The core purposes of clinical supervision are to protect the welfare of clients by ensuring they are receiving ethical, quality care and to promote the growth of pre-licensed clinicians [1].

A couple of main areas that distinguish pre-licensure clinical supervision from consultation, mentoring, or another form of guidance are the evaluative and non-voluntary components of the supervisory relationship [1].

This tends to amplify a supervisee’s existing anxiety related to questions of competency, training demands, and balancing academic, occupational, and personal obligations [2]. Too often, the level of anxiety is suboptimal, negatively impacting learning, growth, and clinical work.

The Need for Collaborative Supervision

Having been a supervisee for many years and working more recently as a supervisor in various settings, I have experienced, observed, and heard others’ reports of the power differential, evaluative components, and related anxiety overshadowing opportunities for growth. It is not that growth and learning never occur, but more that it is inhibited or diminished, and counter-intuitive to the whole purpose of clinical training.

Excess levels of anxiety are correlated with a frazzled, distractible mind state, and low levels are associated with boredom and disengagement [3]. Neither are helpful for learning or performance.

In higher levels of anxiety, the limbic system — our emotion circuitry and home of the fight-flight-or-freeze system — is overactive and disrupts prefrontal cortical engagement [3,4]. The prefrontal cortex is involved in executive function, attention, insight, empathy, and learning, to name a few, so its disruption would interfere with creating an optimal mental state for supervision.

When trainees are anxious in supervision, it is as though the brain-mind system is perceiving a threat of some sort and allocating resources for physical survival, as though there was a mountain lion present. (Supervisors are not mountain lions!) This diminishes resources for empathy and learning, two factors integral to clinical supervision and clinical work.

The physiologically taxing state of anxiety, or panic, makes it difficult for a supervisee to take growth-oriented risks and communicate honestly with the supervisor. Additionally, while the anxiety may be managed and not acutely debilitating — it may not interfere with learning or behavior outbursts — prolonged anxiety can begin to take a toll mentally, emotionally, and physically, gradually shifting into suboptimal conditions for learning and integration [2].

Not all anxiety is troublesome. Moderate levels are found to relate to optimal performance, such as in a state of flow [3]. Required supervised training and evaluation have the opportunity to support that potential for flow.

In its most helpful form, clinical supervision engenders what Zaretta Hammond, Culturally Responsive Teaching and the Brain author and educator, calls “relaxed alertness” [5]. For instance, evaluation in a supportive context encourages effort and thoughtfulness. Hammond notes that relaxed alertness sets the stage for learning, and more so, a learning partnership.

Rather than attending to the power differential and the supervisor’s authority and judgment, emphasizing the collaborative aspects of clinical supervision creates a space for relaxed alertness, bringing about optimal conditions for learning within the context of the relationship. (The context of the supervisory relationship can also affect the supervision, including training setting, resources, phase of the trainee’s development, and the supervisor’s personal and professional development).

If supervisees are able to view supervision as a learning partnership, it has the potential to help reduce superfluous stress, enhance learning through transparency and openness to feedback, and empower the trainee. This, in turn, can positively impact clinical work and the client.

Thus, a collaborative emphasis in clinical supervision is a worthwhile consideration, and its components, such as developing trust, are supported anecdotally, theoretically, and empirically [2,6].

This learning partnership has collaboration and trust at its core. Bean, Davis, and Davey [1] define collaboration as:

…both parties joining together in meaningful dialogue in an environment of trust, each party recognizing and valuing the relationship between the two of them as one central component. A mutually desired outcome is obtained through problem-solving (Chapter 14, Section 2, para. 1)

What follows are a few suggestions for facilitating collaboration in supervision, focusing on developing trust, self-awareness, and individualized learning as building blocks to meaningful dialogue and problem-solving.

Developing Trust

Hammond [5] notes that students encounter difficulties in information-processing when the limbic system is activated, as through anxiety. She asserts that educators — supervisors in this case — have a responsibility to help re-engage the student’s vagal nerves, a component of the parasympathetic nervous system that essentially facilitates calm, returning the student to a state of optimal information-processing (i.e., learning). It can be difficult to develop trust and to learn when feeling anxious.

Foremost, remember that beyond the title of supervisor or supervisee, we are human and all experience what humanness entails, including varied emotions, vulnerability, challenging life experiences, and imperfections.

Supervisors should begin the supervisory relationship by orienting the supervisee to the general collaborative intention and framework, and from there, the supervisor and supervisee can co-create the environment for safety and learning. Providing concrete and detailed information to supervisees is particularly helpful for this early stage when anxiety is elevated [7]. Include a discussion of limitations and boundaries as well. Consider that your tone and body language can send a message about whether you are open to collaboration.

Verbal examples of collaboration include, “I am here to support your professional growth,” “there is no such thing as a dumb question,” “your voice is important,” “we both have wisdom to share and are both growing and learning,” or “I [supervisee] would like space to process the case to see what insights surface before hearing your [supervisor’s] feedback.” Please repeat. Even though certain concepts may be assumed or have already been stated, reminders and reassurance as needed go a long way.

Supervisors can consider asking the supervisee to name a clinical fear (and give your example too, of course). Respond empathically and note that part of the individualized goal may be to develop and strengthen the supervisee’s skillset and confidence to address that particular clinical fear if ever encountered.

This could be a great opportunity to catalyze a sense of trust and increase competence. Plus, naming fears helps reduce activation of that fight-or-flight system and more so when addressed with empathy [4].

By collaborating within a trusting environment, supervisors can empower the supervisee to take responsibility for her training, and supervisees, empower yourselves by taking responsibility for your training, within the context of your training site.

Facilitating Honesty

Supervisees can also empower themselves by giving direct feedback early on. Please do not wait until something has been bothering you for a while before bringing it to your supervisor. Reasonable supervisors are open to feedback, as it is in alignment with the goals of supervision: the client’s well-being and the supervisee’s growth.

Mindful transparency and respectful honest communication by both, and at least modeled first by the supervisor, can also help reduce anxiety. It also invites the supervisee to do the same. Inviting feedback regularly along with responsiveness can be helpful for developing resonance and trust.

When it is time to receive feedback on an evaluation form, ideally, the feedback will not come as a surprise to the supervisee or the supervisor. Hopefully, honest and respectful feedback will have been an ongoing part of the supervisory process. However, honest feedback does not mean harsh criticism. It means identifying what the core issue is, and then using respectful and compassionate “I” perspective language to make yourself heard — for example, saying, “I am noticing feeling alone in this issue and feel fear surfacing that I may not be able to help this client.”

Building Self-Awareness

Self-awareness is a significant component of, well, clinical work in general, and it is an ongoing life process. Both supervisors and supervisees are challenged to consider expectations and assumptions, barriers to empathy, internal and external obstacles for learning, different facets of diversity, as well as areas of privilege.

Be open to explore and examine yourself a little more closely, including areas not previously explored, and pay attention to the subtleties. Reflective conversations and questions are vital to learning to respect and respond to cultural diversity [8].

Scholar and author Brene Brown [9] advocates self-awareness and self-compassion, noting that the depth and breadth we have explored and related to within ourselves allows us to better serve our clients as they bring their joys and darkness into the therapeutic space.

Attuning to Individual Learning

Having a sufficient understanding of the brain and how learning works inform our thinking about what supervisees need in order to learn most effectively [5].

This requires the supervisor to pay attention to what is helpful to the supervisee, and for the supervisee to speak up and state what would be most helpful at the time. An effective learning modality for one supervisee may be less so for another. Or, there may be changes within the same supervisees as they develop throughout the course of training.

Sometimes, giving supervisees space to process in order to gain insights and work toward finding the appropriate intervention on their own is the best solution. At other times, identifying and implementing interventions concretely is more helpful than processing.

The supervisor’s ability to be attuned to the supervisee, and both parties’ clear communication, create the balance between supporting and appropriately challenging the supervisee. This ultimately enhances the learning process [8].

In Essence

Communication and responsiveness are critical to collaborative supervision, and developing trust can establish a foundation for respectfully honest communication. A collaborative approach to the supervisory relationship invites the co-creation of an environment wherein deeply meaningful development can unfold. It can improve the quality of care for our clients and those with whom we interact beyond the therapy room.

There is a plethora of literature within and outside psychology — from Carl Jung and interpersonal neurobiology to quantum physics — that provides support for a collaborative approach to supervision [7]. There are also many ways to set up the collaborative framework to help the supervisee — and supervisor too — shift from anxious states to the relaxed alertness where learning and growth can thrive.

What are some factors you have found to be helpful in developing and maintaining a collaborative relationship in supervision? Share them with the Time2Track community in the comments below!

 

References

[1] Bean, R.A., Davis, S.D., & Davey, M.P. (2014). Clinical supervision activities for increasing competence and self-awareness. New Jersey: John Wiley & Sons, Inc.

[2] Burg, C., Burg, J., Long, S., Melowsky, J., Pasternak, T., Rascon, C., … Walters, C. (2017). Key factors of internship burnout and possible solutions. Psychotherapy Bulletin, 52(3), 16-20. Retrieved from http://societyforpsychotherapy.org/key-factors-internship-burnout-possible-solutions/

[3] Goleman, D. (2012). The sweet spot for achievement: What’s the relationship between stress and performance? Psychology Today. Retrieved from https://www.psychologytoday.com/blog/the-brain-and-emotional-intelligence/201203/the-sweet-spot-achievement

[4] Siegel, D. (2010). The mindful therapist: A clinician’s guide to mindsight and neural integration [Audiobook].

[5] Corwin. (2017, May 4). Culturally responsive teaching and the brain webinar with Zaretta Hammond [Video file]. Retrieved from https://www.youtube.com/watch?v=O2kzbH7ZWGg

[6] Friedlander, M. L., & Shaffer, K. S. (2014). It’s (still) all about the relationship: Relational strategies in clinical supervisionPsychotherapy Bulletin, 49(4), 13-17.

[7] Badenoch, B. (2008). Being a brain-wise therapist: A practical guide to interpersonal neurobiology. New York: W.W. Norton & Company, Inc.

[8] Gray, S.W., & Smith, M.S. (2009). The influence of diversity in clinical supervision: A framework for reflective conversations and questioning. The Clinical Supervisor, 28, 155-179.

[9] Brown, B. (2007). I thought it was just me but it isn’t: Making the journey from “what will people think?” to “I am enough.” [Audiobook].

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Reina Remigio, PhD

Reina Remigio, PhD

Reina Remigio, Ph.D. is an early career licensed psychologist, with a whole-being approach to psychology. She is currently working at various short- and long-term care facilities providing cognitive testing and psychotherapy to the middle to older adult populations. She also provides clinical supervision to pre-doctoral students training at a community mental health center and has a small private practice. Her background includes forensic and community mental health services with a diverse population ranging from young children to adults. She also has experience providing program coordination/development and training to multidisciplinary teams of care providers. She enjoys playing with and learning from her spirited toddler, practicing mindfulness, and frolicking in nature solo or with loved ones.
Reina Remigio, PhD

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