clinic. The scope of responsibility ought to be clarified for all concerned: student, supervisor, and agency or agencies. Sutter, McPherson, and Gesseman (2002) discuss contracting for supervision, while Vasquez (1992) discusses how supervisors can promote ethical practice. SUPERVISEE QUALITIES Are the student’s learning needs being taken into account? Is the client base one that matches the student’s interests and skill levels while still considering his or her learning needs? Have goals for the supervision been stated, to the degree that they can be? How are the less formal but crucial skills and skill deficits to be handled? Are the student’s anxieties being taken into account? THE MATCH Have the supervisor’s and student’s qualities been well matched? Although matching is far from a science at this point in the field, the question about whether the parties have any antipathies or conflicting relationships that will ensure a failed supervision is both valid and necessary to pose. Sometimes there are such conflicts.

Case 27.4 Lara was psychopathic in the professor’s estimation. Nonetheless, the benign and Pollyanna-ish director assigned Lara to her former thesis director. The assessment supervision was frigid and formal. Lara, who had often appeared for research supervision when she chose to, knew better and was on time for each clinical supervision appointment. The supervisor, usually casual in his sense of time, promptly stood at the hour’s conclusion without fail. The director was smug about his match, feeling that the professor’s determination of Lara’s psychopathy was merely the professor’s peculiarity. A year later, the professor was in the clinic when he heard from another room Lara telling her student colleagues, “Watch this.” She then intercepted another professor who headed the clinic and exclaimed, “I have a family emergency! Can I have an extra week on the term paper’s deadline?” He said, “Of course,” and left. Lara joined her colleagues in gales of laughter, revealing to them that there was no such family emergency. The match was ill advised when first made and remained ill advised throughout the supervision, but perhaps this was the first time Lara had to meet conditions or face consequences. Was the supervision successful? I do not know.

PRIVACY CONCERNS Privacy in supervision poses a particular problem. Four intersecting parties have interests in supervision, if one does not consider parents and guardians of minors as a fifth party. The patient has a right to know that he or she is being treated by a student and what information will flow to a supervisor. The student faces a difficult

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dilemma as to what he or she will disclose in light of the supervisor’s boundaries. Does the student trust the supervisor with information that the student may fear will be disclosed to others? What type of information is owed to the supervisor, and what information is discretionary? Agencies and supervisors have a need to know when any jeopardy attaches to the student’s treatment of a client, as in a Tarasoff case or delinquent payments that have accumulated into considerable arrears. In Case 27.3, W took a risk that the information would not go beyond supervision to the annual student evaluation meetings. Certainly patient information must enter supervision for supervision to be effective in helping the client and the student. Furthermore, there is some added emphasis on reporting by the student simply because the student is using the penumbra of the supervisor’s license or the authority of the faculty and program in which he or she is functioning. But the question remains: What are the boundaries for student disclosure? One can see disclosure in two lights. First is disclosure of feelings. That is, if the student feels repelled by the client’s obesity or frivolousness, these feelings ought to be explored in supervision. But there are also disclosures of personal material that might be central to the feelings. If the student saw his or her mother die of obesity and these feelings are central to psychotherapy, then making such a revelation might be crucial for the student to develop as a psychotherapist and to spare the patient of contaminating countertransference. Again, there is no “white-line” test, but rather a variety of considerations are pertinent. The supervisor might have this insight into a blockage in the supervisee, but is the student ready to confront this personal issue? Yalom (1989/2005) delicately showed how he confronted his negative countertransference toward an obese patient and the ways in which he and she were able to grow in psychotherapy. One wonders how the supervisor, who might be a gifted psychotherapist and exercise a precise sense of when the patient is ready for an interpretation, can blithely plunge into a student’s world without the same delicacy he or she would show to patients. To be sure, a supervisor might feel a sense of urgency and the need to benefit the patient, resulting in a real ethical dilemma: Who is served in supervision? The answer, both parties, is what presents the dilemma. These interests can collide. At this point, the supervisor must exercise some degree of judgment and structure. He or she can help the student explore the client’s needs, determine what would benefit the client, and decide which option would be best suited for the student to deliver. The student just may surprise the supervisor with his or her ability to confront the learning dilemma. And if the option does not work well, the student will be well aware of that and be in need of the supervisor’s support in exploring the client–student interaction nonpunitively and warmly. This issue is troublesome and has not been addressed directly in the literature. How permeable are the boundaries of supervision? What material goes to evaluation committees, to the student’s other professors, to major advisors, or to another graduate student in a team supervision who is supervising the student in question and in turn is expected to treat the information in a confidential manner? Is privilege an issue when personal material is discussed in a quasi-therapeutic fashion? Certainly privacy questions are relevant, as in the case of W, who thought she might be vulnerable to psychotic depression problems. No one needed to know of her dilemma, nor did they learn of it.

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Ethical and Legal Considerations in Psychotherapy Supervision 529 WHAT NEEDS TO BE REPORTED OUTSIDE OF SUPERVISION? Unethical and illegal behavior must be reported to the appropriate authorities after consultation with the student. The reason for such a consultation is that the supervisor might be misinformed or not wholly informed and thus at risk for making a precipitous, damaging, and premature decision. There are cases that do require intervention. Consider the disability report quoted in Case 27.5 from S. Walfish (personal communication, March 23, 2007; available from [email protected]).

Case 27.5 “Mental Status Examination: The patient appeared to be a well developed, well nourished, attractive lady who appeared much younger than her stated age of 49. I felt that she was about 22 years of age. She had thick, long, luscious blonde hair. She was dressed in a dress and hose, and dress shoes. She was well made up. Her fingernails were manicured. She was neat and clean. Makeup was a little excessive. After the interview started, and she cried some, much of the mascara was rinsed off with her tears and she became really more attractive. The tears modified the exaggerated makeup to a more acceptable level.”

In this case, the level of acceptable performance by the worker is wholly compromised by his or her lack of judgment. Yet this work needs to be explored by the supervisor with the worker first. The worker might realize he or she is in a job that is inappropriate for his or her skills. Then job reassignment or termination and outplacement becomes a cooperative venture between the worker and the agency. Abrupt termination without consultation leads to further damage to the worker. Naturally, the client ought to be contacted for reassignment or possibly another examination by a skilled clinician or even the supervisor. Any assessment procedure and the limitations of supervision must be discussed with students before supervision commences. The reporting requirements of the program must be specified to students at the beginning of supervision if they extend beyond unethical and illegal behavior. The program and supervisor must know that astute supervisees will then have concerns about surviving the program if they reveal too much of themselves. This is another ethical dilemma. Ethical decisions have outcomes; ethical dilemmas are decisions one must make that have untoward consequences (Purtilo, 1993). Students in an insecure environment will engage in a variety of nondisclosure strategies (Ladany, Hill, & Corbett, 1996; Yourman & Farber, 1996). Any evaluation will naturally raise students’ anxieties and stimulate self-protective mechanisms.

Case 27.6 Peter, a kind and anxious person, was asked to describe the client. Peter was tonguetied, and his usual stammer dramatically increased. He perceived that his research director was punishing toward him and condemning toward his thesis, and the program was scapegoating him. The supervisor asked him to bring in a tape recording. (Continued)

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At the following session, Peter reported that he did not have a tape recorder, and the session foundered. The supervisor ended the session by loaning Peter a tape recorder. At the following session, Peter reported that he forgot to bring a tape, whereupon the supervisor provided a tape. At the following session, Peter proudly punched the “Play” button and produced static. Both Peter and the supervisor stared at each other, at which point Peter slapped his forehead and said, “I placed it on the clock radio on the desk, and that must be the machine’s static.” The supervisor belly-laughed, in part at the unconscious ingenuity shown by Peter to safeguard his fears of being ridiculed and criticized—such ridicule being a lifelong scarring by his peers tormenting him by imitating his stuttering. The supervisor and Peter laughed and discussed baseball for the duration of the session. The supervisor was in a collegial supervision group and expressed his feelings of being an inadequate supervisor who allowed the session to degenerate into a baseball discussion. The group suggested continuing to display the patience that the supervisor had shown so far, that the student needed to experience the nonpunitive atmosphere to build trust in a faculty member from a punitive program. At the next supervision, Peter played his tape. The next several sessions saw more movement in psychotherapy than the client and Peter had shown in the previous 6 months. None of the above was reported nor ought to have been reported to faculty. Peter was one of the most rewarding of the supervisor’s supervisees in decades.

GOALS Have the supervisee and the supervisor explored what each sees this supervision as accomplishing? A sensitive supervisor might ask the student to recount what he or she found helpful and detrimental in previous supervisions. If a student has not previously been in psychotherapy supervision, a good practice is to explore other human service experiences such as training the student may have had helping in a suicide prevention center or even running subjects in research. Recognizing what human relations skills the student may have mastered is empowering for the student and builds a learning alliance. The student sees the supervisor as looking at strengths, not merely hunting for faults. What good aspects does the supervisee recall from prior experiences? Are there goals the student wished the prior supervision had encompassed? What adverse experiences did the student have? All of these answers help to build a sound learning relationship.

Case 27.7 A psychologist brought his daughter to the emergency room because her left wrist had been broken in a fall and needed casting. The surgeon felt her right wrist, at which time the father reminded him of the left wrist. The wise surgeon smiled and said, “I get a baseline of how the wrist ought to feel and also desensitize the patient to my touch by not having my first touch be a painful one.” He taught the psychologist much about how supervision ought to transpire. The competent supervisor builds a relationship with the student, accenting the student’s skill while sensitively addressing skill deficits as an ally of the student.

Misconceptions by either the student or the supervisor might best be clarified right at the beginning. Too often there are ghosts in the sessions that need

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Ethical and Legal Considerations in Psychotherapy Supervision 531 exorcizing. Sometimes, these misconceptions enter as expectations the student or supervisor harbors based on their respective past experiences, or from gossip a student may have heard about the supervisor, or even from scuttlebutt the supervisor has heard from faculty colleagues. Evaluations ought not to be a surprise. People immediately and constantly evaluate others in human interaction. Emotions flow more quickly than cognitions and regulate relationships. Safety and security needs even more than satisfaction needs determine one’s next action. Thus, feedback between humans is continuous, and formal evaluations at periodic intervals or at termination of the supervision ought to be anticlimactic. I have explored some ethical dimensions and dilemmas in supervision, but the competent clinician ought to know about legal parameters of supervision as well. What follows is a primer on legal aspects of psychotherapy supervision. L E G A L I M P L I C AT I O N S 2 The supervisory relationship can result in both tortious and criminal actions in addition to various ethics committee sanctions. Black’s Law Dictionary (Garner, 2004, p. 629) defines a tort as “a private or civil wrong or injury . . . for which a court will provide a remedy in the form of an action for damages.” The most common types of torts are (a) intentional, (b) negligence, (c) strict liability, and (d) product liability, although invasions of privacy and defamation are significant as well. Black’s Law Dictionary (p. 434) further provides a working definition for negligence, that being the instance where one “fails to exercise that degree of care in doing what is otherwise permissible.” Substantial materials exist exploring the scope of liability of psychologists, but here I limit my examination to those implications stemming directly from supervision relationships. Specifically, I look at the following issues:

r Whether the supervisor must establish a supervision relationship in accordance with APA’s ethical principles.

r Assuming supervision meeting APA requirements is met, whether the supervisor is responsible for the actions of the supervisee.

r Assuming supervision meeting APA requirements is met, whether the supervisee is entitled to rely on the guidance of the supervisor. ADOPTION OF STANDARDIZED PRINCIPLES The APA Ethical Principles of Psychologists and Code of Conduct distinguishes between its guidelines and its ethical standards, where guidelines are aspirational and ethical standards firmly fixed obligations. Assuming that a state licensing board has adopted this code of conduct as its own, the principles of the supervisory relationship ought to be established per APA’s Principles and Code. Deviation from regulated principles of a state will result in exposure for damages arising from that deviation. Even where a governmental body has not legislated the acceptance of 2I

am grateful to Leigh Goldman (MBA, JD) for writing the majority of this section.

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standards, courts will look to such as the commonly accepted practices or industry standards and will apply such to the practitioner, if such can be done rationally. Courts also weigh the dynamics involved in a field, assuming that no practice is static. If an emerging field of practice or technology is available, although not universally assumed, courts, although loath to put themselves in the position of experts, will look to see if such practice or technology enjoys a higher degree of safety or offers some other benefit outweighing the costs or detriments related to such. SUPERVISOR LIABILITY Two theories of law are frequently invoked in supervision relationships: respondeat superior and negligent entrustment. Respondeat superior assumes that a master-servant relationship exists, where the party controlling the relationship is responsible for those actions performed in the furtherance of the relationship by the party under said guidance and control. Negligent entrustment exists where the controlled party is empowered to act beyond his or her ability and the superior knows or should know that such control is beyond the abilities of the junior party. Without going too far into the elements needed to prove respondeat superior, a court will look to see if there was a relationship between two parties, with one controlling the actions of the other to some extent (i.e., supervision, employment, providing workplace assignments, instruction). In the case of negligent entrustment, a court will look to see if the superior placed a subordinate into a situation or provided an inferior with tools for which the inferior was ill equipped, without sufficient supervision or instruction to ensure against the tortious conduct of the subordinate. In either case, where a supervisor fails to ensure that a supervisee practices with reasonable care as would be expected of a reasonable person with similar training and expertise, liability will accrue. This is a high bar, as the objective standard is that of an expert. If an injury occurs to a person based on the practitioner’s failure to act with proper care, and the supervisor can be found to have failed in some scope of the supervision relationship, it is likely that the supervisor, or the organization he or she represents, will be held liable for the supervisee’s actions. Did the supervisor consider security when assigning the student to a violent client or sending the student to a ward in which the treatment of unmedicated patients was being studied? Forseeablity of harm plays a key role in determining tort liability. Torts that are intentional involve deliberation in the tort’s perpetration and carry heavier penalties. Torts that involve reckless and wanton disregard indicate a disregard for danger attributed to the supervisor’s actions or inactions. Negligence is a failure to exercise ordinary care. The latter necessitates learning the standards of care of a profession—those that its ethics codes state and those found in canonical texts and journal articles. Obviously, one wants to avoid deliberate wrongdoing, disregard of danger, as well as obliviousness to standards of care. But these are minimal. One wants to practice to the best possible standards, and in doing so he or she can be generally assured to be practicing in a sound ethical and legal manner. Engaging in discussions among peers and keeping up with the literature help hone one’s skills in anticipating or foreseeing both harm and its avoidance, as well as in ensuring the best outcomes for one’s clients.

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Ethical and Legal Considerations in Psychotherapy Supervision 533 SUPERVISEE RELIANCE ON SUPERVISOR Although the case law in this area is not substantial, employment law and case law from medicine set forth a clear basis of example. Although subordinates/students are able to a great extent to rely on the instruction and guidelines set out by their superior, they must exercise due care and judgment as would be expected of a normal, reasonable person with similar training and experience in a similar situation. In short, they are not able to fall back on the instruction of the supervisor alone as a defense for any tort caused. Rather, they must demonstrate that the order was reasonable and that they made some evaluation of the instruction for such reasonableness. If supervisees receive an unclear instruction, they must seek clarification. If they receive an unlawful or harmful instruction, they must consider such for themselves and should have at least some ability to spot potential conflicts or pitfalls in such, modify the instructions so that they fall within ethical guidelines, and refuse such instruction if necessary. Where supervisees fail to use a reasonable evaluation of the instructions given for their propriety within ethical guidelines or against their judgment as a practitioner, their role as supervisee will provide no defense against legal action. Consultation with the director of clinical training or trusted and seasoned clinicians is a reasonable course to take, demonstrating ethical sensitivity. Of course, the student might want to present the dilemma in a disguised form so the consultant will not usurp their decision making. Also, if the parties to the case are clear enough for the consultant to identify, then the consultant now has his or her own ethical dilemma because he or she now has affirmed the student’s judgment and faces liability if the case has an untoward end. I have issued a number of guidelines in this chapter. When all is said and done, we all need to listen to that “small, still voice” in each of us to do the veridical, to act with integrity. Acting with integrity cannot be legislated, but is it really that hard to do the right thing? There are an estimated 40,000 “Sugihara Jews” alive today (progeny of those saved by Japanese Consul General Chiune Sugihara). When asked why he did what he did, Sugihara patiently explained that he followed his nation, but when they did not follow God, he had to follow God instead. “These refugees were human beings and in need of help.” “After all even a hunter cannot kill a bird which flies to him for refuge.” —(Simon Wiesenthal Center, 1997)

REFERENCES American Psychological Association. (1992). Ethical principles of psychologists and code of conduct. American Psychologist, 47, 1597–1611. American Psychological Association. (2002). Ethical principles of psychologists and code of conduct. American Psychologist, 57, 1060–1073. Durant, W. (1933). The story of philosophy. New York: Garden City. Fiske, S. T. (1993). Controlling other people: The impact of power on stereotyping. American Psychologist, 48, 621–628.

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Frankl, M. S. (1989). Professional codes: Why, how and with what impact? Journal of Business Ethics, 8, 109–115. Garner, B. A. (Editor-in-Chief). (2004). Black’s law dictionary. St. Paul, MN: Thomson/West. Gottlieb, M. C., Robinson, K., & Younggren, J. N. (2007). Multiple relations in supervision: Guidance for administrators, supervisors, and students. Professional Psychology: Research and Practice, 38, 241–247. Harrar, W. R., VandeCreek, L., & Knapp, S. (1990). Ethical and legal aspects of clinical supervision. Professional Psychology: Research and Practice, 21, 37–41. Knapp, S., & VandeCreek, L. (2003). An overview of the major changes in the 2002 APA ethics code. Professional Psychology: Research and Practice, 34, 301–308. Ladany, N., Hill, C. E., & Corbett, M. M. (1996). Nature, extent, and importance of what psychotherapy trainees do not disclose to their supervisors. Journal of Counseling Psychology, 43, 10–24. Newman, A. S. (1981). Ethical issues in the supervision of psychotherapy. Professional Psychology: Research and Practice, 12, 690–695. Purtilo, R. (1993). Ethical dimensions in the health professions (2nd ed. ). Philadelphia: Saunders. Simon Wiesenthal Center. (1997). Visas for life: The remarkable story of Chiune and Yukiko Sugihara and the rescue of thousands of Jews. Available from http://motlc.wiesenthal.com/site/ pp.aspx?c=hkLTJ8MUKvH&b=475889-7K-/. Sullivan, H. S. (1953). Schizophrenia as a human process. New York: Norton. Sutter, E., McPherson, R. H., & Gesseman, R. (2002). Contracting for supervision. Professional Psychology: Research and Practice, 33, 495–498. Vasquez, M. J. T. (1992). Psychologist as clinical supervisor: Promoting ethical practice. Professional Psychology: Research and Practice, 23, 196–202. Yalom, I. D. (2005). Fat lady. In Case studies in psychotherapy (pp. 133–155). Belmont, CA: Brooks/Cole. (Original work published 1989) Yourman, D. B., & Farber, B. A. (1996). Non-disclosure and distortion in psychotherapy supervision. Psychotherapy: Theory, Research, Practice, and Training, 33, 567–575.

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PART NINE

RACE, SEX, AND GENDER CONSIDERATIONS

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C H A P T E R 28

Racial and Cultural Aspects of Psychotherapy and Supervision IVORY A. TOLDSON and SHAWN UTSEY

THE PURPOSE of this chapter is to help psychotherapy supervisors and supervisees explore practices and procedures that appreciate the racial and ethnic diversity within the supervision triad: clinical supervisor, supervisee, and client. Crosscultural supervision involves providing clinical guidance to a trainee who is, or who is working with, someone of a different ethnic background from the supervisor. Multicultural competence is a quality of cross-cultural supervision that entails a supervisor helping a clinician to accommodate the unique clinical needs of ethnically diverse clientele. The chapter emphasizes ways in which the supervisor and therapist can enhance the quality and integrity of supervision by developing a better understanding of specific cultural norms and folkways, how sociocultural power differentials manifest within a therapeutic context, and how basic multicultural psychology tenets shape clinical supervision.

R A C E , C U LT U R E , A N D P O W E R I N S U P E RV I S I O N Historically, supervisors and therapists have held authoritative positions over supervisees and clients, respectively (Betha, 1997; Lago, Thompson, & Shipton, 1997; Rogers, 2002). On the surface, the relationship between the supervisor, supervisee, and client appears as a multitiered pyramid-like structure, with the authority centralized at the apex with the supervisor. In this social hierarchy, the supervision triad is an asymmetrical arrangement, whereby the client will never have as much power as the therapist, who will never have as much power as his or her supervisor. In reality, the dynamic underlying the social hierarchy in psychotherapy and supervision has been subject to scrutiny for more than a century and has paralleled social changes in society. 537

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From the early to mid-1900s, therapists, such as Alfred Adler and Carl Rogers endeavored to make the therapeutic process more egalitarian. Adler was the first known psychotherapist to abandon the analytic couch and implement two chairs, whereby the clinician and patient could work as equals (Cambridge, 2002). Rogers became famous for popularizing the term client over patient to discourage clients from surrendering to psychotherapists’ expertise and to encourage psychotherapists to treat clients with individual dignity. It is interesting that the clinical changes that Adler and Rogers initiated were set against the backdrop of social movements that challenged racial stratifications that ascribed power and privilege to certain racial groups over others. By the second half of the 1900s, civil rights movements and decolonialism efforts worldwide challenged traditional, hereditary social stratification systems that were based on race and ethnicity. In the field of psychology, feminist theory and Black psychology radically transformed established views of mental illness and psychopathology, and client–therapist relationships. Feminist theorists juxtaposed the asymmetry between the therapist and client with gender-biased hierarchical systems in society (McKay, Hill, Freedman, & Enright, 2007; see also Chapter 29). Black psychologists introduced the concept of empowering the client by depathologizing mental illness and emphasizing the role of oppression and powerlessness in engendering acute psychological distress (I. L. Toldson & Toldson, 2001). Notwithstanding significant social progress over the past century, varying degrees of racial stratification exist today in most, if not all, modern nations. Likewise, supervisors and therapists have a measure of legitimate power over supervisees and clients that is maintained by vicarious liability1 and other role expectations that confer caste in the supervision triad (Jenkins, 2006). The natural power differential, or hierarchy, that often emerges within supervision triads can be reinforced or convoluted by racial stratifications in society (Betha, 1997).

R E S E A R C H O N C R O S S - C U LT U R A L S U P E RV I S I O N Complex relationships among members of distinct ethnic groups shape the lives and experiences of people living in culturally diverse nations such as the United States. Macrolevel forces (e.g., immigration, emigration, colonialism, and institutional racism) influence collective and individual values, worldviews, and ethnic orientations. Contemporary psychotherapy supervisors are therefore obliged to facilitate a culturally aware clinical environment that accommodates a myriad of racial issues in supervision (Young, 2004). Vontress (1969) advocated for counselor training programs to address the role of race and ethnicity in the therapeutic process, and specifically in the development of counselor–client rapport. Vander Kolk’s (1974) pioneering empirical study revealed that Black counseling students anticipated their supervisory relationships to be less facilitative than did White counseling students. Cook and Helms (1988), broadening the ethnic groups studied, revealed that African Americans, Latinos, 1 In legal terms, vicarious liability holds a supervisor ultimately responsibility for his or her supervisee’s professional behavior. This means that if a supervisee directly or indirectly harms a client, the supervisor is legally liable.

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Racial and Cultural Aspects of Psychotherapy and Supervision 539 and Native Americans expected supervisors to be less helpful and responsive than did Asian Americans. Numerous authors have since used these studies as platforms to broach other aspects of cross-cultural supervision, including (a) bilingualism (Fuertes, 2004), (b) the influence of racial identity (Chang, Hays, & Shoffner, 2003; Constantine, 2001; Cook, 1994; Ladany, Brittan-Powell, & Pannu, 1997), and (c) race matching (Ladany, Brittan-Powell, et al., 1997). Leong and Wagner (1994) is often cited in the literature as a major contemporary critique of cross-cultural supervision literature (Brinson, 2004; Estrada, Frame, & Williams, 2004; Gatmon et al., 2001; Goodyear & Bernard, 1998; Silvestri & Richardson, 2001). Leong and Wagner found that the influence of race is particularly profound with regard to trainees’ expectations of supervisors’ helping attitudes. They also concluded that under certain circumstances race does not seem to influence the supervision process. They stressed the importance of researchers and practitioners viewing race and ethnicity as multidimensional psychological constructs and veering away from simplistic interracial comparisons in supervision. Two central themes combine to shape the character and disposition of crosscultural relationships: (a) social power differentials between races and (b) the racial composition of the supervision triad. Much of the recent literature on cross-cultural supervision has focused on the relationship between the supervisor and supervisee, otherwise known as a supervision dyad (Burkard et al., 2006; Constantine & Sue, 2007; Spanierman, Poteat, Beer, & Armstrong, 2006; Utsey, Gernat, & Hammar, 2005; Worthington, 2006). However, research evidence suggests that a supervision triad (the supervisor, supervisee, and client) best explains the composite of issues that are relevant to the racial aspects of psychotherapy supervision (Constantine, Warren, & Miville, 2005; Gardner, 2002; Ryde, 2000; Young, 2004). The next section elaborates on how power differentials between races can influence the natural social hierarchy that can emerge within a supervision triad. T H E C R O S S - C U LT U R A L S U P E RV I S I O N T R I A D Table 28.1 presents six possible cross-cultural supervision triads in two categories: lateral and paradoxical. In the three lateral systems, the supervisor is a member of a racial group that has historically or traditionally held social, political, and economic Table 28.1 Six Possible Cross-Cultural Supervision Triads System

Supervisor

Supervisee/Therapist

Client

Lateral Laterally integrated Laterally triangulated Paradoxical Paradoxically integrated Paradoxically triangulated Note: Unshaded cells denote individuals who are members of a cultural group that has historically or traditionally held social, political, and economic privileges. Shaded cells denote individuals who are members of a cultural group that has historically or traditionally been disenfranchised.

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privilege (also known as a majority culture). In the three paradoxical systems, the supervisor is a member of an ethnic group that has historically or traditionally been disenfranchised. Note that the discernible differences in the scenarios illustrated in the table are superficial and do not palpably depict the profound diversity that exists within each racial group. However, readers can intuit that each cell embodies a large range of acculturation levels, multicultural competences, racial identity stages, and other concepts that we present in greater detail in subsequent sections of this chapter. LATERAL SYSTEMS A lateral system is a cross-cultural supervision triad whereby both the supervisor and the supervisee are members a majority culture and the client is a member of an ethnic minority group. Because lateral systems are aligned with traditional social power differentials, racially repressive elements in society can manifest within the coalition between the supervisor and supervisee. Owen-Patterson (2000) noted that this alignment has the potential to reenact the dominance and subordination of normative social power relationships (Greene, 2005). Within supervision, the supervisor and supervisee may discuss the client’s personal failings, ego orientation, objective behavioral indicators, or assessment scores without considering the impact of race and ethnicity. A lateral system will often maintain culturally repressive elements when the supervisor and supervisee subtly collude to place the client’s race in a position of marginal importance. This form of exploitation is compounded in mental health settings that serve high volumes of clients of a low socioeconomic status (I. A. Toldson, 2007). The literature also sites cases in which a supervisee who has been exposed to more rigorous cross-cultural training than his or her supervisor can become dissonant (Leuwerke, 2005). The literature suggests that supervision outcomes are improved when White supervisors initiate discussions about the race of the client with White supervisees (Constantine et al., 2005). In a laterally integrated system, a majority culture supervisor is training a minority culture therapist who is working with a majority culture client. The literature has revealed that therapists in laterally integrated systems often complain of supervisor apathy (Estrada et al., 2004; Fong, Lease, Pope-Davis, & Coleman, 1997) and cultural unresponsiveness (Burkard et al., 2006), whereby supervisors will actively discount or dismiss supervisees’ clinical interpretation or judgment. Apathetic and culturally unresponsive supervisors may consider supervisees’ culturally different styles of communication (e.g., lack of eye contact, heightened expressive behavior, or use of touch) as developmental rather than cultural issues. Problems associated with laterally integrated systems are commonly reported among ethnic minority graduate students in university counseling settings at predominantly White colleges and universities (Burkard et al., 2006). In a study of Euro-American supervisees and supervisees of color, Burkard et al. found that supervisees of color experienced general unresponsiveness from supervisors more often than Euro-American supervisees. Supervisors in a laterally integrated system can enhance supervision by understanding the sociocultural history, communication patterns, and other cultural nuances of their supervisees. In addition,

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Racial and Cultural Aspects of Psychotherapy and Supervision 541 supervisors can openly process the cross-cultural exchange between supervisees and clients. In a laterally triangulated system, a majority culture supervisor is guiding a minority culture therapist who is working with another minority culture client. Reports from therapists in this system have described both real and perceived enmeshment and transference between the therapist and the client. In cases in which the supervisee does not feel that the supervisor is culturally sensitive, he or she might disclose only superficial aspects of therapy. Similarly, a supervisor who does not feel culturally competent might steer supervisory sessions away from racially sensitive topics and assume that the supervisee is the expert on race. For example, we know of a young Black male prison psychology intern who reported that his White supervisor only scarcely acknowledged that the intern had a unique connection with the mostly Black inmate population . In reality, the intern had a deep and profound emotional reaction to working with such a large number of inmates who were the same race as he. Williams and Halgin (1995) noted that when there is a match between the race of the supervisee and the client, the supervisor’s role is to help the therapist appraise the attitudes, beliefs, and perceptions that are related to the racially similar therapy dyad. PARADOXICAL SYSTEMS In a paradoxical system, the clinical power structure is contrary, or paradoxical, to the historically established hierarchy in society. In other words, an ethnic minority supervisor is guiding an ethnic minority supervisee who is working with a majority culture client. In a paradoxical system, an ethnic minority supervisor might find it necessary to consider the racial identity of the therapist and the racial awareness and cross-cultural experiences of the client. For example, an African American supervisee reported working in mandatory treatment with a self-proclaimed neoNazi who disengaged and later told a White therapist that having to report his problems to a Black person was “humiliating.” In contrast, another White client reported a preference for a Black counselor because she felt that a Black person would be more sensitive to her hardship. Hird, Tao, and Gloria (2004) found that racial and ethnic minority supervisors generally spend more time discussing cultural issues when supervising a therapist of a similar ethnic background. In a paradoxically integrated system, in which an ethnic minority supervisor is working with a majority culture supervisee who is providing therapy to an ethnic minority client, the supervisee may stereotype the supervisor as a cultural expert (Priest, 1994; Tummala-Narra, 2004). Ironically, Burkard et al. (2006) found that supervisors of color also exhibited more cultural unresponsiveness when working with Euro-American supervisees. In the study, Euro-American supervisees complained that supervisors of color often avoided discussing the impact of culture on treatment and were not open to discussing racial issues in treatment. In contrast, Sanchez-Hucles and Jones (2005) indicated that White counselor trainees felt culturally pathologized when working with ethnic minority supervisors. They reported that in the context of exploring racial issues, White supervisees have the unfair burden of the assumption that only they have problems relating to other races. Note that researchers, their research designs and choice of measures, and

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their interpretations all come from the researchers’ particular beings, with whatever biases those researchers may bear. However, research on minority supervisors suggests that dialogue about the ethnocultural aspects of therapy can result in positive clinical outcomes for the client as well as a richer supervisory experience (Remington & DaCosta, 1989). Priest (1994) noted that minority supervisors at advanced stages of self-development are able to “formulate multiple supervisory methodologies that are respectful of the supervisee’s culture and interactive style, while remaining professional in nature and scope” (p. 155) when working with majority culture supervisees. Paradoxically triangulated systems involve a minority culture supervisor who is working with a majority culture supervisee who is working with a majority culture client. In this system, when the supervisee perceives the supervisor the be a “cultural expert,” he or she may often wonder if the supervisor is qualified to train on any aspects of therapy that do not involve minority status. Issues related to the social paradox seen in paradoxically triangulated systems were introduced decades ago in applied and personnel psychology (Richards & Jaffee, 1972). The research conducted on “Blacks supervising Whites” found that Black supervisors received worse performance ratings than White supervisors in a nonclinical business setting. In addition, trainees supervised by African Americans were more likely to become insubordinate. Richards and Jaffee also found that supervisees with racial biases were more likely to give poorer ratings to Black supervisors than were those with liberal racial attitudes. More recent studies have noted similar dynamics between minority clinical supervisors and majority supervisees (Brinson, 2004; Johnson, 1997). Brinson observed that White and Asian supervisees tended to devalue the expertise of Black and Latina/o supervisors. However, Johnson’s study found that White supervisees who were female and had higher levels of White identity development (as defined in the subsequent section) rated Black supervisors higher than White supervisors. M U LT I C U LT U R A L C O M P E T E N C E I N S U P E RV I S I O N The literature cites several concepts in multicultural psychology that have particular relevance to cross-cultural supervision. By elaborating on one of the six possible cross-cultural supervision triads, we can create a context before exploring the more technical aspects of cross-cultural supervision. Imagine a laterally integrated situation involving Dr. White, a middle-aged Caucasian male supervisor, working with Makena, a 24-year-old African American female supervisee who recently began counseling an elderly Caucasian woman. Dr. White might be considered culturally encapsulated and does not view race as a salient factor; he prides himself on being colorblind. Makena is experiencing what some racial identity theorists consider emersion/immersion. Accordingly, she is often zealous in seeking information and ideas about what it means to be Black and sometimes experiences healthy cultural paranoia when working with White people. One afternoon, Makena comes to supervision nearly in tears over a “compliment” she received from her client. After 3 weeks in counseling, Makena’s client told her, “A racist is someone who can’t tell the difference between a Black person and a nigger. . . . When I look at you, I see a Black person, and a smart one at that!”

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Racial and Cultural Aspects of Psychotherapy and Supervision 543 The foregoing vignette will invoke a mix of emotional invectives and clinical redresses that can range from innovative to contraindicated. A supervisor’s indifference or purposeful neutrality is likely to alienate the supervisee, whereas open antipathy toward the client’s statement might obscure therapeutic objectives. In any case, the supervisor has an ethical responsibility to facilitate a process that will meet the needs of the client, the counselor, the profession, and society. However, the prudent use of supervisory authority might be challenging for a culturally encapsulated supervisor, and a critical misstep or omission is likely to compound or convolute the issues presented in this situation. One could describe an infinite number of different cross-cultural supervision scenarios that fit within the rubric of Table 28.1. Most scenarios will contain racial aspects that are considerably more subtle than those presented in the case of Makena and Dr. White. Subsequent sections of this chapter describe the nuances of psychotherapy supervision within the framework of multicultural counseling and psychological services. This section discusses (a) the definition and meaning of multicultural competence in supervision, (b) key concepts in cross-cultural supervision, and (c) therapeutic and supervision preferences for specific cultural groups.

DEFINITION AND MEANING OF MULTICULTURAL COMPETENCE IN SUPERVISION Culturally competent supervisors embrace the qualities, values, and professional practices of culturally competent therapists. Specifically, they invite open and honest dialogue about race and ethnicity in supervision subsequent to confronting their own biases, assumptions, and prejudices about other racial or ethnic groups. In addition, they use professional resources and activities to develop specific skills to accommodate racially and ethnically diverse supervisees and clients (Arredondo, 1999; Helms & Cook, 1999). Accordingly, supervisors exhibit multicultural competence when they (a) make intentional efforts to improve the cultural awareness of supervisees, (b) enhance supervisees’ training experiences with cultural content, and (c) are self-reflective and are comfortable exploring and disclosing personal racial biases. Sue and Sue (2003) described three core multicultural competencies in psychotherapy that are applicable to cross-cultural supervision. First, awareness holds that therapists are aware of any assumptions, values, and beliefs they may have that could undermine the therapeutic progress of their clients. Psychotherapy supervisors are aware when their guidance to supervisees is culturally specific and their critique of supervisees’ skills is culturally sensitive. Second, knowledge represents therapists’ understandings of the collective history, experience, and values that underpin their therapeutic alliances with clients. In supervision, supervisors are culturally competent when they are able to understand how a history of oppression will influence the therapeutic alliance between supervisees and clients in cross-cultural supervision triads. Finally, skills represents the specific techniques therapists use to accommodate the unique therapeutic needs of their clients (Sue & Sue, 2003). Culturally competent supervisors are able to use their skills to (a) identify and suggest specific techniques to their supervisees, (b) help supervisees use the cultural and individual identity of the client to devise the best

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therapeutic strategies, and (c) adapt process-oriented supervision strategies to effectively communicate to culturally diverse supervisees. Pope-Davis, Coleman, Liu, and Toporek (2003) stressed the importance of assessing and promoting the multicultural competence of supervisors from within supervisors’ frames of reference. They suggested that graduate programs provide forums for discussing the racial aspects of supervision. They also recommended that supervisors consult with other supervisors to get assistance with specific cultural issues that arise in supervision. Their Multicultural Supervision Inventory assesses supervisees’ and supervisors’ perspectives of multicultural competence in supervision (Pope-Davis et al., 2003). Fundamentally, the hallmark of multicultural competence in supervision is the supervisor’s ability to initiate and conduct multicultural case conceptualization (Constantine et al., 2005; Ladany, Inman, Constantine, & Hofheinz, 1997; Shim & Lee, 1998). Multicultural case conceptualization is the ability to interpret the client’s problem etiology, presenting behavior, and treatment course from within a multicultural framework. In supervision, a multiculturally competent supervisor will encourage the supervisee to explore race-related factors when analyzing the client’s experiences. For example, when working with a Latino client who presents with hyper-religious attitudes, the supervisor might encourage the supervisee to explore the cultural underpinnings of spirituality before considering problems with reality testing or psychosis.

KEY CONCEPTS IN CROSS-CULTURAL SUPERVISION Racial Identity Development The literature suggests that level of cultural identity is a key quality that is essential for multicultural competence in supervision for both majority and minority culture supervisors. In the United States, positive cross-cultural supervision outcomes for White supervisors have been associated with their level of White racial identity (Chang et al., 2003; Constantine & Sue, 2007; Constantine et al., 2005). White racial identity theory distinguishes six dispositions of individuals who self-identify as White in relation to their attitudes toward African Americans: (1) contact, (2) disintegration, (3) reintegration, (4) pseudoindependence, (5) immersion/emersion, (6) and autonomy (Helms, 1990). Helms (1990) provided a complete discussion of White racial identity development. In theory, White people with lower levels of racial identity tend to lack interest in and awareness of other cultures, deny the existence of racism, and often have stereotypes about other races. In contrast, White people with higher levels of racial identity actively seek accurate information about other races, are able to perceive overt and institutionalized racism as well as White privilege, and value cross-cultural experiences. Much of the research on racial identity and multicultural competence in supervision has focused on Euro-American supervisors. However, several recent studies have explored the relationship between the cultural identity of supervisors of color and multicultural competence. In the early stages of racial identity (i.e., conformity and dissonance), members of minority cultures often passively accept majority culture values. With African Americans specifically, the stage of racial

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Racial and Cultural Aspects of Psychotherapy and Supervision 545 identity characterized by passively accepting the majority culture’s norms while rejecting those of their own group is called preencounter. African Americans who immerse themselves within their own culture while rejecting the majority culture’s norms are experiencing immersion/emersion (Cross, Parham, Helms, & Jones, 1991). Theoretically, a minority supervisor who is in conformity or preencounter will behave in the culturally unresponsive manner described by Burkard et al. (2006). At the advanced stages of racial identity development, supervisors of color will experience an integrative awareness characterized by having the ability to exhibit pride in their heritage while appreciating that of other cultures. Notably, no evidence in the literature suggests that sheer membership in one ethnic minority group automatically increases awareness of and sensitivity toward other ethnic minority groups. Therefore, all supervisors, regardless of ethnic background, have a responsibility to actively and intentionally incorporate cultural content into supervision. Cultural encapsulation is the practice of disregarding the influence of culture on therapeutic processes. Several authors have noted the effects of cultural encapsulation in psychotherapy supervision (Estrada et al., 2004; Leuwerke, 2005). According to Pedersen’s (2002) five aspects of cultural encapsulation, encapsulated supervisors may (1) define reality with one set of cultural assumptions and stereotypes; (2) be insensitive to cultural variation, viewing only one culture as legitimate; (3) have unfounded and unreasoned assumptions about other cultures; (4) overemphasize clinical techniques that they apply rigidly across cultures; and (5) interpret behaviors from their own personal reference (Pedersen, 2002). Leuwerke presented an example of a culturally encapsulated supervisor in a lateral system who advised his supervisee to stress autonomy when working with an Asian American client who was trying to negotiate demands from her family. However, autonomy is a cultural value held by Western cultures that diverges from the collectivism and interdependence common among many Asian societies. Estrada et al. (2004) suggested that supervisors’ self-disclosure of personal vulnerabilities to cultural encapsulation helps to build multicultural competence in supervision. Acculturation distinguishes the identity of an individual from an ethnic minority culture from the national identity of his or her nation of residence (Phinney & Ong, 2007). For example, a Pakistani in Great Britain who is fully acculturated will adapt the national customs, traditions, and folkways that have been established in the United Kingdom. In the United States, the relationship between ethnic identity and American identity has been debated, however most contemporary positions aver that a strong ethnic identity does not necessarily preclude a strong national identity (Berry, 1997, 2006). Berry (2006) analyzed 13 identity and acculturation variables (ethnic and national identities, ethnic and national language proficiency and usage, ethnic and national peer contacts, acculturation attitudes, and cultural values) and found four distinct acculturation profiles: (1) Integration represents people who are interested in maintaining their own cultural heritage while being involved with another culture, (2) assimilation represents people who abandon their cultural heritage of origin and adapt the cultural identity of the majority culture, (3) separation represents people who reject the majority culture and are only interested in maintaining involvement with their heritage culture, and (4) marginalization represents people who reject their cultural heritage and the majority culture.

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In psychotherapy and supervision, level of acculturation largely determines how relevant culturally specific interventions are for individual ethnic minority clients and supervisees. For example, an Asian American supervisee who is fully assimilated into the United States may wish to be treated the same, and be subject to the same assumptions, as White supervisees. A separated Asian American supervisee may wish to disclose cultural preferences and be treated in a manner that respects his or her heritage norms and folkways. Acculturation scales typically suggest simple questions that relate to a person’s cultural preferences to determine an individual’s level of acculturation (Cokley & Helm, 2007; Holmes, 2007; Rodriguez, Mira, Paez, & Myers, 2007; Unger, Ritt-Olson, Wagner, Soto, & Baezconde-Garbanati, 2007). White privilege, or conferred dominance, describes the unearned societal rewards that Whites receive based on skin color alone (McIntosh, 1998). According to McIntosh, most White people are unaware of privileges because they are maintained across generations through denial. Neville, Worthington, and Spanierman (2001) posited that White privilege is an insidious and complex network of relationships among individuals, groups, and systems that operates in a racial social hierarchy. On the surface, it would appear that Whites only reap benefits from unearned racial privilege. However, a number of social and emotional consequences are associated with receiving White privilege (Helms, 1995; Neville et al., 2001; Pinderhughes, 1989; Thompson & Neville, 1999). For example, Thompson and Neville reported that a group of White counseling psychology graduate students who had become aware of their unearned racial advantage experienced feelings of guilt, shame, and sadness. According to Pinderhughes, people who realize White privilege may experience uncertainty and a sense of entrapment. In cross-cultural supervision, White privilege is associated with many of the racial issues associated with lateral and paradoxical systems, such as White supervisors being culturally unresponsive to minority supervisees, and White supervisees becoming insubordinate with minority supervisors. In counselor training, Utsey, McCarthy, Eubanks, and Adrian (2002) observed that White privilege often manifests as White trainees speaking for themselves, in contrast to Black trainees, who are often called on to speak for their entire race. In addition, Helms and Cook (1999) found that supervisors often attribute clinical errors to clients’ pathology rather than White trainees’ clinical skills in cross-racial counseling relationships. White trainees who have an enhanced sense of their White identity are more effective in negotiating White privilege in cross-racial counseling situations (Utsey et al., 2005). Helms (1995) posited that White counselor trainees can develop a “nonracist” White identity by accepting their “Whiteness” and acknowledging ways in which they benefit from White privilege. Therefore, the task for counselor trainees is to become aware of how subtle White privileges are relevant to their experiences and impact their clinical work with clients from different racial backgrounds (Utsey et al., 2002). Colorblindness Beyond White privilege, Neville et al. (2001) noted that racism is reflected in colorblind racial attitudes typified by ignorance, denial, and a distortion of the reality that race plays a role in people’s lived experiences. Bonilla-Silva (2002)

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Racial and Cultural Aspects of Psychotherapy and Supervision 547 identified the following four major schematic characteristics of colorblind racism: (1) Principles of liberalism are extended to racial matters, (2) social and economic racial disparities are explained in societal terms (e.g., dysfunctional family structure and deficient environmental conditions), (3) racial stratification (e.g., residential and school segregation) is viewed as a naturally occurring phenomenon, and (4) racism is asserted to be a thing of the past. In the context of counselor training, White counselor trainees’ colorblind racial attitudes are often manifest in the attitude that racial minority group clients are no different from racial majority group clients (Utsey et al., 2005). When using colorblind attitudes, White counselor trainees risk overlooking the role of racism and discrimination in relation to clients’ presenting problems. Utsey et al. (2005) noted that colorblindness is unethical, because the Ethical Principles of Psychologists and Code of Conduct (American Psychological Association, 2002) mandates that practitioners address issues related to racism and discrimination as potential sources of distress for racial minority clients. White counselor trainees who adopt a colorblind posture toward their racial minority clients also tend to minimize the influence of their Whiteness on the counselor–client relationship. In addition, colorblindness is a major cause of the disproportionate number of minority clients diagnosed with severe pathology (Ridley, 1995). In cross-cultural case conceptualization in a lateral system, a supervisor and supervisee with colorblind attitudes may ignore important racial issues, resulting in a more severe diagnosis and prognosis for the client. Utsey et al. (2005) posited that in order for counselor training programs to assume greater responsibility for increasing the racial awareness of their trainees, more research is needed that examines the roles of race, racism, and racial dynamics among supervisors and therapists. High and Low Context Communication Subtle variations exist in the communication practices of individualistic and collectivistic cultures. Hall (1969) explained these nuances in terms of high- versus low-context communication. When supervision triads consist of individuals from high-context and low-context cultures, confusion often occurs in the exchange of information. Supervisors, supervisees, and clients from low-context cultures will often assume that a listener should understand and impart statements primarily by the use of words. Low-context supervisors might expect supervisees to say exactly what they mean and process statements in a way that separates the message from the speaker. Low-context communicators also (a) value debate and settling issues of right and wrong; (b) value comments that are clear, brief, and to the point; (c) are uncomfortable with silence and value a steady exchange of ideas; and (d) devalue redundancy and see little value in stating the obvious. The majority culture is low context in the United States, Canada, Australia, and much of Western Europe. In contrast, a person from a high-context culture will place more nonverbal cues into his or her statements so that the listener can derive a particular meaning. A high-context supervisor might connect his or her statements to the supervisee’s ideas and to global issues that value the context of their supervisory relationship. Specifically, high-context communicators (a) value communalities and are less likely to see issues in terms of right and wrong; (b) extrapolate meaning from

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statements from the larger context of the statement, rather than from the statement in and of itself; (c) value silence within conversations to process meaning; and (d) value reiterating and reframing to establish patterns and a shared understanding of information. High-context societies are common in much of Africa, Asia, the Middle East, and Latin America. Because of varying communication styles, verbal and nonverbal cues can be mistaken, unclear, or inadequate within a cross-cultural supervision triad. For instance, a White supervisor using low-context communication might falsely characterize an Asian American supervisee using high-context communication as nonverbal, inarticulate, and unintelligent. Low-context communicators often believe high-context communicators are missing points and communicating ineffectively. High-context communicators might consider low-context communicators to be uncouth, blunt, and inconsiderate (Mio, 1999). Adjustment to Racism and Oppression Racism and oppression contribute to behavioral responses that signal concern about survival and that can either increase psychological distress or promote unconventional survival mechanisms among affected racial groups (Clark, Anderson, Clark, & Williams, 1999). Cultural trauma and historical hostility, for example, assert that historical experiences of oppression are embedded in the collective memory of survivors in future generations (Alexander, 2004; Eyerman, 2001; Vontress & Epp, 1997). Similarly, invisibility syndrome posits that present-day forms of institutional racism and White privilege lead to expectations of racist treatment among people of color and ultimately to generalized race-related stress (Franklin & BoydFranklin, 2000; Franklin, Boyd-Franklin, & Kelly, 2006). The cumulative impact of historic and present-day racism and oppression on minority cultures is healthy cultural paranoia—a unique psychology among otherwise mentally healthy ethnic minority persons that often results in tension and mistrust of majority culture psychotherapists and supervisors (Elligan & Utsey, 1999; I. A. Toldson, 2007). PSYCHOTHERAPY AND SUPERVISION WITHIN AN ETHNOCULTURAL CONTEXT The American Psychological Association (2002) has set forth specific guidelines for providing psychological services to ethnically and culturally diverse populations. The guidelines include (a) assessing language barriers; (b) identifying the stage of racial/ethnic identity development, acculturation, and worldview; (c) avoiding evaluating culturally congruent behaviors as pathology; (d) recognizing and encouraging dialogue about cultural differences when appropriate; and (e) not overgeneralizing culturally specific characteristics to all members of a particular group. Although these guidelines were written for therapists working with culturally different clients, they are relevant to supervisors working with culturally different supervisees and/or clients. On a practical level, the guidelines indicate that when considering the mental health status of ethnic minority cultures, supervisors should help therapists consider the universality of diagnoses, be aware of biases in mental health procedures, and be sensitive to diversity. Universality is the idea that disorders found in some cultures may manifest differently or be obsolete in other cultures (Lee, 2002).

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Racial and Cultural Aspects of Psychotherapy and Supervision 549 This section provides information on the nomenclature and ethnocultural folkways of various racial/ethnic groups. Note that this section is not intended to provide specific therapeutic strategies for specific populations. The literature is replete with novel techniques for addressing the unique therapeutic needs of specific ethnic groups—too many to reiterate in this chapter, but no less deserving of consideration. Typically, however, choosing a supervisory strategy is not the primary problem when working in diverse settings. Several recent articles have warned against using a “cookie-cutter” approach to working with ethnically diverse clients (Bowie, Cherry, & Wooding, 2005; Estrada, 2005; Respress & Lutfi, 2006; Taylor-Richardson, Heflinger, & Brown, 2006). Like a carpenter’s tools, counseling strategies can be as effective, inept, or destructive as the person or organization using them (I. A. Toldson, 2007). Helpers must be self-aware and able to use themselves as agents of change (Middleton et al., 2000). Moreover, individual differences within each race exceed the collective differences one race has from another (Artiles, Rueda, Salazar, & Higareda, 2005; de Valenzuela, Copeland, Huaqing Qi, & Park, 2006). In fact, the practice of forcefitting races into a category reflects a Euro-centric paradigm that relies heavily on taxonomies to understand complex material (Leong & Wong, 2003). Therefore, readers of this section should deemphasize classification systems and guidelines and use the information to develop a deeper appreciation for other cultures and the far-reaching potential of cross-cultural supervision. African Americans With an estimated population of 39.9 million, or 13.8% of the total population, African Americans constitute the second largest non-White ethnic group in the United States (U.S. Census Bureau, 2003). Today, most Black people in the Americas are the progeny of victims of the transatlantic slave trade. From 1619 to 1863, millions of Africans were involuntarily relocated from various regions of West Africa to newly established European colonies in the Americas. Many different African ethnic groups, including the Congo, Yoruba, Wolof, and Ibo, were casualties of the transatlantic slave trade. The Black American population is the aggregate of these groups—consolidated into one race, bound by a common struggle against racial oppression, and distinguished by cultural dualism (I. A. Toldson, 1999). Survey research suggests that persons of Black African ancestry prefer mental health healing practices that are consistent with African cultural mores. Black people are more likely to use prayer, faith, and spirituality to cope with personal difficulties (Constantine, Lewis, Conner, & Sanchez, 2000; Cooper-Patrick et al., 1997; Taylor, Ellison, Chatters, Levin, & Lincoln, 2000). In the Black community, religious figures serve a prominent role in providing counseling services (Levin & Taylor, 1998). The tradition of relying on religious leaders, such as Nat Turner, Elijah Muhammad, Malcolm X, and Martin Luther King, Jr., to overcome adversity is well established within the Black community. Accordingly, in the United States, Black Americans report more religious involvement and more often seek comfort through spiritual activities compared to White Americans (Taylor et al., 2000). Black peoples’ collectivist orientation is evident in their healing preferences. Specifically, persons of Black African ancestry are more likely to rely on family and friends to cope with personal difficulty (Logan, 1996; Ruiz, 1990). The

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“brotherhood/sisterhood” concept among African Americans elevates family extensions to the status of core family members; solutions to personal difficulties often involve meaningful exchange throughout the extended family. Sue and Sue’s (2003) finding that African Americans prefer therapists of the same race or ethnicity likely reflects the collectivist orientation, in which Black people will disclose more readily when they feel a certain kinship with the caregiver. Thus, Black people in therapy may feel compelled to elevate the clinician to the status of an extended family member before actively engaging in the therapeutic process. Naturalistic healing is another value that is evident in mental health healing practices among Black people. In a review of the literature, a report of the U.S. Surgeon General (U.S. Office of the Surgeon General, 2001) found that African Americans prefer counseling to drug therapy and are more likely to have concerns about the side effects, effectiveness, and addiction potential of medications (CooperPatrick et al., 1997; Dwight-Johnson, Sherbourne, Liao, & Wells, 2000). Similarly, Das, Olfson, McCurtis, and Weissman (2006) observed that African Americans may attach more stigma to taking medication and are more likely to have spiritual values that are inconsistent with medication use. The report also revealed that African Americans tend to take an “active approach” (p. 28) to facing personal problems and are less likely than Whites to use any professional services to deal with mental health issues. According to this view, Black people might prefer a process of healing that feels more natural, emphasizes normal adjustments to life transitions, and consists of less intrusive or “technical” approaches such as medication or a formal brand of therapy (Das et al., 2006). I. A. Toldson (2007) suggested group therapy, community-based treatment, and family systems approaches as culturally congruent systems of care for African American clients. American Indians and Alaska Natives In 2001, about 4.1 million American Indians and Alaska Natives lived in the United States (U.S. Census Bureau, 2003). Approximately 569 federally recognized tribes with more than 300 different languages on about 300 reservations exist in the United States. American Indians and Alaska Natives are sovereign entities that receive health care and education from the government due to a treaty with the United States in exchange for land. As the indigenous population of the Americas when Western Europeans arrived, American Indians suffered greatly from colonialism. Between 1 and 10 million Native Americans were in America when Christopher Columbus arrived, but by 1850 the population had decreased to 250,000, primarily due to foreign diseases, displacement, and extermination (Lewy, 2004). Current population estimates suggest that the Native American population is growing, and it is expected to reach 4.3 million by 2050 (Zimmerman, 1994). Compared to Western cultures, American Indians and Alaska Natives have a greater reverence for spiritual and ancestral forces (Hunter & Sawyer, 2006). Their view of health and healing is more holistic, and they tend to believe that the mind, body, and spirit are inseparable. In communication, American Indians are less verbal and avoid excessive smiling. Less acculturated American Indians and Alaska Natives may consider eye contact a sign of disrespect. In psychotherapy, resilience factors for American Indians are typically associated with their strong community and family ties, cultural identity, reverent connection with their past,

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Racial and Cultural Aspects of Psychotherapy and Supervision 551 use of traditional healing methods, strong coping stills, and respect for the wisdom of elders (LaFromboise, Hoyt, Oliver, & Whitbeck, 2006). Therapists working with American Indian clients have reported the need to consult with the community elders before effectively working with their clients. Basic understanding and respect for the Circle of Life is also important for successful psychotherapy interventions with Native Americans (Hunter & Sawyer, 2006). The Circle of Life, or Medicine Wheel, holds that life evolves forever, bringing new lessons and truths. The Earthwalk is a related concept and is based on the understanding that everyone must honor every path, and all lessons talents and abilities are equal. The shape of the circle has spiritual implications for Native Americans, who note that the sun, sky, earth, moon, and other forces created by the god they worship are round. Therefore, a therapeutic path that leads to health and happiness is inherently a spiritual journey. Attempts to strip spiritual components away from the therapeutic process are likely to be regarded with distrust and contempt. Walker and LaDue (1986) recommended that mental health practitioners who work with American Indians become familiar with historical events that have strained their relationship with White Americans. Because American Indians have a strong reverence for the past, they are likely to be distrustful of many White therapists and supervisors. Creating a therapy and supervisory experience that is culturally reaffirming in collaboration with elders and community leaders is effective in building rapport with American Indian recipients. Credibility building is an important initial phase of therapy and supervision that involves discussing any “homework” done to become familiar with American Indian culture, exhibiting a willingness to incorporate community and family into the therapeutic process, and being candid about any lack of expertise (Walker & LaDue, 1986). Latinas and Latinos The Latina/o population in the United States increased 58% between 1990 and 2000. With a current estimate of 35.3 million (14.2% of the U.S. population), the Latina/o population is now slightly larger than the African American population in the United States (U.S. Census Bureau, 2003). More than one third of Latinas/os in the United States are 18 years old or younger (Rosado & Elias, 1993). As ethnonyms, the terms Hispanic and Latino are often used interchangeably and are confused by service providers. Originally, Hispanic denoted persons from the mostly White Iberian Peninsula, including Spain and Portugal, whereas Latino described the indigenous people of Mexico, Central America, and South America. Latino was not included in the U.S. Census Bureau until 2000. Currently, Spanish speakers disagree on how the two terms should be applied. Although Latino is more widely used, a practitioner should clarify preference with the client or supervisee. Latinas/os descend from more than 20 different countries with distinct sociocultural backgrounds and dialects of the Spanish language. Approximately 66% of Latinas/os in the United States descend from Mexico, with most others from Puerto Rico, Central America, South America, Cuba, and the Dominican Republic (U.S. Office of the Surgeon General, 2001). Issues related to bilingualism often emerge in psychotherapy and supervision with Latinas/os (Rothe, 2005). When a translator is used, it is important for the therapist to direct speech to the client and not the translator. Historically, the Latina/o experience in the United States

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has been similar to that of African Americans. Latina/o clients may present with a variety of issues related to underrepresentation and racism that compound mental health problems. Like other cultures, Latinas/os have distinct traditional beliefs that have implications for counselors and supervisors. For instance, they tend to have rigid and separate roles for males and females. The machismo belief views the ideal male as hard working, decisive, and able to protect and provide for his family (Andr´es˜ Hyman, Ortiz, Anez, Paris, & Davidson, 2006). Like other codes among men in disenfranchised communities (e.g., Black male “thug life” and post-Civil War, Southern White, male code of honor), machismo beliefs are vulnerable to corrupt associations, including heavy drinking, risk taking, and physical violence. Traditional expectations for the woman, such as holding higher status for her ability to rear children and stand by her husband, often appear sexist to therapists of other races. Therapists and supervisors should refrain from imposing their values on clients and supervisees. Family dysfunction should be assessed based on cultural standards and clients’ needs. Latino Americans exhibit a strong family and community identity. Their value for elders and elder qualities exceeds that of traditional American culture, which places a greater value on attributes of youth. Latino Americans value familismo, which is the practice of placing family needs above individual needs (Andr´esHyman et al., 2006). Because traditional American culture values individual autonomy, many therapists and supervisors underestimate the magnitude of basic decisions for Latina/o clients. Many Latina/o clients will insist that family members be involved in the clinical process and may refuse to make decisions before consulting with other family members. In therapy, Latina/o clients are more likely to value the role of happenstance, acts of God, and other supernatural forces on their health and healing process. Latinas/os also view physical touch as a symbol of caring and will often value a light tap on the shoulder or arm (Shearer & King, 2004). This is opposite from many Islamic cultures, which may object to any casual opposite-sex touching (Juckett, 2005). Those recently from Latin American countries typically require less physical space than individuals from the United States. Some majority culture therapists and supervisors have reported misunderstanding or being uncomfortable with Latina/o clients getting too close. Attempts to shy away without discussing cultural underpinnings are likely to reduce rapport building. Asian Americans and Pacific Islanders The Asian American and Pacific Islander population grew 95% between 1980 and 1990. The 2000 U.S. census estimated that almost 12 million (4%) people in the United States report themselves as having either full or partial Asian heritage (U.S. Census Bureau, 2003). The largest Asian ethnic subgroups in the U.S. population in order of size are Chinese, Filipinos, Asian Indians, Vietnamese, Koreans, Japanese, Cambodians, Pakistanis, Laotians, Hmong, and Thais (U.S. Office of the Surgeon General, 2001). Currently, more than 60% of Asian American and Pacific Islanders (Oceanic) were born outside of the United States and represent 43 different ethnic groups and more than 100 different languages and dialects.

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Racial and Cultural Aspects of Psychotherapy and Supervision 553 Collectively Asian Americans outperform Blacks, Latinas/os, and Whites on many socioeconomic indicators including household income and college graduation rates. Some consider them to be the “model minority” (Hwang, 2006; McGowan & Lindgren, 2006). However, many Asian Americans report the incidence of prejudice, stereotypes, and discrimination. In addition, aggregated data often conceal social concerns for segments of the Asian American and Pacific Islander population. Southeast Asians, particularly those with refugee experience, have the highest high school dropout rates in the country in addition to problems with crime, poverty, and drug abuse (Coloma, 2006; Liu & Iwamoto, 2007). Asian American and Pacific Islanders are less likely than any other ethnic population to use mental health services (U.S. Office of the Surgeon General, 2001). The low utilization of mental health services has been attributed to stigma and shame (or “loss of face,” as noted in Asian culture). Other barriers include differences in language, culture, and ethnicity; the tendency to endorse somatic rather than emotional and interpersonal problems; and conceptions of mental health disorders that differ from Western views (U.S. Office of the Surgeon General, 2001). Like other ethnic groups, Asian Americans generally have a collectivist orientation and place greater emphasis on the family and community than the individual (Brewer & Chen, 2007; Ponterotto & Park-Taylor, 2007). Asian Americans also value harmony and interdependence. In therapy, they are careful not to disclose anything that will bring shame upon their family. Asian clients and supervisees often expect therapy and supervisors to give concrete instructions and are less likely to give demands or express strong opinions. In cross-cultural supervision, it is important for therapists and supervisors to avoid misinterpreting modesty and reserve as low self-esteem. Level of acculturation as a therapeutic issue has been cited more frequently with regard to Asian American clients (Ponterotto & Park-Taylor, 2007). Among Asian Americans, acculturation is associated with treatment utilization, presentation of mental health disorders, and efficacy of therapy. More highly acculturated Asian Americans use treatment more often, have a more successful course of therapy, and have mental health problems that are similar to those of the majority culture. This pattern primarily indicates that current mental health systems lack adequate accommodations for many Asian American clients. Akutsu, Tsuru, and Chu (2006) recommended providing language- and culture-specific services, services specifically designated for Asian Americans and Pacific Islanders, ethnic matching, multiple explanations for problems, and avenues for incorporating the family into therapy (Akutsu et al., 2006). CONCLUSION Conceivably, various races and ethnicities have healing preferences that are inconsistent with traditional mental health systems in the United States as perpetuated by the rigidity of the Diagnostic and Statistical Manual of Mental Disorders and thirdparty payer guidelines. Many of these inconsistencies can lead to critical missteps in the psychotherapy and supervision process. For example, the spirituality among persons of color is often viewed as a symptom of psychosis. Furthermore, any semblance of “kinship” exhibited by persons in collectivist cultures toward the

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therapist may appear on the surface to deviate from ethical practice standards. Therefore, many supervisors will caution supervisees against clients’ attempts to create a more personal tone to the treatment process. Research evidence suggests that inconsistencies between clients’ cultural mores and traditional mental health systems may lead to some disenchantment among clients. In addition to cultural incompatibility, racism and oppression have contributed to disillusionment with mental health services. Comparing and contrasting Western to non-Western values, one finds that nomenclature and health attitudes are also important in understanding the nuances of cross-cultural psychotherapy and supervision. With respect to health attitudes, Western cultures tend to place more importance on the role of the clinician and formal mental health systems than do individuals from non-Western cultures. Many ethnic minority groups place a greater value on naturalistic healing, spiritual growth, and holistic remedies. Accordingly, many ethnic minority clients start therapy later, often as a last resort, whereas majority culture clients in the United States may use therapy as a preventive measure. Other values associated with Western culture include time efficiency, individual autonomy and independence, and personal control over environment and destiny. In contrast, non-Western cultures tend to value greater time flexibility and relativity, collectivism and interdependence, and environmental control over persons and fate. Due to cultural nuances, many Western-oriented supervisors have difficulties helping supervisees conceptualize cases with some ethnic minorities. Many supervisors and therapists will objectively deduce mental health problems by assembling discrete and specific data (e.g., age, duration of problem, and scores on psychometric assessments) to determine the probability that a client has a particular problem and to predict associated behavioral outcomes (I. A. Toldson, 2007). This diagnosis/prognosis approach implicitly suggests that problems originate and are perpetuated within each individual (Atkinson, Morten, & Sue, 1997), potentially undermining the complexity of ethnocultural determinants of mental health problems and resiliency factors. A non-Western approach to conceptualizing mental health problems is not limited to a description of mental and emotional deficits or to observations of externalized abnormal behaviors (Hill, 2004; Kagawa-Singer, Katz, Taylor, & Vanderryn, 1996; I. A. Toldson & Toldson, 1999). Instead, an accurate assessment extends to describing inherent responses to social and environmental conditions, in which the so-called abnormal behavior might be a “normal” reaction. In other words, pathology is explained as a consequence of dynamic ecological systems rather than the result of intrapsychological deficits (I. A. Toldson & Toldson, 1999). Furthermore, non-Western conceptions of mental health challenges will assert that a client’s potential is more important than his or her position, and “possibility” is as real and material as probability when prognosticating the course of any given disorder. Non-Western approaches might require supervisors and clinicians to grasp clients’ mental health using insight and intuition, intellectual creativity, and abstract reasoning. This might sound absurdly irrational to a staunch adherent to the scientific method. However, in practice, using deductive logic to understand mental health often reduces clients to a blunder of fragmented inferences, rent asunder from the whole in which they belong. The mental health status of

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Racial and Cultural Aspects of Psychotherapy and Supervision 555 culturally different clients should be viewed within the context of their history and nomenclature, as well as the complex set of forces that influence their cultural identity (I. A. Toldson, 2007). Overall, this chapter explored issues related to racial and ethnic diversity within the cross-cultural supervision triad. Before a supervisor initiates clinical guidance with a trainee who is, or who is working with, someone of a different ethnic background from the supervisor, we recommend that he or she assess the supervision triad on a systemic level. Each cross-cultural supervisory system has a unique set of advantages and consequences that mirror those of societal power differentials. In that view, cross-cultural supervision can be lateral (i.e., reenacts and reinforces social power differentials) or paradoxical (i.e., contrary to social power differentials). Multicultural competence in supervision involves a variety of strategies to accommodate the unique clinical needs of ethnically diverse supervisees and clientele. Developing competence in supervision requires becoming familiar with a formal definition and meaning of multicultural competence in supervision. A supervisor can apply key concepts in cross-cultural psychology to the supervision to enhance his or her level of communication with the supervisee and help the supervisee develop more effective ways to work with diverse clients. Finally, being competent requires understanding the therapeutic and supervision preferences of specific cultural groups while respecting the infinite range of experiences, acculturation levels, and racial identity stages of minority and majority culture clients.

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Logan, S. L. (1996). The Black family: Strengths, self-help, and positive change. Boulder, CO: Westview Press. McGowan, M. O., & Lindgren, J. (2006). Testing the model minority myth. Northwestern University Law Review, 100(1) , 331–377. McIntosh, P. (1998). White privilege: Unpacking the invisible knapsack. In M. McGoldrick (Ed.), Revisioning family therapy: Race, culture, and gender in clinical practice (pp. 147–152). New York: Guilford Press. McKay, K. M., Hill, M. S., Freedman, S. R., & Enright, R. D. (2007). Towards a feminist empowerment model of forgiveness psychotherapy. Psychotherapy: Theory, Research, Practice, and Training, 44, 14–29. Middleton, R. A., Rollins, C. W., Sanderson, P. L., Leung, P., Harley, D. A., Ebener, D., et al. (2000). Endorsement of professional multicultural rehabilitation competencies and standards: A call to action. Rehabilitation Counseling Bulletin, 43(4) , 219–240. Mio, J. S. (1999). Key words in multicultural interventions: A dictionary. Westport, CT: Greenwood Press. Neville, H. A., Worthington, R. L., & Spanierman, L. B. (2001). Race, power, and multicultural counseling psychology: Understanding White privilege and color-blind racial attitudes. In J. G. Ponterotto, J. M. Casas, L. A. Suzuki, & C. M. Alexander (Eds.), Handbook of multicultural counseling (pp. 257–288). Thousand Oaks, CA: Sage. Owens-Patterson, M. (2000). The African American supervisor: Racial transference and countertransference in interracial psychotherapy supervision. In L.C. Jackson & B. Greene (Eds.), Psychotherapy with African American women: Innovations in psychodynamic perspectives and practice (pp. 145–165). New York: Guilford Press. Pedersen, P. (2002). Counseling across cultures (5th ed. ). Thousand Oaks, CA: Sage. Phinney, J. S., & Ong, A. D. (2007). Conceptualization and measurement of ethnic identity: Current status and future directions. Journal of Counseling Psychology, 54, 271–281. Pinderhughes, E. (1989). Understanding race, ethnicity, and power: The key to efficacy in clinical practice. New York: Free Press. Ponterotto, J. G., & Park-Taylor, J. (2007). Racial and ethnic identity theory, measurement, and research in counseling psychology: Present status and future directions. Journal of Counseling Psychology, 54, 282–294. Pope-Davis, D. B., Coleman, H. L. K., Liu, W. M., & Toporek, R. L. (2003). Handbook of multicultural competencies in counseling and psychology. Thousand Oaks, CA: Sage. Priest, R. (1994). Minority supervisor and majority supervisee: Another perspective of clinical reality. Counselor Education and Supervision, 34(2) , 152–159. Remington, G., & DaCosta, G. (1989). Ethnocultural factors in resident supervision: Black supervisor and White supervisees. American Journal of Psychotherapy, 43, 398–415. Respress, T., & Lutfi, G. (2006). Whole brain learning: The fine arts with students at risk. Reclaiming Children and Youth, 15(1) , 24–31. Richards, S. A., & Jaffee, C. L. (1972). Blacks supervising Whites: A study of interracial difficulties in working together in a simulated organization. Journal of Applied Psychology, 56, 234–240. Ridley, C. R. (1995). Overcoming unintentional racism in counseling and therapy. Thousand Oaks, CA: Sage. Rodriguez, N., Mira, C. B., Paez, N. D., & Myers, H. F. (2007). Exploring the complexities of familism and acculturation: Central constructs for people of Mexican origin. American Journal of Community Psychology, 39(1/2) , 61–77. Rogers, J. L. (2002). A model of multicultural supervision and its integration with the psychodynamic supervision model of Jacobs, David, and Meyer (Paul David, Donald J. Meyer, Daniel Jacobs). Unpublished doctoral dissertation, the Wright Institute, Berkeley, CA. Rosado, J. W., & Elias, M. J. (1993). Ecological and psychocultural mediators in the delivery of services for urban, culturally diverse Hispanic clients. Professional Psychology: Research and Practice, 24, 450–459. Rothe, E. M. (2005). Hispanic adolescents and their families sociocultural factors and treatment considerations. Adolescent Psychiatry, 28, 251–278. Ruiz, D. S. (1990). Handbook of mental health and mental disorder among Black Americans. New York: Greenwood Press. Ryde, J. (2000). Supervising across difference. International Journal of Psychotherapy, 5(1) , 37–48. Sanchez-Hucles, J., & Jones, N. (2005). Breaking the silence around race in training, practice, and research. Counseling Psychologist, 33, 547–558. Shearer, R. A., & King, P. A. (2004). Multicultural competencies in probation—Issues and challenges. Federal Probation, 68(1) , 3–9. Shim, H. S., & Lee, Y. H. (1998). Assessment of the developmental levels of Korean counselors. Korean Journal of Counseling and Psychotherapy, 10(1) , 1–28. Silvestri, T. J., & Richardson, T. Q. (2001). White racial identity statuses and NEO personality constructs: An exploratory analysis. Journal of Counseling and Development, 79, 68–77.

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C H A P T E R 29

Gender and Sexual Orientation in Supervision JOHANNA E. NILSSON, DANAH M. BARAZANJI, CODI L. SCHAL, and ANGELA D. BAHNER

SUPERVISION IS an intimate and intense interpersonal process between a supervisor and supervisee in which the supervisor is focused on supporting the clinical development of the supervisee as well as monitoring and evaluating the supervisee’s work with clients (Bernard & Goodyear, 2004; Loganbill, Hardy, & Delworth, 1982). Many variables can influence the process and success of supervision, and some of those include aspects of human diversity such as race, ethnicity, age, gender, and sexual orientation (e.g., Bernard & Goodyear, 2004; Brown & Landrum-Brown, 1995; Garrett et al., 2001; Gatmon et al., 2001). Both gender and sexual orientation can have a profound effect on human development, influencing emotions, cognitions, and interpersonal interactions (Crawford & Unger, 2000; Fassinger, 2000; Pearson, 2003) and thus also the supervisory relationship (Gatmon et al., 2001; Granello, 2003; Szymanski, 2005). In this chapter, we focus on the implications of gender and sexual orientation in the supervisory process, specifically on the relationship between supervisors and supervisees. By gender, we are referring to socially constructed assumptions, ideas, values, and norms about men and women that are rooted in a historical, economical, sociopolitical, and cultural context (Fassinger, 2000). Experiences of gender do not occur in isolation from sex and other forms of sexual expression (i.e., sexual orientation and identification), but rather these variables are closely intertwined with one another. Sex refers to biological differences (Fassinger, 2000), whereas sexual orientation refers to the sex of a person to whom an individual is sexually or emotionally attracted (Bohan, 1996). We specifically address sexual orientation issues as they refer to lesbian, gay, and bisexual (LGB) individuals. To accomplish all this, we first address the issues of power in supervision. Then we discuss the influence and dynamics of gender and sexual orientation in 560

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supervision and provide recommendations for supervisors. We conclude with some final thoughts. P O W E R A N D S U P E RV I S I O N Before discussing gender and sexual orientation in supervision, we want to acknowledge the power differential that occurs naturally in supervision between supervisors and supervisees. In this relationship, power is afforded to supervisors due to their evaluative and directive role (Bernard & Goodyear, 2004). This power differential may intensify other dynamics that are already in play due to cultural and societal expectations, norms, and history (e.g., the interpersonal impacts of gender and sexual orientation). Scholars have posited that differential power and status assigned to varying social positions (e.g., based on sex, race, sexual orientation, disability) invariably enter counseling and supervisory relationships (Jordan, Walker, & Hartling, 2004; Sue & Sue, 2003). More specifically, a supervisory dyad consisting of a heterosexual supervisor and an LGB supervisee requires attention as power differences already inherent to the supervision process may be amplified due to the heterosexual supervisor’s culturally dominant status (Martin, 1995; Pfohl, 2004), which can further complicate the supervisory process (Halpert & Pfaller, 2001). Similar dynamics and complications may be true for female supervisees working with male supervisors. Although the situation is slowly changing, data on the sex of supervisors indicate that the proportion of male to female supervisors is still skewed toward more men in the profession (Gilbert & Rossman, 1992; Kurpius, Gibson, Lewis, & Corbet, 1991; McCarthy, Kulakowski, & Kenfield, 1994; StevensSmith, 1995), whereas most trainees are women (Chung, Marshall, & Gordon, 2001). G E N D E R I S S U E S I N S U P E RV I S I O N Although gender has been of interest in the supervision literature for almost 30 years (Granello, 2003), empirical studies are still sparse and most writings in this area are theoretically based (Granello, Beamish, & Davis, 1997; Sells, Goodyear, Lichtenberg, & Polkinghorne, 1997). Downs’s (2000) review of gender issues in the supervision literature highlighted several contradictory findings related to gender, power, communication, and discourse styles. Recent meta-analyses have also indicated that gender accounts for around 1% of the variance in communication, with 85% overlap between men and women in their communicative behavior (Aries, 2006; Dindia, 2006). Thus, in synthesizing this research, we must remind ourselves that men and women are more likely to differ in degree of behavior rather than kind of behavior (Dindia, 2006). In effect, there is a tremendous amount of consensual communication notwithstanding the gender distinction noted. However, power is often used to explain communication differences between the sexes (e.g., Aries, 2006; Krolokke & Sorensen, 2006). Power, as it relates to gender, has been difficult for psychologists, researchers, and feminists to define (Yoder & Kahn, 1992). In their research, Robyak, Goodyear, Prange, and Donham (1986) conceptualized power as being (a) the ability to exhibit expert-like characteristics

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(i.e., knowledge, confidence, and skills); (b) the ability to derive respect due to having values in common with one’s peers or subordinates; or (c) the result of having a certain position, or being one who provides to society without personal profit. Other authors have separated the definition of power into two domains: power over, and power to (Yorder & Kahn, 1992). In an interpersonal interaction, one person may wish to exert more power over the other individual, and communication may be a means of doing so (Yarnold & Kahn, 1992). In most contexts men have more power, feel more power, are perceived as having more power, and are encouraged to exercise power more than women (Frawley-O’Dea & Sarnat, 2001; Yoder & Kahn, 1992). This power differential is believed to be the result of centuries of biological, cultural, sociological, psychological, and religious forces that have encouraged men to uphold such commands (Payne, 2001). In a broad review of the literature from 1995 to 2004, Kalbfleisch and Herold (2006) concluded that the communication styles attributed to powerful individuals are also those typically held by men. Examples of such communication styles are displaying informal demeanors, hiding emotions, using close personal space and touch, limiting self-disclosure, displaying extroversion, acting impulsively, being less observant of nonverbal communication, and being more aggressive. Twohey and Volker (1993) suggested that men compared to women may emphasize moral fairness, rigidity, and what is right versus wrong. In addition, research has shown that men are more likely to interrupt during conversations (Kollock, Blumstein, & Schwartz, 1985); furthermore, this tendency has also been found in the field of psychotherapy, with male therapists interrupting clients more frequently than female therapists (Cooke & Kipnis, 1986). General findings such as these have led to theories and research expectations that male supervisors, in light of their propensity to utilize more power and authority than their female counterparts, will integrate those tendencies into a more directive supervisory style (McHale & Carr, 1998; Miller & Ivey, 2006; Nelson & Holloway, 1990; Sells et al., 1997). However, empirical research has shown inconsistencies. For example, Miller and Ivey found that male supervisors actually utilize an affiliative rather than authoritative discourse style. To explain the disparity between common gender stereotypes and their findings, Miller and Ivey suggested that their participants were from the field of marriage and family therapy and supervision, where traditional gender differences in power and communication might not hold true. In contrast to communication patterns in individuals holding power, communication styles associated with low power statuses and subordinate roles tend to be characteristic of women. These styles include using distant personal space, smiling, showing emotional expression, using self-disclosure, engaging in censorship, and having hesitation in speech (Kalbfleisch & Herold, 2006). However, some researchers challenge that communicative behaviors frequently seen in women are not necessarily indicative of powerlessness, but rather simply reflect women’s relationship expectations and values. For example, Payne, Fuqua, and Cangemi (2001) suggested that that such behaviors stem from women’s desire to be inclusive of others and socially affiliative and to create a nonthreatening atmosphere for those around them. Such behaviors may actually serve to increase women’s power in a room by equalizing the status and control of all participants in a group.

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Similar to the contradictory findings related to male supervisors, research related to female supervisors has also yielded mixed results. For example, McHale and Carr (1998) examined communication and discourse styles in supervision and found directive styles (characterized by more interruptions and the giving of opinions) to be more characteristic of female supervisors than male supervisors, although often in response to resistant supervisees. This finding, of course, contradicts the theoretical assumption that female supervisors are less likely to be directive in their discourse techniques. Broad gender differences in communication styles may perhaps be a consequence of stylistic differences in supervision. For example, it has been shown in empirical research that male supervisors tend to focus their supervision discussions on the supervisee’s clients, whereas female supervisors tend to gear their supervision discussions toward the experience of the supervisee (Sells et al., 1997). Sells et al. suggested that these stylistic differences imply that female supervisors’ styles are more relational, whereas male supervisors’ styles are more skill oriented and methodological. Further support for this argument can be found in Romans’s (1996) study of the Myers–Briggs Type Indicator and counseling trainees. This study showed that female trainees had a higher F score (indicative of a focus on values and harmony) compared to male trainees, who presented with a higher T score (showing a preference for logical and analytical processes).

GENDER INTERACTIONS IN SUPERVISION Whereas some researchers and scholars have addressed the supervisor’s gender on its own as discussed above, others (e.g., DeGroot, Brunet, Kaplan, & Bagby, 2003; Gatmon et al., 2001; Granello, 2003; Heru, Strong, Price, & Recupero, 2006; McCarthy et al., 1994; McHale & Carr, 1998; Miller & Ivey, 2006; Nelson & Holloway, 1990; Robyak et al., 1986; Schiavone & Jessell, 1988; Sells et al., 1997; Smeby, 2000; Worthington & Stern, 1985) have examined how a supervisor’s gender interacts with the gender/sex of the supervisee. An understanding of these interactions can have implications for whether same-sex or different-sex dyads should be favored. Supervision interactions exist under four possible gender dyad combinations: a male supervisor paired with a male supervisee; a male supervisor paired with a female supervisee; a female supervisor paired with a female supervisee; and female supervisor paired with a male supervisee. In general, it appears that same-gender supervision relationships are slightly more common than different-gender dyads (Gatmon et al., 2001; Granello, 2003; Smeby, 2000). This same-gender tendency also seems to occur more frequently among women than men (Gilbert & Evans, 1985; Granello, 2003; McCarthy et al., 1994; Smeby, 2000). It is important to be aware that although this trend exists, it does not necessarily confirm that same-gender dyads are better in nature. Theoretical arguments have been made that same-gender supervision dyads may be favorable, especially for female trainees, as it might expose them to positive, powerful female role models (Gilbert & Rossman, 1992; Smeby, 2000). Research in this area has examined supervisor–supervisee gender interactions in terms of communication styles, and satisfaction and evaluation of supervision.

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COMMUNICATION STYLE Gender interactions in supervision have been examined in relationship to power and communication styles. For example, one examination of the quantity of highand low-power messages used in supervision (Nelson & Holloway, 1990) was an attempt to tap into power differences as well as communication style differences among supervisors. High-power messages were conceptualized as directive, possibly controlling, and forceful messages. Low-power messages were characterized by the speaker making indecisive comments, allowing others to begin communication, being unwillingness to commit to himself or herself, and seeking confirmation. Of interest is that Nelson and Holloway found that male and female supervisors did not vary much in their delivery of messages when initiating communication; however, both male and female supervisors responded uniquely to supervisees’ high-power messages depending on the trainees’ gender. Specifically, if a female supervisee initiated conversation with a high-power message, supervisors regardless of their gender were less likely to respond with low-power messages compared to when a male supervisee initiated with a high-power message. According to the authors, this finding indicates that supervisors do not encourage or allow female trainees to assume the power in communication as they do for male trainees. Furthermore, the researchers found that female supervisees were less likely than male supervisees to respond to low-power messages from their supervisors with highpower messages of their own. This finding suggests that female trainees do not assume power in communication when responding to supervisors. Nelson and Holloway concluded that “supervisors do not reinforce the female supervisees’ attempts to assume the expert role and that, even when a female trainee encounters the opportunity to assume power, she defers” (p. 479). The authors noted limitations of the study but cautioned that if female supervisees are not encouraged to communicate powerfully in supervision, this may affect their professional identity development in the future. Nelson and Holloway’s (1990) initial findings were partially supported by Granello et al. (1997) and Granello (2003). In both of these studies, audiotapes of supervision sessions were transcribed and analyzed for gender differences. Granello et al. found some initial evidence that female supervisees were told more often what to do in supervision compared to male supervisees. In the 2003 followup study, the results revealed that regardless of supervisors’ gender, supervisors asked for more opinions and evaluation from male supervisees than female supervisees. Male supervisees also seemed to respond to this communication pattern, as they provided suggestions 3 times more often than female supervisees. This trend escalated when age was taken into account: Compared to older female supervisees, older male supervisees gave suggestions 10 times more often. However, the study also showed that supervisors were more likely to accept and build on the ideas provided by female supervisees in supervision. According to Granello, it may be that when female supervisees present an idea, although they do so less often than male supervisees, their supervisors are more open to it. Chung et al. (2001) also found support for differences in the treatment in supervisees based on gender interactions. In this study, 76 counseling professionals responded to a case study about a supervisee’s work with a couple. The race

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and sex of the supervisee were manipulated, creating four different experimental conditions. The results showed that male professionals rated female supervisees lower and gave them less positive feedback compared to male supervisees. No differences on female professionals’ responses to the case studies were detected. SATISFACTION AND EVALUATION Fueled by the hypothesis that female supervisors employ a more relational focus to their style as compared to male supervisors’ focus on task-related supervision, Worthington and Stern (1985) expected female supervisors and supervisees to rate supervisory relationships as more successful than male supervisors and supervisees. However, it was found that male supervisors rated the supervision bond more positively in relation to their awareness of supervisees’ feelings, their own direct role in supervisees’ improvement, and the dyad’s closeness. Male supervisees perceived the relationship as more successful regardless of the supervisors’ gender. Worthington and Stern offered several possible explanations for their findings, which contradicted their expectations. One possibility was that men are less conservative or have lower standards than women when rating a relationship as high quality. Another explanation was that the nature of the supervisory relationship is actually more task related and less relational, in which case men would theoretically view the environment as more successful. It is important to be aware that the proposed explanations seem to be an attempt to adhere to or uphold the expected stereotypical tendencies of men and women, when in fact these tendencies may not always exist in supervision. In fact, similar results have been shown among male doctoral students in the natural sciences, social sciences, and humanities. For example, male students have been shown to be more likely than female students to report satisfaction with their supervisor and their supervisory committee (Seagram, Gould, & Pyke, 1998). Possibly one of the most interesting research areas of supervision gender interactions focuses on supervisees’ evaluations of supervisors’ competence and expertise. Past studies have suggested that male and female supervisees may perceive female supervisors as less competent (Goldberg, 1968; Gruber & Gaebelein, 1979; and Nieva & Gutek, 1980, as cited in Schiavone & Jessell, 1988). In fact, in the area of psychiatry supervision, female supervisors were perceived as less competent overall, less enthusiastic, and less knowledgeable by their male and female residents (DeGroot et al., 2003). Also, it has been reported that male graduate students tend to underevaluate female supervisors’ competence in the social sciences (Bagihole, 1993, as cited in Smeby, 2000). However, in a study of counselor education students, Schiavone and Jessell found no such discrepancies and suggested that in this field the negative bias of female professionals as competent seems to be abating. Similar findings were uncovered in a study on social work supervision (Vonk & Zucrow, 1996). IMPLICATIONS FOR SUPERVISION Although this review of the literature seems to indicate support for each end of the spectrum of whether gender affects supervision, many have argued and

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continue to argue that due to the nature of supervision as an interpersonally focused training environment, supervision will inadvertently be influenced by the interplay of supervisors’ and supervisees’ personal variables. In addition to gender, variables such as epistemology, expectations, history, race, ethnicity, and sexual orientation can interact in supervision and shape it (Bernard & Goodyear, 2004; Brown & Landrum-Brown, 1995; Garrett et al., 2001; Granello, 2003; Long, 1996; Mohr, 2007; Taylor, 1994). For example, Granello’s findings showed how age and gender can interact to influence supervisors’ responses to supervisees. In other words, a lack of understanding of and attention to gender differences can threaten the quality of supervision (Twohey & Volker, 1993). It is generally agreed upon in the literature that it is supervisors’ responsibility to address and facilitate discussion of diversity issues in supervision (e.g., Harber, 1996; Hird, Cavalieri, Dulko, Felice, & Ho, 2001; Tyler, Brome, & Williams, 1991). Supervisors are more likely to discuss gender in supervision compared to other aspects of human diversity such as race and sexual orientation. They are also more likely than supervisees to initiate such discussion, although discussions occur more often when supervisors and supervisees are of different genders (Gatmon et al., 2001). However, a conversation about gender within a dyad of the same gender will, if well done, undoubtedly enhance the supervisee’s self- and clinical awareness, and provide tools for how gender can be addressed in counseling. Hence, we recommend that all supervisors address gender issues whether or not their gender matches that of their supervisees. Research has shown that supervisors also value such discussions: They report not only greater satisfaction but also a stronger working alliance when such discussions occur with more depth and greater frequency (Gatmon et al., 2001). In addition to fostering discussions of gender in supervision, we also encourage training programs to help ensure that trainees get exposure to, and experience working with, both male and female supervisors. A meaningful supervisory discussion on gender seems unlikely to occur unless supervisors have worked to gain some awareness of their own gender identity and gender role and have developed an understanding of how these two characteristics shape their worldview and behavior in supervision. In addition, having insight into the politics and consequences of sexism and power seems crucial, as does being knowledgeable about feminist identity development and having a fundamental belief that issues of sex and gender (e.g., gender identity, sexism, power) can impact individual life and thus also counseling and supervision (e.g., Bernard & Goodyear, 2004; Moradi, Subich, & Phillips, 2002; Rigazio-DiGilio, 1998; StevensSmith, 1995). Furthermore, our review of the literature revealed several studies (e.g., Chung et al., 2001; Granello, 2003; Nelson & Holloway, 1990) that showed that supervisors’ communication in supervision is at times dependent on their own and their supervisees’ gender. Given this, supervisors may want to reflect on their comfort in working with female and male supervisees and ask themselves whether they are providing the same supervisory environment for members of both of these groups and developing supervisees of each gender to the fullest of their potential. In addition to engaging in their own reflections on gender, supervisors need to encourage supervisees to do the same. Supervisors should create an environment

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where the supervisees feel safe to raise their questions and observations about gender—in themselves, in their world, and in work with clients and supervisors. Due to its interpersonal nature and the possibility for one-on-one training, supervision allows for a unique opportunity to explore biases and increase self-awareness that will not only empower supervisees and help them become more skilled helping professionals, but may also make supervision more meaningful. G AY, L E S B I A N , A N D B I S E X U A L I S S U E S I N S U P E RV I S I O N Similar to gender, supervisors need to pay attention to sexual orientation issues in their supervisees’ work with LGB clients and in their own relationships with LGB and heterosexual ally supervisees (the latter of which is the focus of this section of the chapter). Not only are there limited empirical data on counseling LGB clients and effective treatment models for this population (e.g., Ponterotto, 1998; Van Voorhis & Wagner, 2001), even less is known about how LGB issues may present themselves in the supervisory relationship (Goodyear & Guzzardo, 2000). What is known, however, is that many professionals will work with an LGB client some time in their careers (Garnets, Hancock, Cochran, Goodchilds, & Peplau, 1991; Murphy, Rawlings, & Howe, 2002) and that many supervisors are likely to encounter LGB supervisees. It is also known that even though more training programs attend to LGB issues in their curriculum, this training may be limited, inadequate, and sometimes biased (Croteau et al., 1998; Phillips & Fisher, 1998; Pilkington & Cantor, 1996). At times, supervision is the setting where trainees obtain their training on LGB issues, but not all supervisors are knowledgeable in this area (Murphy et al., 2002). Furthermore, heterosexist and even homonegative attitudes still exist in many educational and therapeutic settings (Pearson, 2003). These attitudes reflect a belief in the superiority of heterosexuality (Mohr, 2007; Morin, 1977) and negative feelings and thoughts toward LGB individuals (Hudson & Ricketts, 1980). In response, many scholars and professional organizations have underscored the importance for counselors, trainees, and supervisors of being aware of the unique experiences of LGB individuals when working with these populations (e.g., American Psychological Association, 2000; Fassinger, 1991; Fassinger & Richie, 1997; Israel & Selvidge, 2003; Perez, DeBord, & Bieschke, 2000). To date, four different theoretical models (Bruss, Brack, Brack, Glickaug-Hughes, & O’Leary, 1997; Buhrke, 1989; House & Holloway, 1992; Russell & Greenhouse, 1997) have been adapted and applied to LGB issues in supervision (see Halpert & Pfaller, 2001, for a review). We draw on information from these models, the multicultural competency literature, as well as our own and others’ narrative experiences (e.g., Croteau, Lark, Lidderdale, & Chung, 2005) to provide information and recommendations for how supervisors—especially heterosexual supervisors—can provide LGB-affirmative supervision. SUPERVISION MODELS APPLIED TO LESBIAN, GAY, AND BISEXUAL ISSUES Although a full review of LGB supervisory models is beyond the scope of this chapter, we address important considerations gleaned from four models. Bruss and

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colleagues (1997) adapted Stoltenberg and Delworth’s (1987) supervision model for supervisees working with LGB clients. This model highlights the necessity of supervisors (a) assessing trainees’ current level of functioning (e.g., reactions and comfort level with sexual orientation diversity) and knowledge specific to LGB issues and (b) providing supervision that is appropriate for trainees’ developmental levels regarding LGB issues. For example, supervisors may initially provide clarification of expectations (e.g., confront homophobia), whereas process comments focused on integrating experience, knowledge, and skills may be more relevant for trainees in later stages of development. Supervisor self-awareness (e.g., biases, knowledge, and countertransference toward LGB issues) is vital to allow for the provision of appropriate supervisory functions. The other three models focus more on issues inherent in supervisory relationships rather than on supervision of work with LGB clients. Buhrke’s (1989) conflictual situation model discusses possible scenarios for various dyads in supervision. She noted that two combinations (supervisor homophobic, supervisee not homophobic; and supervisor not homophobic, supervisee homophobic) may result in conflictual supervisory relationships, whereas the dyad consisting of both supervisor and supervisee exhibiting homophobia may be the most damaging for LGB clients. In particular, Buhrke noted that the most difficult situation may be when the supervisor exhibits negative biases toward LGB issues and the supervisee does not (maybe being LGB himself or herself or a heterosexual ally). A supervisee is unlikely to confront a supervisor due to concerns about professional repercussions or negative evaluations. Additionally, this model highlights the importance of attending to transference and countertransference issues. In particular, Buhrke’s model notes that common countertransference issues such as sexual attraction may be more challenging for a trainee to process within the context of a same-sex dyad, especially if the supervisor demonstrates an unwillingness to acknowledge or discomfort with same-sex attraction. Also of importance in this model is the issue of identity development, such as either the supervisor or supervisee coming out (i.e., disclosing his or her sexual orientation) and the level of comfort with one’s own sexual identity. In either case, the potential for damage for clients, or the trainee, is greatly increased when the supervisor communicates homophobic or heterosexist attitudes. Along similar lines, Russell and Greenhouse’s (1997) homonegativity model emphasizes the unique role of homophobia, heterosexism, and consequent resistance in supervisory relationships. They proposed that supervisor resistance, influenced by lack of awareness, unresolved conflicts, and/or biases regarding sexual orientation issues, may be an extremely powerful influence in supervision. Supervisors may be confronted by their own privilege as heterosexual and resulting feelings of guilt or discomfort, or they may be challenged to move into areas where they feel less knowledgeable and competent. All of these may cause anxiety and increase avoidance of sexual orientation issues in supervision. Additionally, supervisees may exhibit similar patterns of resistance. Lesbian, gay, and bisexual supervisees may be influenced by internalized homonegativity, contributing to further collusion with the dominant culture’s silence surrounding sexual orientation. Finally, House and Holloway’s (1992) supervisee empowerment model focuses on the supervisory relationship as a context to facilitate the development

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of trainees’ sense of personal empowerment and efficacy in both counseling and supervision. These authors suggested that given the cultural disempowerment experienced by many LGB individuals, affirmative supervision is vital for both LGB supervisees and all trainees working with LGB clients. This model is comprehensive, ranging from an emphasis on the individual characteristics of supervisors and supervisees to development of specific goals, knowledge bases, and skills with regard to LGB populations. The scope of issues addressed by this model also expands beyond the individual to consider institutional policies and regulations that may impact service delivery related to LGB trainees and clients.

IMPLICATIONS FOR SUPERVISION Power, Self-Examination, and Affect In reviewing models of LGB supervisory issues, one theme seems to emerge consistently across all models, and that is the power held by supervisors. Hence, we offer the following recommendations. First, supervisors must be aware of and willing to address their own overt and covert attitudes, beliefs, and biases regarding sexual orientation, as well as subtle heterosexist beliefs and privileges (Croteau, Anderson, Distefano, & Kampa-Kokesch, 2000; Mohr, 2007; Phillips, 2000). A heterosexist orientation may involve anything from prejudice toward and ignorance of LGB issues to assumptions that their supervisees are heterosexual or are overemphasizing LGB issues (Long, 1996; Mohr, 2007). All of these may negatively impact the quality of supervision provided and may place LGB or heterosexual ally supervisees in vulnerable positions. Chung and Brack (2005) suggested that training staff need to recognize the limitations of colleagues related to LGB issues and openly encourage trainees to consult outside of their supervisory relationship should difficulties arise due to supervisors’ lack of knowledge or biases. It is also important to acknowledge the intense affective responses often associated with exploration of one’s own personal attitudes, beliefs, and biases. As noted, supervisors may feel anxiety when challenged with issues outside their expertise (Russell & Greenhouse, 1997), and both LGB individuals and heterosexual allies have described feeling intense anger, rage, shock, dismay, and guilt for injustices related to homophobia (Lidderdale, Lark, & Whitman, 2005). Both LGB individuals and heterosexual allies have highlighted potential emotional exhaustion in dealing with constant societal heterosexism or trying to teach individuals about such issues (e.g., Adams, 2005; Carrubba, 2005; Dworkin, 2005). Any range of emotions in either supervisors or supervisees sets the stage for possible transference/countertransference reactions in supervision, again supporting the importance of supervisors’ personal awareness of such feelings. Thus, it seems vital that supervisors be comfortable with attending to their own emotional reactions in order to provide an affirmative and supportive supervisory relationship should supervisees need to process difficult emotions. The importance of sharing affective responses related to LGB issues cannot be understated as a means of lessening potential feelings of isolation and burnout.

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Establishing a Knowledge Base Supervisors must establish a knowledge base about LGB populations. Although discussing how to provide such a knowledge base is outside the scope of this chapter, we highlight some of the important areas. Lesbian, gay, and bisexual individuals may experience life differently than heterosexuals and may face stereotyping, oppression, and discrimination, including lack of fundamental civil rights, rejection by family, societal and religious condemnation, being targeted by campaigns of defamation and hatred, and physical violence (Dillon et al., 2004; Paul, 1982; Perez et al., 2000). They also have their own unique experience about what it means to be an invisible minority and to be raised in families and communities that do not share their minority status (Israel & Selvidge, 2003). The sociopolitical history, the history of psychological treatment and diagnosing, and the current political climate are also unique and have been costly for the well-being of this population (for more information, see Bieschke, McClanahan, Tozer, Grzegorek, & Park, 2000; Fassinger, 2000; Mohr, 2007). Furthermore, identity development processes, such as the coming out process of LGB individuals, are distinct in this group (e.g., Cass, 1979; Reynolds & Hanjorgiris, 2000). Of unique importance in supervising LGB trainees is having knowledge of sexual identity development models. It is likely that LGB supervisees will differ in terms of their own identity development status and level of “outness.” It seems plausible that supervisors should then also consider each LGB supervisee’s level of comfort and disclosure around sexual orientation, just as counselors have been encouraged to consider a client’s identity development status (e.g., Cass, 1979; Pearson, 2003; Reynolds & Hanjorgiris, 2000). Supervisees’ needs in supervision may differ based on their identity development status. For example, supervisees in early stages of the coming out process may exhibit avoidance around sexual orientation issues, and this could be particularly important for consideration if they would encounter an “out” LGB client during this time. Because of the intimacy and length of supervision with one supervisor, it is foreseeable that this may be a place where trainees first come out in their training program or feel safe to share personal experiences of being LGB. Conversely, out students may be more likely to encounter discrimination or injustice in both their personal and professional lives or to encounter clients who exhibit homonegativity. Thus, supervision might be an important venue in which LGB supervisees can process emotions and receive support. Chung and Brack (2005) suggested that mentors can assist students in evaluating their environments and options surrounding openness with sexual orientation in a manner that empowers trainees to make decisions according to their own comfort level. We assert that supervisors also need to consider such issues in the clinical supervision of LGB trainees in effort to facilitate the integration of personal and professional identities. Affirmative Training Environments Providing LGB-affirmative supervision also involves paying overall attention to actions that help create a safe supervision environment. Israel and Selvidge (2003) pointed out that because sexual orientation is not always visible, counselors must

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be LGB affirming with all clients. The same is true for supervisors. By using nonheterosexist or inclusive language and having LGB-affirming signs on their doors or in their offices, supervisors may set the initial stage for an LGB-affirming environment, all of which may create a greater sense of safety for LGB trainees and important role modeling for heterosexual students (Chung & Brack, 2005; Lark & Croteau, 1998). SUMMARY This section has described important issues related to sexual orientation and supervision. Compared to issues of gender and race/ethnicity, sexual orientation issues tend to be less frequently discussed in supervision (Gatmon et al., 2001). Not surprisingly, Gatmon et al. showed that more discussion of sexual orientation in supervision was associated with supervisees’ greater satisfaction with supervision and perceptions of their supervisor as more competent. We cannot understate the importance of addressing sexual orientation for the well-being of not only LGB supervisees and clients but also heterosexual allies. Although heterosexual supervisees have not had much attention in the literature, scholars have recently underscored that they also need to receive appropriate LGB supervision and training (Croteau et al., 2005; Lidderdale et al., 2005). CONCLUSION In this chapter, we attempted to show how gender and sexual orientation can become part of supervision whether or not they are acknowledged or verbally addressed. We also discussed how the natural power differential in the supervisory relationship may be heightened or complicated by the additional power differentials that accompany varying social identities (e.g., gender and sexual orientation), especially when the supervisee is from a socially oppressed group and the supervisor is a member of the dominant culture. What we did not discuss in depth is the interplay of multiple identities, such as in the case of a gay Latina supervisee working with a White, male, heterosexual supervisor. Multiple identities can further add to the complexity of the supervisory relationship, as well as enrich it. In simple words, each supervision dyad is unique (Bernard & Goodyear, 2004) and as such requires supervisors to attend to each supervisee with open and fresh eyes. Given their power, supervisors must realize that their words and behaviors set the stage and tone for supervision. For a supervisee to be heard, supervisors need to create a space where differences can be attended to in a safe and respectful manner. Despite the possible difficulties in such work, there lays great potential for deepening the supervisory relationship through the exploration and understanding of human differences. REFERENCES Adams, E. M. (2005). Moving from random acts of inclusion toward LGB-affirmative institutions. In J. M. Croteau, J. S. Lark, M. A. Lidderdale, & Y. B. Chung (Eds.), Deconstructing heterosexism in the counseling professions: A narrative approach (pp. 21–28). Thousand Oaks, CA: Sage.

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Stoltenberg, C., & Delworth, U. (1987). Supervising counselors and therapists: A developmental approach. San Francisco: Jossey-Bass. Sue, D. W., & Sue, S. (2003). Counseling the culturally diverse: Theory and practice (4th ed.). Hoboken, NJ: Wiley. Szymanski, D. M. (2005). Feminist identity and theories as correlates of feminist supervision practices. Counseling Psychologist, 33, 729–747. Taylor, M. (1994). Gender and power in counselling and supervision. British Journal of Guidance Counselling, 22, 319–326. Tyler, F. B., Brome, D. R., & Williams, J. E. (1991). Ethnic validity, ecology, and psychotherapy: A psychological competence model. New York: Plenum Press. Twohey, D., & Volker, J. (1993). Listening for the voices of care and justice in counselor supervision. Counselor Education and Supervision, 32, 189–197. Van Voorhis, R., & Wagner, M. (2001). Coverage of gay and lesbian subject matter in social work journals. Journal of Social Work Education, 37, 147–159. Vonk, M. E., & Zucrow, E. (1996). Female MSW students’ satisfaction with practicum supervision: The effect of supervisor gender. Journal of Social Work Education, 32, 415–420. Worthington, E. L., & Stern, A. (1985). Effects of supervisor and supervisee degree level and gender on the supervisory relationship. Journal of Counseling Psychology, 32, 252–262. Yoder, J. D., & Kahn, A. S. (1992). Toward a feminist understanding of women and power. Psychology of Women Quarterly, 16(4) , 381–388.

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PART TEN

STATE OF THE FIELD AND ITS FUTURE

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C H A P T E R 30

Summing Up and Moving Forward ALLEN K. HESS

THE PREFACE depicts psychotherapy supervision as moving from a frequent, important activity that was largely unrecognized to a field or specialty of its own with the publication of the first edition of Psychotherapy Supervision. To be sure, as Chapter 1 shows, there have been many contributors to the education and training of psychotherapists over the millennia. As Ebbinghaus said about psychology, we say as well: “It has a long past but a short history” (as cited in Hess, 1980, p. 525). Psychotherapy supervision has seemed to be guided in part by a quote by Freud: I do not believe one can give the method of technique through papers. It must be done by personal teaching. Of course, beginners probably need something to start with. Otherwise they would have nothing to go on. But if they follow the directions conscientiously, they will soon find themselves in trouble. They must learn to develop their own techniques. (as cited in Blanton, 1971, p. 48)

Since Freud’s observation a number of excellent works in theory, research, and practice from various orientations have been published. They have served well as guides, abetting the practice of supervision. In Chapter 31 of the first edition (Hess, 1980), I addressed a number of important issues that lay ahead of us. On the research front, I suggested looking at supervisor–supervisee matching on various variables to see who best fit and benefited whom. As matching research fell from favor, this did not materialize. I viewed the fracturing of the Shakow-Boulder model by a succession of models (e.g., Northwestern, Thayer, Miami, Chicago, Vali, and Austin) with alarm, as it would affect supervision in ways that splintered our expectations about what sort of psychotherapist we would be training. The specter of third-party payers was a looming presence, the impact of which was predicted but could hardly have been overestimated. With cost effectiveness as its goal, capitation became a term whose meaning psychotherapists quickly learned had devastating consequences 579

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for patients. Although cognitive-behavioral interventions were approved for limited sessions with limited goals by insurance payers, one wonders whether it was really cost effective to patch patients without healing the sources of the conflicts that erupted into the presenting complaints. Because these conflicts were patched but not resolved, follow-up research showed symptom recurrence in greater proportion than with interpersonal approaches, which were also an approved treatment though one less publicized (Klibert, 2008). I mentioned, too, that we might consider credentialing supervisors so that their needs (e.g., compensation) might be represented and guidelines for them developed. From this embryonic history, psychotherapy supervision became a robust youngster, as was indicated by the publication of a comprehensive handbook. Watkins’s (1997) handbook was an indicator of the growth of the field. Tracing the many developments in the 17 years since the present book’s first edition, Watkins ended his volume with a number of musings. These included the importance of supervision that was belied by the lack of supervisor training, the paucity of standards for supervisors, and the differing foci of the schools, all of which confound the need for specification of what we are teaching students. On the research front, Watkins called for better measurement and saw increasingly sophisticated research. The desideratum of education (see Chapter 10 on Vygotsky) consists of a positive learning relationship leading to a mutual investment by teacher and student that, in turn, leads to substantive learning. Developmental schema for supervision have been accepted lore, but the key question about how supervision impacts the clinician’s skills and the patient’s progress in both symptom relief and personality change is still undetermined. In this twenty-first century, psychotherapy supervision might be seen as entering its early adulthood. It faces forces beyond the “clinical rhombus” that includes patient, psychotherapist, supervisor, and agency. These field forces might be termed para-rhombus issues. The balance of this chapter takes a broader perspective by addressing practical concerns regarding these external para-rhombus forces and concludes with a more internal focus. This conclusion may lead psychotherapy and its supervision to provide emotional refinement and serenity to patients, psychotherapists, and their supervisors amid the life conflicts that they face.

PRACTICAL CONCERNS The para-rhombus concerns affecting supervision now and in the future include ethics and legal regulations, certification, uniformity myths, supervision beyond psychology, electronic forms of education, the flood of “professional” psychologists in nontraditional accredited programs as more elite schools have minimized clinical training, de minimis responses to professional school graduates (including the competency model established by the American Psychological Association), and the sense of aspiration that is one of the essential elements of a profession. As a note, one of the strengths of many professional school graduates is their superior clinical skills, because there is an emphasis on supervision and clinical experience. I am noting the diminishing of the scientific aspects of the Shakow model, the minimization of the scientific part of the identity of the professional school graduate, with regret and trepidation.

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Summing Up and Moving Forward 581 ETHICS AND LAW The American Psychological Association (2002) Ethical Principles of Psychologists and Code of Conduct has gone from not recognizing supervision a few editions ago to containing several sections addressing supervision issues. We have yet to see legal cases concerning psychotherapy supervision. Paying attention to legal and ethical concerns has served us well as a preventive measure, and we hope this record of resolving conflict short of the parties seeking legal remedies continues. However, satisfying minimal standards of care is not as fulfilling as practicing toward a best practices model, which in turn allows us to strive toward such metagoals as I describe next in a discussion of the work of Frijda and Sundararajan (2007). Defensive practice can chill a profession, as we see with the defensive practices of law and of medicine. Balancing fully invested students and teachers with proper review by discrete colleagues might help supervision continue to grow and flourish.

CERTIFICATION Because supervision takes so many various forms (as does “consulting”), we will find it hard to define certification in a way that allows for regulation. For example, industrial-organizational psychology has wrestled with the certification of practitioners and the accreditation of its programs for decades but seems to have decided that the drawbacks of accreditation and licensing are more stultifying to its field than the potential gains would be beneficial. Some states require psychologist licensure of certain activities, and presenting oneself to the public as a psychologist also requires licensure, but some activities are amorphous enough that a “consultant” performing them may not need to be licensed. Licensure seems to be a matter of the type of activity and model being employed. When we consider the various models of supervision outlined in Chapter 1, the practitioner who pays for one or two consulting visits about a case is different from the first-year student in close supervision. Can a supervision credential cover such a varied practice? We might still need to consider what benefits and costs accrue to individuals certified in supervision. Also, professors who supervise may find certification of their work as unwelcome as they find any regulation of or intrusion on their freedom to teach in their own way. One paradox that bemuses me is the willingness to test students endlessly (Rogers, 1968) and to call for intense scrutiny of psychotherapy and its supervision by those in academe. But the same critics often show a wall of resistance to studying how effective their own teaching might be, to producing evidence that one favored teaching technique is effective, or even to showing follow-up data from their undergraduate and graduate students as to which of their teaching tactics are beneficial. Even so, we have an obligation to conduct evaluative and efficacy research in psychotherapy and its supervision, and we have strived to do this. The results are encouraging (see Chapters 25 and 26).

ALLIED FIELDS There is remarkably little communication between mental health fields. The walls are high, wide, and impermeable. Yet the fields of psychiatry, social work, and

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allied mental health grapple with the same questions that confront the field of psychology. In fact, some of my most fruitful supervisions were with psychiatrists and social worker supervisors, and with counseling, nursing, and other mental health trainees. They brought a breadth of perspectives and a way of understanding cases and theories that I had not been exposed to in my training and made me examine some of psychology’s perspectives. I am not optimistic at such crossdisciplinary efforts on organizational levels, as psychologists seem not to read other psychologists if they are not in their favorite journal or two or if they are across a narrow interest area. I recall that a psychiatry volume was published 2 years after the first edition of this book. It contained a dozen chapters, all of which were modeled after chapters in this volume, but with no citation. I inquired of my Wiley editor and was told that MDs buy books from MDs, and MSWs buy books by MSWs, but little cross-pollination occurs. I am not sure we psychologists do much better using sources from allied fields – this volume included in this observation, I might add. However, one just might find some rich veins of knowledge in allied disciplines. UNIFORMITY MYTHS Unrealistic expectations can lead to needless anguish. A supervisor is made up of many characteristics, including gender, level of training, theoretical orientation, and a host of personality dynamics. The supervisee brings the same diverse attributes to supervision. Multiply these factors by the attributes of the clients, the time of their lives when the clients enter psychotherapy, agency policies, and the training program’s attributes, and one can easily see that there might well be more heterogeneity in supervision than commonality. Disjunctive supervision can occur because people see stereotypes rather than the human being before them. The expectations for certain entry-level skills versus the actual skill levels of both parties added to the expectations of the supervisee and supervisor regarding the outcomes of supervisions might frustrate both parties. This human and situational non-uniformity can frustrate research and measurement efforts as well. Once these myths and expectations are recognized, the supervision dyad can work in a more realistic, coordinated, and satisfying way. Research might consider alternatives to the typical analysis of variance and large sample designs. Time series analysis, single case studies, linguistic analyses of tapes of successful versus failing supervisions, critical incident methods, matched cohort samples, and goal attainment scaling as well as multisite research for larger sample research might be more fitting for certain research questions. These are not new problems, having been recognized in psychotherapy research by Kiesler (1966) and Corsini and Wedding (2007). THE ELEPHANTS IN THE LIVING ROOM Over the years we have seen the growth of proprietary professional schools that are turning out large numbers of graduates. The premises of the PsyD degree are sound and have their philosophical origins in the years around World War II (Sears, 1947; Shakow, 1942). Shakow called for a full 4-year program that

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Summing Up and Moving Forward 583 began with traditional doctoral education in basic processes (i.e., learning, cognition, motivation and emotion, and personality as found in our canon, the introductory psychology textbook) and research design and analysis. Concurrently, the experimental student had laboratory exposure while the clinical student attended clinic to observe and perhaps take client histories. During the second clinical year the student administered tests, and the third year had the student engaging in psychotherapy while taking increasingly specialized coursework. At the same time, the clinical experience became more technical and intense: On the academic side, the student was engaged in more clinical coursework and research data gathering. Subsequent years saw more specialized clinical coursework, publishing, and increasingly complex clinic work such as more difficult client cases. This was the scientist–practitioner model, and it wedded—nay, welded—a unitary psychologist equally comfortable in both the worlds of conducting relevant research and providing clinical service. This model was criticized aplenty. Even though an individual might choose academic or practitioner paths, the person was of whole cloth. As an academic, he or she might teach and produce research while having a limited private practice. Or the clinician might teach as an adjunct or clinical professor and write a case history. Sears’s (1947) report on the adequacy of clinical training facilities on behalf of the Committee on Graduate and Professional Training is illuminating. It cites 13 accreditation criteria, then lists the 40 university programs intending to offer doctoral clinical psychology training, 18 of which were in compliance. For each program, the marks of meeting or failing to meet each criterion is listed—how is that for transparency and informing the student beforehand! The Committee report noted a dearth of clinical psychologists for training students, a resistance to lower standards simply to satisfy this lack, differences in the availability of clinical facilities and staff due to geography and urban versus rural settings, neglect of the undergraduate program to meet graduate program needs, and physical space needs: “Most universities are being swollen to the point where they must erect temporary quarters for some offices and classrooms”(p. 205). THE ACADEMY The age-old system of thinking that a new supervisor springs de novo because one is a clinical psychologist, or that a whole psychologist can be created by reading about but not doing both the scientific and clinical aspects of clinical psychology, still emerges from the Academy. Building student identities in only the science or in only the practice of psychology creates disdain for the other. One former department head of mine, commenting on clinical psychologists, exclaimed to a student audience that clinicians were “blood suckers, preying on the weaknesses of others.” What was a clinical student to think, to feel? As a Dan Aykroyd line goes: “We mock what we don’t understand.” Thus, we have the “clinical researcher” who too often is an unlicensed nonpractitioner. Some whom I know spent the bulk of their internship year writing their dissertations and did few assessments or psychotherapy interventions on clinical patients. One wonders about the relevance of clinical research by people not involved in clinical service delivery. How can their research be relevant? Or be respected by clinicians? Too many clinical researchers have

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turned “enlightened skeptics,” as exemplified by the attack on the Rorschach and on the efficacy of psychotherapy. The Academy of Psychological Clinical Science is alluring to schools that once turned out Shakow-model clinical psychologists. But grants, publications, and prestige invested in “clinical research” scleroticized the eyes of such departments and their deans. As academicians, they sit on accreditation and granting agency committees, exerting influence as an “invisible college.” Departments wishing to be in the Academy and deans who want faculty to secure grant monies favor funded research. Accreditation review committees are overrepresented with Academy members. Academy member schools express being pressed to teach research skills. They do not let students see clients until Year 3 and then the students carry but three clients in Year 4. Schools tell students that they will get clinical work in internship and that they will have to focus on research now because they will not get opportunities for research in postgraduate years, except for postdoctoral internships. The internships are then put in the position of teaching several years of clinical work in 1 year. They are pressed to offer postdoctoral internships to complete some students’ training, and the postdoctoral years for licensure cements this continued holding pattern for students. Certainly the postdoctoral year is of great benefit, but the education is extended another year. The goals of the Academy are admirable—to establish empirical bases for practice. The corollary that clinical problems ought to influence the research agenda is not apparent. It is easier for a researcher to find funding for a current publicized and focal problem such as bipolar disorder or autistic spectrum disorders than it is to train clinicians and clinical researchers; in short, Shakow psychologists. More of the funding seems to be for focal problems so the professor can put a student on research monies, but there is no money or time allocated for clinical training and supervision. One simply needs to ask the following: What granting agency has allocations for psychotherapy supervision—to pay for faculty release time and to fund the students? And what agency might fund psychotherapy supervision research? Consequently, there is little supervision efficacy research, follow-up research, there is an absence of replications of supervision research, and seldom is a funding source mentioned in research reports. So supervision leads to few rewards in Academy schools. How can our field reward behavior X and be surprised when behavior Y is not forthcoming? How can supervision research be commanded when there are few to no investments in or funding sources for such research? Students seeking such training might get it in community agencies or counseling centers, but faculty are not rewarded for supervision, and their values often are not sympathetic to clinical training. Given this state of affairs, I am in awe of what research base has been built by concerned clinical and counseling researchers, often unfunded and done because these people know it is important. THE PROFESSIONAL SCHOOLS The professional schools, but for a handful of exemplary university-based ones, have roiled the waters of clinical psychology. A few vignettes might show a few of my concerns about our future. I recall attending an hour-long presentation by Kenneth Chatelaine (1992) during which he detailed his dissertation, which

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Summing Up and Moving Forward 585 involved a 5-year odyssey tracking Harry Stack Sullivan’s life, including visiting institutions to examine their archives and personnel records. At the conclusion, one audience member exclaimed, “Yeah man, I know how you must feel. They made me do a 30-page paper for my dissertation-like project for my doctorate at X [professional school].” I expected Chatelaine to suffer cardiac infarction on the spot, but he maintained his composure. Recently I received a request from a state department of mental health to teach eight intelligence tests to their workers to provide “competence” in assessment in a 1-day workshop. These workers ranged in education level from having a bachelor’s to a doctoral degree. The request was made by the doctoral product of one of the major schools in the Academy of Psychological Clinical Science. She was now meeting the professional and paraprofessional world. Did she really not have any intelligence testing at her home university? Did she not know how much technical skill and how much time go into the administering, scoring, and interpreting a single intelligence test? The worst of two worlds collided. Did her employees, including the doctoral products of professional schools, really not know how to administer, score, and interpret intelligence tests? If they did, why were they not delivering the workshop? Later that week, a student called to ask about me supervising her for her online degree. She claimed the distance-learning professional “school” said she was responsible for securing supervision locally. That same week, a conversation on a listserv between several newly minted doctorates went like this: A: Does anyone know what a good rate of pay is for supervision? I am paying 50% of the client fees to my supervisor. B: Seems to me that is good because I paid 60% to start with and then went to 50%, so you may be getting a better deal than I did. The chaos afoot is put in context by the Council of University Directors of Clinical Training (CUDCT). It enumerated that in 2006, 31 programs had 20 or more students applying for internships (1,150), composing 36% of the total (3,210); that 8 programs had 50 or more applicants composing 15% of the total (496), or 1 of every 7 applicants; and that if each of the “20 or more programs” were allowed “only” 20 applicants, there would be 530 fewer students in the internship match. Currently, there is a glut of applicants per available placements. Can a program teach students the art and science of assessment and psychotherapy skills on the foundations of a research base when 30, 40, and 50 students are spewed forth each year? It appears that two responses to counter the “products” of these programs have been to prolong training and to issue competence guidelines. PROLONGED TRAINING (A.K.A. POSTDOCTORAL INTERNSHIPS, OR ARE WE CANNIBALIZING OUR YOUTH?) The flood of graduates from some professional schools has led to a most troubling response. One used to be licensed with a year of predoctoral internship, burnishing one’s clinic experience in graduate school. Because of the apparent inability of psychology to confront the problem of the number of students produced at

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schools with differing models and skill emphases, one solution seems to turn the postdoctoral internship from focal research (e.g., on Schizophrenic delusions) and advanced clinical activities (e.g., study at a family psychotherapy institute) to a required year of the supervised practice that was missing in predoctoral education and was added to state licensing requirements. This puts students in another year of a holding pattern before gaining some professional autonomy. Will this year really make up for deficiencies, real or imagined, that professional schools might have? That Academy schools might have? My observations are the professional school graduates have plenty of the type of training offered in the postdoctoral year. Whatever insufficiency there might be is in the basic psychology and research domains, and in their attitudes about themselves (i.e., clinicians who neither do research nor see themselves as teachers or scholars). In a complementary fashion, Academy products see themselves only as researchers and professors; their core professional identity does not include being a clinician. When clinical science programs will not let students see clients until the third year, and then let them see but three clients that year and only three more the fourth year, telling the students they will get client exposure on internship, faculty values are assimilated that clinical work has no place in students’ core identity. The postdoctoral burden will not compensate one whit for what the Committee on Accreditation or other bodies will not confront when schools are appraised. Postdoctoral internships used to be for students to learn specialty areas such as pediatric psychology or neuropsychology, and to publish. The mandated postdoctoral year of supervised practice for licensure feels as if we are making up in our students for what is lacking in the curriculum of either the Academy schools, clinical training schools, or professional schools: hands-on research. Is this a way to cope with the flood of applicants and keep the market balanced? COMPETENCE GUIDELINES Competence has become a core focus of training. The American Psychological Association established a task force on the assessment of competence in professional Psychology. The results of their work has been published in a set of six articles in the October 2007 issue of Professional Psychology (Task Force on the Assessment of Competence in Professional Psychology, 2007), which examine competence models. The impetus for the focus on competence may have several sources. In society, we are increasingly investing in efficiency and empirically driven methods. Insurance assurance might drive some of this impetus, as well as a crisis in clinical training brought on by factors discussed previously by which we are not training complete, competent clinical psychologists. That is, the Academy is not training and valuing clinical psychologists who can practice, while there is a rising tide of lessthan-research-qualified psychologists. But what distinguishes psychology from allied professions is our research base and our clinical students carefully crafted in the Shakow model. The flood of applicants from a few programs caused the CUDCT great concern because many intern applicants do not find suitable agency matches. The discussion by CUDCT mentioned in “The Professional Schools” led to a few suggested remedies such as instituting ratios of full-time faculty per fulltime students, limiting the number of student internship applicants per program,

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Summing Up and Moving Forward 587 encouraging the professional psychology schools to police themselves, and requiring applicants to pass a test. These suggestions will confront the autonomy that university programs have and are unwilling to concede. My guess is that we will test our students further, as if the test score is the solution. Rogers (1968) decried the number of hurdles we impose on students as if testing were knowledge—it is not. The real solution is not to lay more distractions before our students but to make the accrediting procedures work. At this point, it seems they may not be working. The competence thrust is a good one and addresses some of the questions raised by Watkins (1997) and in the paragraphs above. It might be as well expressed for clinical supervision by Falender and Shafranske (2007) as anyone. It is a good idea to make explicit the skills sets we need, to attend to the measurement of these skill sets, and to have a remediation procedure for less-than-competent graduates. It is an excellent attempt to address major problems, an attempt focused on the student level. But can the competency movement solve the problem upstream, at the university? Or is this a post hoc attempt at a solution? ELECTRONICS Delivery of clinical services through electronic means has received attention in the literature. This para-rhombus issue impacts supervision directly. Does geographically distant supervision really allow for the type of education and training that depends so heavily on contextual cues such as micromuscular responses (e.g., tension in the muscles around the eyes and mouth) that are not captured by electronic media? With a head shot, will we be missing the shifting of feet that might accompany dissimulation in a supervisee? The incidental contact with staff at the same location provides so much information about how a student functions in an agency, but will this be lacking in electronic supervision? People invested in seeing a robust clinical psychology need to reflect upon our field’s fate. In the tumult of changes in our field, we ought not lose sight of the reasons many of us have invested our lives in psychology and in supervision. So let us turn to a more salutary topic—the emotional development of higher human functioning that we need in our students and in ourselves. EMOTIONAL REFINEMENT While worrying about the practical issues impinging on us, I needed some distance, some relief, some way of metabolizing and calibrating the events. So I read about emotions and poetics. James (1884) made a distinction between coarse and refined emotions. Frijda and Sundararajan (2007) described and amplified James’s distinction. Coarse emotions are familiar, occur briskly, involve physical response (e.g., “That makes my blood boil,” seeing muscle tension in balled-up fists), have event–emotion relations (e.g., insult leads to fight or flight), and can be seen overtly (e.g., a blush, perspiration). James’s meeting with the bear in the woods evokes fear. Refined emotions can embrace coarse ones but are characterized by detachment and restraint. They engage second order awareness, contain elaborate appraisals of the eliciting events, and lead to an action readiness. Appraisal here is distinguished from measuring, testing, assessing, or quantifying, as appraisal goes beyond those

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activities. Appraising is not judging an event or experience but sensing its essence and meaning within a greater context. Refined emotions stem from our ability to savor or allow ourselves to take the time to let the meaning-flavor of an event linger on our tongue or resonate in our ears. A patient says once again how lonely she felt and allowed herself to be picked up at a bar. The psychotherapist does not respond, having heard this before and having role-played a few solutions. Now the patient follows with an appraisal: “What a jerk I was last night, again, trying to trade sex for affection, only to be used and driven into further self-deprecation and loneliness.” The patient is savoring. The patient is taking time to distance, to be self-reflexive, to detach. The psychotherapist does not judge, though he or she values. They are in the moment but restrain from action. Action readiness does not involve the bursting need to intervene but the global sense of timing. I watched for most of an hour how a butcher in Toronto’s Chinatown was cutting chickens—one stroke for the drumstick precisely where the tendons were vulnerable, one slice for the other drumstick, each stroke measured and right for that chicken’s drumstick. A diamond cutter does not use strength but takes the measure, the appraisal, of the raw stone, studying the way the light glints from the surfaces and inner reflections. Then the cutter taps the stone at the right fracture point, revealing how the hardest substance we know can yield to the tap and reveal nature’s brilliant structure. The butcher and the diamond cutter were fully engaged. The martial arts master hones the body but has a hovering awareness of the mental balance in himself or herself as well as those around the artist. So it is with the psychotherapist listening to the person struggling for a sense of being without debasement. Finally one day the patient says, “I am tired and worth more than I am giving myself. I am going to use the scenario we rehearsed 3 months ago about how to say ‘no’ to people who seem interested in me but are really gaming me for sex. I am ready to engage them for me. I am worth more than the false bargain I am making of sex for moments of relief of loneliness only to debase myself again. I feel different now.” The supervisor who is successful can partake of an act of creation. The supervisor can teach the art of savoring, can enjoy gauging the supervisee’s learning readiness, and can engage inactive involvement in reviewing sessions and conducting thought experiments to help the student to see how to be emotionally focused with the client.

Case 30.1 The psychotherapist thought her patient did not take psychotherapy seriously. The patient whipped her serape open to breastfeed her baby during moments of the psychotherapy the supervisee thought might be breakthroughs. The psychotherapist felt defeated and leaned forward in supervision. Her blouse had one or two more buttons undone than usual, and she revealed a good deal of her breasts, quite unlike her usual demeanor. The supervisor desisted from interpretation but asked what associations she had. She suddenly recalled that her mother would pull up her skirt to check her underwear when she came home from school. This “inspection” persisted into the psychotherapist’s adulthood, and she found it demeaning and devaluing of her as a person. The supervisor remained mute. The student did not state any connections

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between the feelings she described from the three devaluing incidents: her patient breastfeeding and her feeling devalued, the revealing of her chest to the supervisor, and the mother’s invasion of her privacy. She was not ready yet to make any connections, and any interpretation the supervisor might have offered was premature. It would have aroused resistance. The issue needed to germinate and would return. The sense of readiness was the key ingredient missing for a beneficial interpretation. Offering it would be outside the sense of harmony and readiness. Instead, the supervisee resumed an upright position and later in the session the supervisor noted to himself that the buttons were now buttoned. The supervision proceeded to looking at different ways to note the supervisee’s feelings and associations when the client again breastfed and how she might possibly address the patient. The supervisor did not examine the other two events. In this way, appraisal is seamlessly part of every action or inaction. For the refined emotion, Frijda and Sundararajan (2007) tell us, the outcome is not pleasure, which is ephemeral, but meaning and meaningfulness, which are enduring.

Our profession’s focus may have led us away from the reason many of us entered the field—to find out about ourselves, to make ourselves better human beings, to alleviate human suffering, to create a bit of kindness in our world, and to reach for the better angels in us. It may be most fitting to end this edition by looking at how the first edition ended (Hess, 1980, p. 530): “In our quest for developing ourselves and each other a tale from the Hasidim seems relevant:" The Maggid of Zlatchov was asked by one of his disciples: “in the book of Elijah we read: ‘Everyone in Israel is in duty bound to say: When will my work approach the works of my fathers, Abraham, Isaac and Jacob.’ How are we to understand this? How could we venture to think that we could do what our fathers could?” The Rabbi expounded: “Just as our fathers invented new ways of serving, each a new service according to his own character: one the service of love, the other that of stern justice, the third that of beauty, so each one of us in his own way shall devise something new in the light of the teachings and of service, and do what has not yet been done.” (Buber, 1947, p. 147)

REFERENCES American Psychological Association. (2002). Ethical principles of psychologists and code of conduct. American Psychologist, 57, 1060–1073. Blanton, S. (1971). Diary of my analysis with Sigmund Freud. New York: Hawthorn Books. Buber, M. (1947). Tales of the Hasidim: The early masters. New York: Shocken Books. Chatelaine, K. (1992). Good me, bad me, not me: Harry Stack Sullivan—An introduction to his thought. Dubuque, IA: Kendall/Hunt. Corsini, R. J., & Wedding, D. (2007). Current psychotherapies (8th ed.). Belmont, CA: Wadsworth. Falender, C. A. & Shafranske, E. P. (2007). Competence in competency-based supervision practice: Construct and application. Professional Psychology, 38, 232–240. Frijda, N. H., & Sundararajan, L. (2007). Emotion refinement: A theory inspired by Chinese poetics. Perspectives on Psychological Science, 2, 227–241. Hess, A. K. (Ed.). (1980). Psychotherapy supervision: Theory, research, and practice. New York: Wiley. James, W. (1884). What is an emotion? Mind, IX, 188–205. Kiesler, D. J. (1966). Some myths of psychotherapy research and the search for a paradigm. Psychological Bulletin, 65, 220–236. Klibert, J. (2008, February). Revising cognitive behavioral therapies: A schema approach. Paper based on a dissertation presented at Auburn University at Montgomery Colloquium, Montgomery, AL.

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STATE OF THE FIELD AND ITS FUTURE

Rogers, C. R. (1968). Graduate education in psychology: A passionate statement. In W. G. Bennis, E. H. Schein, F. I. Steele, & D. E. Berlewe (Eds.), Interpersonal dynamics: Essays and reading in human interaction (pp. 687–703). Homewood, IL: Dorsey Press. (Original work published 1965, unpublished manuscript, Western Behavioral Science Institute, La Jolla, CA) Sears, R. R. (1947). Clinical training facilities: 1947. American Psychologist, 2, 199–205. Shakow, D. (1942). The training of the clinical psychologist. Journal of Consulting Psychology, 2, 277–288. Task Force on the Assessment of Competence in Professional Psychology. (2007). Professional Psychology, 38(5), 441–509. Watkins, C. E., Jr. (Ed.). (1997). The handbook of psychotherapy supervision. New York: Wiley.

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Author Index Abel, G. G., 418 Abeles, N., 302, 303 Abrams, J. C., 83 Achenbach, T., 274 Adams, E. M., 569 Adams, J. B., 343 Aderhold, V., 361 Adler, A., 10, 115, 132 Adler, P., 397 Adrian, G., 546 Aichhorn, A., 377 Aikins, D., 226 Akutsu, P. D., 553 Alanen, Y. O., 437 Albee, G., 246 Aldea, M. A., 353 Alexander, F., 131, 366 Alexander, J. C., 548 Alexander, J. P., 295 Allen, F. H., 269 Allen, G. J., 58, 61, 505 Allen, J., 290 Alley, S., 249 Allison, D. B., 223 Allsop, S., 348 Alonso, A., 11, 86, 334 Alpher, V. S., 504 Althen, G., 72 Al-Timimi, N., 73 Altman, A., 40 Amrhein, P. C., 350 Anastasi, A., 477, 493, 494 Ancis, J., 504, 510 Anderson, A. Z., 70, 71, 72, 73, 74, 75, 76, 77, 78 Anderson, D. C., 450, 456 Anderson, M. P., 503 Anderson, M. Z., 511, 569 Anderson, N., 548 Anderson, S. A., 180 Anderson, T., 193 Andr´es-Hyman, R. C., 552

Andrews, B., 397 Andrews, D. A., 401 ˜ Anez, L. M., 552 Angelone, E. O., 507 Angus, L. E., 115, 116, 117, 118, 119 Apfel, F. H., 224 Arbona, C., 72 Ardila, A., 312 Aries, E., 561 Arkowitz, H., 347 Armstrong, J., 315 Armstrong, P. I., 539 Arredondo, P., 543 Artiles, A. J., 549 Atkinson, D. R., 75, 508, 509, 554 Atwood, G., 133, 158, 201, 376 Auerbach, S., 251 Auld, B. F., 109 Ax, R. K., 383 Axline, V., 279 Azar, S., 249, 250, 251, 252, 253, 255, 257, 258, 259 Bacigalupe, G., 508 Baezconde-Garbanati, L., 546 Bagby, M., 563, 565 Bahrick, A. S., 41, 487, 502 Bakal, D., 296 Baker, A., 73 Baker, D. K., 418 Ball, J. D., 511 Ball, S. A., 345, 352, 355 Bambling, M., 507 Banchero, R., 456, 459 Bandura, A., 171 Bankart, C. P., 75 Barbaree, H. E., 413 Barber, T., 230, 231 Barkley, R., 266 Barlev, A., 303 Barlow, D., 299 Barnard, T., 426

591

aind

JWBK186/Hess

592

June 4, 2008

16:50

Char Count=

AUTHOR INDEX

Barnhardt, T. M., 231 Barrett, D. E., 355 Barry, K. L., 309 Bartels, B., 249 Bartol, A. M., 383 Bartol, C. R., 383 Basilio, I., 326 Bates, J., 398 Battino, R., 226 Bauer, S., 256 Baum, A., 452, 453, 454 Baumeister, R. F., 162, 444, 446 Baumgartner, H., 495 Beamish, P. M., 561, 564 Bebbington, P., 395 Bebeau, M., 13, 68 Bechtel, M. A., 490 Bechtle, A. E., 317 Beck, A., 121, 380, 381, 415 Beck, M., 44, 46, 503 Becker, D., 511 Becker, J. V., 418 Becker-Schutte, A., 570 Beehr, T. A., 72, 73 Beeler, A., 398 Beer, A. M., 539 Beggs, M. A., 503 Beier, E. G., 5, 163 Beigel, A., 323 Belar, C. D., 451, 452, 453, 454, 456, 457, 458, 462, 463, 464, 465, 466, 467, 468 Bell, K., 290 Bellack, A. S., 475, 476 Benedetti, G., 359, 367 Benning, R., 398 Ben-Porath, Y. S., 217 Benson, H. F., 224 Berant, E., 215 Berdie, R., 383 Bergin, A. E., 13, 258 Bergman, A., 27 Berman, J., 248, 501 Bernard, G. W., 329 Bernard, J. M., 12, 41, 44, 45, 46, 51, 58, 70, 74, 75, 77, 86, 89, 90, 343, 346, 350, 473, 474, 475, 478, 488, 491, 503, 506, 511, 539, 560, 561, 566, 571 Bernheim, H., 227, 229 Bernsen, A., 506 Bernstein, B. L., 501 Berry, J. W., 545 Betancourt, H., 73

Betha, L. A., 537, 538 Bettelheim, B., 378 Beutler, L. E., 456, 459 Bhat, C. S., 509 Bielstein Savoy, H., 570 Bieschke, K. J., 567, 570 Biggs, D. A., 73 Binet, A., 228 Bingi, R., 72 Bitterman, M. E., 169 Bjick, E., 226 Black, M. J., 99 Blackburn, R., 401 Blackmon, B., 509 Blagov, P., 116, 124 Blai, A., 226 Blanchard, J. J., 341, 344 Blanton, J., 249 Blanton, S., 158, 579 Blatt, S., 26 Blau, T., 249 Bleach, G., 251 Bloom-Feshbach, J., 28 Bloom-Feshbach, S., 28 Blow, F. C., 309 Blumstein, P., 562 Blundin, A., 165 Blustein, D. L., 477, 493 Bober, J. F., 464 Bohan, J. S., 560 Bolognini, M., 292 Bonecutter, B., 467 Bonilla-Silva, E., 546 Bonner, R. L., 393 Bonta, J., 401 Book, H., 116, 120 Booth, A. L., 342 Boothby, J. L., 380, 403 Bor, R., 511 Borckardt, J. J., 20 Borden, K. A., 345 Borders, L., 70, 73, 254, 255, 341, 347, 355, 491, 505, 560, 566 Bordin, E. S., 41, 45, 49, 76, 92, 501 Borrill, J., 397 Boscolo, L., 192 Bowers, K. S., 223, 231 Bowes-Bouffard, B., 116, 119 Bowie, S. L., 549 Bowman, P. J., 129 Boyd, C., 302 Boyd, J., 7 Boyd-Franklin, N., 196, 548

aind

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June 4, 2008

16:50

Char Count=

Author Index Brack, C. J., 567, 568, 569, 570, 571 Brack, G., 567, 568 Bradley, L., 72, 352, 353, 354, 491, 511 Braid, J., 227, 228 Braithwaite, V. A., 308 Bramwell, J. M., 227, 232, 233 Brandchaft, B., 158, 201 Brandt, S. M., 383 Bratslavasky, E., 162 Bray, J. H., 452, 453, 463, 464 Breggin, P. R., 376 Bremmer, J. D., 317 Brems, C., 271 Brenner, C., 105, 447 Brenock, K., 504 Breuer, J., 4 Breunlin, D. C., 188 Brewer, M. B., 553 Brice-Baker, J., 76 Brief, A. P., 41 Brinson, J. A., 539, 542 Brittan-Powell, C. S., 502, 509, 539 Brockopp, E., 252 Brodsky, A., 475 Brody, D. S., 451 Broer, S., 247 Brome, D. R., 76, 566 Brondino, M. J., 355 Bronson, M. K., 511 Brotherton, D., 70, 73, 560, 566 Brotman, L. M., 247 Brown, E. J., 247 Brown, H. D., 72, 73 Brown, L. L., 491 Brown, M. T., 70, 560, 566 Brown, S., 256 Brown, T. N., 549 Brownmiller, S., 420 Brugha, T., 395 Bruhn, A. R., 115 Bruner, J., 114, 132, 133 Brunet, A., 563, 565 Bruss, K. V., 567, 568 Bryan, A. K., 72, 73 Bryant, R., 223 Buber, M., 157, 161, 166, 174, 175, 589 Buhrke, R. A., 567, 568 Buirski, P., 201 Burgess, A., 322 Burkard, A. W., 49, 347, 508, 509, 539, 540, 541, 545 Burke, B. L., 347 Burnam, M. A., 322

593

Burton, A., 380 Bushman, B. J., 444, 446 Bushnella, C., 230 Buss, A. H., 445 Butcher, J. N., 464 Butler, C. C., 354 Butler, S. K., 49 Caldwell, M. B., 247 Caldwell, R., 257, 259 Caligor, L., 4, 106, 504 Callahan, J., 303 Calopinto, J., 192 Calzada, E. J., 247 Cambridge, P. R., 538 Campbell, D. T., 477, 479, 480, 481, 482, 486, 504 Campbell, T. C., 345, 354, 355 Campbell, W. K., 444, 446 Cangemi, J., 562 Cantor, J. M., 567 Carcione, A., 119 Cardoso, E. D., 343 Carey, J. C., 488, 503 Carifio, M. S., 58, 456 Carini, R. M., 73 Carkhuff, R., 10, 248, 249 Carmen, E. H., 315 Carozzoni, P., 50, 51 Carr, A., 180, 562, 563 Carroll, J. J., 341, 342 Carroll, K. M., 341, 343, 345, 350, 354 Carrubba, M. D., 569 Carson, R. C., 18, 166 Cass, V. C., 570 Catalan, J., 511 Catlin, L., 345 Causton-Theoharis, J., 247 Cavalieri, C. E., 508, 566 Cawyer, C. S., 90, 511 Cecchin, G., 192 Cellini, H. R., 396, 413 Cellucci, T., 343 Ceperich, S., 352, 355 Cerce, D., 413 Chan, F., 343 Chang, C. Y., 539, 544 Chapman, D. W., 73 Chappel, J. N., 342 Charles, D., 44 Chassequet-Smirgel, J., 32, 33 Chatelaine, K., 584 Chatters, L. M., 549

aind

JWBK186/Hess

594

June 4, 2008

16:50

Char Count=

AUTHOR INDEX

Chaves, J., 231 Chen, C. P., 72, 73 Chen, E. C., 501 Chen, H. T., 476, 493 Chen, Y.-R., 553 Cherchia, P., 247 Cherry, D. J., 549 Chethik, M., 281 Chinsky, J., 247 Christensen, A., 247, 248, 249 Christenson, M. D., 345 Christiansen, N. D., 72, 73 Chu, J. P., 553 Chung, Y. B., 561, 564, 566, 567, 569, 570, 571 Chur-Hansen, A., 503 Chwalisz, K., 88 Cicchetti, D., 317 Cimmarusti, R. A., 188 Claiborn, W., 251 Clark, R., 548 Clark, V., 548 Clements, C. B., 380, 403 Cling, B. J., 315, 323 Cochran, S. D., 567 Cochran, S. W., 327 Cohen, C., 27, 34 Cohen, D. R., 376 Coid, J., 395 Cokley, K., 546 Cole, M., 165 Coleman, H. L. K., 540, 544 Collins, J. J., 404 Collins, J. R., 73 Colliver, J. A., 315 Coloma, R. S., 553 Combs, A. W., 227 Concha-Eastman, A., 247 Cone, J. D., 476, 493 Connelly, R., 397 Conner, L. C., 549 Consoli, A. J., 508, 509 Constantine, M., 50, 52, 70, 303, 507, 508, 509, 539, 540, 544, 549 Conti, L., 119 Contreras-Tadych, D. A., 49, 508, 509, 539, 540, 541, 545 Conway, M. A., 114 Cook, D. A., 509, 538, 539, 543, 546 Cook, T. D., 477, 479, 480, 481, 482, 486 Cooke, M., 562 Cooker, P., 247

Cooley, S., 302 Coons, W. H., 401 Cooper, H. M., 478, 487 Cooper, L. F., 239 Cooper-Patrick, L., 549, 550 Copeland, S. R., 549 Corbet, M., 561 Corbett, M., 46, 56, 57, 467, 487, 490, 506, 529 Cormier, L. S., 503 Cornish, J., 306 Cornish, J. A., 473 Cornish, J. A. E., 83, 86, 90, 91 Correia, K. M., 383 Corsini, R. J., 157, 582 Costa, P. T., Jr., 126 Couchon, W. D., 506 Cowburn, J., 447 Cowen, E., 247, 256, 257, 259 Cox, J. F., 398 Coyle, J., 226 Craig, R., 479, 490 Craine, L. S., 315 Crave, D., 329 Crawford, H. J., 228, 229, 231 Crawford, M., 560 Crethar, H. C., 460, 505 Crimmings, A. M., 473 Crits-Christoph, P., 116 Crose, R., 306, 307 Cross, W. E., Jr., 545 Croteau, J. M., 567, 569, 571 Crutchfield, L. B., 70, 73, 560, 566 Culbreth, J., 247, 254, 255, 341, 347, 355 Cummings, G., 414 Curl, J., 42 Curtis, R., 70, 73, 560, 566 Cusick, G. M., 325 Czyzewska, M., 231 DaCosta, G., 509, 542 Dahlstrom, W. G., 464 Dakof, G. A., 295 D’Andrea, M., 49 Danesh, J., 398 Daniel, J., 302 Daniels, H., 165 Daniels, J., 45, 46, 49, 75 Daniels, R., 224 Danish, S., 249 Daood, C., 345 Darley, J. G., 383

aind

JWBK186/Hess

June 4, 2008

16:50

Char Count=

Author Index Darnell, A., 317 Das, A. K., 550 Davidson, L., 552 Davis, B., 477, 479, 480, 486 Davis, T. E., 77, 509, 561, 564 Day, D. M., 414 Day, J., 437 Deane, F. P., 403 Deardorff, W. W., 451, 452, 453, 454, 456, 457, 458, 462, 463, 464, 465, 466, 467 DeBellis, M. D., 317, 318 DeBono, E., 417 DeBord, K. A., 567, 570 Deck, M., 41 Deffenbacher, J. L., 197 DeGroot, J., 563, 565 Deitch, I., 302 deJong, G., 246, 247 Dell, D. M., 507 Delworth, U., 86, 353, 460, 479, 483, 489, 560, 568 Demanchick, S., 247 Dennin, M. K., 505 De Pascalis, V., 229, 231 Deqiang, G., 414 de Valenzuela, J. S., 549 Devenis, L. E., 493 Dewald, P. A., 51 Diamond, G. M., 511 Diemer, R. A., 447 Dillon, F. R., 570 Dimaggio, G., 119 Dindia, K., 561 Dishion, T. J., 293 Distefano, T. M., 569 Ditton, P. M., 381 Doan, R. E., 116, 118 Dobmeyer, A. C., 458 Dobson, K. S., 296 Dodds, A. K., 70, 76, 511 Dodds, J., 271 Dodenhoff, J. T., 503 Dodson, J. D., 43 Doehrman, M. J., 504 Donham, G., 509, 561, 563 Donovan, D. M., 351 Dorcus, R. M., 243 Dorta, K. P., 293 Doty, D. R., 180 Dove, W., 256 Downs, L., 561 Dowrick, P., 247

595

Doyle, M., 247 Draguns, J., 303 Drake, R. E., 345 Drejer, A., 47 Dressel, J. L., 508, 509 Duan, C., 49, 74, 76, 78, 508 Duffy, M., 303, 306, 307 Dulko, J. P., 508, 566 Duncan, B. L., 87 Duncana, G. H., 230 DuPree, W. J., 503 Durant, W., 522 Durlak, J., 247, 248 Dutton, M. A., 328 Dwight-Johnson, M., 550 Dworkin, S. H., 569 Dye, H. A., 509 Eagle, M. N., 447 Easser, R., 29 Ebener, D., 549 Eberz, A. B., 567 Edelbrock, C., 274 Edgar, M., 325 Edwards, E., 317 Edwards, K., 355 Edwards, T. M., 451 Efstation, J. F., 76, 489, 501 Ehrenwald, J., 4 Eibl-Eibesfeldt, I., 443 Eisner, J. R., 342 Eissler, K. R., 103 Ekstein, P., 215 Ekstein, R., 10, 99, 160, 504 Elias, M. J., 551 Elkes, C., 247 Ellerby, L. A., 426 Elligan, D., 548 Elliott, T. R., 450 Ellis, A., 121, 250 Ellis, M. V., 11, 44, 46, 473, 474, 477, 478, 482, 483, 484, 486, 487, 488, 491, 492, 493, 496, 501, 502, 503, 504, 505, 506, 507 Ellison, C. G., 549 Embretson, S. E., 477, 496 Emerick, R., 426 Emmelkamp, P., 246, 247 Emmons, R. A., 121, 126 Engels, M. L., 325 English, K., 428 Enright, R. D., 538 Epp, L. R., 548

aind

JWBK186/Hess

596

June 4, 2008

16:50

Char Count=

AUTHOR INDEX

Epston, D., 115 Erickson, C. D., 50, 52, 507, 508 Erickson, M. H., 231, 234, 235, 239 Erikson, E., 31, 289 Ernst, C., 246 Esnil, E., 504 Estrada, D., 539, 540, 545, 549 Etherage, J. R., 458 Eubanks, R., 546 Evans, S., 563 Ewing, C. P., 392 Ewles, C., 417 Eyerman, R., 548 Fabiano, E., 417 Fagan, T. J., 383, 404 Fairbairn, R. W. D., 362 Fairbank, J. A., 326 Faith, M. S., 223 Falender, C., 12, 50, 51, 58, 83, 86, 89, 90, 91, 306, 345, 473, 491, 587 Falicov, C. J., 196 Fallon, J., 402 Falvey, J. E., 475 Farber, B. A., 57, 164, 467, 506, 529 Farley, F., 291 Farrenkopf, T., 426 Fassinger, R. E., 52, 560, 567, 570 Fazel, S., 398 Feldman, R. D., 287 Feldman-Summers, S., 325 Felice, A. A. D., 508, 566 F´er´e, C., 228 Fernandez, Y. M., 412, 421 Finch, A. E., 506 Finn, S., 200, 201, 202, 203, 204, 205, 206, 207, 212, 218, 219 Fiore, D., 119 Fischer, A. R., 567 Fischer, C., 201, 202, 203, 207, 208 Fischer, L., 295 Fisher, A. R., 567 Fisher, B. L., 197, 505 Fisher, C. B., 11 Fish-Murray, C. C., 318 Fiske, D. W., 504 Fiske, S. T., 58, 64, 523 Fivush, R., 132 Fletcher-Jantzen, E., 312 Flint, A., 247 Foa, E. B., 328 Folen, R. A., 452, 454 Follette, V. M., 317, 328

Follette, W. C., 328 Fong, M. L., 509, 540 Ford, D. E., 549, 550 Forrest, L., 68 Forsten, R., 247 Forsyth, J. P., 401 Forsythe, A. B., 322 Foster, J. H., 341, 342 Fowler, C., 210 Fraiberg, S., 362 Frame, M. W., 539, 540, 545 France, K., 252 Frank, J. B., 4, 225 Frank, J. D., 4, 225 Frank, R. G., 452, 453, 463, 464 Frankiel, R., 28 Frankl, M. S., 522 Frankl, V. E., 168 Franklin, A. J., 548 Frawley-O’Dea, M. G., 562 Freedman, S. R., 538 Freeman, B., 479, 488, 489, 491, 496 Freeman, E. L., 454 Freeman, E. M., 509 Freeman, R., 279 Freestone, J., 503 Freitas, G. F., 46, 503 Freitas, G. J., 11, 501, 506 Fremouw, W. J., 292 French, S., 396, 402 French, T. M., 131, 366 Freud, S., 4, 28, 30, 33, 36, 37, 38, 115, 120, 373, 377, 423 Freudenberger, H., 248 Friedlander, M. L., 40, 41, 43, 49, 50, 51, 58, 61, 75, 164, 334, 487, 488, 489, 502, 504 Friedman, A. F., 325 Friedman, B., 488 Frijda, N. H., 61, 581, 587 Fromm-Reichmann, F., 374 Fuertes, J. N., 539 Fuhrman, M., 345 Fuhrman, T., 289 Fukuyama, M. A., 508 Fulcher, L., 350 Funderburk, V. W., 327 Fuqua, H. E., Jr., 562 Furlan, G. M., 367 Gafford, J., 463 Gale, J. E., 508 Galietta, M., 296

aind

JWBK186/Hess

June 4, 2008

16:50

Char Count=

Author Index Gallagher-Thompson, D., 307 Gallon, S. L., 352, 355, 475 Garcia, M., 352, 355 Garcia-Preto, N., 196 Garcia-Shelton, L., 468 Gardner, E., 247 Gardner, R. M. D., 49, 539 Garfield, S. L., 13, 258 Garner, B. A., 531 Garnets, L., 567 Garrett, M. T., 70, 73, 560, 566 Gatchel, R. J., 452, 453, 465, 466 Gately, L., 253 Gatmon, D., 70, 76, 539, 560, 563, 566, 571 Gatz, M., 300 Gawinski, B. A., 451 Gay, P., 6 Gediman, H. J., 438 Gelfand, A., 315 Gelso, C., 52, 250, 251, 255, 259, 447 Gendreau, P., 396, 401, 402 Gerbasi, J. B., 383 Gergen, K. J., 132 Gergen, M. M., 132 Gernat, C. A., 509, 539, 546, 547 Gesseman, R., 527 Getz, H. G., 473 Giangreco, F., 247 Gibat, C. C., 413 Gibbons, K., 293 Gibson, G., 561 Gilbert, L. A., 561, 563 Gill, M., 27 Gillespie, K. N., 490 Gilmore, J., 344 Gilmore, S. K., 10 Gingras, T., 511 Giordano, J., 196 Gitlin, M., 305 Glasziou, P., 87 Glencavage, L., 283 Glickaug-Hughes, C., 567, 568 Glick-Hughes, C., 59 Glidden, C. E., 507 Glidden-Tracey, C. E., 477 Gloria, A. M., 541 Glover, G., 279 Gluck, M. R., 58 Goggin, C., 402 Golding, J. M., 322 Goldston, D. B., 291 Gomez, M. J., 52 Gonsalvez, C. J., 503

597

Gonzales, J. J., 549, 550 Gonzalez, T., 42 Good, R. H., III, 477, 479, 480, 486 Goodchilds, J., 567 Goodkind, J., 247 Goodman, L., 361 Goodman, S., 101 Goodstein, R. K., 308 Goodwin, A., 504 Goodyear, R., 12, 41, 44, 45, 46, 51, 58, 70, 74, 75, 77, 83, 86, 89, 90, 91, 343, 346, 350, 473, 474, 475, 478, 491, 507, 508, 509, 511, 539, 560, 561, 562, 563, 566, 567, 571 Gopaul-McNicol, S., 76 Gorcey, M., 323 Gordan, K., 458, 459 Gordon, A., 414 Gordon, B., 229 Gordon, J. R., 416 Gordon, L. L., 561, 564, 566 Gottlieb, M. C., 524 Gough, K., 398 Gould, J., 565 Gould, M. A., 382 Graham, J. R., 217, 464 Granello, D. H., 560, 561, 563, 564, 566 Grant, T., 246 Graves, T. D., 72 Gray, E. L., 501, 506 Gray, G. V., 451 Gray, L. A., 504 Green, J. P., 223 Greenberg, J., 99 Greenberg, L., 123, 476, 502 Greene, B., 506, 540 Greenfield, L. A., 329 Greenhouse, E. M., 567, 568, 569 Greenson, R., 32 Griffin, B., 344 Griffith, P. L., 325 Groeger, J. A., 234 Groscup, J. L., 438 Gross, J. J., 124, 447 Gross, S. M., 42 Grzegorek, J. L., 570 Gubi, P. M., 510 Guerra, R. M., 570 Gulgoz, S., 74 Guthrie, R. M., 223 Gutierrez, F. J., 72, 75 Guy, J., 269, 283 Guzzardo, C. R., 508, 567

aind

JWBK186/Hess

598

June 4, 2008

16:50

Char Count=

AUTHOR INDEX

Haag, A. M., 395 Haaga, D., 254 Haas, L. J., 451, 457 Haase, R. F., 486 Haber, R., 350 Habermuller, M. S., 223 Haffey, W. G., 256 Haglund, P., 201 Hahn, W. K., 56, 60, 164 Haley, J., 163 Haley, W., 300, 463, 464 Halfon, O., 292 Halgin, R. P., 541 Hall, D., 352, 355 Hall, E. T., 547 Hall, G. C. N., 429 Halpert, S. C., 561, 567 Hambleton, R. K., 477, 496 Hamboyan, H., 72, 73 Hammar, L., 509, 539, 546, 547 Hammer, A. L., 496 Hancock, K. A., 567 Handler, L., 200, 201, 205, 210, 213, 218, 219, 220, 445, 511 Handley, P. G., 501 Haney, C., 395 Hanjorgiris, W. F., 570 Hanna, C., 317 Hansen, N. B., 506 Hanson, R. K., 414 Harber, R., 76, 566 Hardy, E., 560 Hargrove, D. S., 454 Harkins, K., 317 Harley, D. A., 549 Harp, J. S., 50, 51 Harper, M., 302 Harper, R. G., 462 Harralson, T. L., 325 Harrar, W. R., 522 Harris, A. J. R., 414 Harris, R., 325, 353 Harrison, P., 380 Harrow, M., 467 Hart, S. D., 438 Harter, S., 289 Hartling, L. M., 561 Harvey, R. J., 496 Hatcher, R., 83, 86, 90, 91, 306, 473, 492 Hattie, J., 248 Hauer, A., 249 Haukka, J., 397

Hauser, S., 290 Hawk, K. M., 403 Hawkins, P., 476 Haworth, M., 281 Hayes, B., 253 Hayes, J., 50, 51, 250, 251, 255, 259, 447 Hayes, L., 397, 398 Haynes, R. B., 87 Hays, D. G., 539, 544 Hays, P., 304 Hechanova-Alampay, R., 72, 73 Heckman-Stone, C., 479, 483, 489 Heflinger, C. A., 549 Heldring, M., 452, 453, 463, 464 Helm, K., 546 Helms, J. E., 509, 510, 538, 543, 544, 545, 546 Hemlick, L. M., 479, 488 Henderson, C. E., 90, 511 Henderson, P., 456 Hendrickson, M. L., 349, 350, 352, 355 Henggeler, S. W., 86 Henley, R. W., 10 Hennen, J., 416 Henson, C. E., 315 Hepp, U., 400 Heppner, P. P., 501 Herbert, J. T., 479, 488 Herlihy, B., 256 Herman, J. L., 315, 317, 320, 324, 328, 329, 330, 331, 332, 334 Hermans, H. J. M., 118, 125 Herold, A. L., 562 Herron, W. G., 504 Hersen, M., 277, 326, 475, 476 Hertz, J. H., 432 Heru, A. M., 563 Hess, A., ix, 10, 11, 13, 19, 20, 56, 58, 82, 86, 157, 160, 164, 166, 249, 301, 328, 336, 350, 383, 454, 456, 579, 589 Hess, K. A., 454 Hess, K. D., 336 Hess, S., 253, 347 Hess, T. H., 445 Hesson, K., 296 Hetherly, V., 456 Hettma, J., 346, 347, 356 Hicks, B. M., 397 Higareda, I., 549 Hightower, A. D., 256 Hilberman, E., 322 Hilgard, E. L., 230, 232

aind

JWBK186/Hess

June 4, 2008

16:50

Char Count=

Author Index Hilgard, J., 230 Hill, C., 44, 46, 48, 50, 51, 56, 57, 253, 467, 487, 490, 503, 506, 529 Hill, J. P., 287 Hill, M. S., 538 Hill, R. L., 554 Hill, T., 231 Hillier, L., 293 Hilsenroth, M., 201, 210, 511 Hilton, D. B., 509 Hinrichson, G., 302 Hinze, T., 396 Hird, J. S., 508, 541, 566 Hirsch, S., 437 Hirschman, R., 217 Ho, D. Y. F., 75 Ho, T. A., 508, 566 Hobbs, N., 247 Hobfoll, S. E., 317, 326 Hofbauerb, R. K., 230 Hoffman, J., 247 Hoffman, L., 192 Hoffman, M. A., 46, 503 Hofheinz, E., 509, 544 Hogan, R. A., 86 Hoge, R. D., 401 Hoke, S. E., 414 Holland, D., 247 Hollander, J., 256 Hollin, C. R., 383 Holloway, E., 12, 13, 40, 41, 44, 82, 86, 160, 343, 354, 501, 505, 509, 562, 563, 564, 566, 567, 568 Holmbeck, G. N., 288, 289 Holmes, D. J., 293 Holmes, E. A., 546 Holmes, S. E., 46, 503 Holmstrom, L., 322 Holtz, R. L., 286 Holtzman, C., 426 Homeyer, L., 279 Hong, B. A., 452 Hood, K., 355 Hopkins, M., 250 Horney, K., 121, 446 Hornyak, L. M., 223 Horvath, A., 476, 502 Hossack, A., 247 House, R. M., 567, 568 Howard, E., 40 Howe, H. E., 501 Howe, S. R., 567 Hoyt, D. R., 551

599

Hoyt, W. T., 476 Huaqing Qi, C., 549 Huband, N., 403 Hubble, M. A., 87 Hudson, R., 300 Hudson, S. M., 413, 419 Hudson, W. W., 567 Hull, C., 230 Hulsey, T. L., 318, 325 Humphreys, K., 254 Hunt, T., 310 Hunter, D., 550, 551 Hunter, S. B., 344 Huws-Thomas, M., 355 Hwang, W.-C., 553 Hyman, M., 109 Ingram, K. M., 507 Inman, A. G., 40, 180, 196, 502, 509, 510, 544 Isley, E., 451 Ismond, D., 274 Isomets¨a, E., 397 Israel, A., 275 Israel, T., 567, 570 Ivey, D. C., 562, 563 Iwamoto, D. K., 553 Jackson, A. P., 317, 326 Jackson, D., 70, 76, 493, 494, 539, 560, 563, 566, 571 Jackson, G. E., 376 Jackson, K. E., 426 Jacobs, E. G., 58 Jacobson, N., 248 Jaffee, C. L., 542 James, I., 473 James, L. C., 452, 454 James, W., 30, 227, 587 Janet, P., 227 Janis, L., 117, 118 Jenckes, M. W., 549, 550 Jenkins, J. M., 161 Jenkins, P., 538 Jenkins, R., 395 Jessell, J. C., 509, 563, 565 Johnson, A. J., 49, 347, 508, 509, 539, 540, 541, 545 Johnson, D., 247, 451 Johnson, J., 269 Johnson, M., 159, 542 Johnson, P., 342 Johnson, R. J., 293

aind

JWBK186/Hess

600

June 4, 2008

16:50

Char Count=

AUTHOR INDEX

Johnson, S. B., 463, 464 Johnson, T. P., 342 Johnson, W. R., 345 Jones, K., 253 Jones, L., 428 Jones, N., 541 Jones, R. L., 545 Jongsma, A., 271 Jonsson, C. O., 511 Jordan, J. V., 561 Josselson, R., 132 Juckett, G., 552 Juhnke, G., 254, 255 Junker, G., 398 Kachele, H., 377 Kaemmer, B., 464 Kafka, M. P., 416 Kagan, H., 45 Kagan, N. I., 45 Kagawa-Singer, M., 554 Kahn, A. S., 561, 562 Kahn, F. I., 326 Kalafat, J., 252 Kalbfleisch, P. J., 562 Kampa-Kokesch, S., 569 Kaplan, A. S., 563, 565 Kardash, C. M., 76, 489, 501 Karno, M. P., 505 Karon, B. P., 362, 366, 374, 376, 377 Karrer, B. M., 188 Kaser-Boyd, N., 315, 319, 327, 328 Kaslow, N., 68, 83, 86, 90, 91, 306, 473, 492 Kassem, L., 318 Katchadourian, H., 289 Katz, P. A., 554 Kavanagh, K., 293 Kavanaugh, P. R., 73 Keane, T. M., 326 Kearney, C. A., 275 Kearns, B., 426 Kell, B. L., 10 Keller, K. E., 43 Kelly, F. D., Jr., 490 Kelly, G. A., 434 Kelly, S., 548 Kenfield, J. A., 561, 563 Kennard, B. D., 58 Kerlinger, F. N., 477 Kern, J. M., 326 Kernberg, O., 26, 27 Kessler, J., 273, 275 Kiesler, D. J., 582

Kihlstrom, J. F., 231 Killian, K. D., 70, 73, 74, 76, 78, 508, 509 Killman, P., 251 Kilpatrick, D. G., 323 Kim, B. S. K., 49, 74, 75, 508, 509 King, D., 511 King, L. A., 117 King, P. A., 552 King, R., 507 Kingston, D. A., 417 Kipnis, D., 562 Kirkley, D. E., 353 Kirsch, I., 223, 225 Kitayama, S., 77 Kivlighan, D. M., 76, 507 Klaus, P., 329 Kleespies, P. M., 401 Klein, G., 27, 171 Klein, M., 27 Kleintjes, S., 508 Klibert, J., 580 Knafo, D., 437 Knapp, S., 522 Knight, B., 301, 303 Knight, R. A., 413 Knight, R. P., 371 Knox, L., 247 Knox, S., 253, 506 Koby, E. V., 318 Kogan, S. M., 295 Kohut, H., 29 Kollock, P., 562 Koocher, G. P., 295 Koshkarian, L., 70, 76, 539, 560, 563, 566, 571 Kottler, J. A., 352, 353, 354 Koverola, C., 317 Kozlowski, J. M., 49, 347, 508, 509, 539, 540, 541, 545 Kozulin, A., 165 Krasner, R. F., 5 Kratochwill, T., 281 Krause, A. A., 505 Krengel, M., 11, 44, 46, 473, 477, 478, 482, 483, 484, 486, 501, 503 Kroger, J., 287, 290 Kroger, W. S., 223, 224 Krolokke, C., 561 Krone, A., 254, 256 Kronenberger, W., 271 Krystal, J. H., 317 Kuh, G. D., 73

aind

JWBK186/Hess

June 4, 2008

16:50

Char Count=

Author Index Kulakowski, D., 561, 563 Kurpius, D., 561 Lacina, J. G., 72 Ladany, N., 11, 40, 41, 46, 47, 49, 50, 51, 52, 56, 57, 58, 61, 334, 467, 473, 474, 477, 478, 479, 482, 483, 484, 486, 487, 488, 490, 491, 492, 496, 501, 502, 503, 504, 505, 506, 507, 508, 509, 510, 511, 529, 539, 544 LaDue, R. A., 551 LaFromboise, T. D., 551 Laget, J., 292 Lago, C., 537 Lai, E. W. M., 73 Lakoff, G., 159 Lambert, M. J., 250, 258, 504, 506 Lambert, W., 325, 507 Lancaster, G., 400 Landreth, G., 279 Landrum-Brown, J., 70, 560, 566 Landy, F. J., 477 Lane, C., 355 Lane, S., 400 Lanning, W., 488 Lark, J. S., 567, 569, 571 Larson, L. M., 45, 46, 75, 76, 490 Lassiter, K. D., 473, 492 Latts, M. G., 52 Lawless, J. J., 508 Laws, D. R., 413 Layton, J. C., 426 Lazarus, A. A., 8 Lazicki-Puddy, T. A., 293 Leader, E., 295 Lease, S. H., 509, 540 Lebow, J., 254 Leddick, G. R., 473 LeDoux, J., 317, 319 Lee, A. F. S., 413 Lee, H. B., 477 Lee, R. E., 187 Lee, S., 548 Lee, Y. H., 544 Lefter, L., 318 Lehrman-Waterman, D., 47, 479, 487, 491, 496, 502, 503, 508, 511 Leifer, M., 251, 318, 479, 490 Leigh, I. W., 13, 68 Lent, R. W., 473 Leong, F. T. L., 49, 539, 549 Lerner, H., 27, 28 Lerner, P., 25, 27, 28, 37, 219

601

Lester, D., 246, 251, 252 Leung, P., 549 Leuwerke, W., 540, 545 Leve, R. M., 266, 272, 274, 275, 279, 281, 283, 293 Levenson, E. A., 112 Levenson, R. W., 447 Leventhal, G., 83, 86, 90, 91, 306, 452, 468, 473 Levin, J. S., 549 Levine, D. M., 549, 550 Levinson, R., 381 Levitt, D., 247 Levy, B., 329 Lewak, R., 325 Lewicki, P., 231 Lewin, J., 116, 119 Lewin, K., 349 Lewis, E. L., 549 Lewis, G., 395 Lewis, J., 561 Lewis, M., 129 Lewy, G., 550 Liao, D., 550 Lichtenberg, J. W., 13, 509, 561, 562, 563 Licinio, J., 317 Lidderdale, M. A., 567, 569, 571 Liddle, H. A., 191, 295, 511 Lieberman, K. S., 438 Lincoln, K. D., 549 Lindbloom, G. L., 475 Lindgren, J., 553 Lindley, C. J., 310 Lindner, R. M., 383 Linehan, M. M., 415 Link, N., 451 Linton, J. C., 464 Lipton, D., 401 Litwack, T. R., 438 Litz, B., 247 Liu, W. M., 544, 553 Livingston, J. A., 414 Loewald, H., 27 Logan, S., 509, 549 Loganbill, C., 560 London, S., 87 Long, J. K., 566, 569 Lonner, W., 303 ¨ Lonnqvist, J., 397 Lopez, M., 302 Lopez, S. J., 345 Lopez, S. R., 73, 509

aind

JWBK186/Hess

602

June 4, 2008

16:50

Char Count=

AUTHOR INDEX

Lorion, R., 257, 259 Lovell, C., 505 Luborsky, L., 116 Lurigio, A., 402 Lutfi, G., 549 Lynch, C., 293 Lynch, M., 317 Lysaker, J. T., 119 Lysaker, P. H., 119 MacLean, D. G., 315 Macran, S., 5 Maddaleno, M., 247 Madson, M. B., 49, 343, 347, 354, 355, 508, 509, 539, 540, 541, 545 Magaletta, P. R., 383, 404 Magnuson, S., 504, 511 Maguen, S., 247 Mahler, M., 27 Mahrer, A. R., 137, 138, 139, 142, 146, 147, 149, 150, 152, 153, 154 Malan, D., 374 Mallinckrodt, B., 72, 73 Malloy, P. F., 326 Malmgren, K., 247 Maltzman, I., 165 Mann, S., 447 Manuel, J. K., 349, 355 Markus, H. R., 77 Marlatt, G. A., 256, 351, 413, 416 Marlyere, K., 433 Marques, J. K., 413, 414 Marshall, J. A., 561, 564, 566 Marshall, L. E., 412, 421 Marshall, W. L., 403, 412, 419, 421 Martin, A., 561 Martin, H., 200 Martin, T., 349, 355 Martinez, J., 350 Martino, S., 352, 355 Martinson, R., 380, 401 Martone, M. W., 318 Martos-Perry, N., 70, 76, 539, 560, 563, 566, 571 Marucci, F. S., 232 Maruschak, L., 381 Mash, E., 266 Maslach, C., 251 Massey, R., 254, 256 Matarazzo, J. D., 166 Matthews, K. L., 456 Mauer, M., 380

Maxwell, S. E., 488 May, K., 247 May, P. R. A., 363 Mayman, M., 32, 36 Mazza, J., 191 McAdams, D., 117, 118, 119, 120, 121, 126, 129, 132, 201 McCall-Perez, F., 323 McCann, L., 426 McCarthy, E., 546 McCarthy, P., 561, 563 McClanahan, M., 50, 51, 570 McClarty, B., 317 McCollum, V., 256 McCracken, J. E., 50, 51 McCrady, B., 254 McCrae, R. R., 126 McCullom, E., 426 McCullough, L., 43 McCullough, M. E., 509 McCurtis, H. L., 550 McDaniel, S. H., 452, 453, 454, 463, 464 McFall, R., 248 McGoldrick, M., 196 McGovern, M., 345 McGowan, M. O., 553 McGrath, R. J., 414 McGuire, D. E., 188 McGuire, J., 383, 401 McHale, E., 562, 563 McHenry, S., 479, 488, 489, 491, 496 McInnis, W., 271 McIntosh, P., 546 McKay, K. M., 538 McKenzie, E. B., 320 McLean, S., 503 McLellan, A. T., 341 McLeod, J., 115, 117, 118, 201 McMurran, M., 403 McNeill, B., 60, 86, 353, 460, 504, 505 McPherson, R., 72, 527 McQuaid, J. H., 247 McRoy, R. G., 509 Meddings, D., 247 Medlicott, D., 397 Meehan, C., 400 Meehl, P. E., 445 Megargee, E. I., 444 Meier, S., 479, 490 Meiselman, K. C., 325 Melby, J. N., 476 Melchert, T. P., 345, 355 Melikian, K., 426

aind

JWBK186/Hess

June 4, 2008

16:50

Char Count=

Author Index Melincoff, D. S., 502, 506 Menchola, M., 347 Menn, F., 317 Menninger, K., 441 Meo, M., 232 Messer, J. M., 292 Messick, S., 477, 491, 493, 494 Meyer, C. B., 323 Meyer, L., 72 Meyer, R., 271, 362 Michel, K., 400 Middleton, R. A., 549 Miller, K., 50, 52, 507, 508 Miller, M. E., 223 Miller, M. M., 562, 563 Miller, S. D., 87 Miller, T., 247 Miller, W., 247, 248, 249, 340, 341, 343, 345, 346, 347, 348, 349, 350, 352, 353, 354, 355, 356, 421 Milligan, R., 397 Millon, T., 452 Mills, T., 315 Milne, D., 88, 473 Minatrea, N., 253 Mio, J. S., 548 Mira, C. B., 546 Mitchell, C., 426 Mitchell, S. A., 99, 121, 158 Mittleman, M., 418 Miville, M. L., 539, 540, 544 Mohr, J. J., 566, 567, 569, 570 Moisan, D., 325 Molina, A., 70, 76, 539, 560, 563, 566, 571 Molinaro, M., 502, 503, 511 Moller, I. U., 437 Molock, S. D., 291 Monte, C. F., 158 Montgomery, G., 223, 225 Moore, M., 20, 329 Moorhouse, A., 180 Moos, B., 254, 255 Moos, R., 254, 255, 341 Moradi, B., 566 Morales, P., 303, 307 Mordechai, E. M., 58 Moreau, D., 293 Morgan, C. D., 464 Morgan, M. M., 180 Morgan, R. D., 383 Mori, S., 72 Morin, S. F., 567 Morrell, J. S., 326, 327

603

Morris, G. H., 180 Morris, R., 281 Morrison, A. P., 361 Morten, G., 554 Moskovitz, A., 345 Mothersole, G., 504 Moulds, M. L., 223 Moulton, R., 106 Mowrer, O. H., 432 Moyers, T. B., 343, 347, 349, 350, 352, 355 Muehlenkamp, J. J., 401 Mueller, W. J., 10 Mueser, K. T., 345 Mufson, L., 293 Munoz, R., 247, 248, 249 Murakami, J. L., 291 Muraven, M., 162 Murphy, J. A., 567 Murphy, M. D., 20 Murphy, M. J., 42, 180 Murphy, W., 414 Muse-Burke, J. L., 41, 50, 52, 492, 504, 507, 508 Mustaine, B. L., 343, 346 Mutchnick, M., 201 Myers, H. F., 546 Myers, R. W., 325 Myrick, R. D., 490 Nagayama Hall, G., 217, 291, 414 Nash, M. R., 20, 318, 325 Naugle, A. E., 317, 328 Neill, T. K., 511 Neisser, U., 158 Nelson, C., 414 Nelson, G. L., 90 Nelson, K., 132 Nelson, M. L., 40, 41, 49, 50, 51, 164, 334, 502, 504, 505, 509, 562, 563, 564, 566 Nelson, P. D., 13 Nemiah, H. E., 224 Nering, M. L., 496 Neufeldt, S. A., 89, 456, 459, 491, 505 Neville, H. A., 546 Newman, A. S., 523, 526 Newman, G., 329 Newman, R., 247, 451 Nicholaichuk, T., 414 Nichols, D. P., 187 Nichols, D. S., 325 Nichols, W. C., 187 Nilsson, J. E., 70, 71, 72, 73, 74, 75, 76, 77, 78, 511

aind

JWBK186/Hess

604

June 4, 2008

16:50

Char Count=

AUTHOR INDEX

Nixon, R. D. V., 223 Nock, M. K., 292 Nora, A., 72 Norcross, J., 269, 283, 301, 503 Norem, K., 504, 511 Norton, N., 248 Nunnally, J. C., Jr., 476 Nuro, K. F., 345 Nussbaum, D., 82, 438, 454, 457, 500 Nutt, E., 46, 56, 57, 467, 487, 490 Nutt, L., 506 Oatley, K., 161 Oberg, K., 73 O’Brien, K. M., 48, 506 O’Connor, C., 279 O’Connor, T., 290 Odum, T., 187 Ogden, T. H., 121 Ogles, B. M., 250, 258, 504 ¨ Ogren, M. L., 511 Okun, L., 329 Olasov, B., 328 Olds, S. W., 287 O’Leary, M., 567, 568 Olfson, M., 550 Oliver, L., 551 Oliver, M., 247 Oliver, V., 88 Olk, M., 40, 41, 43, 58, 75, 164 Ollendick, T., 277 Omizo, M. M., 74 O’Neil, M., 29 O’Neil, P., 20 Ong, A. D., 545 Oordt, M. S., 452, 453, 465, 466 Orange, D., 201 Ortega-Villalobos, L., 49, 76 Ortiz, J., 552 Osborn, C. J., 77 Oslin, D. W., 309 Ostini, R., 496 Overholser, J. C., 461 Owens, M. J., 317 Owens-Patterson, M., 540 Packard, M., 249 Paez, N. D., 546 Pagalilauan, G., 246 Painter, A. F., 505 Palmer, E. J., 397 Palmer, M., 350 Pals, J. L., 117, 120

Pannu, R. K., 502, 509, 539 Papalia, D. E., 287 Papas, R. K., 468 Paradis, C., 426 Parekh, S. A., 296 Parham, T. A., 545 Paris, M., 552 Park, J., 570 Park, M., 549 Parkinson, B., 161 Park-Taylor, J., 553 Parr, G., 72 Parry, A., 116, 118 Pasupathi, M., 118 Pate-Carolan, L., 501, 506, 509 Patel, N., 70, 76, 539, 560, 563, 566, 571 Paton, J., 397 Patrick, C. J., 397 Patten, A. H., 129 Patton, J., 76, 489, 501, 510 Paul, W., 570 Paulston, C. B., 72 Pausb, T., 230 Pavlov, I. P., 228 Paxton, S., 293 Payne, K. E., 562 Peake, T. H., 82, 454, 457, 500 Pearlman, M., 426 Pearson, Q. M., 560, 567, 570 Peca-Baker, T. A., 43 Pedersen, P., 73, 303, 508, 545 Pedro-Carroll, J., 247, 256 Pelcovitz, D., 324 Penk, W. E., 401 Penn, P., 192 Pepinsky, H. B., 475 Pepinsky, P. N., 475 Peplau, L. A., 567 Pepper, S. C., 159 Perez, R. M., 567, 570 Perkins, C., 329 Perlman, M., 426 Perrin, S., 326 Perry, J. C., 315 Perry, N. W., 452, 453, 454 Persons, J. B., 126 Peters, E., 213 Petersen, D. A., 506 Petersilia, J., 428 Peterson, C. M., 503 Peterson, D. R., 83, 159 Peterson, L., 271 Peterson, R. L., 83

aind

JWBK186/Hess

June 4, 2008

16:50

Char Count=

Author Index Petrovich, J., 293 Petruckevitch, A., 395 Peyrot, M. F., 404 Pfaller, J., 561, 567 Pfohl, A. H., 561 Phillips, J. C., 566, 567, 569 Phinney, J. S., 545 Piaget, J., 288, 289 Piccione, A., 450, 456 Pilkington, N. W., 567 Pillemer, D. B., 117 Pinderhughes, E., 546 Pine, F., 27 Pipher, M. B., 43 Pirritano, M., 350 Pisani, A., 46 Pisecco, S., 72 Pithers, W. D., 413 Plake, B. S., 73 Plancherel, B., 292 Platinov, K., 228 Polkinghorne, D. E., 509, 561, 562, 563 Polson, M., 426 Polusny, M. A., 317 Ponterotto, J. G., 553, 567 Pope, K., 253, 506 Pope, M., 70 Pope-Davis, D. B., 49, 76, 540, 544 Portnoy, S., 13 Poser, E., 247, 250 Poteat, V. P., 539 Potenza, M. T., 490 Poulin, K., 41 Powe, N. R., 549, 550 Powell, D. J., 343, 344, 475 Poyrazli, S., 72, 73 Prange, M., 509, 561, 563 Prentky, R. A., 413 Price, J. W., 463 Price, M., 563 Pricec, D. D., 230 Priest, R., 509, 541, 542 Prieto, L. R., 511 Primavera, L. H., 504 Prinstein, M. J., 292 Prochaska, J., 269, 281 Pruett, S. R., 343 Pruit, C. T., 347 Pruitt, N. T., 49, 508, 509, 539, 540, 541, 545 Pryor, R., 376 Puddy, R. W., 293 Pugh, K., 511

Pugh, R. H., 495 Pullen, S., 428 Purtilo, R., 529 Putnam, F. W., 317, 318 Putney, L. G., 167, 169 Putney, M. W., 509 Pyke, S. W., 565 Pynoos, R. S., 317 Qualls, S., 306, 307 Quarto, C. J., 42 Quay, H., 274 Quinsey, V. L., 414 Quintana, S. M., 488 Rahman, O., 73 Raichelson, S. H., 504 Rainville, P., 230 Ramirez, S. M., 504 Ramos-S´anchez, L., 504 Ramsay, N., 511 Ramsundar, N., 250 Rand, J. R., 329 Rappaport, J., 247, 274 Rasbury, W., 269 Ratliff, D. A., 180 Raue, P., 507 Rawlings, E. I., 567 Ray, W., 226 Raz, A., 232 Read, J., 361 Recupero, P. R., 563 Reed, G. M., 451 Reed, K. G., 44 Reicher-Atir, R., 215 Reik, T., 5, 111 Reise, S. P., 477, 495, 496 Reisman, J., 10, 277 Remington, G., 509, 542 Resick, P. A., 323 Resnick, R. J., 450, 461 Respress, T., 549 Revenstorf, D., 223 Rexhaj, B., 119, 120 Reyna, V. F., 291 Reynolds, A. L., 570 Reynolds, C. R., 312 Reynolds, J., 129 Rhinesmith, S. H., 74 Rhodes, N. R., 320, 326 Ribner, S. A., 381 Rice, L. N., 9 Rich, K. D., 426

605

aind

JWBK186/Hess

606

June 4, 2008

16:50

Char Count=

AUTHOR INDEX

Richards, J. M., 447 Richards, S. A., 542 Richardson, T. Q., 539 Richardson, W. S., 87 Richie, B. S., 567 Richmond, I. C., 341, 342 Ricketts, W. A., 567 Ridley, C. R., 547 Rieker, P. P., 315 Rigazio-DiGilio, S., 180, 566 Riggs, S., 504 Riley, D., 400 Ringel, C., 329 Rioch, M., 247 Ristvedt, S., 345 Ritterman, M., 225 Ritt-Olson, A., 546 Robbins, M. S., 295 Roberts, M. C., 293, 345, 473, 492 Robertson, M. H., 10, 376 Robertson, P., 507 Robiner, W. N., 11, 345, 500, 507 Robinson, E., 253 Robinson, J., 247 Robinson, K., 524 Robling, M., 355 Robyak, J. E., 509, 561, 563 Rodenhauser, P., 505 Rodriguez, N., 546 Roe, R. A., 12 Roehlke, H., 49, 74, 76, 78, 488, 508 Rogers, C. R., 8, 9, 10, 61, 115, 118, 149, 343, 349, 581, 587 Rogers, H., 248, 477, 496 Rogers, J. L., 537 Roland, B. C., 327 Rollins, A., 402 Rollins, C. W., 549 Rollnick, S., 340, 347, 348, 349, 352, 353, 354, 355, 421 Rollock, D., 73 Rollstin, A. O., 326 Romans, J. S., 563 Ronen, T., 7, 511 Ronnestad, M. H., 43 Rooney, S. C., 570 Root, M. P. P., 332 Rosado, J. W., 551 Rose, D. S., 321 Rosenbaum, M., 7, 511 Rosenberg, W., 87 Rosewater, L. B., 326 Ross, A., 281, 361

Ross, R., 417 Rossi, E. L., 231, 232, 239 Rossman, K. M., 561, 563 Roth, S., 324 Rothe, E. M., 551 Rotondi-Trevisan, D., 116, 119 Rounsaville, B. J., 345 Rowan, A. B., 458 Roysircar, G., 72, 302 Rozensky, R. H., 450, 451, 454, 461, 464, 468 Rubin, L. J., 326, 327 Rubin, N., 13, 68, 479, 490 Ruddy, N. B., 463 Rudisill, J. R., 505 Rudolph, B., 479, 489, 490 Rudzinski, D., 109 Rueda, R., 549 Ruiz, D. S., 549 Rush, A. J., 415 Russell, C. S., 503 Russell, G. M., 567, 568, 569 Russell, M., 252 Russell, R. K., 41, 473, 509 Rutan, J. S., 334 Rutter, C., 315 Ryckoff, I., 437 Ryde, J., 539 Saakvitne, R., 426 Sabatino, D. A., 383 Sackett, D. L., 87 Sager, W. R., 414 Sahakian, W. S., 162 Salazar, J. S. J., 549 Salmi, S. W., 41, 509 Salovey, P., 121, 122 Salt, H., 511 Salvatore, G., 119 Samenow, S., 415 Samstag, L., 250 Sanchez, D., 549 Sanchez-Hucles, J., 541 Sanderson, P. L., 549 Santiago, J. M., 323 Sapirstein, G., 223, 225 Sarbin, R. R., 230, 231 Sarbin, T. R., 114, 132 Sarnat, J. E., 562 Saroff, A., 215 Saunders, K., 315 Sawyer, C., 550, 551 Schacht, A. J., 501

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Author Index Schaefer, C., 279 Schaefer, R., 173 Schaufeli, W., 251 Scher, I., 511 Scherl, D. J., 322 Schiavone, C. D., 509, 563, 565 Schlenger, W. E., 404 Schlossberg, M., 180 Schneider, B., 247 Schneider, J., 305 Schniewind, M. D., 224 Schnyder, U., 400 Schoenberger, N., 223, 224 Schoenfeld, N., 171 Schoenfeld, W. A., 293 Schoenwald, S. K., 86 Schofield, W., 11, 500, 507 Schroeder, C. S., 454, 463 Schuler, R. S., 41 Schult, D., 11, 473, 477, 478, 482, 483, 484, 486, 501 Schulte, T. J., 451 Schumm, J. A., 317, 326 Schwaber, P., 28 Schwartz, B., 383, 413, 418 Schwartz, P., 562 Schwartz, R. C., 191 Schweitzer, R., 507 Schwitzer, A. M., 42 Scott, C. L., 383 Scott, K. J., 507 Scott, R. L., 325 Seagram, B. C., 565 Searight, H. R., 463 Sears, R. R., 582, 583 Seliger, R. V., 383 Sells, J. N., 509, 561, 562, 563 Selvidge, M. M. D., 567, 570 Semerar, A., 119 Semrud-Clikeman, M., 266 Serlin, R. C., 477 Serran, G. A., 403, 412, 421 Sexton, T. C., 325 Shadish, W. R., 477, 479, 480, 481 Shafranske, E., 12, 50, 51, 58, 83, 86, 89, 90, 91, 306, 345, 491, 587 Shakow, D., 582 Shanfield, S. B., 456 Shapiro, J. P., 318 Shapiro, T., 232 Sharpley, C., 248 Shavelson, R. J., 476 Shaw, B. F., 415

607

Shaw, D., 20 Shea, D., 300 Shea, S. J., 397 Shealy, C. N., 451 Shearer, R. A., 552 Sheehe, J., 344 Sheinbein, M., 219 Sherbourne, C. D., 550 Sherry, A., 510 Sherwood, V., 27, 34 Shim, H. S., 544 Shipton, G., 537 Shoffner, M. F., 539, 544 Shohet, R., 476 Sholomskas, D. E., 345 Shulman, S., 437 Siegel, J. M., 322, 442 Siegel, L., 269 Siegel, S. M., 504 Sifneos, J. C., 224 Silberg, E., 247 Silvestri, T. J., 539 Simpkins, A. M., 223, 226, 227, 231, 233, 238, 239 Simpkins, C. A., 223, 226, 227, 231, 233, 238, 239 Singaravelu, H. D., 70 Singer, J. A., 114, 116, 118, 119, 120, 121, 122, 124, 126, 127 Skillman, G., 247 Skogstad, P., 403 Skovholt, T. M., 43 Slaikeu, K., 252 Slavin, J. H., 511 Slovenko, R., 296 Smeby, J. C., 563, 565 Smith, I. L., 68 Smith, J. A., 5 Smith, N. G., 507 Smith, P., 402 Smith, R. D., 511 Smith, R. R., 383 Snow, L., 397 Snyder, C. R., 450 Snyder, J., 487 Sobey, F., 249 Sodowsky, G. R., 73 Soldz, S., 43 Sollad, R. N., 158 Somer, E., 247 Sonne, J. L., 506 Sorensen, A. S., 561 Sorenson, G. P., 295

aind

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608

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16:50

Char Count=

AUTHOR INDEX

Sorenson, S. B., 322 Soto, D., 546 South, T. L., 226 Southwick, S. M., 317 Spaid, W. M., 342 Spanierman, L. B., 539, 546 Spanos, N., 231 Speaker, T. J., 396 Spector, G., 247 Speice, J., 451 Spence, D. P., 117, 132 Spencer-Rodgers, J., 73 Spicer, J., 403 Spinazzola, J., 324 Sprenkle, D. H., 180 Spring, B., 87 Squires, S. P., 342 Stabb, S., 253 Stanley, B., 296 Steadman, H. J., 381 Steele, J., 347 Steenkamp, J. E. M., 495 Stein, J. A., 322 Stein, M. B., 317 Steinberg, A. M., 317 Steinberg, L., 287, 292 Steketee, F., 328 Stenack, R. J., 509 Stephan, P., 292 Sterba, R., 377 Stern, A., 509, 563, 565 Steven, D. T., 507 Stevenson, J. F., 503 Stevens-Smith, P., 561, 566 Stewart, S. M., 58 Stiles, W. B., 5 Stines, L. R., 317, 326 Stollos, S. J., 58, 61 Stolorow, R., 133, 158, 201 Stoltenberg, C., 46, 86, 353, 460, 505, 511, 568 Stone, D. A., 325 Story, K. E., 74 Strachey, J., 374 Stratton, J. S., 511 Strauss, S. E., 87 Streissguth, A., 246 Stricker, G., 83, 432 Strickland, T. L., 312 Strong, D., 563 Strutts, M. L., 511 Studer, J. R., 491 Subich, L. M., 566

Sue, D., 509, 539, 543, 544, 550, 554, 561 Sue, S., 561 Sullivan, H., 6, 120, 201, 289, 433, 526 Sundararajan, L., 581, 587 Sunday, S., 324 Sundin, E. C., 511 Suominen, K., 397 Surdam, J. C., 73 Sutherland, S., 322 Sutter, E., 527 Suzuki, L. A., 490 Swafford, K. G., 507 Swaminathan, H., 477, 496 Swan, G. E., 450, 456 Swartz, L., 508 Sweeney, D., 279 Sweet, J. J., 451, 454, 464 Syracuse-Siewert, G., 345 Szmukler, G., 293 Szymanski, D. M., 509, 560 Tabachnick, B., 253, 506 Tagini, A., 114 Tamer, J. S., 424, 425 Tamir, E., 247 Tan, J. A., 41 Tankersley, M. J., 325 Tansey, T. N., 343 Tantam, D., 403 Tao, K. W., 541 Tapp, J., 252 Tarbell, S., 452, 453, 454 Tataryn, D. J., 231 Taylor, D. A., 554 Taylor, M., 566 Taylor, R. J., 549 Taylor, S. E., 323 Taylor-Richardson, K. D., 549 Teers, R., 397 Teicher, M. H., 318, 416 Teitelbaum, S. H., 507 Teixeira, M., 374 Tellegen, A., 464 TenEyck, T. G., 475 Teplin, L., 381 Tharp, R., 247 Thoma, H., 377 Thomas, K., 72 Thompson, C. E., 546 Thompson, J., 451, 537 Thompson, L., 307 Thorne, A., 117 Thornhill, E. S., 420

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Char Count=

Author Index Thornhill, N. W., 420 Thyer, B. A., 473 Tice, D. M., 162 Tindell, S. D., 82, 454, 457, 500 Tinterow, M. M., 227 Toldson, I. A., 538, 540, 548, 549, 550, 554, 555 Toldson, I. L., 538, 554 Tomkins, S. S., 120, 129, 132 Tompkins, M. A., 126 Tonsager, M., 200, 201, 202, 203 Toporek, R. L., 49, 76, 544 Torchia, M. G., 317 Torres-Rivera, E., 70, 73, 560, 566 Totterdell, P., 161 Toulouse, A. L., 490 Touster, L. O., 504 Tovian, S. M., 451, 454, 464 Tozer, E., 570 Tracey, T. J., 477, 507 Trezek, B., 247 Trickett, P. K., 318 Trimble, J., 303 Truax, C., 249 True, J., 249 Tryon, G. S., 505 Tsai, M., 325 Tsuru, G. K., 553 Tulkin, S., 252 Tummala-Narra, P., 541 Turner, C. W., 295 Turner, W., 345 Twohey, D., 562, 566 Tyler, F. B., 76, 566 Tyler, J., 249 Umemoto, D., 75 Unger, J. B., 546 Unger, R., 560 Unitzer, J., 315 Updegrove, A. L., 288 Urbina, S., 477, 493, 494 Usdansky, B., 247 Utsey, S., 509, 539, 546, 547, 548 VandeCreek, L., 522 VandenBos, G. R., 366, 374, 376, 377 van der Kolk, B. A., 315, 318, 324 Vander Kolk, C., 538 Vanderryn, J. H., 554 Van Hasselt, V. B., 326 Van Horn, R. K., 72, 73 van Ommeren, A., 414

609

Van Sell, M., 41 Van Voorhis, R., 567 Van Wagoner, S. L., 447 Vasquez, M. J. T., 527 Veach, P., 505 Vera, H., 329 Vera, M., 329 Verdeyen, V., 383 Verona, E., 397 Veronen, L. J., 323 Vespia, K. M., 479, 483, 489 Vik, P., 343 Vitanza, S. A., 507 Volker, J., 562, 566 von der Lippe, A. L., 437 Vonk, M. E., 473, 565 VonKorff, M., 315 Vontress, C. E., 538, 548 Wagner, K., 546 Wagner, M., 567 Wagner, N. M., 49 Wagner, N. S., 539 Walfish, S., 252, 253, 254, 256, 257, 259, 433 Walker, B. B., 87 Walker, E. A., 315 Walker, J., 46, 501, 502, 504, 506, 508, 509 Walker, L. E. A., 320, 321, 328, 330, 331, 332, 333, 335, 336 Walker, M., 561 Walker, R. D., 551 Wallace, J., 341 Wallace, S. A., 247 Wallerstein, P., 215 Wallerstein, R., 10, 99, 160, 504 Walsh, K. W., 441 Walters, G. D., 396 Wampler, K. S., 180 Wampold, B. E., 19, 477, 479, 480, 486, 501 Wan, T.-Y., 73 Wang, C. D., 72, 73 Ward, L. G., 488, 489 Ward, T., 403, 413, 419, 479, 488 Wark, L., 197 Warren, A. K., 539, 540, 544 Washton, A. M., 342, 343, 345, 355 Waterman, A. S., 161 Watkins, C. E., ix, 249, 301, 306, 423, 424, 425, 454, 456, 459, 460, 501, 505, 507 Watkins, C., Jr., 11, 12, 13, 86, 90, 166, 474, 511, 580, 587 Watkins, K. E., 344

aind

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610

June 4, 2008

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Char Count=

AUTHOR INDEX

Watkins, R. E., 383 Watson, J. B., 446 Webb, A., 46, 506 Webb, J. T., 325 Webb, N. M., 476 Wechsler, D., 166 Wedding, D., 157, 582 Weinberger, J., 87, 88 Weiner, I., 383 Weisleder, P., 296 Weissman, M. M., 293, 550 Weitzenhoffer, A., 230 Welch, T., 326 Wells, K. B., 550 Wells, M., 503 Wenzel, S., 344 Werry, J., 274 Wertheim, E., 293 West, P. L., 343, 346 Westen, D., 162 Westermeyer, J., 341 Wetzel, R., 247 Wheeler, S., 46, 506, 511 Whilde, M. R., 510 Whiston, S., 488 Whitbeck, L. B., 551 White, J. H. D., 479, 489 White, K., 213 White, M., 115, 116, 120 Whitman, J. S., 569, 571 Whitman, S. M., 58, 456 Whittington, R., 400 Wicks-Nelson, R., 275 Widaman, K. F., 495 Widener, A. J., 362 Wiederanders, M., 414 Wiesel, E., 56 Wilbourne, P. C., 346, 356 Wilcoxon, S. A., 504 Wilks, J., 401 Williams, B. E., 58, 61 Williams, C. B., 539, 540, 545 Williams, D., 548 Williams, J. E., 76, 566 Williams, S., 503, 541 Wilson, R. J., 458 Winfrey, L. L., 451 Wink, J., 167, 169 Winkel, J., 213 Winnicott, D., 28, 64, 279 Witbeck, L. B., 291 Witkiewitz, K., 256 Witt, P. H., 414

Wittmann, L., 400 Wolberg, L., 281 Wolgast, B., 502, 503, 511 Wolpe, J., 224 Wong, P. T., 549 Wong, S., 414 Wong, T. M., 312 Wood, B., 173, 432, 448 Wood, R. M., 396 Woodford, M., 247 Wooding, L. H., 549 Work, W. C., 256 Worthen, V., 60, 504 Worthington, E. L., 505, 509, 563, 565 Worthington, E., Jr., 12, 19, 488, 539 Worthington, R. L., 41, 546, 570 Wraith, R., 317 Wright, D. W., 42, 180 Wright, G., 317 Wright, L. K., 504 Wyman, P. A., 256 Wynne, L. C., 437 Wyrick, B., 343, 346 Yahne, C. E., 350 Yalom, I. D., 43, 48, 528 Yapko, M., 223, 224 Yates, P. M., 417 Yerkes, R. M., 43 Yoder, J. D., 561, 562 Young, C., 249 Young, R., 538, 539 Younggren, J. N., 11, 524 Yourman, D. B., 57, 164, 467, 506, 529 Yuen, J., 247 Zapf, P. A., 438 Zaragoza, M., 217 Zax, M., 247 Zayas, L. H., 291 Zelhart, P. F., 327 Zgoba, K. M., 414 Zhao, C.-M., 73 Zielke, R., 433 Zillmer, E. A., 326 Zim, S., 215 Zimmerman, J. F., 550 Zivney, O. A., 318 Zucrow, E., 565 Zweben, J., 342, 343, 345, 355

sind

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May 23, 2008

9:2

Char Count=

Subject Index Abuse survivors: assessment of, 325–328 battered women, 319–321, 326–327, 333, 335 building trust relationship with, 330 of childhood abuse, 316–319, 325–326 crisis intervention for, 328–329 dangerousness issues, 334–335 defensive avoidance by, 327–328 difficulty in treating, 315–316 posttraumatic stress disorder, 315, 323–324 prevalence of, 315 psychotherapy for, 329–333 rape survivors, 321–323 of sexual abuse, 325–326 suicide by, 335 supervising psychotherapy of, 315–336 therapeutic interventions for, 328–333 transference/countertransference issues with, 333–334 Abusive relationships, reasons for staying in, 319–321, 329 Academy of Psychological Clinical Science, 583–584 Accreditation process, 10 Accrediting organizations, 99–100 Acculturation, 72, 74, 75, 77–78, 545–546 Acme psychology, 165 Active interventions, in couples and family therapy, 179, 185–186 Active self, 162 Active stance, 181 Adaptive behavior, in correctional settings, 385–386 Administrative issues, in medical settings, 467–468 Administrative segregation, 393 Administrative supervision, 474

Adolescence: defining, 286–287 emotional and cognitive changes during, 288–290 risky behaviors during, 291–293 Adolescent psychotherapy: areas of concern in, 291–293 confidentiality and, 295–296 group therapy, 295 literature on, 287–288 supervision of, 286–297 technical considerations, 293–295 third-party relationships and, 295–296 treatment efficacy, 288–290 Adolescents: consent to treatment by, 296 therapeutic assessment of, 218–219 Affective numbing, 418 Affective responses, to LGB issues, 569 Affective tone, 182–183 Affirmation, 349 Affirmation needs, 61 Affirmative training environments, 570–571 African Americans, 549–550. See also Cross-cultural supervision; Multicultural issues racial identity development, 544–546 Against Our Wills (Brownmiller), 420 Age, 301–303 Ageism, 303–304 Agency, 166 Aggression, 434–436 Aging, attitudes toward, 308 Alaska Natives, 550–551. See also Multicultural issues Alcohol abuse, by abuse survivors, 332 Alcoholics Anonymous (AA), 254, 255 Alder, Alfred, 538 Alienation, 444–445 Allied fields, 581–582

611

sind

JWBK186/Hess

612

May 23, 2008

9:2

Char Count=

SUBJECT INDEX

Ambivalence, 349 American Association for Correctional and Forensic Psychology, 384 American Board of Forensic Psychology, 384 American Correctional Association (ACA), 383, 389 American Indians, 550–551. See also Multicultural issues American Psychoanalytic Association, 99–100 American Psychological Association (APA): accreditation program of, 10 codes of conduct, 11, 295, 522, 531–532, 581 competence guidelines, 586–587 American Psychology-Law Society, 384 Analysand. See also Clients informing, of psychoanalytic supervision, 107 relationship between analyst and, 106 responsibilities of, 108–109 “Analysis Terminable and Interminable” (Freud), 37–38 Analyst. See also Therapist relationship between analysand and, 106 responsibilities of, 108–109 Analytic neutrality, 32 Anesthesia, 239 Anger: in abuse survivors, 331–332 dealing with client, 259, 432 understanding, 433–434, 446 Anger management, 225 Angry clients, 433–434 need to manage, 432–433 responding to, 446–447 Angyl, Andras, 166 Animal learning, 169 Animal magnetism, 227–228 Anorexia, 292–293 Antidepressants, 376 Anxiety: of abuse survivors, 330–331 anger and, 433–434 in battered women, 319 hypnosis for, 224, 224–225 reasons for, 375 supervisee, 43–45, 162, 211–214 Anxiety medications, 331 APA Presidential Task Force on Evidence-Based Practice, 13

APA Task Force on the Assessment of Competence, 13 Appraisal, 587–588 Approach-approach conflict, 349 Approach-avoidance conflict, 349 Archetype, personal, 117 Arrogance, 103 Asian Americans, 552–553. See also Multicultural issues Asian students, 75 Asociality, 163, 163–164 Assessment. See also Evaluation; Measurement of abuse survivors, 325–328 collaborative, 207–209 in correctional settings, 391, 394–395 custody, 217–218 defining, 475–476 in geropsychology, 308–311 interpretation during, 218 in medical settings, 464–466 psychometric theory and, 210–211 qualitative review of, 487–491 quantitative study of, 478–487 referrals for, 212–213 role of, 473 state of the art in, 473–496 time limitations on, 213 traditional versus therapeutic, 201–203, 211 of violent people, 441 Assessment intervention sessions, 205–206 Assessment Interview Skill Deployment Inventory, 490 Assessment research, 20 Assimilation, 545 Assisted suicide, 302–303 Association learning, 165 Attention, fixation of, 228 Attentiveness, 33, 118 Audiotapes, 46, 62, 89 Authentic communication, 163–164 Autonomy, 166, 220, 289–290, 462 Avoidance, defensive, 327–328 Avoidance-avoidance conflict, 349 Axis II disorders, 395–396 Bakan, David, 166 Bars, violence in, 444 Battered women, 319–321, 326–327, 333, 335. See also Abuse survivors Battered women syndrome, 319 Battle neurosis, 9

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May 23, 2008

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Char Count=

Subject Index 613 Beck, Aaron, 159 Behavior: adaptive, 385–386 ambivalence and change in, 349 delinquent, 435 self-defeating, 120, 123–125 Behavioral approach, 158–159 Behavioral disturbances, in older patients, 310–311 Behavioral gap, 348 Behavioral medicine, 450–452. See also Health psychology Behavioral metaphor, 159 Behaviorism, 7–8. See also Cognitive-behavioral therapy Benign countertransference, 425 Bets, 192–193 Binary identities, 510 Binet, Alfred, 170 Biopsychosocial model, 456, 463 Bipolar disorders, 440 Bisexual issues, 567–571 Black psychology, 538 Blind spots, 17 Bomb dropping, 57 Borderline Personality Disorder, 315 Boulder model, 9–10, 450 Boundaries, 32–33, 84 Braid, James, 228 Brain changes, from chronic childhood abuse, 317–318, 416 Brain syndromes, 440–441 Breuer, Josef, 3–4 Budapest school, 5 Bug-in-ear technique, 7 Bulimia, 292–293 Burnout, 250 Capitation, 579–580 Case conceptualization, multicultural, 544 Case management, 475 Case review, 61–62 Case review model, 14, 16 Catatonic stupor, 374 Center for Sex Offender Management, 427 Cerebral cortex, 228, 229 Certification, 581 Change mechanisms, 26–30 Change talk, 349–350, 354 Child abuse survivors, 276, 316–319, 325–326. See also Abuse survivors Child development theories, 273

Childhood transitions, 266 Child molesters, 418–419. See also Sexually disordered patients Child psychotherapy: beginning, 280–281 confidentiality and, 275–277 developmental process and, 272–274 diagnosis, 274–275 parent-therapist contacts, 277–279 play therapy, 279–280 responsibility in, 270 student therapist’s role, 270–271 supervision of, 265–284 supervisor’s role, 267–270 termination of, 280–281 treatment options in, 269, 282–283 trends in, 281–282 unique aspects of, 266–267 Children: aggression in, 257–258 of battered women, 319 psychotropic medications for, 282 therapeutic assessment of, 218–219 Chronic terror, 374 Chumships, 289 Circle of Life, 551 Civic Research Institute, 384 Civil Rights Act (1871), 381 Civil rights movement, 538 Civil Rights of Institutionalized Persons Act (1980), 382 Civil suits, 381–383 Classical test theory, 477 Clergy, 421 Client-centered counseling skills, 349 Client-centered psychotherapy, 8–9, 115 Client outcome, 506–507 Client resistance: to hypnotherapy, 239–240 maladjustment and, 432–433 Clients: angry, 432–434, 446–447 assessment of, 121–122 defensive, 217–218 depathologizing, 538 hostile, 432–434, 436–438 interpretations of, 48 rapport-building with, 8 rights of, 31 sexual attraction toward, 506 sexually disordered, 409–429 therapeutic questions by, 216–217 understanding, 3 violent, 438–443, 448

sind

JWBK186/Hess

614

May 23, 2008

9:2

Char Count=

SUBJECT INDEX

Clinical assessment, 476. See also Assessment Clinical attitude, professional identity and, 31–35 Clinical expertise, 88 Clinical health psychology, 450 defined, 453 differences between mental health care and, 455 emergence of, 452–454 Clinical judgment, 268 Clinical prediction, of violence, 445 Clinical researchers, 583–584 Clinical rhombus, 10 Clinical sensitivity, 8 Clinical supervision, 474–475. See also Supervision Coach model, 14, 17–18 Coarse emotions, 587–588 Codes of conduct: APA, 11, 295, 522, 531–532, 581 functions of, 522–523 Coexisting conditions, 344–345 Cognitions, 159, 161 Cognitive abilities, 226 Cognitive-affective theory, 120–121 Cognitive-behavioral therapy, 158–159, 281 for sex offenders, 412, 415–417 teaching of, 7–8 use of hypnotherapy with, 225 Cognitive development, 27–28, 272–274 Cognitive-perceptual theory, 115 Cognitive processes, 159 Cognitive psychology, 158–159 Cognitive reframing, 253 Cohort effects, 303 Coleman v. Wilson (1995), 382 Collaboration, 349 Collaborative assessment. See also Therapeutic assessment definition of, 200–203 procedures, 207–209 supervision of, 209–215 Collaborative Outcome Data Project on the Effectiveness of Psychological Treatment for Sexually Disordered Individuals, 414 Collegial-peer model, 14, 16 Colorblindness, 542, 546–547 Combat fatigue, 10 Combs, Arthur, 227 Command hallucinations, 439

Committee on Graduate and Professional Training, 583 Communality, 166 Communication: authentic, 163–164 differences in, between sexes, 561–563, 564–565 high and low context, 547–548 nonverbal, 64 Communication skills, 349–350 Communicative competence, 72–73 Community-based programs, 402 Competence, 12–13, 72–73, 363 cultural, 88, 180, 196–197, 542–552, 555 guidelines, 586–587 linguistic, 72–73 in psychology supervision, 83 Complementary identification, 447 Complex PTSD, 318–319, 324 Computer-adaptive testing, 496 Conceptual framework, need for, 35–37 Conceptualization, in family and couples therapy, 181–182 Concordant identification, 447 Concreteness, 58 Conditioned response, 229 Confidence, inspiring, 19 Confidentiality, 63 adolescent psychotherapy and, 295–296 child psychotherapy and, 275–277 in correctional settings, 385, 391–392 in geropsychology, 302 in medical settings, 466 in sex offender treatment, 412 Confirmatory statistical procedures, 477 Conflicting feelings, 349 Conflicts: identifying enduring, 121–122 between supervisor and supervisee, 42 working with, in family therapy, 183–184 Conflictual supervision, 504–505 Conformity, 544 Confrontations, 440 Confusion, 360 Conscious resistance, 360–363 Consensual validation, 166 Consensus Rorschach, 219 Consent to treatment, by adolescents, 296 Construct validity, 481–482, 485–486, 495–496

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May 23, 2008

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Char Count=

Subject Index 615 Consultant role, 105–106, 352–353 Consultations, 3–4, 191–192 Content validity, 494 Context: of narrative sequences, 123 of supervision, 104 Control, loss of, 446 Control analysis, 4, 5, 100 Control issues, 42, 183–184 Convict culture, 385, 388 Core conflictual relationship themes, 116 Correctional officers, 386–387, 388 Correctional settings: adaptive behavior in, 385–386 allies in, 387 assessment in, 391, 394–395 confidentiality and, 385, 391–392 convict culture in, 385, 388 court decisions regarding treatment in, 381–383 crisis intervention for, 396–401 effectiveness of treatment in, 401–403 fairness and firmness in, 386 families in, 388 group therapy in, 401–404 individual therapy in, 401–404 making rounds in, 393–394 mental disorders in, 381 new behaviors in, 387 paramilitary nature of, 385 resources for, 383–384 screening in, 389–391 security issues, 384–385, 386 segregation in, 392–396 staff in, 386–387 suicide prevention in, 396–401 supervision in, 380–404 telepractice in, 404 therapist role in, 389 training for practice in, 383 treatment planning in, 392 Cortisol, 317–318 Cost-effectiveness: of paraprofessionals, 247–248 of therapy, 579–580 Council of University Directors of Clinical Training (CUDCT), 585, 586 Counseling, 84–85 Counseling psychology, 20 Counseling self-efficacy, 74–76 Counselor-Evaluation Rating Scale, 490 Counselor Self-Estimate Inventory, 490

Countertransference, 5, 19, 50–52 with abuse survivors, 316, 333–334 addressing, 51 with angry patients, 447 benign, 425 identifying, 50 management of, 250–251, 447 negative, 423–424 with older patients, 304, 307 parallel process and, 51–52 parents of children in treatment and, 278 positive, 423, 424 psychoanalytic supervision and, 101 with sex offenders, 422–426 supervisee, 50–51 supervisor, 52, 507–508 Couples therapy: assessment in, 219 deciding on appropriateness of, 196 skills needed for, 181–185 Couples therapy supervision, 179–198 models of, 187–191 research, 180–181 special problems in, 195 special techniques for, 191–194 Covert processes, 159 Crisis intervention, 328–329, 396–401 Crisis services, 251–254 Cross-cultural samples, 495 Cross-cultural supervision. See also International students colorblindness and, 546–547 high and low context communication, 547–548 race identity development, 544–546 research on, 538–539 supervision triad, 539–542 Cross-validity samples, 494–495 Cultural competence, 88, 180, 196–197, 542–552, 555 Cultural differences, 72–73 Cultural encapsulation, 542, 545 Cultural issues. See also Cross-cultural supervision; Multicultural issues with abuse survivors, 332–333 in supervision, 76–77, 508–511 Culturally diverse populations, psychological services for, 549–553 Cultural mentors, 79 Cultural paranoia, 439, 542, 549 Cultural skills, 49 Cultural trauma, 549

sind

JWBK186/Hess

616

May 23, 2008

9:2

Char Count=

SUBJECT INDEX

Cultures, high-context and low-context, 547–548 Culture shock, 73 Custody assessments, 217–218 Dangerousness, in abuse survivor cases, 334–335 Death with Dignity Act, 302–303 Debriefing, 64–65 Decolonialism, 538 Defense mechanisms, 158, 162 Defenses, collapsing, 444–445 Defensive avoidance, 327–328 Defensive clients, 217–218 Delinquent behaviors, 435 Delusions, 375, 439–440 Dementia, 440 Depression, 375, 376 in abuse survivors, 331 hypnosis for, 224 Depth psychology, 165 Derivation samples, 494 Desensitization therapy, 224 Detroit Psychoanalytic Institute, 99–100 Developmental issues, with children, 272–274 Developmental models, of supervision, 18–20, 86–87, 459–461 Diagnosis, 274–275 Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), 202, 274–275, 451 Diagnostic labels, 32 Dialectical Behavioral Therapy (DBT), 415, 418 Didactic analysis, 100 Didactic material, 374–375 Didactic supervision, 187–188 Direct observation, 43 Disclosure, 46–47, 527–528 Discovery-oriented approach, 137, 149–155 Discrepancy, 348 Disease model, 341 Disordered eating, 292–293 Disorders of extreme stress, 318–319, 324 Dispositional diagnosis, 275 Dissociation, 332 Dissonance, 544 Distancing mechanisms, 158 Diversity samples, 495 Division 12, 20 Division 17, 20

Domestic violence, 319–321 Double approach-avoidance conflict, 349 Double-sided reflections, 351 Drama therapy, 418 Dreams, 374–375 Dual diagnosis, 344–345 Dual relationships, 107–108, 523–525 Dynamic factors, 438 Easser, Ruth, 29 Eating disorders, 292–293 Economic accountability, 281–282, 366, 452, 579–580 Education: lifelong, 5 psychoanalytic, 99–100 state of, 582–583 Educational process model, 164–175 Education committee, 4, 10 Educator model, 14, 18, 351–352 Effects of battering, 319 Egocentric language, 166, 173–174 Egocentric thought, 161 Ego depletion, 162 Ego psychology, 201 Eighth Amendment, 381 Elderly. See Geropsychology; Older patients Electroconvulsive therapy (ECT), 376 Electronic service delivery, 587 Ellis, Albert, 159 Emersion, 542, 545 Emotional availability, 33, 59 Emotional exhaustion, 334 Emotional handles, 123 Emotional learning, 166–167, 446–448 Emotional reactions, to clients, 50–51. See also Countertransference Emotion regulation tactics, 124 Emotions: coarse, 587 experience and, 161 learning and, 166–167 refined, 587 Empathic skills, 48–49, 57, 89–90, 343 Empathy: development of, in sex offenders, 418 motivational interviewing and, 343, 348 Emphatic attention, 118 Emphatic listening, 118 Empowerment, 125 English proficiency, 75

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Subject Index 617 Epinephrine, 317–318 Erickson, Milton H., 231 Estelle v. Gamble (1976), 381, 382 Ethical codes, 11, 295 Ethical dilemmas, 529 Ethical guidelines, for supervisory behavior, 41–42 Ethical issues, 581 children and, 273–274 in medical settings, 466–467 multiple relations, 523–525 with paraprofessionals, 256 privacy concerns, 527–528 reporting requirements, 529–530 in supervision, 107–108, 511, 521–531 supervision as therapy, 525–526 Ethical Principles of Psychologists and Code of Conduct (APA), 11, 295, 522, 531–532, 581 Ethical standards, 522–523 Ethnic groups, 549–553 Evaluation. See also Assessment anxiety over, 43–44 as component of supervision, 61 defined, 476 evaluation of approaches to, 491–492 formative, 90 functions of, 503 gender and, 565 importance of, 90 of international students, 76 by new supervisors, 90–91 research on, 502–504 role of, 354–355 student-guided, 59–60 summative, 90–91 to third parties, 102 Evaluation Process within Supervision Inventory (EPSI), 487–488, 491 Evaluator role, 354–355 Evasion, by supervisee, 56–57 Evidence-based practice, 87–88, 281, 345–346 Existential phenomenology, 201 Experiences: cognitions and, 161 emotions and, 161 internalization of, 26–30 Experiential psychotherapists interested in discovering deeper ideas about psychotherapy, 147–155 supervision and training of, 137–155

Experiential psychotherapy: goals of, 138–139 versus other approaches, 139–140, 145–146 steps in, 140 Experiential sessions: features of, 139–140 goals of, 138–139 in-session changes, 150–151 logistics of, 139, 142 modalities of, 161 proficiency in, 140–141, 146 recording, 142, 145 trainees having own, 146–147 training in, 140–145 Experiential training, in hypnotherapy, 235–238 External language, 166, 173–174 External narrative processing, 119 External reality, 158 External validity, 482, 486 Extrafamilial influences, 362 Eye Movement Desensitization and Reprocessing (EMDR), 415, 418 Facilitative conditions, 249 Facilitator role, 185 Families: changes in, during adolescence, 288–290 hostility in, 436–438 violence in, 443 Family backgrounds, of sex offenders, 419–420 Family therapy: for abuse survivors, 333 with adolescents, 288 deciding on appropriateness of, 196 skills needed for, 181–185 Family Therapy Skill Evaluation, 180 Family therapy supervision, 179–198 balancing needs of supervisee with those of family, 197–198 bets, 192–193 consultation interviews, 191–192 cultural competence and, 196–197 didactic, 187–188 engaging in, 185–198 level of trainee experience and, 197 live, 188–191, 192 models of, 187–191 narrative interviews, 194 optimal level of arousal in, 197

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SUBJECT INDEX

Family therapy supervision (Continued) reflecting teams, 193–194 research, 180–181 role-playing, 194 special problems in, 195 special techniques for, 191–194 therapeutic splits, 192 videotaping, 188 Faulty schema, 123 Fear reduction, in abuse survivors, 330–331 Fears, hypnosis for, 242–243 Feedback, 42, 45–47 for live supervision, 190 motivational interviewing and, 354–355 positive, 61 on psychotic patients, 365 role of, 503 in therapeutic assessment, 206–207, 214, 217 written, 207 Feedback sandwich, 355 Female objectification, 420 Female supervisors, 563, 565. See also Gender issues Feminist theory, 538 Finn, Stephen, 200, 201 First signal system, 229 Fischer, Connie, 200–201, 202, 203, 208–209 5 As, 87 Fixation of attention, 228 Flexibility, 184, 461 Follow-up sessions, 207 Forensic settings. See Correctional settings Formative evaluations, 90 Fourteenth Amendment, 381 Frailty, 305 Freud, Sigmund, 3–4, 6 on efficacy of analysis, 37–38 on identity, 30 on internalization, 27 on mourning, 28, 36 narrative-based psychotherapy and, 115 on supervision, 579 Friendships, during adolescence, 288–289 Gay issues, 567–571 Gender, defined, 560

Gender bias, 509–510 Gender issues: communication styles, 561–563, 564–565 power and, 562 same-gender dyads, 563 in supervision, 561–567 Gender matching, 509 Generativity scripts, 117 Gentleness, 67–68 Genuineness, 58 Geropsychology: age and, 301–303 assessment supervision, 308–311 assisted suicide, 302–303 cohort effects and, 303 confidentiality and, 302 medications, 305–306 multicultural issues in, 303–305 practical issues, 307–308 shortage of professionals in, 299–300 supervision of, 299–311 theoretical issues, 306–307 The Gift of Therapy (Yalom), 43 Global Impressions of the Diagnostic Interview-Revised, 490 Goals, 167–168, 530 Graded response IRT, 496 Group control analysis, 5 Group supervision, 13, 45, 88–89 Group Supervisory Behavior Scale (GSBS), 489 Group therapy, 295, 401–404 Growth mechanisms, 26–30 Guidelines for Psychological Practice with Older Adults (APA), 300 Guilt, 412 Hallucinations, 238–239, 374–375, 439 Handbook of Psychotherapy Supervision (Watkins), 12, 13 Hand levitation, 238 Haworth Press, 384 Health-care economics, 452 Health Insurance and Accountability Act (HIPAA), 276 Health psychology, 450. See also Clinical health psychology emergence of, 452–454 evolution of, 451–452 Healthy cultural paranoia, 439, 542, 549 Hedonic tone, 161 Helping skills, 48

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Subject Index 619 Heuristic approach, to treatment, 283 High-context communication, 547–548 Hilgard, Ernest, 230 Hippocratic Oath, 82 Historical hostility, 549 Holidays, violence during, 444 Homeostasis, 182, 186 Homonomy, 166 Hospitalization, 376 Hospital policies, 467–468 Hospitals. See Medical settings Hostile clients, 432–433, 436–438 Hostility, 434 Hotlines, 251–254 Hull, Clark, 230 Humanistic attitude, 31–32 Humanistic-existential-experiential ideas, 147–148 Humanistic theory, 201, 353 Humiliation, 60 Hyperesthesia, 239 Hypnosis: actions during, 234–235 applications of, 241–243 awareness and, 234 client questions about, 232–235 client resistance and, 239–240 coming out of, 233 conditioned response and, 229 fixation of attention, 228 neo-dissociation theory of, 230 neuroscience view of, 232 nonspecific factors and, 225 responsiveness to, 232–233 sleep theory of, 228–229 social-psychology view of, 230–231 state theory of, 231–232 submissiveness and, 234 suggestion and, 229–230 theories of, 227–232 therapeutic use of, 223–226 training in, 235–238 trance phenomena, 238–239 transitioning out of, 237 vitalism, 227–228 Hypnotherapy supervision, 223–243 experiential training, 235–238 special considerations in, 239–241 structuring first session, 232–235 Hypnotic induction, 236 Hypothesis testing, 477 Hypothesis validity, 480, 485

Identity: concept of, 30–31 development of, in adolescence, 289 life story theory of, 117–118 multicultural, 510–511 narration and construction of, 117–118 narrative memory and, 120 professional, 30–31 racial, 544–546 violence and, 444–445 Ideological setting, 117 Ideomotor response, 229 Imagery, 133, 159 Imagination mental imagery, 159 Imagoes, 117 Immersion, 542, 545 Imposter syndrome, 86–87 Improvisation, 360 Incarceration rates, 380 Incompetence, 12, 91 Indirect suggestion, 231–232 Individualizing Psychological Assessment (Fischer), 208–209 Individual supervision, 88–89 Indoctrination, 59 Induction, 186 Industrialization of mental health care, 301 Inferences, 475 Inflated egoism, 446 Inmates. See also Correctional settings lawsuits by, 381–383 mental disorders in, 381 with personality disorders, 395–396 screening of, 389–391 threats by, 392 Inner life, 161 Inner speech, 161 Insecurity, 446 Insight, 26 Institutional model, of psychoanalytic training, 99–100 Instruction, versus supervision, 83–84 Integrated development model, 460 Integration, 322, 545 Integrative awareness, 545 Intelligence, unconscious, 231 Intelligence testing, 166, 170–171 Internalization, 26–30, 220 Internal language, 166, 173–174 Internal narrative processing, 119 Internal validity, 480–481, 485

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SUBJECT INDEX

International students. See also Cross-cultural supervision acculturation issues, 77–78 counseling self-efficacy and, 74–76 demographic information, 71–72 general information about, 72–73 recommendations for supervising, 77–79 supervision of, 70–79 supervisory expectations and, 77 working alliance with, 76–77 Interpersonal approach, 157–175 assumptions of, 160–164 behavioral, 158–159 educational process model, 164–175 psychodynamic, 158 Interpersonal characteristics, of supervisor, 89–90 Interpersonal conflicts, identifying enduring, 121–122 Interpersonal process recall, 45 Interpersonal relationships, internalization and, 26–30 Interpersonal skills, 349–350, 418–419 Interpersonal theory, 159–160, 201 Interpretations: phrasing of, 370–371 of transference, 124 Intersubjective, 158 Intersubjective theory, 201 Interventions: for abuse survivors, 328–333 assessment, 205–206 in collaborative assessment, 208 in couples and family therapy, 179, 185–186 crisis, 328–329, 396–401 effectiveness of, for sex offenders, 412–414 in family and couples therapy, 184 in medical settings, 457–458 Interverted-U model of anxiety, 43, 45 Introjection, 27 Invisibility syndrome, 549 IRT, 496 Isomorphism, 6–7 Item pools, 493 I-Though relationship, 161 Jenkins v. United States (1962), 10 Johari window metaphor, 47–48 Judgmental attitude, 48–49

Keane MMPI-PTSD scale (PK), 326–327 Kindling effect, 317 Knight, Robert, 371–372 Korean Conflict, 10 Language: egocentric, 166, 173–174 external, 166, 173–174 internal, 166, 173–174 as signal system, 229 Vygotsky’s views on, 173–174 Language barriers, 72–73, 75, 78–79 Laterally integrated systems, 540–541 Laterally triangulated systems, 541 Lateral systems, 540–541 Latinas/Latinos, 551–552. See also Multicultural issues Lawsuits, 381–383 Lay analysis, 6 Learning: animal, 169 association, 165 emotional, 166–167, 446–448 as historical, 165–166 learner-initiated, 167–168 practical, 170 procedural, 17–18 scientific, 170 as social, 166 spiral omnibus model, 170–171 zone of proximal development and, 169–170 Learning needs, of students, 58 Learning opportunities, 172–173 Learning process, supervisee, 47–48 Learning structures, internalizing, 170 Learning theory, 7 Lecturer model, 14, 15 Legal issues, 531–533, 581 Lerner, Paul, 219–220 Lesbian issues, 567–571 Letters to a Young Therapist (Pipher), 43 Liability, of supervisor, 532 Licensing boards, 521–522 Licensing laws, 10 Lifelong education, 5 Life stories, 117–118 Linguistic competence, 72–73 Listening skills, 9 Literary texts, 133–134 Literature: on adolescence, 287–288 reading pertinent, 56

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Subject Index 621 Literature searches, 87 Live supervision, 89, 188–191, 192 Logic, 161–162 Loss, 27–29, 36 Low-context communication, 547–548 Major depressive episode, 331 Majority culture, 539–540 Male supervisors, 561, 565 Malpractice insurance, 382–383 Malpractice issues, in medical settings, 466–467 Managed care companies, 276, 281–282, 301, 366, 451, 579–580 Management by walking around, 388 Managerial supervision, 474 Manics, 440 Marginalization, 545 Master-apprentice model, 99, 105 Mead, George Herber, 166 Meaning making, 114 Meaning-seeking orientation, 33–35 Measurement. See also Assessment defined, 476 modern view of, 476–478 Measurement invariance tests, 495 Measurement theory, 477 Measures, 476 construction of, 477–478, 492–496 cost-effectiveness of, 495–496 qualitative review of, 487–491 quantitative study of, 478–487 Media, sexual images in, 420 Medical education, 6 Medical model, 456 Medical psychology. See Health psychology Medical schools, 452 Medical settings: administrative/organizational issues, 467–468 assessment in, 464–466 clinical health psychology in, 452–454 confidentiality and, 466 ethical issues in, 466–467 evolution of care in, 451–452 extent of sessions in, 450 hierarchical structure of, 462 interaction with physicians in, 456–457, 463 interventions used in, 457–458 issues common to, 462–463 malpractice issues in, 466–467

pace in, 456 patients in, 463 professional behavior in, 462–464 professional issues in, 462 supervision in, 450–468, 454–468 Medications: antidepressants, 376 anxiety, 331 for older patients, 305–306 for sex offenders, 413 use of, 376–377 withdrawal effects of, 376 Medicine Wheel, 551 Memories: manifest content of, 115 narrative, 115, 116, 120–121, 128–129 self-defining, 117–118 Memory enhancement, 226 Memory reconstruction, 115 Mental Health in Corrections Consortium, 383–384 Mental health screening, in correctional settings, 389–391 Mentally Ill Offender Treatment and Crime Reduction Act, 384, 403–404 Mentally ill patients: conscious resistance by, 360–363 frequency of sessions with, 366–370 painful experiences of, 360–361 parental issues with, 361–363 phrasing with, 370–371 in prison, 380–404 supervising treatment of, 359–378 use of medications with, 376–377 Mesmer, Franz Anton, 227–228 Mesmerism, 227–228 Metaphors: in narratives, 133 shared, 123 Methodological isomorphism, 6–7 Methodological variables, 483–484 Michigan State Psychotherapy Research Project, 366–367, 373 Military facilities, 433 Millon Clinical Multiaxial Inventory (MCMI), 325, 327 Mind-body link, 229 Minimization, 416 Minnesota Multiphasic Personality Inventory (MMPI), 217–218, 325–327, 464 Minority supervisors, 542 Misconceptions, 530–531

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622

May 23, 2008

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SUBJECT INDEX

Model, supervisor as, 105 Monitor role, 14, 16 Monomethod bias, 504 Mood disorders, 331 Morality, 273–274 Motivation, 161 Motivational interviewing (MI), 340 ambivalence and, 349 empathy and, 343, 348 introduction to, 347–348 principles of, 348 as supervisory style, 350–355 training issues, 349–350 Motor abilities, assessment of, 309–310 Mourning, 28 “Mourning and Melancholia” (Freud), 28, 36 Multicultural case conceptualization, 544 Multicultural competence, 88, 180, 196–197, 542–552, 555 Multicultural discussions, 76–77 Multicultural issues, 49 in geropsychology, 303–305 in supervision, 508–511 Multicultural supervision, 70–79. See also Cross-cultural supervision Multigroup CFA, 495 Multiple perspectives, 118–119 Multiple relations, 523–525 Multiple subjective realities, 182 Music, 134 Narrative-based psychotherapy: background of, 115–116 case study, 125–132 common principles of, 116–117, 117–120 goals of, 119–120, 124–125 introduction to, 114–115 person-centered approach to, 120–132 supervision of, 114–134 teaching of, 117–120 types of, 116 Narrative change, 119 Narrative identity, 118 Narrative interviews, 194 Narrative memories, 115, 116, 120–121, 128–129 Narrative mode of thought, 114, 133 Narrative processing, 119 Narratives: coherent and differentiated, 119–120

listening to, 133–134 reconstruction of, 118–119 Narrative sequences: anticipating and preempting, 124 helping clients overcome, 123–125 identifying, 122–123 tracking of, 129–130 transference manifestations in, 130–131 Narrative therapy, 115, 116, 134 National Association for the Advancement of Psychoanalysis, 99 National Association of State Mental Health Program Directors, 384 National Commission on Correctional Health Care (NCCHC), 389 National Institute on Alcohol Abuse and Alcoholism, 345 National Institute on Drug Abuse, 345 Native Americans, 550–551. See also Multicultural issues Need Principle, 402 Negative countertransference, 423–424 Negative supervisions, 12 Negligence, 531 Negligent entrustment, 532 Neo-dissociation, 230 Neurological imaging, 230 Neuroscience, hypnosis and, 232 Night clubs, violence in, 444 Nondisclosure, 45–46, 466–467, 506, 529–530 Nonevaluative stance, 163–164 Nonjudgmental attitude, 32 Nonprofessionals, 246. See also Paraprofessionals Nonspecific therapist factors, 159, 225 Non-uniformity, 582 Nonverbal communication, 64 Non-Western approaches, 554–555 Norepinephrine, 317–318 Normative data, assessment of older adults and, 310 Nuclear episodes, 117 Nursing homes, 299 Object relations, internalization of, 27 Observation: in correctional settings, 398–399 live, 89, 188–191, 192 supervisor, 44 Observations, 475 Obsessions, 439

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Subject Index 623 Older patients, 299–300. See also Geropsychology assessment of, 308–311 behavioral disturbances in, 310–311 medications for, 305–306 sexuality of, 307 On-the-job training, 138 Open questions, 48, 349 Oppression, 549 Optimism, 365 Organizational hierarchy, 109 Organizational structure issues, 42 Origination instinct, 166 Pacific Islanders, 552–553 Pain control, hypnosis for, 223–224, 241–242 Panic attacks, 375 Paradigmatic mode of thought, 114 Paradoxically integrated systems, 541–542 Paradoxically triangulated systems, 542 Paradoxical systems, 541–542 Parallel process, 17, 19, 51–52, 57 as pivot, 172–173 research on, 504 study of, 106 in therapeutic assessment, 215–216 Parameter, 103 Parameter phobias, 103 Paranoid conditions, 439–440 Paraprofessionals: cost-effectiveness of, 247–248 countertransference management with, 250–251 recovering versus nonrecovering, in SUD context, 346–347 roles for, 246–247 in schools, 256–259 substance abuse counseling by, 254–256 for telephone crisis counseling, 251–254 training and supervision of, 248–251, 252–259 Para-rhombus issues, 580–581 Parenting mistakes, 362 Parents: abuse by, 316–317 of adolescents, 288–290, 296 of children in therapy, 275–279 conscious resistance and, 361–363

Partial sleep, 228–229 Participant observer, 212 Passive aggression, 432, 434 Patient characteristics, 87–88 Patient confidentiality, respect for, 63 Patient-focused supervision, 458–459 Patients. See Clients Pavlov, Ivan, 228, 229 Pedophiles. See Sexually disordered patients Peer counseling, 360–361 Peer relationships, in adolescence, 288–289 Peer supervision, 3–4, 67 Perceptions, as reality, 160–161 Performance, anxiety and, 43 Personal analysis, 5 Personal-centered assessment, 121–122 Personal coaching, 18 Personal factors: of supervisee, 101–102 of supervisor, 102–104 Personal issues, 59 Personality, 120, 148 Personality change, 118–119 Personality disorders, 324, 395–396, 462 Personality restructuring, 8 Personality traits, assessment of, 121 Personal striving task, 121 Person-based psychotherapy, 116 Person-centered approach, to narrative-based psychotherapy, 120–132 Perspectives, multiple, 118–119 Pessimism, 365 Phrasing, of interpretations, 370–371 Physical abuse, 253–254 Physical reality, 160–161 Physicians, interaction with, in medical settings, 456–457, 463 Piaget, Jean, 27–28, 273 Pivots, 171–173 Play therapy, 279–280 Positive countertransference, 423, 424 Positive feedback, 61 Positive psychology, 165 Postdoctoral internships, 585–586 Posttraumatic stress disorder (PTSD). See also Abuse survivors Posttraumatic Stress Disorder (PTSD), 315, 323–324 Power differentials, 539–542

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624

May 23, 2008

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SUBJECT INDEX

Power issues: gender and, 562 sexual orientation and, 569 in supervision, 42, 58, 537–538, 561 Power use, 180 Practical learning, 170 Preencounter, 545 Primary care psychology, 453 Primary care settings, 453 Primary Mental Health Project (PMHP), 256–259 Prison chaplains, 387 Prison Litigation Reform Act (1997), 382 Prison Rape Elimination Act, 403 Prisons. See Correctional settings Privacy concerns, 527–528 Prizing, 9 Proactive supervision, 12 Problem-oriented supervision, 106 Procedural learning, 17–18 Process experiential psychotherapy, 116, 119 Process notes, 89 Professional associations, 521–522 Professional demeanor, 63 Professional Discretion Principle, 402 Professional environment, simulation of, 42 Professional identity, 30–38 clinical attitude and, 31–35 theoretical framework and, 35–37 therapeutic voice and, 37 Professional schools, 582–583, 584–585 Program Integrity Principle, 402 Protective custody, 393 Proximal development, zone of, 162, 169–170 Pseudoadjustment, 322 Psychic reality, 98 Psychic structures, internalization of, 27 Psychoanalysis: conceptualizations of, 98–99 psychoanalytic therapy and, 377–378 Psychoanalytic abstinence, 5 Psychoanalytic education and training, 4–7, 99–100 Psychoanalytic incognito, 5–6, 163, 447 Psychoanalytic institutes, 99–100 Psychoanalytic metaphor, 159 Psychoanalytic supervision, 97–112 ethics of, 107–108 issues in, 101–104 theories of, 100–101

Psychoanalytic therapy, 377–378 Psychoanalytic training, 4–7 Psychodynamic analysts, 7 Psychodynamics: of supervisee, 101–102 of supervisor, 102–104 Psychodynamic theory, 158 Psychological assessment. See Assessment Psychological effects, of childhood abuse, 318–319 Psychological processes, awareness of, 162 Psychological reality, 160–161 Psychological testing. See Assessment Psychologists: licensing of, 10 in medical schools, 452 Psychology, 6 acme, 165 Black, 538 cognitive, 158–159 depth, 165 ego, 201 health, 450, 452–454 narrative, 114–115 positive, 165 Third Force, 165 Psychometric theory, 201, 210–211 Psychopathology, 359 Psychopaths, violent behavior in, 441. See also Mentally ill patients Psychosomatic medicine. See Health psychology Psychotherapist role, 14, 17 Psychotherapy: for abuse survivors, 329–333 adolescent, 286–297 child, 265–284 client-centered, 8–9, 115 deeper ideas about, 148–149 economic accountability for, 281–282 within ethnocultural context, 549–553 history of, 3–9 narrative-based, 114–134 person-based, 116 process experiential, 116, 119 sequence of training in, 371–372 skills needed for, 170 societal images of, 173 supervision as, 525–526 systems of, 4–9

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Subject Index 625 Psychotherapy research, 9 Psychotherapy sessions. See Sessions Psychotherapy supervision. See Supervision Psychotic patients. See Mentally ill patients Psychotropic medications, for children, 282 Public schools, paraprofessionals in, 256–259 Punitive segregation, 392–393 Race identity development, 544–546 Racial issues, 537–538, 538–539. See also Cross-cultural supervision Racial matching, 509 Racial power differentials, 539–542 Racism, 509, 546–547, 549 Rape, 420 Rape crisis centers, 322 Rape survivors, 321–323 Rape trauma syndrome, 322 Rapists, 418 Rapport, 8, 42, 202 Rating protocols, 476 Rationality, 161–162 Rationalization, 416 Reality, 98, 158 perception as, 160–161 physical, 160–161 psychological, 160–161 subjective, 182 Real-world responsibilities, 56 Reasoning and Rehabilitation program, 417 Recidivism, 413–414, 428 Reciprocal revelations, 5–6 Reclamation, 29 Record keeping, in abuse cases, 336 Referrals, for assessment, 212–213 Refined emotions, 587–588 Reflecting teams, 193–194 Reflection, 48, 349 Reflective listening, 349 Reflexive narrative processing, 119 Reframing, 123 Relapse, 351 Relapse prevention, 416–417 Relationship building, 45 Relationship-/therapist-focused supervision, 458–459 Religious issues, 510 Repetition, 120–121, 162

Reporting requirements, 529–530 Representation, 28 Repression, 4 Research: best available, 87 on client outcome, 506–507 on conflictual supervision, 504–505 on cross-cultural supervision, 538–539 on evaluation, 502–504 in family and couples therapy, 180–181 on parallel process, 504 on supervisee variables, 505–506 on supervision, 500–512 on supervisor variables, 507–508 on supervisory process, 501–505 training in, 85–86 Resentment, 432 Residential treatment programs, 254, 341 Resistance, 4, 51, 360–363, 432–433 Respect, 58 Respondeat superior, 532 Responsibilities, of supervisors, 526–527 Responsiveness, 63 Responsivity Principle, 402 Restraint, 399–400 Restriction, in correctional settings, 399 Retardation, 440–441 Revenge fantasies, 331 Reverse role-plays, 124 Risk aversion, 165 Risk Principle, 402 Risky behaviors, during adolescence, 291–293 Rogers, Carl, 8–9, 149–150, 538 Role ambiguity, 41–42, 75, 164 Role conflict, 41–42, 164 Role confusion, 15 Role expectations, 40–43 Role induction, 45 Role-modeling, 58 Role-playing, 49–50, 124, 194, 213, 216 Role relationship, 58 Role shock, 86–87 Root metaphor, 159–160 Rorschach tests, 325, 327, 584 Rossim Ernest, 232 Rounds, in correctional settings, 393–394 Same-gender dyads, 563 Sapir, Edward, 166 Sarbin, Theodore R., 230 Scaffolding, 170, 435–436

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May 23, 2008

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SUBJECT INDEX

Scales, 476–478, 492–496. See also Assessment Schizoaffective disorder, 331 Schizophrenic patients, 3, 361–362, 374 Schools: children in, 266–267 paraprofessionals in, 256–259 professional, 582–585 Scientific learning, 170 Screening, in correctional settings, 389–391 Script theory, 120–121 Secondary traumatization, 426–427 Segregation, in correctional settings, 392–396 Self-blame, by abuse survivors, 330 Self-change, narration and, 117–118 Self-construction, narration and, 117–118 Self-defeating thoughts and behaviors, 120, 123–125 Self-defining memories, 117–118 Self-disclosure: with adolescents, 293–294 multicultural issues with, 74 by supervisors, 46–47, 508 Self-discovery, 5 Self-efficacy, 74–76, 348 Self-esteem, 166–167, 444, 446 Self-evaluations, 59–60 Self-hypnosis, 228 Self-mutilation, 292, 335, 400–401 Self-reflection, 51 Self-report data, 19, 89 Self-supervision, 505 Self-understanding, 26 Semantic learning, 17 Seminar Process Evaluation Form-Revised, 490 Sensory abilities, assessment of, 309–310 Sensory alterations, in trance, 238 Separation, 28, 545 Separation anxiety, 273 Sessions: anxiety in, 44–45 boredom in, 68 delayed, 57 experiential, 138–139 frequency of, 103–104, 366–370 live supervision of, 188–191 in medical settings, 450 reflection on, 3 videotaping, 188 Session transcripts, 62

Sex, 560 Sex offender treatment: confidentiality and, 412 counterproductive public policy on, 427–428 differences between traditional mental health treatment and, 411–412 efficacy of, 412–414 relapse prevention, 416–417 subspecialization, 422 teaching cognitive skills, 417–421 therapist skills in, 421–422 vicarious traumatization and, 426–427 Sex Offender Treatment and Evaluation Project, 414 Sexual abuse, 253–254 adult victims of, 325–326 childhood, 316–319, 325–326 Sexual assault, 321–323 Sexual attraction, toward clients, 506 Sexual identity development models, 570 Sexual images, in media, 420 Sexuality: of older clients, 307 violence and, 443 Sexually disordered patients, 409–429 affective numbing in, 418 biological factors, 415–416 challenges of treating, 409–410 civil commitment of, 427 clergy, 421 cognitive factors, 416–417 family backgrounds of, 419–420 guilt and shame in, 412 lack of interpersonal skills in, 418–419 lying by, 411 recidivism of, 413–414, 428 registration of, 427 societal factors influencing, 420 specialized training for treatment of, 410–411 transference/countertransference issues with, 422–426 treatment approaches, 415–417 treatment efficacy with, 412–414 Sexual orientation, 510 defined, 560 supervision and, 567–571 Shame, 60, 412 Shared metaphors, 123 Shell shock, 9 Silence, 48

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Subject Index 627 Silent injuries, 426–427 Sin eaters, 409–410 “Sitting still,” 33–35 Skill building, 48–50 Sleep theory of hypnosis, 228–229 Smoking cessation, hypnosis for, 242 Social cognition, 159 Social hierarchy, 537–538 Social power differentials, 539, 539–542, 561 Social psychology, hypnosis and, 230–231 Social role theory, 230–231 Social skills, 184–185, 195, 418–419 Social values, 165–166 Societal factors: influence of, on language and thought, 166 sex offenders and, 420 Societal images, 173 Soviet psychology, 165 Specialization areas, 511 Spiral omnibus model, 19, 20–21, 170–171 Spiritual issues, 421 Spontaneity, 103 Sporting venues, violence in, 444 Stage theories, 18–19 Stampfl, Thomas, 7–8 Standardized principles, 531–532 Standardized testing sessions, 204–205 Standards, arbitrary, 103–104 Stanford-Binet Intelligence Scale, 20 Stanford Susceptibility Scale, 230 State theory, 231–232 Static factors, 438 Statistical conclusion validity, 480 Statistical variables, 483 Statistics, 20 Sterba, Richard, 99–100 Strategic reflecting teams, 193–194 Stress, among international students, 73 Stress hormones, 317–318 Structure, 45 Student confidentiality, respect for, 63 Students. See Supervisees Subjective reality, 182 Subjectivity, 158, 182 Substance abuse: by abuse survivors, 332 in battered women, 321 by older patients, 309 violent behavior and, 441 Substance abuse counseling, 254–256

Substance abuse treatment: education and training gaps in, 342 evidence-based practice and, 345–346 history and developments in, 341–342 holistic approach to, 343–344 motivational interviewing, 347–355 recovering versus nonrecovering supervisees in, 346–347 special considerations in, 342–347 supervision of, 340–356 training and competency in, 343–344 Substance use disorders (SUDs): clinical attitudes toward clients with, 342–343 coexisting conditions, 344–345 stigma surrounding, 341 Suggestion. See also Hypnotherapy hypnosis and, 229–230 indirect, 226, 231–232 nonspecific factors and, 225 therapeutic use of, 223–226 utilization theory and, 231–232 Suicidal threats and gestures, 397 Suicide, 291–292, 335, 375–376, 397 Suicide prevention, in correctional settings, 396–401 Suicide prevention centers, 251–254 Summarizing, 349 Summary discussion sessions, 206–207 Summative evaluations, 90–91 Superego, 364–365 Superego development, 27 Supertransference, 507–508 Supervisees: addressing fears of, 3 anxiety, 43–45, 162, 211–214 countertransference, 50–51 debriefing of, 64–65 development of, 505 development of personal style by, 268–270 experiential, 138–147 goals of, 167–168 as individuals, 87–88 with insufficient social skills, 195 learning process, 47–48 match between supervisor and, 527 needs of, 60–69 new, 40–52 nondisclosure by, 45–46, 506, 529–530 personality of, 101–102 personal problems of, 146 personal sharing by, 84–85

sind

JWBK186/Hess

628

May 23, 2008

9:2

Char Count=

SUBJECT INDEX

Supervisees (Continued) perspective of, on supervision, 55–69 problematic behaviors by, 91 qualities of, 448, 527 recovering versus nonrecovering, in SUD context, 346–347 responsibilities of, 109 role expectations, 40–43 role of, in child psychotherapy, 270–271 selection of, 372 skill building in, 48–50 suggestions for, 56–57 transitioning from, to supervisor, 82–92 voice finding by, 65–66, 67 Supervisee variables, 505–506 Supervision: of abuse survivor psychotherapy, 315–336 administrative, 474 of adolescent psychotherapy, 286–297 assessment in, 473–496 behavioral, 7–8 of child psychotherapy, 265–284 cognitive model of, 249–250 of collaborative assessment, 209–215 competencies, 83 conflictual, 504–505 context of, 104, 110 in correctional settings, 380–404 of couples and family therapy, 179–198 cross-cultural, 538–542 defined, 474–475 developmental models of, 18–20 discovery-oriented approach, 149–155 educational process model of, 164–175 emergence of, as specialty, 9–13 emotional learning and, 446–448 ethical issues in, 511, 521–531, 581 of experiential psychotherapists, 137–155 gender issues in, 561–567 of geropsychology, 299–311 group, 13, 45, 88–89 historical overview, 3–4, 3–9 of hypnotherapy, 223–243 versus instruction, 83–84 of international students, 70–79 interpersonal approaches to, 157–175 as interpersonal process, 560 legal issues in, 531–533, 581 live, 89, 188–191, 192

in medical settings, 450–468, 454–468 models of, 14–18, 108–112, 459–460, 558–561 multicultural competence in, 542–552, 555 multicultural issues in, 508–511 of narrative-based psychotherapy, 114–134 of paraprofessionals, 246–259 patient-focused, 458–459 power issues in, 561 practical concerns affecting, 580–587 proactive, 12 problem-oriented, 106 process of, 104–106, 110 psychoanalytic, 97–112 versus psychotherapy, 216 recent developments in, 20–21 relationship-/therapist-focused, 458–459 research on, 500–512 sexual orientation and, 567–571 structure of, 159–164 of substance abuse treatment, 254–256, 340–356 supervisee perspective on, 55–69 supervision on, 66–67 teaching as essence of, 445–446 of telephone crisis counseling, 251–254 of therapeutic assessment, 209–215 as therapy, 525–526 of treatment of mentally ill, 359–378 Supervision discourse, 45–47 Supervision dyad, 539 Supervision format, 88–89, 373 Supervision Questionnaire-Revised (SQ-R), 488 Supervision time, respect for, 63 Supervision triad, cross-cultural, 539–542 Supervision Utilization Rating Form (SURF), 489–490 Supervisor observation, anxiety over, 44 Supervisors: choosing, 109–112 as coach, 17–18 as consultant, 105–106, 352–353 countertransference, 52 development of, 86–87, 507 as educator, 18, 351–352 ethical guidelines for, 41–42 ethical responsibilities of, 107 as evaluator, 354–355

sind

JWBK186/Hess

May 23, 2008

9:2

Char Count=

Subject Index 629 Supervisors (Continued) feedback and disclosure from, 46–47 impact of, 64 interpersonal characteristics of, 89–90 as lecturer, 15 liability of, 532 match between supervisee and, 527 as model, 105 as monitor, 16 motivations of, 102–103 as peer, 16 personality of, 102–104 preparation for, 83–86 as psychotherapist, 17 qualifications of, 526 qualities of, 448, 454, 456–457 responsibilities of, 526–527 rewards for, 60 role of, in child psychotherapy, 267–270 roles of, 13–18, 350–355 as safety net, 363 self-disclosure by, 508 sharing work by, 214 suggestions for, 58–60 as supporter, 353–354 as teacher, 15–16 transitioning to role of, 82–92 as troubleshooter, 106 Supervisor-supervisee mismatch, 195 Supervisor variables, 507–508 Supervisory Emphasis Rating FormRevised (SERF-R), 488–489, 491 Supervisory environment, 60–61 Supervisory expectations, 77 Supervisory goals, 30–38 Supervisory posture, 364–365 Supervisory process, research on, 501–505 Supervisory relationship, 12, 501–502 anxiety and, 45 cultural differences and, 196–197 in didactic supervision, 187–188 in experiental supervision, 145–146 international students and, 74 unsatisfactory, 164 Supervisory Styles Inventory (SSI), 488 Supervisory techniques, 363–366 Supervisory working alliance, 41, 42 asociality and, 163–164 with international students, 76–77 in medical settings, 460 models of, 501–502

Supporter role, 353–354 Survivor therapy, 330 Symbolism, 133 Symptom alleviation, hypnosis for, 224–225 Systematic desensitization, 224 Systems theory, 13 Tarasoff v. Regents of the University of California (1976), 385 Tarasoff warnings, 440, 442, 528 Teacher model, 14, 15–16 Teaching, 83–84, 445–446 Teen suicide, 291–292 Telephone crisis counseling, 251–254 Telepractice, 404 Termination, of child psychotherapy, 280–281 Tests, 476. See also Assessment in collaborative assessment, 208–209 standardized, 204–205 in traditional assessment, 202 “The Ego and the Id” (Freud), 27, 28 Thematic Apperception Test, 121, 318, 362 Theoretical framework, need for, 35–37 Theories, of supervision, 86–87 Therapeutic alliance: assessment of, 121 narration and, 118 Therapeutic assessment (ta), 200 with children and adolescents, 218–219 of couples, 219 functions of supervisor in, 214–218 students’ anxiety and, 211–214 supervision of, 209–219 Therapeutic Assessment (TA): assessment intervention sessions, 205–206 definition of, 200–203 follow-up sessions, 207 initial session, 203–204 obstacles to learning, 210 procedures, 203–207 standardized testing sessions, 204–205 summary discussion sessions, 206–207 supervision of, 209–215 Therapeutic blending, 282–283 Therapeutic frame, 32–33 Therapeutic interventions. See Interventions Therapeutic questions, 216–217

sind

JWBK186/Hess

630

May 23, 2008

9:2

Char Count=

SUBJECT INDEX

Therapeutic relationship: hypnosis and, 226 in therapeutic assessment, 211–212 Therapeutic splits, 192 Therapeutic voice, 37 finding a, 65–66, 67 Therapist: clinical attitude of, 31–35 roles of, 152 sharing by, 5–6 Therapist confusion, 360 Therapy. See Psychotherapy Third ear, 5 Third Force psychology, 165 Third parties, adolescent psychotherapy and, 295–296 Time, 33–34 Time distortion, 239 Time series designs, 20 Torts, 531, 532 Trainees. See Supervisees Training: for correctional settings, 383 of paraprofessionals, 248–251 prolonged, 585–586 psychoanalytic, 99–100, 99–100 in research, 85–86 sequence of, 371–372 state of, 582–583 for treatment of sexually disordered patients, 410–411 Training analysis, 4, 100 Training syllabi, 10 Trance. See Hypnosis Trance induction, 235–236 Trance phenomena, 238–239 Trance ratification, 237–238 Transcripts, 62 Transference, 5 with abuse survivors, 333–334 interpretations of, 124, 131–132 manifestations of, in narrative sequences, 130–131 with older patients, 304 parents of children in treatment and, 278 with sex offenders, 422–426 Transference jam, 6 Transformation, 139 Traumas, learning to deal with, 64–65 Trauma survivors. See Abuse survivors Treatment modalities, blending of, 282–283

Triggering circumstances, 123 Troubleshooter, supervisor as, 106 Trust, 51, 76, 330 12-step model, 254 Two-way mirrors, 46, 62 Typologies, 18–19 Ultimatums, by adolescents, 294 Unconscious, 98, 162 Unconscious communication, 111 Unconscious conflicts, 108–109, 115 Unconscious intelligence, 231 Unconscious processes, 161–162 Uniformity myth, 56, 582 Universality, 549 Utilization method, 231–232 Validity: construct, 481–482, 485–486, 495–496 content, 494 cross-validity samples, 494–495 external, 486 hypothesis, 480, 485 internal, 480–481, 485 statistical conclusion, 480 Values, 165–166, 303, 554 Verbal communication, 64 Veteran’s hospitals, 9–10, 433 Vicarious traumatization, 334, 426–427 Victim selection, 441 Victims of abuse. See Abuse survivors Videotapes: for case review, 46, 62, 89 in family therapy supervision, 188 Violent clients, 438–442 assessment of, 441 need to manage, 432–433 psychotherapy for, 441–442 types of, 438–441 working with, 448 Violent situations, types of, 442–445 Visual imagery, 238–239 Vitalism, 227–228 Voice, finding a, 65–66, 67 Vygotsky, Lev Semeonovich, 164–175 Watson, John, 7, 446 Wechsler, David, 166 Weekends, violence during, 444 Weight control, hypnosis for, 243 Weitzenhoffer, Andre, 230 White privilege, 546 Wolpe, Joseph, 224

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JWBK186/Hess

May 23, 2008

9:2

Char Count=

Subject Index 631 Women’s shelters, 328–329 Working alliance, 41, 42 asociality and, 163–164 countertransference and, 50 empathy and, 49 with international students, 76–77 in medical settings, 460 models of, 501–502

Working Alliance Inventory, 487, 502 Workplace violence, 443–444, 446 World War I, 9 World War II, 9–10 Zone of proximal development, 162, 169–170