Chapter 8 - SUPERVISION ISSUES / MATERIALS TO COVER

PREPARATION FOR LICENSING

Preparation for licensing will vary some from state to state. The information that follows is pertinent specifically to California, but other states' information will not be very different. The general path is:

• Get your master's degree (Social Work, Marriage and Family Therapy, Counseling) from an accredited college or university
• Register with the Board of Behavioral Sciences
• Gain your supervised post-masters work experience
• Complete any required additional coursework
• Apply for Examination Eligibility
• Pass the Standard Written Examination
• Pass the Written Clinical Vignette Examination
• Get your official license

Your supervisees will likely have a multitude of specific questions for you, questions such as:

• When can my hours begin counting towards licensing requirements?
• What is the maximum number of hours of supervision I can gain in a week?
• What is the ratio of supervision hours to client contact hours that I need?
• Are there other pre-licensure coursework requirements I must meet before applying for the licensure test?
• Is a background check (and/or fingerprints) required for a license?
• What about experience I gained in another state?
• What is the requirement for post-master's experience?
• What disciplines can provide my supervision toward licensure?
• Do I need to be employed or can I count volunteer hours supervised towards licensure?
• Can I obtain my supervision hours in a setting other than a private practice or government clinical setting?
• How much money will this application process cost?

You can direct your supervisees to a site where they can find the answers to these and other questions for your specific state and for their specific license:

All Psychology Careers.com (http://www.allpsychologycareers.com/).

At this site they can find licensure information for every state in the fields of psychology, counseling, social work, and marriage and family therapy.

MANAGING THE BUREAUCRACY OF THE ORGANIZATION

Most folks who have ever held a job have likely at some time or other groaned about problems because of bureaucracy--perhaps without fully knowing what a bureaucracy is. Dictionary.com gives four definitions for it:

• Government by many bureaus, administrators, and petty officials.
• The body of officials and administrators, especially of a government or government department.
• Excessive multiplication of, and concentration of power in, administrative bureaus or administrators.
• Administration characterized by excessive red tape and routine.

Health care organizations, including mental health, have customarily used bureaucratic management because of the precision and consistency it can create. The original theory of management came into being to overcome management that had become "inefficiently managed, with decisions based on personal relationships and loyalty" (Barnett, 2006).

In the 1920s, Max Weber characterized his ideal bureaucracy as (Max Weber, n.d.):

• Hierarchical organization
• Lines of authority in fixed activities of labor
• Authority based on position, not tradition or charisma
• Formalized, written rules
• Impersonality
• Career advancement based on ability judged by organizations, not individuals

However, with time bureaucracies became over-organized, over-defined and over-run with confusion and red tape. Bureaucratization has become "a state in which employees work increasingly by fixed routine rather than through the exercise of intelligent judgment. With bureaucracy, narrowness in thinking emerges. There is a proliferation of hard-and-fast rules and fixed procedures—wrongly thought to contribute to efficiency and quality control. With bureaucracy in place, the original goal of an organization fades into the background. Individuals within the organization begin building small bastions of power and devising ways of warding off any potential threats to their power. Change is usually interpreted as a threat" (Paul, and Elder, 2002a).

Unfortunately, this is all too true of many mental health agencies, as well as government agencies. What do you do to guide your supervisees to cope in the maze of your agency's bureaucracy?

The first thing you must do is recognize exactly what bureaucratic pitfalls are in your organization (Paul, and Elder, 2002b). You might ask yourself:

• To what extent is there a struggle for power underway in the organization?
• To what extent must we deal with "power hungry" individuals?
• What is the hierarchy of power in the organization? To what extent are those at the top easily threatened by thinking that diverges from their own?
• How does the organization present itself both within and without? Are there any important contradictions or inconsistencies between the two? To what extent do inconsistencies exist between how the organization represents itself and how it actually functions?
• To what extent is short-range thinking dominant in the organization?
• To what extent is there a problem of bureaucratic inefficiency within the organization?
• To what extent is there a problematic "ideology" that stands in the way of change?
• To what extent is the organization forced to compete meaningfully with other organizations?
• To what extent is the organization suffering from stagnation?
• To what extent is bad short-term thinking misleading the leadership of the organization?
• To what extent are ethical considerations ignored or denied in favor of vested interest within the organization?

The bigger question, once you've answered those above, is, "How does that affect my--and my supervisees'--ability to do our jobs?" Then you can determine how you can cope with them. Most times you'll find that the best way to cope is to ignore the bureaucracy and concentrate on the clients, doing required paperwork, and attending to other specific requirements of the job. A hefty dose of humor is also a great help:

[QN.No.#78. Most mental health organizations have a bureaucratic management system. Ways you and your supervisee can copy with bureaucratic problems include:]

Rules of Bureaucracy (Office Humor Blog, 2005):

• Preserve thyself.
• It's easier to fix the blame than to fix the problem.
• A penny saved is an oversight.
• Information deteriorates upward. The first 90% of the task takes 90% of the time; the last 10% takes the other 90%.
• Experience is what you get just after you need it.
• For any given large, complex, hard-to-understand, expensive problem, there exists at least one short, simple, easy, cheap wrong answer.
• Anything that can be changed will be, until time runs out.
• To err is human; to shrug is civil service.
• There’s never enough time to do it right, but there’s always enough time to do it over.

WORKING WITH BURNOUT

Burnout is largely due to the many stresses in one's job. Some of the more frequent causes of stress related to a person's job are (Brusman, n.d.):

• Conflicting job demands
• Excessive bureaucracy, too much paperwork from higher-ups
• High interpersonal conflict
• Lack of sufficient acknowledgment, support, and reward
• No clear endpoint to one's efforts
• Value clashes between the individual and the organization
• Work overload
• Work with high emotional intensity

Dr. Brusman (n.d.) also offers some of the frequent signals of possible burnout that you might observe n your supervisee (or yourself!):

• Interpersonal Problems--Examples include overreacting to conflicts, isolating one's self from others.
• Emotional Fatigue--Normal feelings of frustration, anger, and dissatisfaction become predominant
• Low Productivity--Caused by unusual depression, disillusionment, cynicism, hopelessness, loss of enthusiasm and ability to concentrate.
• Health Problems--Feeling run down and tired; common symptoms include:
  • Back pain
  • Chest pains or palpitations
  • Colds
  • Gastrointestinal problems
  • Headaches
  • Insomnia, fitful sleep, or nightmares
  • Nervous tics
  • Rashes or hives
• Addictive Resolutions--Resorting to substance abuse, or addiction to TV, the computer, food (or loss of appetite)
• Obsessive Thinking--The job is on one's mind all of the time--generally focusing on problems instead of solutions, and he's unable to put it into a larger, more meaningful context.

[QN.No.#79. Signs of possible burnout in you or your supervisee do NOT include:]

Burnout does not happen "out of the blue." Rather it's a gradual wearing down, beginning with normal feelings that every working person experiences from time to time of being a little tired of your job that grows to total exhaustion.

To prevent burnout, job stress must be dealt with; the provider needs to discover what is contributing to job stress and how to best take care of herself. Brusman (n.d.) makes the following suggestions:

• Examine Your Denial about Your Job Stress.
• Avoid Isolation.
• Reduce Intensity/Pressures in Your Life.
• Learn to Pace Yourself.
• Minimize Worrying.
• Take Care of Your Physical Needs (Diet, Exercise, Sleep).
• Nurture Yourself as Much as You Do Others (Learn to Say No and to Delegate).
• Take a Close Look at What Your Work Means to You.

However, if job burnout occurs, Bellafiore (n.d.) encourages us to think of it as a gift--one that lets us know that something in our lives has gotten out of order. We are motivated to look deeper within to resolve the burnout--and you're motive to help your supervisee do this. With no burnout crisis, what would prompt us to at last search for answers to some crucial life-questions? Questions such as:

• What am I trying to accomplish with my work life?
• What are my key interests and does my work fit with them?
• What are my key skills and does my work use them?
• What are my core values about life balance, about family, about money, about the treatment of people? Is my work in synch with these?
• Am I overworking? If so, why?
• Where is the balance in my life between work and play?
• How would I live my life if I no longer had to work?
• What does work accomplish for me and what is it preventing me from accomplishing?
• Can I shift the focus of my current work or should I look into another type of work?

Since you don't want to cross the supervisor boundary into counselor for your supervisee, you may need to see that she gets counseling to answer these questions. This focused examination of work-life issues can lead her to sort out the work-life stresses and return to blooming in the job and the rest of life.

AVOIDING RISK FACTORS FOR MISCONDUCT WITH CLIENTS

It's not uncommon for therapists to feel sexual attraction to clients at least once in their career. In fact, Pope, Keith-Spiegel, and Tabachnick (1986) related that 87% of psychologists (95% men and 76% women) reported that attraction. However, only 9% considered that they could talk to their supervisor about it. This suggests you need to be on the alert for a supervisee needing to talk about this sexual attraction.

A supervisor is obligated to investigate any and all indications of harm to clients, to say nothing of your own liability. Even if there is only an attraction, the possible counter-transference can compromise successful therapeutic treatment. You must warn supervisees against acting out such intense sexual feelings, and encourage him to discuss them by offering him a safe, open, and sensitive atmosphere for that. You should also document the discussion (Cole, 2001).

For starters, in California if you're the primary supervisor, you're required to review with all of your supervisees a pamphlet entitled Professional Therapy Never Includes Sex. You may find this booklet online and it can be used by supervisors and therapists in any state. This booklet is especially to give clients information about pertinent laws, warning signs that a therapist may be heading towards sexual exploitation, what they should do if something happens and who they should talk to, and what their reporting options are. If you see a supervisee giving signs of sexual attraction, a second (or third, etc.) review of this booklet might be good.

To aid your alertness in this direction, you might learn about the risk factors for therapist-client sexual misconduct as outlined by Hamilton and Spruill, J. (1999):

• Trainee Characteristics
  • Loneliness: The trainee may be somewhat isolated, have few friends, i.e., problems with personal relationships.
  • Prior "counseling" experience: Prior experience as a volunteer counselor, where volunteers often befriend clientele, may have caused a belief that a close personal relationship is therapeutic.
  • Professional inexperience: Because quality of therapy is hard to evaluate, supervisees might overvalue certain inadequate indicators of therapeutic progress such as friendliness on the part of the client, or the trainee may be fearful of alienating the client.
• Training Factors
  • Ethics training: Trainees will have all pretty much been given the information that therapist-client sexual involvement is unethical, but they may not have been taught to recognize the unethical intermediate steps to that involvement.
  • Failure to recognize ethical conflicts: Trainees have been given hypothetical, laboratory ethical situations to analyze; they may not carry that over real-life situations.
  • Doing what needs to be done: Trainees likely don't have an armamentarium of behaviors for responding to sexual overtures from clients.

[QN.No.# 80. While sexual attraction to a client may be normal and ethical, acting on that attraction is not ethical. Risk factors for therapist-client sexual misconduct include:]

Once you engage a supervisee in a conversation about their sexual attraction to a client, there are two main topics that you need to discuss with them (not give a "classroom lecture" about):
Such attraction is normal
Drawing the line between feelings and actions

PROJECT PRIORITIES

How do you determine which projects, daily tasks and activities, or steps towards your goals to do first? Your supervisees may need some guidance in this area. There have been many excellent books and articles on determining priorities; several potential methods are presented here.

Student services at the University of Minnesota give students a list of ten items to help define priorities (One Stop Student Services, n.d.). Although they're referring primarily to money management, the list is appropriate for determining any sort of priorities:

• Narrow your objectives.
• Focus first on the goals that matter.
• Be prepared for conflicts.
• Put time on your side.
• Choose carefully.
• Include family members.
• Start now.
• Sweat the big stuff.
• Don't sweat the small stuff.
• Be prepared for change.

One of the most common approaches is to list everything that you need to accomplish. You may have several lists, such as what needs to be done today, or what steps must be taken to reach a particular goal. Items on each list are given a number for the order in which things must be done. Number one is the first priority of the day, and so on for however many items are on the list.

Another approach (How to Set Priorities, n.d.) is to have three priorities, and list the items that fit into each priority:

• High Priority--Must Do: Goals or activities that you must achieve in order to consider yourself "successful."
• Medium Priority--Should Do: Goals or activities that should be achieved (but are not essential) in order to consider yourself "successful."
• Low Priority--Nice to Do: Goals or activities you'd like to do, but that need not be done until things listed in the other two priority lists have been completed; if you don't do them, it's not a big deal.

The "Urgent/Important" matrix is way of prioritizing actions that is quite different from the ways folks usually follow. President Dwight Eisenhower is said to have used this to organize his tasks, and it's sometimes called the "Eisenhower Matrix." Steven Covey popularized the method in The 7 Habits of Highly Effective People (Habit 4: Think Win-Win).
In this context, the difference between "Important" and "Urgent" is focal:

• IMPORTANT = Activities whose outcomes lead to achieving our goals.
• URGENT = Activities requiring immediate attention (meeting with a client at 10:00 a.m.), often connected to helping someone else meet their goals.

With these distinctions in mind, use these steps to prioritize your activities (Urgent/Important Matrix, n.d.):

• List all activities and projects you feel you need to do, no matter how important or unimportant. Record everything that takes up your time at work.
• On a scale of 1-5, designate the IMPORTANCE of each activity.
• Evaluate whether each activity is URGENT or NOT-URGENT. (When you've completed this step, each activity or project will have both a number to indicate IMPORTANCE and an URGENCY designation.)
• Schedule your priorities using the concepts on matrix that follows. The numbers in red on the matrix are the order in which your activities should be done.

TIME MANAGEMENT

Time management is closely tied to establishing priorities. Both are needed for a person to be as productive as possible. If a person has problems managing his time, he will spend the day in a frenzy of activity without accomplishing much of anything. In addition to getting more done in a day, according to Mayo Clinic Staff (2008), this will also give you some important health benefits, minimize stress, and improve your quality of life. Ward (n.d.1) offers some tips for managing one's time.

• Realize That Time Management Is a Myth
  • You can be perfectly organized, and still not add one hour to the day. At best you can manage yourself and what you do with the time you have.
• Find Out Where You're Wasting Time
  • What activities do you do regularly that are time thieves? Reading e-mail? Checking out Facebook? Surfing the Internet? Gossiping with your friends? For a week, keep a daily log of how much time you spend on activities. You don't need to go into detail; for instance you might write "Did research on ADHD for client."
• Make Time Management Goals
  • Since you can't change time, you must change your behavior. To begin, set one goal to not take personal phone calls when you're working. Ward (n.d.2) suggests the following wording for setting your goals (to aid your specificity of goals writing):
    "(Time) from now, I will (goal performance measure) BY (specific actions)."
    An example might be, "Two months from now, I will work three hours less per week BY becoming better organized."
• Implement a Time Management Plan
  • This is an extension of tip #3. You'll actually do what you said you would in your stated goal(s). Be sure to track them to verify that you're accomplishing them.
• Use Time Management Tools
  • You'll need some way to help you plan and remember how you're going to spend your time in the future. It may be a Day-Timer, or the calendar that comes with your e-mail program. The software program not only allows you to easily schedule events, but it can be set to remind you of the events at specific times.
• Ruthlessly Prioritize
  • Either end a day with prioritizing the tasks for the next day, or begin the day with planning its events. Set your performance benchmark. If you list 25 tasks for the day, how many of them must you truly accomplish (see the section above on prioritizing tasks).
• Learn to Delegate and/or Outsource
  • There is seldom a need for a person to be a one-person team. As supervisor, you'll likely delegate some jobs to the supervisee. Does the buck always stop there, or can you show her times when she can also delegate or outsource?
• Establish Routines and Stick to Them As Much As Possible
  • Although you can't avoid crises, if you can follow routines most of the time you'll be much more productive.
• Get in the Habit of Setting Time Limits for Tasks
  • A good example of how this works is with your e-mail. You could spend half or all of the day reading and answering e-mail. Instead, set a limit of one hour a day for this, and then stick to it.
• Be Sure Your Systems Are Organized
  • If you're wasting a lot of time trying to find files on your computer, take the necessary time to organize your files. You might manage them with a purchased document management system, or you can make your own system of files and sub-files in Microsoft Office programs (just don't go too many layers deep or you'll likely defeat your purpose).
• Don't Waste Time Waiting
  • There is no way to avoid waiting for someone (client meetings, doctor's appointments, etc.) or something (telephone call, certain e-mail, etc.). You can choose to sit and twiddle your thumbs or read the year old magazines in the waiting room. Or you can take something with you that needs doing: a report to be read, a checkbook to be balanced, or simply a pad of paper to plan something for the job. You might take your laptop and do whatever work you need to do on that while you wait.

Mayo Clinic Staff (2008) includes a few additional tips in their list:

• Say no to nonessential tasks-Consider your goals and schedule before agreeing to take on additional work.
• Take the time you need to do a quality job-Doing work right the first time may take more time upfront, but errors from haste usually result in time spent making corrections, which takes more time overall.
• Practice the 10-minute rule-Work on a dreaded task for 10 minutes each day. Once you get started, you may find you can finish it.
• Limit distractions-Block out time on your calendar for big projects. During that time, close your door and turn off your phone, pager and e-mail.
• Get plenty of sleep, have a healthy diet and exercise regularly. A healthy lifestyle can improve your focus and concentration, which will help improve your efficiency so that you can complete your work in less time.
• Take a break when needed-Too much stress can derail your attempts at getting organized. When you need a break, take one. Take a walk. Do some quick stretches at your workstation. Take a day of vacation to rest and re-energize.

WORKING WITH OTHER PROFESSIONALS

You've heard the famous quote from the English poet John Donne, "No man is an island." You've experienced, and your supervisees will experience the truth of that profoundly in the helping field you've all chosen, especially if you work with families and children.

For example, if you work with children that are in the state's Child Protective Services, sooner or later you'll need to work with people from the following professions or vocations:

• Attorneys
• Foster parents
• Judges
• Physicians
• Police
• Psychologists, counselors, and other mental health therapists
• Social workers
• Teachers
• Volunteers (e.g. Court Appointed Special Advocates)
• Support services

Even though you may never all meet together, you'll need to be a team, working together to the good of the child/client. There are 12 "C-Tips" (Heathfield, n.d.) to keep in mind as you play your role in the team. You and your supervisee will need to apply them to yourselves; you'll seldom be in a position to do more than that:

• Clear Expectations--Although these are generally understood, every team member needs to know:
  • Why the team is in existence
  • What your role is in the team
  • What resources you and others on the team have to accomplish the goals
  • Priorities of the team as a whole, and each member individually
• Context--Strategies that will be used by each member to care for the client
• Commitment--Each team member must be committed
• Competence--Each team member needs to be competent in their job for the team as a whole to succeed
• Charter--The vision, mission, and strategies for caring for the client. This involves:
  • Goals are defined and communicated
  • Anticipated outcomes (e.g., reuniting children and parents, foster care, adoption)
  • Timelines
  • Processes to meet the task
  • Outcome measurement
• Control--Does each team member:
  • Have freedom and empowerment to do their job?
  • Understand their boundaries?
  • Understand and experience the team's reporting relationship and accountability?
  • Have the freedom to make suggestions to any or all other team members?
  • Have accountability for meeting goals and timelines?
• Collaboration--Do you:
  • Understand team and group process?
  • Cooperate and work effectively with other team members?
  • Understand your role and responsibilities and how they fit in with those of other team members?
• Communication--Team members need to:
  • Keep other team members updated (within HIPAA regulations) as to where things stand in your team job
  • Give and receive honest feedback
  • Work together to resolve any conflicts
• Creative Innovation--Often there is no opportunity for this other than what the supervisee does in therapy. However, at times, he may have a suggestion for one of the other professionals that might make their job easier or more effective.
• Consequences--It's too often easy to take other team members and their accomplishments for granted. Give them the "consequence" of a compliment whenever possible. The "consequences" of your doing so will be improved relations with other team members.
• Coordination--Usually it's the social worker in charge of the case who might be considered the coordinator for the team. But many team members are used to working as a team of one. The social worker is often loaded down with too many cases. Perhaps you and/or your supervisee could ask if there is any part of the coordination you could to that would ease their burden.
• Cultural Change--Do team members recognize that there is no hierarchy in a team such as this (even though their job may be part of a hierarchy), but that everyone is equal. Because of the difference of the person's job and her position on the team, it may be difficult for him to adapt to this cultural change.

MANAGING CONFLICTS WITH OTHER EMPLOYEES

There's probably something wrong with you or your supervisee if you've never encountered someone who frustrates you so much that you want to scream and pull your hair. Everyone has met at least one person like that, and most have found a colleague that fits that bill.

For example, your supervisee may:

• Turn in paperwork late or only after much prodding
• Habitually come late to supervisory meetings
• Vehemently stick to all of his views
• Refuse to collaborate . . . and more.

Instead of getting frustrated, of thinking she's irresponsible or difficult, or wishing you didn't have to work with her, try these principles (Chua, n.d.) instead:

• Be calm
• Understand the person's intentions
• Get some perspective from others
• Let the person know where you're coming from
• Build a rapport
• Treat the person with respect
• Focus on what you can change, not what you cannot change
• Ignore when possible
• If all else fails, escalate to a higher authority for resolution