Making every moment of clinical supervision count

By Tiffany Warner

January 2022

When I started providing clinical supervision nine years ago, the standard at my clinic was to use the entire session to discuss cases. Case review is foundational to the supervision process, but later in my career, I learned of alternative methods of supervision. Even when I used different methods, however, there were still too many topics to cover during the one hour of supervision per week. 

Whether one looks at the 2016 Council for Accreditation of Counseling and Related Educational Programs (CACREP) Standards or the 2014 ACA Code of Ethics, it is clear that supervisors are responsible for addressing a multitude of areas with supervisees. Unfortunately, figuring out how to cover every topic seems daunting at best and impossible at worst for many supervisors, especially when coupled with their gatekeeping responsibilities. In reality, there are too many core domains in counseling to cover in every supervision session, and this must be balanced with ensuring that supervisees discuss cases for client welfare. In addition, supervisees are often unsure what to bring up in supervision; without structure, they have difficulty identifying the most salient cases or topics. 

I know from my early experiences that this was a significant challenge. I was often trying to figure out what needed to be addressed first in supervision. I recall one example when I was working with a supervisee on the topic of self-care, but as the supervisee described their self-care practices, I could hear themes related to professional development, lack of confidence, ethical considerations and diversity factors. This moment raised many questions for me: What area do I address? Is it realistic to address them all? Do we have time to do that and discuss the supervisee’s clients to ensure quality of services? 

At this point, most supervisors, myself included, would focus on any high-risk needs, but the options are not always between low-risk and high-risk situations. Consequently, in my early career, I chose to address the areas in which I was most confident or that most interested me. This response is consistent with many of the supervisors I meet as well. 

To confront this challenge and to change my pattern of addressing limited topics, I developed a three-step method to help myself cover more topics with supervisees in the same amount of supervision time. I have found this three-step method has not only helped address a wider range of areas in supervision but also modeled for supervisees what types of issues to introduce. The development of this three-step method started when I was running internship groups in a master’s counseling program. I found it very challenging to cover all the core areas that students were trying to learn while also helping the students make the leap from book knowledge to application. However, I did not want to create so much structure that students no longer had the opportunity to discuss urgent or complex cases. Therefore, the three-step method that I started using includes: 

1. Identifying a topic list
2. Collaborating with supervisees on the schedule 
3. Developing processes to incorporate topics naturally into supervision

This three-step method can be incorporated into individual or group supervision formats. At its core, the method is designed to help supervisees deeply apply the knowledge gained during their education. 

Step 1: Identify a topic list

Whether you are someone who loves order (like me) or prefers a more organic flow, identifying a topic list can be useful to help keep pace as a supervisor. It enables you to ensure core areas are addressed and provides an opportunity to assess the supervisee in different competencies. In a sense, this creates personal accountability by developing core areas that need to be addressed and devising a method to track them.   

The topic list I have most often used is a case conceptualization. This assists supervisees with identifying important parts of a case conceptualization, learning ways to articulate the case and working toward a cohesive understanding of the case. Several options are available for outlining a case conceptualization (see also “Case conceptualization: Key to highly effective counseling” by Jon Sperry and Len Sperry in the December 2020 issue of Counseling Today). You can use the case conceptualization format that is most familiar. However, I prefer using the following outline because the order helps students build a deeper understanding of their cases. 

1. Background and historical information: Salient details such as family structure, relationships, historical trauma, history of mental health or addiction issues, mental health treatment and medical history.
2. Presenting problem or concern: Client’s description of their problem, what they hope to achieve, risk factors and substance use.
3. Testing and assessment measures: Identification of any test or assessment measures that are useful for the client, their problem or treatment.
4. Diagnosis: Past and current diagnosis, differential diagnosis process.
5. Multicultural considerations: Demographic information, diversity or cultural considerations for the case, important cultural components that impact treatment or mental health.
6. Systems or developmental theory considerations: Identification of any systems or developmental models or theories that are important for this case.
7. Counseling theory: The theories or modalities that are being used, research support for the counseling theory.
8. Treatment plan: Description of the goals, objectives and interventions for the case.
9. Ethical considerations: Current or potential ethical issues that apply to this case. 

Another option for the topic list is to use the 2016 CACREP Standards, specifically the eight core counseling domains found under Section 2.F.: 1) professional orientation and ethical practice, 2) social and cultural diversity, 3) human growth and development, 4) career development, 5) counseling and helping relationships, 6) group counseling and group work, 7) assessment and testing and 8) research and program evaluation. Although this topic list does not provide the ordered structure of a case conceptualization, it does cover the core areas that developing counselors need to understand and apply to clinical cases. 

One final option would be to use the various competency standards for professional counselors such as the Competencies for Addressing Spiritual and Religious Values in Counseling developed by the Association for Spiritual, Ethical and Religious Values in Counseling or the Minimum Competencies for Multicultural Career Counseling and Development created by the National Career Development Association. Using competency statements can be particularly beneficial if you are supervising within certain settings such as a religious institution or career center. Depending on organization of the competency standards, you would use each standard to help build competencies over the course of supervision. Because most competency standards include a focus in areas of knowledge, awareness, skills and ethics, you can still cover most of the areas outlined in the case conceptualization but with a focus on a particular genre or population. 

My three-step method provides flexibility for you to create a topic list that fits the supervisee, setting and population. I believe the case conceptualization is a better option given its practicality to the counselor’s everyday work. In addition, it provides language and an understanding of the case that is easier to translate into documentation, billing and other business aspects of a counselor’s work. No matter what topics are used, what is important is identifying a list that fits well within your supervision model and setting.

Step 2: Collaborate in setting the schedule

The onus is on the supervisor to ensure that the supervisee is building competency, which might lead to the supervisor determining the schedule of topics. However, there is value in involving the supervisee in this process. In this second step, the supervisor brings the suggested topic list to the supervisee to establish the schedule of topics. This has several purposes. 

First, it provides opportunity to assess the supervisee and their developmental level. You can use formal or informal processes at this step. The goal is to ascertain what the supervisee understands and their current skill level. In this way, you can tailor the list to the need of your supervisee.

Second, this step helps the supervisee take ownership of their development by identifying their own strengths and growth areas, which can assist you in targeting how to incorporate each topic (see step 3 below). For example, a supervisee might show solid understanding of counseling theory but need more assistance with knowing when to use what theory. Another supervisee might demonstrate strong skills with understanding a case but struggle to create a cohesive case conceptualization. At this step, supervisees are also able to identify areas of interest that might be included in the schedule of topics. 

Finally, this step can model the process of collaborating with a client to develop goals. This creates a great parallel process in which the supervisee learns how to work together to create the goals for supervision, which translates well to the counseling room.

After collaboration, the schedule is set up to address one topic per supervision session within a specific time frame, such as over a three-, four- or six-month period. At the end of this time frame, the schedule could be repeated or a new schedule created. 

At the conclusion of this step, you’ll have a set schedule of topics that incorporates the topic list from step 1 along with the supervisee’s feedback. So, you could end up with a four-month rotation of topics in which weeks one through nine focus on going through the case conceptualization and weeks 10 through 16 focus on reviewing the supervisee’s areas of interest. Another option might be a schedule in which each CACREP standard is reviewed in weeks one through eight and then weeks nine through 16 are spent taking each standard deeper to strengthen the supervisee’s development. In this way, the creation of the schedule becomes part of the supervision process. 

Step 3: Incorporating topics into supervision

While the schedule of topics is very structured, the final step offers more flexibility. I prefer to weave the topic into the cases or questions that are already discussed in supervision. In this way, the schedule of topics can be inserted into supervision organically. It uses time more efficiently by capitalizing on what is already brought into supervision. It also enhances a supervisee’s understanding of how these topics directly relate to their current clients. For example, if the topic is “diversity considerations,” you might pose questions during the case discussion or use an existing case to explore the topic deeper. Because this process is more organic, it requires that you quickly formulate the best plan to incorporate the topic. 

To help explain this process better, I’ll offer a case vignette of a supervision meeting. In this example, the topic of the week is the “presenting problem or concern.” The supervisee has brought up a particular case that has been difficult for her because she does not think progress is being made in treatment. The supervisee has been discussing a client who has sought treatment for depression but reports continued depressed mood and lack of motivation. In addition, the client reports a history of addiction but has been clean for six months. The supervisee and client have been seeing each other for five sessions. 

This supervisee has struggled in the past with clients who lack motivation. So, prior to this portion of the supervision session, the supervisor and supervisee focused on the countertransference that the supervisee experiences with clients with low motivation. At this point, the supervisee has had the opportunity to work through the reason for bringing up the case, and the supervisor sees an opportunity to bring in the scheduled topic. 

Supervisor: As I mentioned earlier today, this week’s topic is the presenting concern, and it seems like this client might be a good fit for the topic. As you have mentioned, the client seems to lack motivation. Tell me about what the client’s presenting concern is or how the client would describe their problem.

Supervisee: Well, when we first started, he said he wanted to be less depressed, but we have not really worked on that much. He doesn’t seem to want to talk about anything when he comes in.

Supervisor: So, he identified reduced depression when he started. What other things did he mention?

Supervisee: I can’t think of anything. 

Supervisor: Let’s see if we can’t expand on that a bit. It is common for clients to not have a clear description of what they want when they first start. Based upon your meetings with the client, what do you think the presenting problem or concern is?

Supervisee: I guess that is part of the challenge when I meet with him. I am still not sure. I guess he wants to reduce the depression, but it has been so hard to discuss this with him.

Supervisor: So, we have already established that he lacks motivation, which is common with people who are depressed. I wonder if we can be more specific and think about how you might describe the problem from either a behavioral, cognitive, affective or interpersonal lens? 

Supervisee: Well, he has mentioned several times wanting to see his children again. He stopped seeing them after his last relapse. This might be a behavioral problem that he doesn’t see his children. 

Supervisor: Great. How have you explored this area with him so far?

Supervisee: We haven’t done much. When he brings it up, I ask about what he can do to make that happen, and he just becomes upset. 

Supervisor: Well, it sounds like there might be some deeper challenges there, but let’s finish up with the presenting problem. You have at least one possible goal for the client. I wonder if there are others.

Supervisee: When he talks about wanting to see his children, he has mentioned several times about how he is a failure because of his past substance use. So, I guess there could be something there regarding a cognitive-based problem. 

Supervisor: So, it seems like there are maybe more specific concerns that you could bring into session.

As this vignette makes evident, the supervisor addresses the main concern brought to supervision and uses the same client to also address the day’s topic. This leads to an even richer conversation with the supervisee around some barriers to treatment, such as unclear goals. By using the existing client to discuss the topic, the supervisor is also able to skip repeating the case information, which utilizes supervision time more efficiently, and connect the topic to the clinical issues that the supervisee is wanting to address.

I prefer a more organic incorporation of the topics, but for some supervisors with less experience, this may be too challenging at first. Another option is to have set time during supervision to cover the topics. This could include doing activities such as role-plays, reviewing the major content in the topic area, selecting a client who fits well with that topic or using vignettes to discuss a topic. For example, if that week’s topic is “background and historical information,” the supervisor might role-play how to conduct an intake interview. If the week’s topic is “diagnosis,” the supervisor could include a vignette to help the supervisee work through differential diagnosis. This process can be useful when working with supervisees who are early in their development as counselors. However, it can also seem forced or too basic for more advanced supervisees or require setting aside time that might already be limited. 

Another aspect to consider when choosing the process for incorporating the schedule of topics is the background knowledge that the supervisee possesses. Some supervisees come to supervision with a strong understanding of the different topics, whereas others are early in their development or didn’t receive much prior training on the topic. In these instances, taking time to provide a short training or refresher may be useful. For example, if the topic is “test and appraisals,” you might consider reviewing validity, reliability and the process for determining an appropriate test. 

Finally, you have the option to use some or all of the processes identified here. You could consider providing a short training on the topic, identifying key questions and bringing those questions into the cases discussed during supervision. Ultimately, as a supervisor, you will determine which process fits best with your development as a supervisor, your supervisee and your setting. 

Benefits and problem-solving

An additional benefit of this three-step method is that it assists you in knowing what core areas have been addressed throughout supervision. It is easy to be unaware of the developmental areas that are missed with supervisees, and structuring supervision in this fashion can help mitigate this potential issue.

This can then translate well during evaluation times to allow for a more robust formative evaluation process. For example, some evaluations used in state licensure require that a supervisor specifically address the counselor’s diagnostic competency. The supervisor who uses this three-step method can be confident of their assessment of a supervisee’s diagnostic skills. 

The biggest challenge to using the three-step method can be the appearance of rigidity. As any supervisor knows, there are times when high-risk or urgent clinical needs take precedent over any other topic in supervision. Using a topic list does not preclude you from addressing urgent needs; there is space to change course in supervision and not address the topic. 

In fact, the topic list can produce the identification of urgent needs more regularly by training the supervisee on the different areas that should be addressed in supervision. For example, regularly bringing in ethical considerations can move the supervisee from seeing the ethical standards as rules and toward realizing how ethics standards apply to specific cases. This in turn can help supervisees move beyond just addressing confidentiality and abuse reporting to also recognizing potential boundary issues and scope of practice questions. 

The three-step method and group supervision

We have focused mostly on the use of this three-step method in individual supervision. However, there is value to using it in group supervision as well. 

In group supervision, managing time is even more challenging because multiple supervisees are vying for space to address clinical issues. Often, the goal with group supervision is that supervisees will learn as much from each other as from discussing their own caseloads. By establishing a topic list and schedule, you can be sure that more topics are covered for the benefit of multiple supervisees. 

Regarding the earlier vignette, if this conversation took place in a group setting, the other members would have the opportunity to listen and offer feedback on how to address countertransference and the role the presenting problem can play in treatment, even without bringing up their own cases. This could result in these supervisees being more likely to incorporate the presenting problem in other cases. 

Using the three-step method as a supervisee

The role of the supervisor is to teach, model and assist the supervisee in development as a counselor. But even if you are not providing direct supervision — if you are receiving supervision instead — you can still use this three-step method in your own development. 

This could include developing your own schedule based on the case conceptualization provided to you in your training or the competencies that you want to improve. After creating the schedule, you can use that to determine different topics that you want to address in supervision while prioritizing the high-risk issues and supervisor instruction. In this way, you can receive the benefit even if your supervisor uses other models of supervision. 

Supervision is a beautiful process of becoming a seasoned counselor, and as a supervisor, I have had the honor of walking with many supervisees through this process. I take this charge very seriously, which is why I emphasize providing a well-rounded supervision experience. Using this three-step method, I have found success with engaging supervisees on many fronts more efficiently while providing practical application of a counselor’s core functions.

Tiffany Warner is a licensed professional counselor and board-approved supervisor who specializes in working with severe and persistent mental illness. She is currently working as adjunct faculty at Multnomah University and is pursuing her doctorate in counselor education and supervision through the University of the Cumberlands. Contact her at twarner@multnomah.edu.

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