A continuing education course for 6 ces

APA, APT, BRN, CA BBS, FL, NASW, NBCC, TX

meeting the CA BBS & BOP requirements for Supervision and Law & Ethics

Faster than a speeding bullet
More powerful than a locomotive!
Able to leap tall buildings at a single bound!
Look! Up in the sky!
It's a bird! It's a plane!
It's Super...visor!

(You are kidding, right? No one can live up to that!)

In this course, we will cover aspects of supervision, including:

Legal and ethical issues in clinical supervision

Current laws and regulations pertaining to supervision

Supervisor's responsibilities

Records to keep

Roles and functions of Clinical Supervisor

Models of clinical supervision

Mental health related professional development

Methods and techniques in clinical supervision

Supervisory relationship issues

Cultural issues in clinical supervision

Evaluation of supervisee competence and the supervision process

Reverberations in the 3-dimensional Interpersonal Field between supervisor and supervisee as it parallels the field between supervisee and his or her patient

And, in blue, the Journal of an anonymous supervisor, including raw and unedited countertransference material, as well as examples of Parallel Process in action

Featuring excerpts from DSM-S - The DSM-Supervisors, with a special examination of DSM-S 004.78 -Engaging in an Act of Desperation by Desperate Supervisor

Contains an extensive Supervision Bibliography

Please note that many of the legal and ethical considerations are repeated in Parts II & III of the Clinical Supervision series.

Applies to supervising interns, trainees, social work associates, psychological assistants; to anyone in the Helping Professions of psychology, social work, counseling, psychotherapy, etc.

is approved by the: American Psychological Association to offer continuing education for psychologists - www.psychceu.com maintains responsibility for the program. The Association for Play Therapy (#02-117) Board of Registered Nursing (#13620) California Board of Behavioral Science (#1540) Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling (BAP #753) NAADAC - The Association for Addiction Professionals (#478) National Association of Social Workers (#886382116) National Board for Certified Counselors (#6055) Ohio Counselor, Social Work and Marriage and Family CPE (#RCST090402) The Texas State Board of Examiners of Professional Counselors (#52526) The Texas Board of Social Work Examiners (#CS3473) www.psychceu.com maintains responsibility for the program.

 

Please join our clinical discussion on material from this course at: http://www.psychceu.com/forum/default.asp

 

Note: This journal appeared anonymously in our e-mail box. With it was this note:

"Please use this as a supervision course. I am staying anonymous, because it contains very raw and honest countertransference material, and I am afraid that it will ruin my reputation when therapists see how my shadow emerged when I was supervising. I am particularly embarrassed about the times when I had an urge to 'throttle my intern'. I do hope that you will publish this as a course, however. I think it will help supervisors to hear about a truthful account of supervision. I also included the law and ethics stuff, but the journal is mostly about my experience as a supervisor. Thank you."

 

A Supervisor's Journal Clinical Supervision, Law and Ethics Part I- Supervising a first year intern by Anonymous, LMFT

 

(Choose one or both of the following statements as true:)

I sat down, eager to meet my new supervisee. I remembered, over the years, supervising many, many interns and trainees, with varying degrees of experience. I always looked forward to the first session, as everyone who I have supervised to date has brought me new awareness and insight into the art and science of psychotherapy.

or
I sat down, reluctant to meet my new supervisee. I remembered, over the years, supervising many, many interns and trainees, with varying degrees of experience. I always dreaded the first session, as everyone who I have supervised to date has brought me new awareness and insight into my own shadow.

(I think I would have to choose both!)

'Daniel' (all names and identifying details have been changed) followed me into the consultation room, glancing at me through wire-rimmed glasses, not really making eye contact. He immediately took out a pen, to start taking notes. He looked scared; no doubt concerned that I would judge him, finding him inexperienced, incompetent, and whatever else his self-doubt could throw at him. (Boy, was I wrong about Daniel! After our session, I ran to my well-thumbed copy of the DSM-S - The DSM-Supervisors, and realized that I had succumbed to DSM-S 378 -Engaging in an Act of Projection onto Intern by Supervisor.) He had been assigned to me by the Counseling Center, and this was our first meeting. My agenda was to begin to get to know him, to put him at ease, and to review the legal and ethical implications of being an intern.

He looks awfully serious, I think. Maybe in his early thirties. This is his first placement; I remember when I first started seeing clients, in my first internship, when I was 24. I felt so scared! I knew I didn't know anything, although I would never admit it to my supervisor. I hope Daniel's in therapy; and, unfortunately, the Counseling Center cannot require therapy for its interns. Learning to be a therapist is really painful at times. I think the closest model is that of initiation. If it feels excruciating, and that every bone is broken, and every part of your psyche activated, then you will probably end up being a good therapist. If you just cruise through, you won't ever be able to go to the depths with your clients. Poor Daniel! I bet he doesn't have a clue what he is in for!

There is a resonance in the field between supervisee and supervisor, a 'parallel process' that occurs in supervision, so I wanted to model for Daniel the feeling of an initial session, as he would soon be starting to see clients. Initial sessions can be problematic in supervision, as there is a lot of ground to cover regarding responsibilities, law and ethics, paperwork, things to review, as well as the most important part, which is beginning to get a sense of the person. In some ways this is akin to an initial therapy session, particularly in a clinic setting where there are intake forms, releases, notification of intern status, etc.

Kaiser (1992), addressing the issue of supervisory relationship in family therapy supervision, highlighted the “phenomenon of isomorphism; what happens in supervision is reflected in the therapy” (p. 284). This is referred to later in this entry as the “parallel process,” in which the interaction between supervisor and supervisee directly affects the relationship between the social worker and the client. In reviewing the literature from the fields of social work, psychology, and marriage and family therapy, Kaiser identified four consistently cited issues: “the process of accountability (maintaining objectivity), the need for promoting the supervisee's personal awareness, the importance of establishing trust, and the need to attend to power and authority issues” (p. 284). (Shulman, L., “Supervision and Consultation”, From: A Social Policy Course at University of North Carolina, at Pembroke, taught by Stephen M. Marson, Ph.D., ACSW)

The concept of parallel process has its origin in the psychoanalytic concepts of transference and countertransference. The transference occurs when the counselor recreates the presenting problem and emotions of the therapeutic relationship within the supervisory relationship. Countertransference occurs when the supervisor responds to the counselor in the same manner that the counselor responds to the client. Thus, the supervisory interaction replays, or is parallel with, the counseling interaction. (Sumerel, Marie B., 1994, Parallel Process in Supervision. ERIC Digest ED372347)

I also wanted Daniel to get a sense of who I was, as we would be spending one hour a week for the next nine months together, unless something drastic happened. Whenever I consider this, my thoughts go to the other nine months in our lives, the time in the uterus. My job was perhaps like that of the mother, to create the 'free and protected place' as Dora Kalff used to say, for a therapist to develop. There are many ways in which therapists and supervisors err with regard to boundaries. One way to guard against this is to imagine that the therapeutic container is "sacred space", a temenos or 'free and protected' place. Conceptualize psychotherapy and supervision as a 'safe harbor' in which competent help is given in a clear and respectful manner, a place where the psyche of the client is honored above all. Anything that interferes with this is unethical and possibly illegal. That includes most contact outside of the therapeutic hour, including having coffee or lunch with a client or supervisee, bartering with a client for supervision or therapy in exchange for services or products, working with a client in more than one capacity, and most certainly, having a sexual relationship with a client.

My first supervisor was brutal; supervision with him was the opposite of the 'free and protected' place. When I reported to him after my first session as an intern, he told me that it was the "worst session he had ever supervised." It didn't help that all my friends had raved about him as a professor, although, years later, I realized that none had had him as a supervisor. Teaching, doing therapy and supervision are quite different at times! The person who creates the unconditional safe space of therapy may in fact be a lousy supervisor, unwilling to confront the supervisee. By the same token, the professor with many publications, who is his or her own harshest critic, may also be a poor supervisor. Such was the case with Dr. M and me. His blunt style and high expectations were a poor match for a feeling type, brand new baby therapist. I never wanted to do that to anyone I supervised.

Years later I realized that those who have been initiated cruelly will tend to be cruel in their initiation of others. It is the 'wounded who wound', unless they find within themselves the archetype of the wounded healer. Having been hurt by my first supervisor, I knew to be careful, to not repeat history. In fact, I tell my students and interns "It is a 'practice' that we do, not a perfect!"

I introduced myself to Daniel, and asked him to tell me about himself. I knew that if I had been interviewing him to be my intern (rather than him being assigned to me by the counseling center) that I could not ask his age, marital status, ethnic background, whether he has children, his religion, whether he has any disabilities or health problems, etc.; basically anything that could be considered discriminatory. In fact, a supervisor cannot even ask if an intern or supervisee is in therapy!!! (source: Riemersma, Mary, The Do's and Don't of Interviewing Interns and Trainees, May/June 1992 issue of The California Therapist)

I follow these guidelines when students are assigned to me, as I think they serve three purposes: they protect the intern against feeling judged unfairly or discriminated against; they protect the psyches of both the intern and supervisor from any prejudice, conscious or unconscious that might be there, and they afford some legal protection. I always notice (much like in a therapy session) at what point the intern trusts me enough self disclose about who he or she is.

Daniel didn't tell me much about himself, other than that he felt quite ready to see clients. I asked him what part of seeing clients excited him, and he responded that actually he was not very excited about seeing children, that this placement had been his second choice. He had applied to a Psychoanalytic Center, but they turned him down, saying he needed experience before he could be accepted there.

Great! Just what I need! A person who doesn't want to be here!
But then I got a little bingo in my brain, and realized in some ways this was perfect, because many of the children and adolescents Daniel would be seeing would not want to go to therapy; but rather it was imposed on them from outside sources: school or parents.

So, I asked Daniel how it felt to be here, when he really didn't want to be here.

I knew I had to be careful here, as I didn't want to cross the boundary between supervisor and therapist. I tried the old open-ended question, and Daniel stammered a bit, and was clearly uncomfortable with my question about how he felt. It seemed that, so far, in this initial session, that I was doing a lousy job of establishing rapport with Daniel. I reminded myself to trust that when and if I needed to know more, it would be revealed. But I do hope whatever ambivalence he has about being here has been worked through in therapy.

This is an issue in supervision that comes up again and again; where is the line between supervision and therapy? How much does a supervisor need to know about an intern in order to be an effective supervisor?

So, I tried again. "Daniel, can you please tell me something about yourself?" I asked.

He bent down to his briefcase and pulled out his resumé. It stated that he was 33 years old, had graduated with honors, from a very prestigious school, with a major in electrical engineering. His job experience had been in the field of computers, and he had entered Psychology graduate school one year ago. There were references listed, all in his former field. He stated on the resumé that he was single, with no children. There was nothing in his resumé at all related to psychotherapy. I had no idea how he had gotten from computers to psychology. I was wary, however, in the process of what had occurred. Not red flag alarmed; more like a yellow warning sign. It seemed as if he was being very open, and self-disclosing, by offering his resumé; but in fact, it told me nothing.

The Interactive Field

Here I fell back on my trusting the process. By and large, whatever needs to be revealed, will be revealed. If Daniel's issues regarding changing fields were to become a factor in his work, I trusted that I would know about them when I needed to. I also tuned into my own process as Daniel and I were talking, and realized all my images were about my own scientific and technical ineptness. I know that I am what is considered to be a 'feeling type', and Daniel was certainly presenting like a 'thinking' type. This would explain the blank expression he had when I asked how he felt about being here.

So, taking a deep breath, I tried a different tactic.

"Daniel, what do you think about being here?" Suddenly, Daniel was speaking about being at the counseling center, and all that he had done to prepare for his internship. Time and time again, when I reflexively asked him how he felt, he drew a blank. When I asked about the exact same issue, but instead remembered to ask him what he thought, then he would address the issue at hand. This is a type of diversity, I feel, that often is overlooked. "Typology Diversity" seems largely ignored, yet in some ways typology seems to be 'hardwired 'into how we process information. A smart feeling type (DSM-S 133.33, Supervisor talking about self in a way that no one is supposed to know that she is talking about herself) is often considered not bright, because abstract thinking can take a back seat to feeling in our schools and Western culture. While it is much easier to supervise someone of one's own typology, supervising those who are different stretches us. An example is with one intern I had years ago. When it came time to evaluate her, I marked her as somewhat defensive and oppositional. When she asked why, I told her it was because she seemed to fight me on everything I said. She looked puzzled, and asked for an example. I gave her one, and then she said, "That's thinking! I was thinking about it." (Thank you, Annabelle!) And she was right!

What I had felt to be oppositional, was really her thinking about what I was saying.

For an online typology test, please go to: http://www.humanmetrics.com/cgi-win/JTypes2.asp

I asked Daniel if he had any other thoughts or concerns about becoming a therapist. "No" he said. "I feel ready, I already have the first session mapped out." The little red warning light went off in my brain. I was psychically starting to hyperventilate, as can happen in the presence of the opposite type. I pulled myself back from the edge of hysteria. I cannot imagine how someone could have a treatment plan without having seen the client, nor know anything about him or her!!!

Fortunately, my training stood me in good stead, as I assumed the 'poker face' of the therapist or supervisor who has been taken off guard. "Hmmm.." I said to Daniel. No response. So I tried again. "Hmmm..can you say more about that?"

Daniel again bent down to his briefcase, pulling out a bibliography of many pages. "You see", he said, "I made a quantitative analysis of initial sessions, and have figured out exactly what has the best chance of success. You see, here it says you need a complete developmental history, and here is the diagram that you need to figure out the core issue. It is an equation with .333 weight given to the symptom, .333 to the family history or family of origin, and .333 to how the client is while in the session. Then you find out what these issues have in common, and when that is isolated, then you have the 'core' issue. From there, every thing you say or do relates to the core issue."

"Hmmm.."I said. "Daniel, have you given any THOUGHT to how this will apply with a seven year old? Or a teenager?"

"Well," he said, "that was my reason for wanting to work with adults at the psychoanalytic institute. But I have prepared this form to get an accurate history." Here he handed me a copy of his 20 page developmental history form. "I think with young children, I will send home the developmental history form for the parents to fill out. Latency age children might need some assistance, but they could do it primarily by themselves. I know I could have, when I was that age. Adolescents would certainly have the capacity to complete the questionnaire on their own."

Now, many of the children who he would be seeing in the schools had parents who had recently immigrated, and spoke little or no English. When I looked over the form, mentally filling it out regarding my 11 year old son, I realized that there was no way that my son could do it, and doubtful that I could fill it out. Maybe I have no memory left, but I cannot imagine why it would be relevant to know at what age his third tooth came in! I actually feared asking Daniel why that was on his developmental history, not wanting another bibliography to come out of his briefcase.

"Hmmm..." I said. And wondered what trickster had assigned Daniel to me!

And because, quite frankly, I didn't know what to say, I brought the interview back to his tasks, and general issues about being an intern.

We spent the rest of the first hour talking, and I reviewed with Daniel the basics of being an intern. We would have at least one other session before Daniel was assigned any clients, so I hoped in the next session I could develop some rapport with Daniel and we could begin to get to know each other. I went over my expectations of him, and I made sure he knew of the legal and ethical aspects of being an intern.

Legal and ethical aspects

Daniel realized that he would be telling people that he was an intern, not a licensed therapist, and working under supervision. I stressed to him that personal relationships with patients and dual relationships would not be condoned. We talked about what would constitute a dual relationship. I also asked him, once he started seeing patients, to please let me know if he had any fantasies or dreams about a patient.

I reminded myself about the importance of therapeutic boundaries in the supervisory relationship, to avoid all dual relationships with my supervisees. I keep my own journal of feelings, fantasies and my reactions regarding about my supervisees, and discuss them in my consultation group. I had learned that the unconscious feelings stirred up in me by my supervisees and my patients can lead to the very heart of the supervisory and therapeutic process, if I have the courage to really look at them.

Therapeutic boundaries

Daniel and I discussed why a sexual boundary should never be crossed.  Both therapy and supervision are relationships of power. If we become unconscious of the power shadow, then it wreaks havoc upon us! 

According to California laws:

Any kind of sexual contact, asking for sexual contact, or sexual misconduct by a therapist with a patient is illegal, as well as unethical, as set forth in Business and Professions
Code sections 726, 729, 2960(o), 4982(k) and 4992.3(k).

“Sexual contact” means the touching of an intimate part of another person, including sexual intercourse.

“Touching” means physical contact with another person, either through the person’s clothes or directly with the person’s skin (Business and Professions Code section 728).
Sexual contact can include sexual intercourse, sodomy, oral copulation, fondling and any other kind of sexual touching. Sexual misconduct also covers a broader range of activity, including nudity, kissing, spanking, verbal suggestions, innuendoes or advances.
This kind of sexual behavior by a therapist with a patient is sexual exploitation. It is unethical, unprofessional and illegal.

In California there is a pamphlet that we are required to give to our clients who have had a sexual relationship with a therapist. It is a Department of Consumer Affairs publication entitled "Professional Therapy Never Includes Sex".  It is available on-line at: www.psychceu.com/proftherapy.pdf.

The contents include:

 
Patient Bill of Rights
Definitions and warning Signs
Where to Start
What Can You Do?
Reporting Options
Administrative Action
How the Complaint Process Works
Professional Association Action
Civil Action
Finding an Attorney
Criminal Action
Where to Get Help Finding a Therapist
Self-Help Support Groups
Frequently Asked Questions

You will need Adobe Acrobat in order to read this. Please get this free downlaod at: Adobe Acrobat is certified virus free

 

Therapists have been disciplined by their licensing boards for not supplying this pamphlet to clients who have had a sexual relationship with a previous therapist. Single copies of the publication are available at no charge from Publications Office, California Department of Consumer Affairs, PO Box 310, Sacramento California 95802.  For a copy of the Board of Behavioral Science Examiners Licensing Laws and Regulations, go to: http://www.bbs.ca.gov/law-reg.htm.
 

Daniel and I talked about confidentiality, and how he was going to handle questions from parents, teachers, other children (which is a very common occurrence working in a school setting), as well as outside agencies (foster homes, protective services, etc.).

We talked about laws and ethics, including:

5150 (involuntary psychiatric holds)

informed consent,

accountability,

competence,
scope of practice,
client welfare,
what constituted an emergency, and
how emergencies would be handled.

(For more detail on these issues, please consider reading Safe Harbor II: Law and Ethics in Supervision)

I asked Daniel about how we (notice the 'we', not 'he') could protect a client's confidentiality. It is a paradox of supervision that we are training our interns to uphold the confidentiality of their clients as we ask them to break it in supervision. We talked about how to inform clients about confidentiality, and what would be grounds for breaking it. We discussed Tarasoff (which in 25 years of practice, I have never had to use); child abuse; elder abuse; suicide; and 5150, in which a client needs to be involuntarily hospitalized for their own protection.

I told Daniel a bit about my experiences breaking confidentiality, and how kind and supportive both child protective services and the local police (when I had to 5150 someone) have been. I wanted him to realize that therapists only break confidentiality for very good reasons: abuse, and life or death issues. When we do break the container, it is our task, as much as possible, to ensure that the people who are called to intervene are compassionate and truly protective.

There is however another paradox of supervision, which is something I wrestle with every semester. How confidential is supervision? How can I create a safe and protected place for my interns when I have to evaluate them, and report on our work in the supervisors' meetings?

We discussed the agency policy that patient files are not to be removed from the office, under any circumstances, nor did the agency permit photocopies of records, due to the possible breach of confidentiality and the difficulty safeguarding these records.

We went over how clients were to pay, that any checks received would not be made out to him, but to the Counseling Center. (If he had been a private practice intern, the client checks would be made out to me, as the supervisor, not to the intern.)

I had to be very conscious not to get into "robot" mode as we went over laws, rules, regulations, paperwork, etc. (While these are my least favorite parts of supervision, I know the importance of establishing an intern's knowledge of the laws and ethics regarding psychotherapy. Ultimately, our laws and ethics are there for the protection of the client, the therapist, the supervisor, and the therapeutic process. Clear boundaries make possible the creation of the 'free and protected' space.)

In a study of supervision, Kadushin (1974) conducted a national survey of 750 supervisors and an equal number of supervisees. The purpose was to identify the sources of satisfaction for both supervisors and supervisees. Supervisors in the study took great satisfaction in helping supervisees grow and develop professionally; their greatest source of dissatisfaction related to dealing with administrative red tape. Supervisees identified being able to share responsibility with supervisors and being able to obtain support for difficult cases as their greatest source of satisfaction. A majority of both the supervisors and supervisees in Kadushin's study believed that as the supervisee gained experience, the relationship became one of consultant–consultee, a form of supervision preferred by many social workers. Strong dissatisfaction with supervision was reported by many social workers, who believed the authority of the supervisor was exercised in a negative manner. (Shulman, L., “Supervision and Consultation”, From: A Social Policy Course at University of North Carolina, at Pembroke, taught by Stephen M. Marson, Ph.D., ACSW)

I reviewed with him the Counseling Center's grievance policy if either of us found it impossible to work with each other. If Daniel had been a private practice intern, I would have made it clear (both in writing and verbally) that he was hired "at will." (At this point, though, I thought that Daniel would be the least likely person who I would hire in my practice! - See the DSM-S 899.99 Negative Countertransference from Feeling type Supervisor to Thinking Type Student in the Initial Session.) "At will," means that I could "fire" him, "at will", or for any reason whatsoever, with or without cause. I have had to do this once, for severe ethical lapses on the part of a private practice supervisee, who simply would not respect therapeutic boundaries with her clients. I never want to go through that again!

I gave Daniel the website address of the Frequently Asked Questions for MFT Interns and Trainees at the California Board of Behavioral Science at http://www.bbs.ca.gov/lic-req8.htm (Which, of course, he already had...)

The LCSW Associate Frequently Asked Questions is at: http://www.bbs.ca.gov/lic-req9.htm

If you are not a California therapist, please go to your Licensing Board for relevant information. We have some links listed in our website at http://www.psychceu.com/statece1regs.html.
Please e-mail us your state information, so that we may include it in future versions of this course! Thank you!

Note for California Therapists:
Although the information regarding BBS and BOP supervisor requirements are current at the time of this writing, it is your responsibility to stay current with the regulations. We recommend that you periodically check with your professional organization and licensing board for updates.

The California BBS has a page on their website of "Forms and Publications at: http://www.bbs.ca.gov/pdf/mfrespon.pdf which includes the following:

APPLICATION PACKAGES

• Intern Registration application package
• Associate Registration application package
• Associate Extension application package
  
  
• MFT License application package
• LCSW License application package
• LEP License application package
  
  

APPLICANT MATERIALS

• MFT Experience Verification
• MFT Weekly Summary of Hours of Experience
• MFT Supervisor Responsibility Statement
  
• Clinical Social Worker Experience Verification
• LCSW Supervisor Responsibility Statement
• Supervisory Plan
• Termination of Supervision

Being a believer in "as above, so below", meaning that in order to keep the power dynamic balanced, I gave myself the same homework assignment. When I got home, I went to the CA BBS site at http://www.bbs.ca.gov/law-reg.htm and reviewed the:

California Board of Behavioral Science Laws And Regulations Relating To The Practice Of Marriage, Family, And Child Counseling, Licensed Clinical Social Work, And Licensed Educational Psychology.

 

Mandatory Continuing Education

(A) Effective January 1, 2000, supervisors who are licensed by the board shall complete a minimum of six (6) hours of supervision training or coursework every two years. This training or coursework may apply towards the continuing education requirements set forth in Sections 4980.54 and 4996.22 of the Code. (B) Supervisors who are licensed by the board who have completed a minimum of six (6) hours of supervision training or coursework between January 1, 1997, and December 31, 1999, may apply that training towards the requirement described in subsection (A).
(C) Supervisors who are licensed by the board who commence supervision on and after January 1, 2000, and have not met requirements of subsection (A), shall complete a minimum of six (6) hours of supervision training or coursework within sixty (60) days of commencement of supervision.

I hope he uses the journal, although he did look at me like I was a bit of an alien, from who knows which planet!! (DSM-S 536.99a: Supervisor imagines he or she is being perceived as an alien by intern; unable to verify, because it is too soon in the process for supervisor to ask intern if he or she is perceiving supervisor as an alien. Differential diagnosis: 536.09n: Supervisor imagines he or she is being perceived as 'nuts' by intern, unable to verify, because it is too soon in the process for supervisor to ask intern if he or she is perceiving supervisor as 'nuts'.)

I find the journal an invaluable tool for staying in touch with my own countertransference, and my own truth. I hope he feels that it is a safe place for him to process how it feels to be becoming a therapist. I am a bit concerned that this meeting had been a big zero, with no real connection made between the two of us. I usually hate these types of sessions, in which most of our time is spent with paperwork, and the legal and ethical aspects of supervision, but Daniel was very prepared. Either I always fear that I have forgotten something crucial, or that the laws have changed. I have no doubt that if they do, that Daniel will be aware of it, as he told me he has been a student member of every professional organization that he could join, and that he has a system for weekly monitoring of their websites.

I admit that I was exhausted after this session!

While our session was still fresh in my mind, I started a file on Daniel for my records.

Daniel's file included forms provided by the counseling center, that he had signed as we ended:

• the written agreement between the school, employer and supervisor setting forth each party's responsibility.
• Intern job description and note taking responsibilities for client notes.
• a copy of a signed statement that he understands and will follow procedure regarding Tarasoff, child abuse, elder abuse, 5150, and suicide issues.
• His emergency phone or pager number (I also made sure that he had my emergency numbers.)
• Whom to contact in case of an emergency involving him
• His resumé
• My supervision notes

Once he starts seeing clients, then I include:

• Copies of his weekly summaries of experience, once he started to keep them
• Copies of Intake files on his clients
• Treatment plans

If he had been a private practice intern, I would also include:

• a copy of his malpractice insurance
• statement of employment and termination at 'at will"
• W2
• If he already had her degree, a copy of the receipt showing that the intern or associate is currently registered.

Supervising Psychological Assistants

For psychologists, please go to http://www.psychboard.ca.gov/laws_regs/index.htm:
as there are new laws in effect. (This version reflects the most recent changes, thus has two letters for some of the items.)

Mandatory Continuing Education

If you are supervising aspiring psychologists you are also required to obtain six hours of training in supervision. Effective January 1, 2003, primary supervisors who are licensed by the board shall complete a minimum of six (6) hours of supervision coursework every two years.

If you are supervising persons pursuing the psychology license, you are required to file an annual report that addresses specific criteria.

For the complete 2003 State of California Department of Consumer Affairs Laws and Regulations Relating to the Practice of Psychology please go to: http://www.psychceu.com/lawsreg2003.pdf

Please visit for the NBCC's Code of Ethics.

For the California Board of Behavioral Science Examiners Laws And Regulations Relating To The Practice Of Marriage, Family, And Child Counseling, Licensed Clinical Social Work, And Licensed Educational Psychology.

For the American Psychological Association's Code of Ethics

Please visit for the American Counseling Association Code of Ethics and Standard Procedures.

Please visit the California Association of Marriage and Family Therapists' Code of Ethics

Please visit the National Association for Social Workers' Code of Ethics

Please visit the Association for Play Therapists' Code of Ethics

After Daniel left, I was very glad that I had a free hour in which to process. I try, whenever possible, to schedule a break after anyone new, either client or supervisee. It helps me to 'cement' who the person is in my psyche, and to give me time to record my fantasies, projections, and countertransference. This process seems to allow me to let go of the session more easily, so that it does not linger in my psyche, and bleed into the next person's hour. I find if I am still thinking about a session, then usually either there is something left undone, or my countertransference is activated. I realized, that as supervisors, we carry a lot! We are charged with:

1. training a new therapist,

2. holding our own countertransference,

3. trying not to become the

• parent
• authority figure
• therapist

of the intern

4. at the same time holding the intern and ALL of the psyches of his or her clients within ourselves!

5. Add to this that the supervisor's license is on the line for legal and ethical lapses on the part of the intern!

Daniel's second session

Daniel came to the second session prepared (why was I not surprised!!); he had gone to the licensing board website, and joined even more professional associations as a student member. This gave him subscriptions to various journals, as well as access to the 'members only' section of the websites, which contained valuable articles, forums for discussion, etc. He had printed out more information from the licensing board, as well as the relevant Code of Ethics, as well as almost every article posted online from the previous years of The California Therapist.

I was pleased that he was taking his internship so seriously, and wondered about his level of preparation. Usually, interns come to beginning supervision a bundle of nerves; Daniel's rigidity and over-preparation seemed somewhat defensive to me. I was worried about what would happen when Daniel started seeing a 'real 'child in therapy, as opposed to a statistical survey of what children do. Was he going to be capable of being spontaneous? Would he be able to play?

I asked him if he had any questions from our last session, and he said he didn't. I wondered (out loud, to him) if he had any questions for me, about me...who I was, my experience, etc. He said he didn't, that he had researched my credentials, and read everything that I had written. I left the door open, so to speak, telling him if he did wonder about me, to please feel free to ask.

The reason I did this was because he had been assigned to me. Now, if I remember correctly from my schooling, counseling centers were a hot bed of gossip, rumor and innuendo. Most students knew a lot about their prospective supervisor, much of it untrue. I wanted to elicit Daniel's projections to me, as an authority figure, as that would be a part of his clinical work. The people he saw as a therapist would perceive him as an authority, and to know his own process and projections around this power dynamic would be helpful in his work.

I also know from reading, that if the supervisor's authority came solely from the agency, that the supervision tends to be less effective than if the authority came from the person of the supervisor.

Supervisor–Supervisee Relationship
Other models of supervision focus on the nature of the supervisor–supervisee relationship. These have been described in the literature as ranging from more traditional, authoritarian models in which the supervisor's authority emerges from agency sanction on one end, to more collaborative models in which the authority emerges essentially from the supervisor's competence on the other end.
Munson (1981, 1983) surveyed 65 supervisees and 64 supervisors. He focused on models of supervision in three areas: (1) structure (traditional–individual, group, and independent); (2)authority (sanction versus competence); and (3)teaching (Socratic, growth, and integrative). He examined the impact of the use of different models on social worker satisfaction with supervision and integration. Munson (1981) found that “The structural models did not produce significantly different outcomes regarding interaction and satisfaction, but the authority models did. The competence model of authority was the most productive in all respects” (p. 71). This was the model in which the supervisor's authority was derived from competence and skill rather than from agency sanction.
(Shulman, L. “Supervision and Consultation”, From: A Social Policy Course at University of North Carolina, at Pembroke, taught by Stephen M. Marson, Ph.D., ACSW Sources cited: Munson, C. E. (1981). Style and structure in supervision. Journal of Education for Social Work, 17, 65–72. , Munson, C. E. (1983). An introduction to clinical social work supervision. New York: Haworth Press.)

Daniel and I talked about the initial session in therapy. He, of course, knew all the paperwork he had to go over with his clients, so now we could focus on the dynamics of the first session. Daniel had two roles at the agency: to go to the schools and work with students, from elementary through high school, and to see clients at the Counseling Center. After our session, he would be assigned his first in-school client, and see his first client at the counseling center. As the semester progressed, more clients would be added to his caseload.

He said he had thought a lot about working with children and had some questions for me about technique and theory. He pulled out a long list from his briefcase, and started asking away. He wanted to know what to do if the presenting problem was encopresis, in a latency age child, what to do with a hyperactive preschooler, a sexually acting out teenager, etc. His list was very specific, and I felt that I had to move him into more general territory. I talked about establishing rapport, and how to create the 'free and protected place' in therapy so that the client will feel safe enough to disclose who they really are.

Daniel knew that his first client in the school was a 8 year old girl who we shall call 'Maria'. Maria had been referred to the counselors seeing students in the schools because of a suspected diagnosis of ADHD, and acting out behavior. Her mother had recently given birth to a boy, after a tenuous pregnancy, which involved almost 5 months of bedrest. Maria's brother, born prematurely, was fine now.

I suggested to Daniel that he could ask Maria why she thought she was seeing a counselor, and what she wanted to do. If Daniel could hear what Maria said, Maria would not only be letting Daniel know how to work with her, but also would get clues to Maria's transference.

Daniel thought about what projections he might carry, and realized that he might have a 'father' or 'big brother' transference from his clients. He started to take out his print outs regarding ADHD and oppositional defiant disorder, but I stopped him. I asked him what he thought about play.

He looked a bit confused, and again reached for the briefcase. "Daniel" I said (trying really hard not to be impatient), "Play? What was your favorite thing to do as a child?"

"Umm, well, I guess I played a lot of video games. And I had my picture in the Lego magazine when I was in latency, for a Lego ship that I built. Games? I don't really remember much about my childhood. Let's see, I was very good at chess, and was always in the chess club at school. Play? That's about it really. I was an only child, of two professors, who were quite old when I was born, so I didn't really play with a lot of other children. I was always in the accelerated learning courses. On weekends I would do my homework, read, and then play the video games."

"But what does this have to do with me seeing a child in therapy?"

Daniel would soon find out!

Daniel sees Maria

Daniel came into our next session looking somewhat dejected. "I saw Maria, and I don't think it went very well. She didn't seem to know why she was there, and didn't understand about confidentiality and Tarasoff. She couldn't even read my developmental history form, and kept wiggling all around when I tried to do the paperwork with her. "

"I tried to explain about being an intern, and that I would be discussing the work with my supervisor. I reviewed with Maria the reasons I would have to break confidentiality, and then asked Maria if she had any questions. All she said was 'no, who cares, blah blah blah!' and then she laughed. And asked if she could play."

"All she wanted too do was play. And the worst thing was, when I suggested chess, she laughed at me, again! I can see exactly why she is considered defiant."

"And all she wanted to do was play Candyland! She didn't even want to do a House-Tree -Person drawing for me, or play with something that had some symbolic content to it, like doll house play or sandplay, which I have read extensively about. No, all she wanted to do was play Candyland!"

I asked Daniel what he did.

"I played Candyland. For 45 minutes, I played Candyland. And the galling thing is, there is no strategy about Candyland, no skill, no logic. I can see why my parents never let me play Candyland. I almost think it should not be the playroom, it has no educational value whatsoever."

I was concerned here on two counts:

1. Daniel did not really seem to know how to play

2. He was still very tied in to what his parents' belief system had been.

I wondered if he was experiencing the inflation that often happens as an intern learns to be a therapist. Frequently the fears are so great that a compensatory inflation gets established in the psyche, and the intern acts as if he or she is omnipotent. Then supervision becomes a minefield, as the supervisor must be simultaneously gentle with the defense while deflating the grandiosity. This can work, but I have ended up with either an intern who is enraged, as he or she struggles to maintain the defenses, or has dissolved into a puddle of tears when the underlying doubts and fears surface.

I also did not want to cross the supervision/therapy boundary, so decided to hold these thoughts in abeyance, and address Maria's desire to play Candyland.

He said that he had been thinking of Candyland in the psychoanalytic tradition, and that it seemed to be about the earliest stages of development: the oral stage. He said that is why he wanted to know about if Maria was breastfed, and, if so, for how long.

I asked Daniel if perhaps he thought Maria was drawn to Candyland because she was feeling somewhat deprived. She had lost her mother's attention for a long time, during her bedrest and preoccupation with her difficult pregnancy. The birth of a premature baby, such as Maria's new brother, can be very disruptive to the older child in the family. Did Maria miss her parents? Did Maria fear the new baby would die? Did she, at some level, want the new baby to die? Could Candyland be comforting to her? Could it represent 'yummy' times? Counter a feeling of deprivation? (I doubt that many children would play a game called "Vegetableland" in which the goal was to attain a big salad, or a plate of broccoli.) Did Maria need to be somewhat regressed? Was she going back in time, to when she had more of her parents? Did the randomness of Candyland help her master how out of control her life had become?

Daniel looked at me as if I were nuts! (DSM-S 536.09n: Supervisor imagines he or she is being perceived as 'nuts' by intern, unable to verify, because it is too soon in the process for supervisor to ask intern if he or she is perceiving supervisor as 'nuts'. Differential diagnosis: DSM-S 536.99a: Supervisor imagines he or she is being perceived as an alien by intern; unable to verify, because it is too soon in the process for supervisor to ask intern if he or she is perceiving supervisor as an alien.) How could a stupid game like Candyland reveal all of this? "No thanks," his body language seemed to say, "I am sticking with my theory, not yours!"

As he was leaving the session, Daniel said, "Oh! I wanted to tell you. The baby's name is 'Daniel' but they call him 'Danny'.

It never ceases to amaze me how often a client or intern will 'drop the bomb' at the end of the session. I wondered if Daniel realized the significance of the fact that Maria's little brother had the same name as Daniel. How would that play out? What did it mean, coming at the end of the session?

I reread this article, Strategies and Methods of Effective Supervision, keeping in mind how developmental considerations interface with supervision. As a supervisor to a first semester intern, I knew that my supervision would be primarily supportive and educational. Often it takes interns until they are in their second year of training to be less frightened, and confident enough to really grapple with parallel process.

The Next Sessions

We continued in this vein for several more sessions, with Daniel starting to see additional clients, including high school students, and a family at the Counseling Center. His main energy however centered on Maria, so, for the purposes of this course, we will stay with Daniel's experience with Maria.

Maria's mother had returned Daniel's developmental history form to him. He was shocked. It was sticky with some kind of baby food, and the answers were terse. For the first five pages, questions on Maria's intrauterine development and the pregnancy, Maria's mom had scrawled 'easy'. On the other fifteen pages, Daniel's precise questions about teeth coming in, walking and talking, the answers were, "OK. " The only thing that indicated any problem was at the very end, when he asked about the reasons for the child being in counseling at this time, and any symptoms. The answer was, "Things are hard now. She is not so happy."

Several of his more elaborate questions were marked with ??? for answers. Daniel was "appalled that a parent could care so little for his or her child not to take the time to answer important questions." It was much later that Daniel realized that answering questions did not correlate to love, and that his questions might be hard for a parent to answer if English was not his or her primary language. After a few more parents either failed to return his developmental questionnaire, or had brief or no answers to most of the questions, Daniel acknowledged that perhaps the questionnaire wasn't working.

I was very glad that he came to that conclusion on his own! I remembered something one of my teachers had said years ago: "The best 'Aha!'' is the one you don't make", meaning that if the client or supervisee makes the connection, it is much more powerful.

Daniel had a hard time thinking that playing games was therapeutic. I asked him to read The Therapeutic Powers of Play by Charles E. Schaefer, Ph.D. (Editor). He learned that:

Game play contributes to a child's cognitive, emotional, and social development. Since games involve rule-governed behavior, ego control must be stronger than impulse-driven behavior. Game play also prepares children for their roles in the social world, including both competitive and cooperative roles. Among other ego-enhancing powers of games are: (1) helping distractible children focus and sustain their attention, (2) seeing the immediate consequences of one's actions in a game develops a sense of an inner locus of control of the environment; the challenge inherent in games helps overcome feelings of boredom and dullness. (p.13)

But to no avail.

There were times when I dreaded seeing Daniel. It was exhausting to feel that I had to document every suggestion with copious amounts of research. I often felt that, no matter what I told Daniel, it was not good enough. (DSM-S 140.00 Supervisor's Unresolved Stuff Arises in the Process of Supervision.) I felt devalued by Daniel's style, and knew that I needed to work on my issues and past experiences as my negative countertransference appeared.

And then was the scandal: it came to be known as

GATE.

Another intern came in to supervision upset because Candyland was missing from the playroom. Now, every child therapist knows that toys do get up and walk away, so money was requisitioned for another set of Candyland. But then the first set mysteriously reappeared, then the following week both sets were gone, and then both were back again!

Playing detective, I realized that the second intern, who had discovered the loss of Candyland, used the playroom directly after Daniel did. So, I asked him about it, and he sheepishly admitted that he so despised Candyland that he would remove it from the playroom before he saw children there. And a few times he had gotten so wrapped up in his process notes that he forgot to return it.

I gently explained to him that the toys had to stay in the playroom..all of them!

And that perhaps he needed to make peace with Candyland.

Daniel just didn't get it. No matter how much he read, he couldn't quite understand how game playing, especially Candyland, could actually be therapeutic. So, feeling desperate (DSM-S 004.78 - Engaging in an Act of Desperation by Desperate Supervisor; subcategory games) I pulled out my ratty old game of Candyland. Daniel looked surprised, to say the least, horrified might be more accurate. This was role play in its most playful form; actually playing!

"OK, Daniel, let's play!"

And so we played Candyland.
At first, Daniel didn't like the one rule of Candyland, which was that the youngest goes first. Even though this was to his advantage, being almost a generation younger than I am, he didn't think it was "fair".

For those of you who forget (or never played) the game is played by choosing cards, and advancing to that place on the board. The winner is the first one who gets to the castle at the end.

Daniel was very intense as he played, and kept getting flustered by "Plumpy"

Plumpy is the card in the deck that sends you back almost to the beginning.

No one likes Plumpy, but I think of the game as a highly evolved, spiritual game, in that it lets us know what we can control (taking turns, not cheating) but is like life, in that there is much we cannot control, like love, or birth or death. So, when a Candyland player is going along, and is suddenly swept up to the Queen Frostine card, or cast down to the little plum, Plumpy, then that is a lesson in things we cannot control. For children, much of their lives are involve things over which they have no control: where they live, who their teachers are, whether their parents get divorced, or stay together, etc. So I love Candyland.

But Daniel did not.

At one point he was scowling so much I feared that I had made a huge mistake, having him play.

Then I feared perhaps he was diabetic, and candy had been forbidden to him.

Or that his parents had been dentistry professors. I worried that perhaps he had an eating disorder...

But as we played, he began to open up.

After he got a particularly good card (Princess Lolly) while I was stuck in the Molasses Swamp, he actually laughed.

And then Daniel started to talk about never playing games as a child, because there were never any children around. He said his one game was chess, and that he had learned to please his father. His parents were very intellectual, and serious about their 'miracle', late in life child, Daniel. As a result, he was not allowed to play rough and tumble games, and only allowed to choose the same number of pieces of candy as his age on Halloween to eat. The rest had to be thrown out. "I remember really wanting to be 50, so I could eat 50 pieces of candy. It never occurred to me that 50 year olds don't trick or treat!"

He suddenly sat up, as if startled. "I am remembering something else...when I was in preschool, I played Candyland. And when Mother came to pick me up, she told the teacher that I couldn't play Candyland anymore. I think she thought it wasn't educational enough, or maybe it would make me want to eat candy." He then said that in his three sessions a week psychoanalysis he had never been able to remember much about his childhood. He said that he would see his analyst later in the day, and tell him about his "breakthrough".

This is a paradox of supervision, of course. As we are charged with upholding legal and ethical standards, making sure our students have the information they need, and respecting our authority, we can't really (and shouldn't) run supervision sessions like therapy sessions. Time and time again I would catch myself mirroring my intern's body language and feelings, then would have to pull back and teach, or, in some cases, lay down the law. A balancing act, to be sure. I was very glad to hear that Daniel was in therapy.

He said that it was easier to talk when he didn't have to concentrate so much, and that playing this game might actually not be a bad thing.

And then he said, "I think I have perhaps been a little too controlling with Maria in our sessions."

I was very pleased that Daniel had figured this out on his own. I felt this was an example of  "The best 'Aha!'' is the one you don't make".

And so it went, Daniel learning how to play, with little Maria leading the way. I kept thinking about what Winnicott wrote:

Psychotherapy takes place in the overlap of two areas of playing, that of the patient and that of the therapist. Psychotherapy has to do with two people playing together. The corollary of this is that where playing is not possible the work done by the therapist is directed towards bringing the patient from a state of not being able to play into a state of being able to play... Furthermore: It is in playing and only in playing that the individual child or adult is able to be creative and to use the whole personality, it is only in being creative that the individual discovers Self. (Playing and Reality, pp. 38, 54)

The paradox here was that Maria was teaching Daniel to play!  Again and again, I am struck by how our patients are our teachers. I often feel that it is never an accident who comes to us for therapy (and supervision). I wondered what Daniel was going to teach me!

Finally, it seemed time to get some more objective information, rather than rely solely on Daniel's self-report.

Observing Daniel

There is an ever increasing sentiment in the field of supervision on the benefits of directly observing interns at work. Research tends to find that "Although the traditional method of counselor self-report is often used, this form of data-gathering is notoriously inaccurate." (Hart, Gordon M., Strategies and Methods of Effective Supervision.)

Generally, one of three methods are employed:

• tape recording the session
• videotaping the session
• direct observation via two-way mirror.

Which method you choose will depend upon not only upon your preference, but the equipment available where you supervise.

Supervisors may choose from a variety of interventions, including direct approaches (e.g., audiotape and videotape review, co-therapy, live observation, and live supervision), and more indirect approaches (e.g., self-report, case conferences, review of case notes). There is evidence that, without regulations, supervisors rely almost exclusively on counselors' self-reports (Borders, Cash well, & Rooter, 1995; Borders & Usher, 1992), and there is ample evidence that self-reports are unreliable if not biased accounts of counseling sessions (Bernard & Goodyear, 1992; Borders & Led dick, 1987). The need for a balance of both direct and indirect approaches is cited in two ACES statements of standards, the "Standards for Counseling supervisors" (Dye & Borders, 1990) and the "Ethical Guidelines for Counseling Supervisors" (Hart, Borders, Nuance, & Paradise, 1995). (Source: Borders, L. DiAnne, Supervision Issues in Counselor Credentialing at http://ericcass.uncg.edu/redden/borders.html)

In the case of the schools, there was no opportunity for either direct or video supervision, so I broached with Daniel the idea of getting Maria's and her parents' permission to tape a session, for purposes of supervision. (Asking the child for permission is not a legal requirement, but one that I feel is an ethical one.) We discussed that if Daniel presented the idea of taping as a help to Daniel, and not about Maria, that Maria and her parents would feel more willing to consent.

Daniel did get their permission to tape the session, and brought the tape and a transcript to a later session. (We had discussed when both Daniel's and Maria's comfort level would be such that taping would show some of Daniel's counseling techniques. Daniel chose a date about 3/4s of the way through the first semester.)

One trick I had stumbled upon accidentally was to be at the school when an intern was leading the client either to or from a session. One time I had been at the school to observe a child client of mine in the classroom, and happened to be there at a time in which an intern was leading a very reluctant student to a counseling session. The interesting thing was that to listen to the intern, this student was the most cooperative and enthusiastic counseling client ever! So, by spying, I saw another side of what was going on. I have since always tried to see the intern having some contact with the client.

While observing another child at the school, I had seen Maria. She was on the small side, with dark eyes and hair. She was very animated in the classroom, very chatty with her friends. I could see why she was considered to have ADHD. I was not able to time my visit to see Daniel with Maria, but it struck me that she was probably the opposite of studious, serious Daniel in many ways. I was looking forward to hearing Daniel's tape of the session, and reading his transcript.

What I learned from the tape

I was impressed with Maria's ease with Daniel, how spontaneously she chattered away with him. She talked about school, and her friends, and she showed Daniel her "Owie", a bruise on her leg. Daniel asked what happened. She said she bumped her leg on her bed. She told Daniel how her best friend Audrey had been mean to her, not sharing her dessert at lunch. Maria told Daniel that she was never going to give Audrey even a tiny bite of her lunch, ever!

Daniel tried to reason with Maria, explaining that maybe that was a bit drastic. Maria didn't seem to take in what Daniel was saying, instead said, "Blah, blah blah. What do you know? Let's play!"

Out came the Candyland, and Daniel did very well here, playing the game without resistance, and even laughing and groaning when he had setbacks in the game. As they were playing, Daniel asked Maria how things were at home. She started to talk about her new brother, Danny, and how he cried a lot. She said that she wished he would hurry up and grow up, so that he could play with her. She said, "I wish he was Daniel, not Danny, and big like you. Then he could play Candyland with me."

Daniel did quite well here. Maria seemed to feel safe enough to open up to Daniel, and Daniel, for the moment, was doing quite well at letting Maria talk, and not trying to reason her out of her feelings. Later he said how touched he was by Maria's comments; that he felt something 'soften' inside himself.

Maria was talking more about how much baby Danny cried: "All the time! It drives me crazy." Daniel picked up on the feelings, and asked Maria what it was like to have Danny crying so much. Maria talked about how tired and cranky her mother was, and how Danny stayed up all night, just crying. She said her mom sometimes couldn't get Maria any breakfast, so Maria got herself some cereal. And today was a bad day, because Maria spilled the milk all over when she was pouring it, and her mom started screaming at her. Maria said she didn't like it when that happened.

Then Daniel said he could help her. He told Maria that at eight years of age she should know how to pour milk out of a carton. He said, "Let's practice." He got a pitcher of water, and a paper cup, and went over to the sandtray. He put the cup in the tray, and asked Maria to watch while he poured. "See! It's easy! All you have to do is focus and take your time. You try it."

Maria came over and poured the some water into the cup, but some spilled over. "No!" Daniel said, "Like this" and again, he demonstrated, spilling nothing.
When it was Maria's time to try, she poured the entire pitcher of water into the cup, overflowing the cup and flooding the sandtray.

"Maria!" Daniel said. "This is inappropriate behavior!"

There was silence on the tape, and then I could hear the sound of wet sand flying around.

"Stop! Maria, stop!" I heard Daniel say.

It was clear that Maria was not stopping. I heard her voice on the tape, "Stupid! I am so stupid! I can't even do anything right. Everyone yells at me!"

I wondered if Daniel would realize what had happened, that he had inadvertently recreated the morning's milk episode. Maria had once again failed, and gotten yelled at.

I listened for his next intervention.

"Maria," he said, "Is this what happens to you in school? That you feel stupid?"

Maria replied, "Dummy!" not specifying whether it was herself or Daniel she was addressing.

Daniel seemed taken aback, not knowing what to do. There was a pause, and Daniel said, "I will help you clean up this mess."

Silence on the tape, then the sound of paper towels being ripped off the roll.

Daniel's voice got very stern on the tape. "Come here, NOW, Maria, and help me clean this up. Now, Maria."

(At this point, listening to the tone in Daniel's voice, my reaction was the classic DSM-S (the DSM for supervisors) 139.82: The urge to throttle an intern! Then I realized this was Parallel Process in Action! Much as Maria's mother had yelled at her, and then Daniel had yelled at Maria, I wanted to yell at Daniel.)

Daniel then asked Maria if her mother ever hit her when she was mad at her.

Maria said nothing.

"Or does she ever shake you? Or say mean things? How often do you have to get your own breakfast?""Do you always have lunch? Do you always have clean clothes?"

Then Maria started to cry, then sob. She said, "My mommy loves Danny more than me. She yells at me every morning!"

Daniel seemed like a bloodhound chasing a scent.

"What else does your mom do? Or your dad, does he ever hit you?"

Maria was sobbing very loudly now. Finally, Daniel said, "It is OK Maria. It is OK. I know you didn't mean to spill the water when I asked you to pour it."

Daniel was quiet for a moment, then he said, "Maria! I am so sorry. I yelled at you for spilling, didn't I?"

"I am sorry. Is this what happened this morning with your mom?"

More silence on the tape.

Then Daniel said, quietly, empathically, "It must be hard."

Maria said only, "Let's play Candyland."

And they played until the session ended.

When Daniel came for supervision, I replayed this part of the tape for him. He said he was very concerned that Maria was being neglected, in light of the comments her mother had made on Maria's developmental survey.

I was a bit confused about what Daniel meant. "Well," he said, "She is obviously neglected if her parents can't take the time to fill out the answers, or give her breakfast."

My reaction was the DSM-S 126.90348558: "What planet is this intern from? Doesn't he know that having a newborn in the house, and no sleep, is incredibly stressful? And don't all parents yell at their kids in the morning?" Then I went into my own self doubt, thinking that maybe I was a bad mother, for yelling at my son in the morning! Oh dear! Maybe it was not normal to yell at your child, especially when he wouldn't get ready for school. I pulled myself back from my crisis of self-doubt, and struggled to find a neutral place inside myself, and asked Daniel what he meant.

"Obviously, the child is neglected. I am thinking that I need to make a Child Protective Services report. That's why I asked her what else her parents did to her. I know that we are charged with reporting child abuse. Her mentioning that bruise was quite suspicious, I think. And the fact that she is not fed breakfast is significant. "

I knew that I had to pull back my countertransference, and not blast Daniel. I didn't want to recreate in the supervision what Daniel had done in the session, when he yelled at Maria for spilling the water and throwing the sand.

As Daniel's task with Maria was delicate, so was mine with Daniel. How much of this parallel process should I discuss with Daniel?

I decided not to go into the parallel process at that moment, but inside to focus on Daniel's content. Like in therapy, the supervisor often has to choose between making a PROCESS intervention, versus a CONTENT comment. It seemed to me where Daniel was going was potentially explosive, so I asked him what other signs of abuse or neglect he was sensing.

"Well, her clothes often have spots on them. And she is very skinny. This isn't the first bruise that I have noticed, and she always has a story to tell me about how she got hurt. When I asked him to say more, he said, "She always tells me how she got hurt. Her stories are pretty wild, like swinging on the playground equipment, and falling off. Or having a contest  with her friend Audrey about how high she could swing, and then jump off. Or bumping into things. I think I need to call CPS."

None of this seemed necessarily suspicious to me - Daniel was describing the injuries of an active, impulsive child. I asked Daniel if there was anything else. He said no.

I pulled out of my notebook a definition of child neglect, from the National Clearinghouse on Child Abuse and Neglect Information, from: http://www.calib.com/nccanch/pubs/focus/acts.cfm#neglect

While I was pleased that Daniel was taking the issue of child neglect so seriously, I did wonder what planet he was from! (DSM-S 123.456237543 Supervisor wonders if intern is from another planet, and is an alien; wonders if intern is just totally oblivious to realities of family life, or is revealing unconscious sexism...) Daniel seemed oblivious to the normalcy of Maria's bruises and bumps, and to the syndrome of the sleep deprived parent who is trying to get a child off to school in the morning: tired, with little patience, etc. The spots he described on Maria's clothes (at what age do child learn to use a napkin?) seemed very normal for an active child. So I tried to educate Daniel as to what constituted neglect, and what was within the bell curve graph for the normal behavior and appearance of an active child.

He finally agreed that Maria did not meet the criteria for neglect, but said he would keep an eye on the situation.

There was little time left, but I wanted to address what had happened in the session between Daniel and Maria.

My task was to be compassionate toward Daniel, and help him become a good therapist. Rather than confront him, I decided to ask him if there was anything he would do differently.

Some questions that can be helpful when listening to a tape with a supervisee include:

1. What do you wish you had said to him/her?

2. How do you think he/she would have reacted if you had said that?

3. What would have been the risk in saying what you wanted to say?

4. If you had the chance now, how might you tell him/her what you are thinking and feeling?

5. Were there any other thoughts going through your mind?

6. How did you want the other person to perceive you?

7. Were those feelings located physically in some part of your body?

8. Were you aware of any feelings? Does that feeling have any special meaning for you?

9. What did you want him/her to tell you?

10. What do you think he/she wanted from you?

11. Did he/she remind you of anyone in your life?
(source: Cashwell, Craig S., Interpersonal Process Recall, http://www.ericfacility.net/databases/ERIC_Digests/ed372342.html)

Daniel sat silently, and then said he should not have lost his temper with Maria. We talked about the synchronicity of therapy; that often a situation will emerge in the session which duplicates that  which happened in the patient's life. The replication is a strong pull from the unconscious of the patient. The task is not to prevent the pull, but rather to be conscious of it when it appears, and then to respond differently.

I did not tell Daniel how angry I felt listening to the tape. We didn't have enough time to get into it, and Daniel struck me as still too defensive to benefit from a discussion of parallel process.

Daniel and I role-played a bit about what he could have done after Maria spilled the water, pouring it into the cup until it overflowed and flooded the sandtray. No matter how hard he tried, Daniel got stuck trying to play the acting out Maria! We went over different interventions, until Daniel came up with that he could have stayed with Maria's anger instead of yelling at her to stop.

Daniel Returns...

Daniel entered the supervision session with a worried look on his face. He was uncharacteristically late. Frankly, I had been dreading the session, knowing that I would have to discuss what Daniel had done. A strange word kept jumping into my brain...'inappropriate'. It is not that the word itself is so odd, it is just that that was not a word that I used very often, and today, for some reason, it was stuck in my brain. I was half hoping he wouldn't come , but also aware that if he didn't, we would have a LOT to deal with! So, I was both relieved and disappointed when he showed up.

We discussed how hard it was to see a supervisor after a difficult session. After working together on some of Daniel's other clients, Daniel raised the question of what he should do about Maria. He said that Maria didn't want to see him for her session, and, once there, had been quite withdrawn in their session, and acted 'very very good.' He reported that she was quiet, and had "perfect  behavior - no messes, no chattering, like she was on tiptoes." He realized that something was off, that this was not a 'cure' of her ADHD and acting out behavior, but maybe something to do with the previous session.

I asked him what he thought  he should do. He bent down to his briefcase, then caught himself and sat up. He looked embarrassed, and said, "I thought you could just tell me what to do." I made some neutral noise, the old, "hmmm..." or some such therapist stalling noise. It worked... Daniel started to talk about what he thought he should do. He decided to try to follow where Maria was, and to go from there. He realized that, after being yelled at, then sobbing, that Maria might need to reestablish rapport with Daniel. She might be feeling that the 'free and protected space' of therapy had been compromised.

Daniel took a deep breath. "Actually," he said, "I really didn't want to see you today. I felt so bad about what I had done with Maria, and then rather like I had overreacted regarding calling CPS for neglect. I really was afraid that you would yell at me, or kick me out of the program. Or that you would think I was really bad, or something. I just didn't know what to expect. I have been quite anxious all week."

Bingo! Parallel Process in action! Much as Maria had told Daniel she didn't want to be in session, Daniel had told me the same thing! As I had spent the session re-establishing rapport with Daniel, so I wondered what he would do next.

Now it was my turn to take a deep breath. I knew Daniel was pulling from me to react as he had in the session, yelling at him, or telling him his behavior was inappropriate. I wondered how many times he had heard that as a child?

I reassured Daniel that ALL therapists make mistakes. It is not the mistakes that matter so much, but what happens afterward. How do we handle it? In all human relationship, mistakes are made. Part of being a therapist was to be conscious of the mistakes, and willing to process, in a non-defensive manner, whatever comes up in a session. If a mistake is made, then we must try to not react in the way that the client's psyche is pulling us to react. To provide a different solution.

Here I went out on a limb, and risked bringing the parallel process to consciousness.

"Daniel, let's talk about what is happening here. It seems to me that you came in here today, full of fear that I would yell at you, or say what you did was 'inappropriate' after your session with Maria. It seems as though you were as reluctant to come here as Maria was to see you."

I waited to see what Daniel's reaction would be.

His face got red. "Oh! I get it! Just like Maria somehow recreated her morning, I just did the same thing. I guess I feel like I always have to act correctly, or there will be consequences for being inappropriate. And I thought that you would say what I did was inappropriate. (Aha! Now I knew why that word had been stuck in my brain all morning!) My parents always told me when my behavior was inappropriate, and I guess that is why I told Maria she was being inappropriate. Wow! I am going to tell my analyst about this! This is amazing! "

Then I asked Daniel what it was like to make a mistake, and get a different reaction. He said it was too new, but he thought it felt good.

We then talked about how he would handle the session with Maria.

He was "good to go", or so I thought!

Later that week...

I got a message on my voice mail, from Daniel. I could hear the panic in his voice. "I got a call from Maria's parents. They said Maria said that he had said they were hitting her, and they weren't and they wanted therapy to end. Daniel was uncharacteristically in a tizzy! Panicky, he said, "I knew it was too good to last. See, I was 'inappropriate', and there are consequences. What do I do? I'm scared, What should I say? They want me to call them. Please, please help. I don't know what to do."

I called Daniel back, and we briefly discussed his feelings of anxiety, and what he would say to Maria's parents. I suggested that he schedule a meeting with them. He said he was too scared to. We role played a few scenarios, and he asked if he could call me back after he spoke with Maria's parents. I said yes.

He called back, and said that he had explained to them that part of his job was to make sure no one was hurting Maria. He apologized to them for the misunderstanding. He asked more questions about Maria, and got a lot more information than he had gotten from his developmental form. He thanked them, and said that he hoped they would allow him to continue working with Maria, and that he would clarify to her that he didn't think they were hurting her. They agreed to allow Maria to continue, and told him how stressed Maria had been since the difficult pregnancy with Danny, and his subsequent premature arrival. They said they wanted Maria to get help, but they were not sure what Daniel was doing was helping.

When  he called me, there was a new humility in his voice. "I think I have misconstrued the whole situation with Maria. I think that probably she is reacting to the loss of her mother, first due to her bedrest, and then because of the new baby. I really appreciate her parents calling me, because of what I learned. However, it was hard to hear how badly I had blown it."

Daniel's work continues...

Daniel's work until the end of the school year was different, his arrogance and rigidity had been replaced, by and large, with humility, and a willingness to learn and to make mistakes. Once he realized the origin of Maria's wound, he was quite effective in working with her, even playing doll house with her. Like many therapists in the beginning of their training (DSM-S 133.33, Supervisor talking about self in a way that no one is supposed to know that she is talking about herself), he had felt that he knew all the answers, and could be a better parent to his client than his or her real parents. He did eventually meet with Maria's parents, and was impressed with how loving they were, and how concerned about Maria. He resolved to throw out his developmental questionnaire, and to meet with the parents of child clients within the first few weeks of getting a referral.  He said, "I need their help. I can't work with their child unless I know them, and they trust me."

Daniel realized that he knew very little of other cultures, a surprising admission from one, who, at the beginning of his internship, had known so much about everything! He was quite shocked when he began to look at his own assumptions, and was struck by the realization "that the 'counselor culture' has at its core a set of white cultural values and norms by which clients are judged." (Katz, J. H. "The Sociopolitical Nature of Counseling." THE COUNSELING PSYCHOLOGIST" 13 (1985): 615-623., Lauver, P. J. "Extending Counseling Cross-Culturally: Invisible Barriers." Paper presented at the annual meeting of the California Association for Counseling and Development, San Francisco, CA. ED 274 937 cited in Issues in Multicultural Counseling. Highlights: An ERIC/CAPS Digest. at: http://www.ericfacility.net/databases/ERIC_Digests/ed279995.html).

I knew that I had found Daniel very ignorant about how life is with a newborn, especially a high needs premature baby, as well as out of touch with the bumps, bruises and dirty clothes of an active child. I don't think this was particularly an issue of cultural bias or sexism, but rather a lack of empathy and knowledge regarding how difficult family life can be at times. There were times with Daniel when I felt like modifying the above quotation to: "that the 'counselor culture' has at its core a set of 'white male thinking type without children' cultural values and norms by which supervisors are judged".

Maria continued to be Daniel's teacher. She periodically got angry at him, and threw sand around the office. And Daniel periodically got angry at me, and I had to resist my own ancestral pull, from my family of origin. (No, he did not throw sand around the office...even parallel process has its limits!) At one point, as he seemed to criticize my lack of documentation and research regarding a suggestion that I had made, I suddenly got it! Daniel was temperamentally like Dr. M., my first supervisor! Once I realized that, I saw how working with Daniel was healing the wound I had incurred with my first supervisor. Seemingly, right after I had that realization, Daniel was much more accepting of my ideas, and seemed to stop asking for bibliographic references. (However, it may be that it was my perception had changed....)

As Daniel learned to stay with Maria's feelings, these episodes diminished. As Maria's anxiety lessened, and baby Danny started sleeping through the night, Maria ADHD-like symptoms and acting out behavior decreased. No question, she was a very active, impulsive child, but did not meet any criteria for ADHD or ODD by the time the school year was ending.

A delightful time came as their work together was ending. Daniel had realized that Maria's learning style was more 'emotional' than cognitive, and with that, he actually started lightening up on others (including his supervisor, me!) who also were less analytically inclined. As Maria started talking about teaching 'her baby Danny' to speak, she also began to teach Daniel some Spanish. By the end of his internship, Daniel knew all the names for the doll house furniture, and the colors, in Spanish!

It was in reading in the above article, "One characteristic that is of paramount importance in most Hispanic cultures is family commitment, which involves loyalty, a strong support system, a belief that a child's behavior reflects on the honor of the family, a hierarchical order among siblings, and a duty to care for family members" that Daniel realized how much he had blundered in his supposition of child neglect. It wasn't that Hispanic families have any more or less abuse and neglect than any other families; it was how he had approached it. He realized that he had put Maria in a very uncomfortable position, by grilling her, and was culturally insensitive. He felt very grateful that her parents had allowed her to continue her therapy with him.

Like most beginning interns, there was a time when Daniel had to make a CPS report, on another child he was seeing. Looking back, he said that it was very clear to him that Maria had not been neglected or abused.

Evaluating Daniel

Part of supervision is, of course, evaluation. My evaluation of Daniel changed over time, as did his of me. In the beginning, I found him rigid and overcontrolling, he found me overvaluing feelings to the detriment of thinking, and sometimes too casual or seemingly impulsive in my recommendations to him.

Over time, we both switched. As he began to appreciate my style and experience, I learned from his ability to do research. As we learned to value each other's styles, we each stopped dreading our sessions. As I learned to stay with his thoughts, eventually he would find his way to feelings. He became more comfortable , and especially when he realized that I would not label his interventions or questions as 'inappropriate'.

A breakthrough came when he said he realized that when he felt the impulse to say that something was 'inappropriate' that meant he was caught in his complex regarding his parents, and that he stepped back, and didn't say it. ((DSM-S 148.00, Supervisor  very proud of intern!)  Instead, he said nothing, or 'hmmm..." until he could figure out what to do or say.

His clinical skills improved as he relaxed and become more confident (rather than defensively confident, as he has been at the beginning of his training.) He became very adept at recognizing parallel process in the therapy sessions and at times in supervision.

Toward the end of our work together, he gave me back the journal that I had given him. It was blank. He said, "I wanted you to know that I felt a bit strange when you said to use this, to record my fantasies and dreams about my clients. I even talked to my analyst about it. Thank you for never asking about it; for letting it be completely private. I did it, and it was very helpful. But you might want to 'get with it'...nobody writes anymore. I did mine on my laptop."

Saying good-bye

The school year was ending, and it was time for Daniel to say good-bye to the students and families he had counseled, and for me to say good-bye to him. He was able to actively use the concepts of the parallel process as he felt his feelings about leaving our work together, and how it reverberated through his good-byes to his clients.

He said that working with children had touched him deeply, and that childhood memories were coming back a lot more now. While he still did not have enough experience to be accepted in the psychoanalytic clinic as an intern, he was leaving to do another internship, this time with adults.

We made it a habit to periodically play Candyland, and even used metaphors from Candyland to describe how the work was going. He would confess to a "Plumpy" session, in which nothing seemed to go right, or when he felt stuck, he described it as being "Gloppy", caught in the molasses swamp.

When last I heard, Daniel had graduated from the master's program, had gotten a doctorate and was teaching psychoanalytic developmental concepts at a prestigious university. I don't know whether he ever plays Candyland...or teaches it in his classes!

 

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