CRISIS MANAGEMENT DURING “LIVE” SUPERVISION: CLINICAL AND INSTRUCTIONAL MATTERS
Charlés, Laurie L
In this article, we illustrate two examples of “live” supervision with marriage and family therapy trainees whose clients presented in the therapy room in immediate crisis. The case examples, one a client with suicidal thoughts and the other a parent who had struck her child, demonstrate how the university-based therapy team managed the recursive clinical and supervision processes that unfolded during the sessions. We present the case examples from the perspective of both supervisees and supervisor, discussing how our different experiences of the supervision unfolded in real time. Case discussion and reflections later in the article illustrate the need for an open, transparent, dialogical process throughout supervision. A case is made for supervisory participants to create alternative formats in which multiple supervisory voices can be heard.
INTRODUCTION
In marriage and family therapy (MFT) training programs, clinical supervision has been shown to be a generative and invaluable method of promoting a therapy trainee’s clinical development (Liddle & Schwartz, 1983; Montalvo 1973; Storm, Todd, Sprenkle, & Morgan, 2001; Storm & Sprenkle, 1997; Todd & Storm, 1997). Clinical supervision is the primary way new clinicians develop skills and build theoretical understanding, as well as learn values and norms about the MFT culture (Everett, 1980; Lee, Nichols, Nichols, & Odom, 2004; Nichols & Lee, 1999). In particular, the intensity of live supervision can be an extremely generative learning platform for both supervisor and supervisee. Indeed, the intense focus on cases in “live” supervision (i.e., when a supervisor is observing from behind a one-way mirror) is a routine process in many MFT programs and institutes. It is both a distinguishing feature and hallmark of the field (Storm et al., 2001).
Conducting live supervision with therapy trainees who find themselves in the midst of a client crisis adds even more complexity to the supervision process. The supervisor/supervisee relationship, a therapy team’s synergy, and the context in which the supervision takes place are all variables that influence how the crisis is handled. Further, a supervisor’s theoretical views of therapy and model of supervision are critical elements that also shape how a trainee manages a crisis intervention process. The team context and supervisory relationships can determine how effective any intervention might be. A supervisor’s guidance can either help or hinder how a clinical trainee manages the crisis in the room.
In this article, the authors (an American Association for Marriage and Family Therapy [AAMFT] approved supervisor [LLC] and three MFT supervisees, [MTK, KT, and BBS]) discuss how crisis interventions were handled during the live supervision of two clinical situations. The cases took place during two separate practica, the first of which was master’s, and the second, doctoral. In the first example, a client revealed thoughts of slashing her wrists and ending her life. In the second, a father revealed to the therapist that his wife had hit their 10-year-old child in the face, bloodying her nose. In this article, we will illustrate how the therapists and supervisor on the case managed, discussed, and reflected on the clinical decision-making process in these cases as they occurred in real time. We present our perspectives in a narrative format, from the voices of both supervisees and supervisor in each case.
The case narratives provided will illustrate how a collaborative supervision model (Anderson, 1997; Flemons, Green, & Rambo, 1996; Green, Shilts, & Bacigalupe, 2001) influenced the clinical and instructional matters in both cases. In addition, we will discuss how systemic thinking informed the clinical management of these potentially life-threatening situations (Bobele, 1987), and how systemic questioning elicited difficult and highly emotionally charged information from clients. We also discuss how the team met legal and ethical standards and provided a reasonable standard of care.
SYSTEMIC UNDERSTANDINGS OF CRISIS INTERVENTION
The systemic management of crisis is a topic that has received notable, but limited, attention in the field of MFT. Yet, Bobele (1987) noted that “life-threatening behavior is a relatively common encounter in the day-to-day practice of many clinicians” (pp. 225-226). Thus, instruction on how to manage crisis events that occur in a clinical context is necessary for new and developing MFT trainees. Considering the systemic elements of how crises begin and develop is an important part of the learning process. As Bobele suggested (1987), “interventions designed to prevent the dangerous behavior without taking into account the interactional context of the threat run the risk of actually increasing the likelihood that tragedy will occur” (p. 225).
A systemic approach considers how a crisis makes sense in the context in which it occurs (Bateson, 1972; Everstine & Everstine, 1983). A therapist operating from this perspective must be prepared to deal with the clinical information generated by a systemic exploration into the details of a client’s crisis. However, it is less clear how clinical supervisors guide trainees through the management of a client’s crisis as it unfolds in the therapy room.
Part of the reason for the lack of information on this topic may be that, typically, crisis management-specifically, the guidance from a supervisor-often occurs out of synchronization with the trainee’s interaction with the client’s crisis event. That is, in most clinical situations, a client’s crisis is managed out of the immediate awareness of or direct observation by the clinical supervisor. Live supervision is the exception to the rule. In live supervision, the unfolding of a client’s crisis, its immediate clinical response, as well as the supervisory guidance from behind the mirror, can take place in the same context. In this article, we provide both the view of the supervisor and supervisees on cases of crisis management during live supervision as a way to illustrate the complexities, richness, and challenges of the live supervision process in the midst of a clinical crisis.
The Complexities of Live Supervision in Crisis Cases
In crisis sessions that occur during live supervision, the supervisor has multiple goals and responsibilities. The supervisor must make sure that the trainee meets legal and ethical responsibilities and ensures a reasonable standard of care in the session. In addition, it is especially important for supervisors working from a systemic perspective that the supervisee meet these responsibilities while maintaining (and quite possibly enriching) his or her relationship with the client. In a live crisis session, the supervisor finds a way to do all of this from behind the mirror, allowing the supervisee an opportunity to manage the client crisis. Supervisors do this knowing that such opportunities take place in the context of multiple legal and ethical duties, as supervisors are “legally liable for the work of their supervisees” (Todd & Storm, 1997, p. 3).
Introduction to Case Examples: A Supervisor’s Perspective
As a supervisor working from a collaborative perspective, my intentions are to access and develop the ideas, views, and resources of my supervisees. I believe supervisees are more likely to do what I suggest if it fits with their own ideas. I also think they will do a better job as clinicians if they believe in and understand what they are doing. I see it as my goal to discover their beliefs and understandings, hone in on what is useful or significant to the case, and encourage the supervisee’s use of that information in a way that is clinically relevant. Overall, I see this process as developing supervisees’ clinical expertise-their confidence and their competence.
My model works well for me when I can find that fit between the supervisees’ ideas and my own. However, when I cannot, I struggle, and my supervision tends to become directive. Also, when I discover that a supervisee’s ideas are inconsistent with some component of my identity or experience as an MFT (i.e., my view of a systemic perspective, my take on the AAMFT ethical code), I slow down my collaborative model considerably. Instead, I primarily focus on guiding the supervisee toward identifying and challenging their beliefs. It is difficult for me to maintain this focus in a productive way during the intensity of live supervision. Interestingly, I have noticed that it is also at these times that my supervision tends to become directive.
The cases presented took place in the Spring and Fall of 2002, respectively, during two MFT clinical live supervision practica-one doctoral (Spring) and one master’s (Fall). KT was the clinician in the doctoral practicum; MTK and BBS were the clinicians in the master’s. In the case in which MTK and BBS were therapists, BBS had joined the case as a cotherapist after MTK had had several sessions alone with the client. Both cases occurred during practica that were a part of the curriculum requirements in a Commission for Accreditation on Marriage and Family Therapy Education accredited program that grants both master’s and doctoral degrees in MFT. LLC was the supervisor behind the mirror on both cases.
As a supervisor and researcher, I (LLC) am curious about how supervisees make sense of their supervision. In the cases presented in this article, I was curious to better understand how supervision had played a part in the supervisees’ ability to manage their client’s crisis. In these cases, I had been confident that the trainees had done well and that I had reached my goals as a supervisor. I also thought that I had been true to my collaborative model of supervision. The cases each demonstrated a commendable, reasonable standard of care, and each supervisee had seemed receptive and open to supervision. In each case, the trainees had adjusted their initial clinical behavior to fit with a model that more clearly addressed the clients’ unfolding crisis. My impressions of the work of MTK, KT, and BBS had done in these cases was good. Thus, I asked few questions of them about the cases once they had ended.
When an opportunity arose to present at an AAMFT state division conference (Texas Association for Marriage and Family Therapy [TAMFT]), I consulted with MTK, KT, and BBS, asking them if they were interested in talking about our work together on the crisis cases. They were interested and agreed to present if our proposal was accepted. I wrote and submitted the abstract, “Crisis management during ‘live’ supervision: Clinical and instructional matters” (Charlés, Barber-Stephens, Tyner, & Ticheli, 2003), which I emailed to them for their approval. The abstract was accepted. MTK, KT, and BBS contacted their former clients and gained permission to use their case data in the presentation. Several months later, as I began to prepare for the presentation, I asked MTK, KT, and BBS to write up a synopsis of the case on which they had worked. I asked them to address the specifics of the case, the actual crisis session, their experience of the supervision, and how they had incorporated supervision information into their management of the crisis. These questions focused on the purpose of our presentation, which was to address both clinical and instructional matters in live supervision during a crisis.
We present the case narratives here in the same format as our presentation. The specific questions I (LLC) had posed to supervisees are subheadings in this article. My supervisory comments are placed after the supervisees’ sections. Essentially, each case example reads like a story of the crisis session, from both the trainee and supervisor point of view. In this article, we also add our insights from the experience of giving the TAMFT presentation and the discoveries that took place there. In the presentation, KT and LLC realized that they had diametrically opposed views of how the live supervision process took place in KT’s case: LLC had perceived it as helpful and collaborative, whereas KT had perceived it as less than helpful and directive. This discovery, which unfolded in the midst of the case presentation, led to a curious, openended dialogue with the small audience (8 people) about the complexities of the live supervision process. Audience members commented on how interesting it was that KT and LLC had each perceived the case supervision so differently. Their questions and reflections helped KT and LLC to further question how the difference in their perceptions made sense. It also led to more exploratory questioning of my (LLC) supervision processes, illustrated to some degree in this article.
Finally, we include a note on how we prepared for the presentation. Each of us constructed our narratives separately. I (LLC) did not ask to review or approve the supervisees’ portions of the presentation, although both BBS and MTK consulted with me prior to the conference. I (LLC) also wrote my narratives after the trainees had written theirs, and I did so without consulting them. To write my part, I used notes I had taken behind the mirror and during supervision meetings as a way to reconstruct (Ellis, 2004) my memory and build on my ideas. The first time the trainees became aware of my supervisory thought processes at the time of their case crises was during the TAMFT conference presentation. I did not discuss my ideas with the supervisees prior to the conference for several reasons. Two of the supervisees (BBS and MTK) and I had little contact with each other after the semester ended; in the case with KT, I had assumed that our supervision on the case was complete and required no further discussion. It was only at the presentation, approximately 1 year later, that I realized my assumptions about my work with KT were mistaken.
The narratives we present next reflect ideas and understandings about our work prior to our collaborative presentation of it at the MFT conference. This is consistent with how we all experienced the supervision and clinical processes in real time. Discussion on how the presentation discovery shaped further supervisory reflection by LLC is presented later in the article.
CASE EXAMPLES: MULTIPLE PERSPECTIVES ON THE CRISIS SESSION AND ITS SUPERVISION
Case Example One: The Sad Woman (MTK and BBS, Master’s Students)
Case overview. This case involved a young woman in her early thirties. She was separated from her second husband of 8 years and had three children who ranged in age from 8 to 14. The client, “Susan,” had a recently widowed father and several sisters and brothers for whom she helped to care. Their ages ranged from 8 to 19. Susan’s initial complaints included issues with her family and general feelings of being stressed out and unappreciated. Her ex-husband was unfaithful to her during each attempt at reconciliation, and she continued to move back and forth between her father’s house and living with her husband. She complained of feeling used by everyone and at the end of her rope.
Synopsis of the session. During the session in which a crisis occurred, Susan discussed her role in the family and the obstacles she faced around being independent from her husband and father. She went on to say that very often after dealing with either of them she began to wonder why she is “still here.” When we asked her to clarify what she meant, MTK posed the question: “Do you mean here as in this world?” she replied, “Yes. I mean, why am I still alive?” The conversation then turned toward a discussion of what she was dealing with that led her to feel like giving up.
Susan talked about her feelings of being used by everyone for something-sex, money, rides, and babysitting. She stated that everyone would be better off without her. We (MTK and BBS) pointed out how that idea contradicted all the prior information she had given us. We attempted to reframe her perception by telling her that, according to the information she had given us, it sounded as if she was very important and needed. The course of the conversation then turned away from Susan’s comment about not wanting to be in this world and toward her attempted solutions. At this point in the session the supervisor called for a break and the team suggested that we go back to Susan’s remark about “still being in the world.” For the remainder of the session, we focused on questioning Susan about her suicidal thoughts.
Our impressions as the therapists. Although our initial plan of talking to Susan about her boundaries and relationship with her ex-husband was critical to the therapeutic process overall, this dialogue should have been secondary to a discussion around Susan’s comment about wondering why she is still alive and in the world. The session proved to be a vital learning experience for my (MTK) growth as a therapist when dealing with crisis situations. During the beginning of our session, our conversation did not reflect a typical crisis situation, because the comment was made in such a subtle way, and Susan did not seem to be distressed at the time. We ended up talking about what is going on when she feels that way, what she has tried, and what she can do about it. I (MTK) think that, without the team supervision, the opportunity to intervene could have easily been missed. Although the topic more than likely would have come up again, timing is critical and no comment or remark to that effect should be overlooked or discarded.
Our experience of the supervision process as it was on-going. The supervisor and the team behind the mirror really helped us to stay on track and focused on the issue of suicide. It was difficult to gauge how direct to be when it was clearly difficult for Susan to elaborate on the subject. After a while and several phone calls from LLC, we began to feel a real connection to the team and a better sense of how to approach the situation. I (MTK) began to feel more connected to the client as well. It seemed as though the surer of myself I became, the more at ease Susan became at talking about her situation.
How we incorporated supervision data (or not) into the session. It was very easy to incorporate the ideas and suggestions of our team during this session, because the direction we received empowered us as therapists. We realized we were being “too careful” by worrying about whether or not we were being harsh or pushy with Susan. Once we changed our focus to the subject of suicide and the ethical concerns involved, we were able to get more important information from the client and reached our goal of having an agreement with her.
Reflections and commentary from the supervisory perspective. In this case, I (LLC) still can distinctly remember hearing the client’s statement, “I wonder what it’d be like if I wasn’t here?” Susan said this very softly, while looking down and slouching low on the couch. I also remember becoming nervous when neither therapist in the room responded to this comment. I waited to see what BBS and MTK would do, to see if they would change direction. Instead, they continued on their original plan, which involved getting the client to do a behavioral chart of her interactions with her ex-husband. This did not allow for discussion of what the client had said.
Shortly after that initial comment, the client then said, more strongly, several other things that concerned me: “Everybody’s using me;” “Sometimes I wonder why I’m here;” and, “I don’t understand what I’m doing here.” After the latter comment, one of the therapists in the room, BBS, asked her, “What do you do when you have these thoughts?” The client stated that she suppresses those thoughts, because she would hurt too many people if she weren’t here. I was glad BBS had commented on the client’s remark. However, the therapists’ responses afterward did not seem helpful. They said to the client, “You’re contradicting yourself,” and told her that her remarks were “incongruent.” I phoned in, asking BBS and MTK to take a short break to consult with me and the team behind the mirror.
During the break, I pointed out to the therapists the phrases the client had made. Both therapists had noticed the comments, but had chosen not to address them. I told them we had to focus the rest of the session on the client’s comments and do a suicide assessment. BBS and KT seemed hesitant and pointed out that they thought they had done that. I walked them through a typical lethality assessment and suggested questions for them to ask: What had the client imagined doing? What had she attempted doing? What had kept her from succeeding thus far? BBS and KT seemed receptive to my suggestions and went back in the room.
Back in the room, MTK began to explore with the client how she had avoided hurting herself in the past: “Who do you think of? What stops you [from hurting yourself]? Susan responded, “My mother.” As a team we were all aware that the client’s mother was deceased, and I was concerned that she had only her deceased mother as a resource.
BBS asked Susan, of all the things she had thought of doing, (which included taking pills and cutting her wrists), “What are you more likely to do?” Susan then said, very softly, “Slit my wrists. . . . I’m tired. I’ve got nothing left to give.” Finally, after a long silence in which I was grateful that both BBS and MTK participated, Susan said, barely audible, “I’d like a little bit of help.” She also said, quietly, “I don’t know who I am.” At this point, the client was despondent, barely completing her sentences. This seemed to throw the therapists a bit of a curve; the more despondent the client got, the less the therapists asked her questions about what that was like. I remember thinking (and telling the trainees behind the mirror) that perhaps Susan may sense that the therapists are afraid or do not want to ask her such painful questions. Thus, Susan may try to “help them out,” by not being more forthcoming.
By that point in the session, we knew that Susan went to sit on the bathroom floor to think about cutting her wrists. We did not know much more than that. BBS and KT seemed hesitant to go further. As a supervisor, I wanted BBS and MTK to “get on the bathroom floor” with the client metaphorically, and find out what it was like for her there. What was happening at those times? More importantly, what had kept her from doing anything thus far? Why had she remained attempt free? I called into the room and encouraged the therapists to have this conversation with Susan and to try to elicit some information from her about what kept her going even in those moments. I remember thinking that if BBS and MTK were fearful; I should reflect calm and confidence in making my suggestions. In this way, I tried to convey that it was okay to ask these questions, and that they could deal with the answers.
In the next part of the session, we learned that the client’s aunt had attempted to commit suicide by slitting her wrists. We discovered that Susan did not feel she had anyone to talk to that could or would really listen to her needs. We also learned why she had been so afraid to talk to anyone; she thought her children would get taken away by Child Protective Services (CPS). She did not see any wisdom in telling anyone else what she had told BBS and MTK.
With this information in hand, the therapists worked with Susan on a plan for what she could do in those moments she felt like hurting herself. Their increasingly skillful questioning elicited important information-Susan preferred calling an anonymous help line to calling someone she knew. She also said she felt comfortable calling the therapists or our MFT clinic. This encouraged us. In addition, as Susan talked, she said that she knew she would never hurt herself on the bathroom floor, because she was a coward-she couldn’t do it. Quickly, I phoned in to BBS and MTK to tell the client that on the contrary, her refraining from harming herself was an act of bravery, not cowardice. What she was doing was the brave thing-for it took courage to go on when she felt so much pain and isolation. Susan looked up, for what seemed like the first time that session, and said “Yes, I guess that’s true.” By the end of the session, we all felt Susan was depressed and in need of help as she said, but we felt certain she was not in danger of harming herself or anyone else.
I called in one last intervention to MTK, who was nearest to the phone and who seemed to have had the most trouble focusing on the client’s scary comments. I asked her to find a way to get the client to tell her she would follow through on a plan to talk to others when she felt the urge to hurt herself. I remember telling MTK to “make sure [the client] looks you in the eye” when she said it. I asked MTK, “Can you do that?” “Yes, I can,” MTK said. And she did.
After the session, I talked with BBS and MTK. Although they had started out hesitantly, feeling around new ground, by the end of the session, they were doing an excellent job getting information. In fact, by the end, they were fearless about asking hard questions, those to do with Susan’s desire to cut her wrists, to sit alone on the bathroom floor and talk to her dead mother. By the end of the session, BBS and MTK could hear those comments and respond sensitively to them, without trying to persuade Susan that she need not feel what she did. BBS and MTK did a superb job, and I told them so. MTK then told me, “Once I got over worrying so much about me and what I was asking . . . and just asked her about her, it worked. It clicked.”
Case Example Two: The Angry Mother (KT, Doctoral Student)
Case overview. This case involved a mother and father who brought their 10-year-old daughter in for problems with lying, urinating on herself, and poor hygiene. It also appeared that the parents were concerned about their daughter’s motivation in school; however, the daughter’s overall grades were not bad. The mother reported being “at the end of her rope” with the fighting and bickering between the 10-year-old daughter and her older brother (12 years old). She reported that the two would scream at each other and that the mother could actually feel her blood pressure rise during these fights. The mother was concerned that “normal siblings” did not scream at each other this way; however, the father found nothing unusual about the behavior.
Synopsis of the session. During the session in question, the father came into the therapy room first; the mother was late, coming to the session directly from work. The 12-year-old son had stayed at home, but the 10-year-old remained in the lobby while I (KT) spoke to the father first. The father explained what had been happening in the household during the last week. Shortly after, the mother came in and the discussion led to an incident that had occurred over the weekend. The mother explained that her two oldest children had been screaming at each other again, and that she had asked both of them to stop. The daughter, who was standing close to the mother at the time, screamed one more time at her older brother and the mother “lost control.” She slapped her daughter across the face and unintentionally hit her nose, causing it to bleed. After the incident, the mother apologized to the daughter and explained to all of her children that what she had done had not been the right thing to do.
Immediately after the parents told me their story, my supervisor called into the session and asked me to take a break. The supervisor met me out in the hallway and told me that I was going to have to make a call to CPS. We talked briefly about what had occurred in the therapy room and about the procedure for making the call. LLC offered to go into the room and tell the clients for me that CPS would have to be called. I declined. Despite the fact that I was nervous and did not want to tell the parents that I was calling CPS on them, I realized that I would have to be the one who made the call, and that I could not rely on my supervisor to do it for me. LLC and I also discussed giving the couple some options regarding the call: They could make the call themselves, I could make the call with them in the room, or I could make the call after they had gone home.
After going back in to the room I explained to the parents that I was going to have to report the incident to CPS. The mother commented that she knew from the look on my face while she was telling the story that I was going to call. She seemed concerned and afraid, but not angry. The father, in contrast, was extremely upset and did not understand why I had to make a report. The mother was also concerned as to what would happen as a result of the report. She was concerned that her daughter would be taken out of the home and stated that she would rather leave than to have her daughter removed from the home. The mother also requested individual sessions to help her deal with her children’s fighting better. I stated that I was unsure what would happen, but that I would inquire as to the possibilities when I made the call. I explained to the couple my reasons for making the report: That I was ethically bound to report any incidents of violence involving children, and I reminded them of the therapy agreement that they had signed upon entering therapy. They understood and took me up on the offer to sit with me while I made the phone call.
During the phone call, which I made in another room with the clients sitting next to me, I got the impression that the person taking the information did not appreciate the severity of the situation. I explained what had happened and, as promised, asked what may come of my making the report. I was told that probably little, if anything, would happen. I was told that someone might come to the home and talk with the parents and with the daughter, but that this would probably be the extent of the consequences. I made the parents aware of this information. After the session, I explained to LLC what I had been told on the phone. She suggested that I make another call to CPS at that time to explain my concerns. I made this telephone call; however, the family had already left and did not know about my subsequent call.
My impressions as the therapist. I knew the moment that the story was revealed to me that I was going to have to call CPS, and I remember becoming very nervous because of it. I was not sure how the parents were going to handle the situation, and I was sure that I had lost them as clients. Although I was touched that LLC offered to go into the therapy session and do the difficult work for me, I knew that I would have to be the one that did it. I realized that this would probably not be the only time that I was to be required to make a report to CPS and did not see any point in delaying the inevitable. I appreciated the suggestion given to me by LLC to offer the parents some options as to how the telephone call would be made. In a time of crisis and uncertainty, I believe that it was helpful for the parents to feel as if they had some control in the situation. I did not want them to feel as if all of their power had been taken away and that they were being punished, just as they might punish their children for poor judgment. I wanted them to understand that this was something that I was ethically bound to do and that I wanted them to be just as involved in the experience as they wished to be.
My experience of the supervision process during the crisis as it was on-going. It was helpful to have a supervisor present during this crisis situation. Although I had made a call to CPS before, I had never made a report on a parent that was actually a client of mine. It was helpful for LLC to be there to reassure me that the steps that I was taking were the right ones to take. I remember appreciating the supervision experience during this process. As for my reasoning for not wanting LLC to come into the room with me and explain to the parents why a report had to be made, I felt as if the parents had enough to deal with without having to be presented with another person’s presence in the therapy room. I felt as if the mother was punishing herself enough, and that she might be uncomfortable with another person in the room other than me.
How I incorporated supervision data (or not) into my intervention into the crisis. Without LLC’s supervision on this case, I am unsure as to what I would have done. I know that I would have made the call and that I would have told the parents that I had done so, but I am not sure as to how I would have gone about the process. I do know that I would not have offered the parents the option of being in the room while I made the call; I simply would not have thought of this option on my own. I probably would have made the call after the parents had left the session. I found LLC’s suggestion of giving the clients the option to be present when I called wonderful. It is a suggestion that I will keep in mind for my next CPS report.
Reflections and commentary from the supervisory perspective. KT and I (LLC) had worked on the case of the angry mother for several months as supervisee/supervisor. KT had had the case for several months prior to that. The 10-year-old’s initial presenting problems had been that she was urinating on herself, refusing to maintain personal hygiene, and picking at her skin so much that it scabbed. KT and her previous supervisors, including myself, had suspected abuse of some kind. However, there was never any indication of abuse or neglect in- or outside the home, until this session.
As a clinician with a long background in crisis intervention, I (LLC) was all too willing to be helpful regarding KT’s initial timidity about how to manage the crisis presented in her session. Given the family’s history, and the 10-year-old’s fairly recent symptoms, it was clear to me that we would report this incident to CPS. I was convinced of this by a comment the mother had made when describing the incident with her daughter. She stated that she had been afraid she would “pummel her to death.”
During the mid-session break, during which KT and I discussed how she would let the family know she was going to call CPS, I felt a need to rescue KT. I wanted to be helpful, but I was anxious about following our ethical and legal duties as therapists. I remember being anxious that KT might not have appreciated the magnitude of the mother’s remark about wanting to pummel her daughter to death; KT had not commented on it in the room.
I asked KT, “Do you want me to come in the room with you?” KT paused a moment, then said to me, “Well, I think I need to do this.” Hearing this, I was both elated and relieved. I was so glad she told me “no”; I wanted her to tell me “no.” In fact, her “no” was a turning point in our supervisory relationship; KT was telling me that she did not need me to “rescue” her. I was glad she felt competent and confident enough to tell me she could do the job herself.
The session over, I felt KT had done well clinically and that I too had done well as a supervisor. Every indication illustrated that the case was successful-the parents listened to KT’s call to CPS, they were prepared for the CPS visit the next day, and KT began working with the mother more intensively to address her issues (also seeing her the next day). As a supervisor, I felt my job was done. The only time I discussed the case after that was when I used it as a teaching tool in my ethics classes. In fact, that night, I had two prepracticum students from my ethics class observing behind the mirror with my permission. The clients and KT were aware of the students’ presence, which was not an atypical event at our MFT clinic. The two students were spellbound watching KT’s case; they tried to ask me questions and comment on the case while we were behind the mirror. Not wanting to be distracted, I told them to hold on to their questions for now so I could focus on the case. Eventually, the prepracticum students became invisible to me. However, in hindsight, I realize that their presence may have detracted from KT’s experience of my supervision.
ANALYSIS OF CASE EXAMPLES: A SUPERVISOR’S VIEW
In examining these cases more closely, I (LLC) can see there were three particular challenges I faced as a supervisor. These challenges presented themselves in the same way that the clients’ crises presented themselves to my students-they were immediate, anxiety-provoking, and had an uncertain ending. Although all of my supervisory dilemmas are at some level anxiety-provoking and have an uncertain ending, the immediacy of managing a clinical crisis in real-time stressed my supervision in a way I had not experienced before as a supervisor. In examining the cases, I can see a pattern quickly emerged, illustrating my strategies as a supervisor behind the mirror during a crisis session. My actions revealed a more directive approach, one that seemed inconsistent with my ideal view of collaborative supervision. This discovery (which was crystallized for me during KT’s part of our presentation) surprised me and compelled me to ask more questions about what I do as a supervisor and how it is that I know when I am doing it.
Promoting a State Of Calm
In the cases presented above, I believed it was important for me to focus on the supervisees’ ability to connect with the client in spite of the supervisee’s own fear, anxiety, or apprehension about what the client might say. Thus, I tried to convey a message of calm and confidence to them, and I attended to their state of mind during the session by asking “How are you doing in there?” when the therapists came behind the mirror for a consult. I also spoke calmly and forthrightly in giving my interventions to the therapists behind the mirror-a technique I also use when trying to get a client to “slow down” and relax. I felt that this strategy worked for with regard to MTK; she wrote in her narrative that once she stopped worrying about what to say and just focused on the client, things clicked for her.
In the case of KT, I tried to convey a sense of lightness and calm about her needing to call CPS, saying to her when she came back behind the mirror, “You know what you have to do, right?” Unfortunately, I believe she perceived my attempt at “lightness” as directive. KT’s description of what I said and did when she took her first break to consult with me illustrates the difference in our two perceptions about what happened behind the mirror. KT remembers me coming into the hallway to tell her to call CPS. She even says, “The supervisor actually came into the hallway.” The difference in our perceptions, which center on a directive versus nondirective supervisory approach, indicates to me that my strategy for conveying calm to KT backfired.
Accessing the Supervisees’ Confidence and Convincing Them of their Expertise
It was important for me that the therapists in both cases find a way to use my guidance, but in such a way that best fit their own therapeutic approach and style. I wanted them to incorporate my suggestions or ideas, but in their own way. As a supervisor/researcher, I also look for evidence of this in the trainee’s work. In the case of KT, that evidence was clear. KT was able to tell me directly she was going to do the intervention herself; she did not need me to go into the room with her. I saw KT’s telling me “no” as to me a sign of successful supervision.
However, if I could go back in time, I would do things differently with KT. Instead of offering to “rescue” KT, I would ask her, “What would you like to do at this point?” or, “What is happening for you right now?” I am curious about this now as a result of what KT stated in her narrative. She states that she knew right away what she would have to do-that she would have to call CPS. However, KT did not tell me this behind the mirror. Nor did I allow her the opportunity to tell me before I posed the question myself. My question shaped our next discussion, which became about whether or not I would be in the room with her. I wince when I realize that the discussion was really about me as a supervisor and my anxiety about KT. I did not allow KT the chance (at least not right away) to tell me what she thought about the case. Instead, it is more likely my question and the ensuing talk conveyed a message to KT that I did not trust her judgment.
In this presentation/article project, however, I did learn something of what KT found helpful about my supervision. In her narrative, she states that she would not have had the idea to call CPS with the parents. I was surprised that KT pointed this out; I assumed she already knew of this technique. It appears giving this suggestion may have been the most helpful thing I did for her that night. This knowledge conflicts somewhat with my philosophy of supervision. Generally (but especially with advanced doctoral students like KT) as a supervisor, I prefer not to be in role of someone who directly provides ideas to the supervisee. Rather, I prefer a supervisory role that involves generating ideas. However, I think KT’s comment suggests that I should not underestimate the value of providing specific ideas to a supervisee, regardless of his or her graduate level. In fact, I am much more likely to do this now, as I have acquired more (and more diverse) supervision experience.
In the case of MTK, a clear example to me that she had accessed her own expertise was when I asked her over the phone if she could get the client to make a verbal contract with her to telephone someone when she felt like “getting on the bathroom floor.” I did not want to tell MTK how to do this; I wanted her to find a way to do this on her own. When I asked her if she felt she could do it, she immediately responded in the affirmative, and then she did it. This was especially notable because it had been MTK that had been most reluctant to address the client’s despondent comments. To hear MTK (both in the session that night and in the narrative of this article) identify and overcome her own mistaken assumptions and to see her change her behavior accordingly in such a short amount of time was greatly rewarding for me as a supervisor.
Getting the Supervisee to Attend to the Client’s Language
In both cases, the clients had used subtle language that conveyed very powerful feelings about either hurting themselves or someone else. Also in both cases, it appeared to me that the therapists had not noticed these remarks or had underestimated their significance. Alternatively, I focused on the clients’ specific and vivid language as a vehicle both for conducting a lethality assessment and as a way to prescribe interventions. I wanted KT, BBS, and MTK to focus on these things as well. This illustrates my belief in attending to clients’ language as both a way to better understand their worldview and also as a way to monitor the client’s success.
In the “Sad Woman” case, MTK and BBS eventually appreciated their client’s statement about not wanting to be in this world anymore. I think they had been fearful to ask about this, and the client sensed their hesitancy. I knew that somehow I needed to get both MTK and BBS curious about the client’s remark. I felt that only if they were curious could they sincerely and effectively question the client about her worldview, which was conveyed in that remark. Based on the narrative by MTK and BBS, and also in my witnessing the outcome of the session, I believe I achieved my goal in getting them curious about the client’s provocative language.
In KT’s “Angry Mother” case, I was very concerned about the language and tone the client had used to describe her reaction to her daughter, about wanting to “pummel her to death.” I was also concerned about KT’s past experience of the case, which I knew had been frustrating for her. I assumed her frustration would override her clinical decision making. I think my assumption is evident in that I did not choose to ask KT about the remark or her experience of it when she came behind the mirror. Rather, I quickly focused on her making the CPS report, then whether or not I should go into the room with KT.
It is also noteworthy that KT made the second call to CPS at my insistence. KT had not reported the “pummel” comment in the first call to CPS, perhaps because of the parents’ presence. Perhaps she felt it was not necessary to do so. However, rather than work on getting KT to become curious about the remark, I chose to insist she report the remark in a second phone call to CPS. I did not attempt to work with KT, other than by telling her what to do, thus asserting myself as her supervisor. In the immediacy of the crisis, I focused on my ethical and legal responsibilities as the supervisor. I did not focus on getting KT curious about the mother’s remark. My decision on a certain outcome (reporting to CPS) negated me asking further questions of KT about her experience. In this case, I believe it is very doubtful that I succeeded in instilling in KT curiosity about attending to the client’s language.
Our experience illustrates that, even in cases in which the supervision is apparently successful in the outcome of a case, there can still be divergent and contrary views on the actual utility of the supervision process. This revelation suggests the need for further investigation into the complex learning processes during live supervision. Such investigation should address both the supervisor’s and supervisees’ points of view. The intensity of live supervision in such cases warrants on-going examination of the effectiveness of supervision from multiple perspectives that include all those involved.
In addition, we suggest that supervisors create multiple and alternative formats for discussing and hearing supervisees’ views of their supervision experience. Supervisors must be proactive in considering and exploring creative ways to hear supervisees’ points of view about the supervision process, particularly during pivotal clinical moments in the supervisee’s development. Professionally presenting casework at conferences or in other similar formats can be a unique way, as it was in our case, to learn about and explore differing views on the supervision process.
DISCUSSION
Our TAMFT conference presentation of these two cases, the sequence of which followed the order in which the cases appear in this article, evolved into a supervision debriefing of our collective experiences. The discovery made during the presentation-that KT and LLC had had diametrically opposed perceptions of the supervision process-presented a forum for us to talk openly and to explore in greater depth how each of us made sense of the supervision. The presentation format provided an alternative and exploratory venue, different from the typical live supervision talk behind the mirror, in which we could learn more about how each of us perceived the supervision process.
Initially, this article was strictly a narrative about crisis management during live supervision. It began with the story of two clinical cases, and culminated in the form of a conference presentation in front of an MFT audience. Unexpectedly, the presentation form and content yielded rich information about the understandings about supervision processes that occurred during the crisis cases. That discovery crystallized a pivotal moment during the life of this project. At that point, this article became a story about the complexities of supervision, and participants’ variant experiences on the process.
Yet another transformation has taken place in the writing of this article. Since the presentation, and throughout the writing and review process, the voices of KT, BBS, and MTK have continued to influence my (LLC) understandings of supervision. As noted earlier, I (LLC) have broad experience as a clinician and researcher in the area of crisis intervention and crisis management. When the cases of KT, BBS, and MTK presented themselves to me as a supervisor behind the mirror, I knew exactly how to handle the clinical work that was coming. I was very familiar with the skill, responsibility, and anxiety that come with hearing about a client’s crisis in real-time; I was comfortable with the sense of urgency, panic, and fear that comes with the territory in these cases. When these two cases presented themselves, I had no doubts about what needed to be done, and no qualms about doing it.
However, in my role as a supervisor behind the mirror, I was on unfamiliar ground. My collaborative goals as a supervisor were in conflict with some of the more hierarchical clinical views I necessarily hold regarding crisis management. A crisis stresses a system. In this case, my supervisory roles were stressed in a way that they had not been before. In hindsight, I can see how that stress limited the questions and ideas I could pose as a supervisor.
In essence, writing this article has allowed me to do more fully what I strive to do as a supervisor in real time, as supervision is occurring. It has helped me to identify gaps in my supervision processes and to develop clearer understandings about what works for me in supervision, as well as what does not. Writing this article has helped me to see the areas in which I have consistency between my practice and theory as a supervisor as well as areas in which I struggle and am challenged to grow as a supervisor.
The TAMFT presentation and this article illustrated for me the necessity of exploring the covert processes of my supervision in these cases. I am able to form new questions about my supervision and have new types of supervisory conversations about my work. I doubt I would have had the opportunity or drive to question or acknowledge my supervision in these cases otherwise. Although I did not know it at the time, I still had much to learn about my supervision work in the above cases. The cases had ended well, and I had not seen a need to talk about them further with my trainees. However, after the TAMFT presentation, I learned that there were more stories (other than mine) about the supervision processes that unfolded in those cases.
In my reflecting on the work, and in my talking with other supervisors (including the anonymous reviewers and the editors of this journal), I have had to rethink many ideas I held about my supervision in these two cases. The crisis-management component of the work, which was the initial impetus for the project, has receded to the back of the room. In its place now is the role of the supervision. As a result, I have found myself de-familiarized and de-centered from the certainty I had had about the cases’ success. I am now asking myself different questions about my supervision in those cases. Interestingly, as I moved away from “my” story of the cases, the voices of my supervisees-as represented by their narratives-have become stronger and louder. My new off-center stance, as that of a learner and not a teacher, has allowed me to hear them in a way I could not before. The collaborative effort I strive for as a supervisor did not end when the crisis sessions described in this article were over. The voices of MTK, KT, and BBS became even more prescient to me than they were when I first heard them.
In this article, the evolution of my supervisory process moved from a teaching paradigm to a learning paradigm. This has resulted in a higher level of reflection about my supervisory processes. The cases came out perfectly; the clinical outcomes were successful. Yet, I wonder, did the supervision in those cases come out the way I wanted? In doing this project, I can see how my meta-reflection processes have expanded the voice I have as a supervisor. I am asking broader, more informed, and expansive questions. But 2 years have passed. The cases with MTK, BBS, and KT are long over. As a supervisor, I wonder, is there a way I can contract the time frame in which that expansive voice can develop?
My questions speak to larger ones about the supervision process: How can one proactively evolve as a supervisor? How do you bring that evolutionary learning to the forefront? How does a supervisor, with all the hierarchy, restrictions, and complexity involved in the supervision process (particularly live supervision in a crisis), get at that process? Until a supervisor allows him or herself to be challenged, in whatever format presents itself, it is unlikely that such questions will be asked, or that such learning will occur.
CLOSING COMMENTS
Supervision should be a process in which all participants feel safe to share both their great ideas and anxious concerns; they should also, sense and hear that they are respected for doing so. Live supervision in MFT is especially powerful in this way, in that it provides an opportunity for learning in that all participants-both supervisors and supervisees-have the opportunity to try out new skills immediately, to test the soundness of new ideas (and the sanctity of old ones)-and to challenge the status quo. The voices of MFT trainees in discussions of how the supervision process works is fundamental to this approach, and is a necessary part of collaborative supervision (Gardner, Bobele, & Biever, 1997; Green et al., 2001; Storm, et al., & Morgan, 2001).
According to Fine and Turner (1997), collaborative supervision in MFT involves “face to face ongoing dialogues between a supervisor and therapist where goodwill prevails; the learning is mutual and intense; the power relations are transparent; and the emphasis is on meeting standards of the profession, ensuring the well-being of clients served by the supervisory participants” (p. 229). The field needs to further address MFT supervisees’ and also supervisors’ first-person accounts about how the process unfolds.
In this article, our examination of two crisis sessions provided a useful window of information about how clinical training processes unfold behind the mirror, and in-real time. Furthermore, our article demonstrates how on-going supervisory reflection, from a learning versus teaching paradigm can allow new, compelling, and generative questions to be asked. Our case illustrations show that even when a case may be deemed “successful,” it is useful to examine the multiple perspectives and voices of all those involved in the supervision process. Such investigation can lead to more informed questions about the role of supervision in MFT clinical training, its utility and effectiveness, and furthers the field’s understanding about the complexity of the live supervision process.
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Laurie L. Charlés
University of South Florida
Michele Ticheli-Kallikas
Lemosos, Cyprus
Kelly Tyner
University of Louisiana at Monroe
Brandi Barber-Stephens
Lamar University
Laurie L. Charlés, PhD, Department of Rehabilitation and Mental Health Counseling, University of South Florida; Michele Ticheli-Kallikas, MA, LMFT Intern, Lemosos, Cyprus; Kelly Tyner, MA, Department of Family Therapy, University of Louisiana at Monroe; Brandi Barber-Stephens, MA, Lamar University.
The work described in this article took place while the first author was at the University of Louisiana, Monroe. Portions of this article were presented at the 2003 Texas Association for Marriage and Family Therapy conference in Dallas, Texas.
Address correspondence to Laurie L. Charlés, PhD, Assistant Professor and Director, MFT Certificate Program, University of South Florida, BEH 315, 4202 East Fowler Avenue, Tampa, Florida, 33620. E-mail: lcharles@cas.usf.edu
Copyright American Association for Marriage and Family Therapy Jul 2005
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