Overview of Supervision

As you can see, Sean needs supervision for various reasons: maintaining occupational wellness, balancing work demands, and helping to deliver quality evidence-based interventions for his caseload. Supervision encompasses the various ongoing clinical supports of individuals providing therapeutic services, ranging from activities that support quality of the clinical services rendered to clients to professional development of the clinician providing the service (Bearman et al., 2013; Falender et al., 2014; Bearman et al., 2017; Schriger et al., 2021). Supervision is a way to enhance clinician therapeutic skills and to understand the relational aspects of providing psychosocial interventions (Falender et al., 2014). There are various modalities of supervision, ranging from individual supervision (one-on-one), group supervision (one-supervisor to many supervisees), and peer supervision (peer-to-peer support without a senior professional). Supervision is one of key opportunities to make therapeutic concepts actionable (Bearman et al., 2013), and it has effects on patients, clinicians themselves, and organizations.

This chapter will cover the impact of supervision, the various roles and activities of the supervisor, and insights on how to use the valuable resource of time in a supervisory hour, based on the supervision literature.

Why is Supervision Important?

Clinical supervision has an impact on client outcomes, therapists, and organizations. Clinical supervision can produce benefits to patients and health organizations, typically when a working alliance is established between supervisor and supervisee (Martin & Milne, 2018). Leadership is required from a supervisor to provide direction and the supervisee to provide collaborative decision-making when faced with negotiating needs and self-evaluations (Martin & Milne, 2018). With clients’ impact, clinical supervision is known to account for up to 16% of variance in client outcomes, evidenced in better numbers of symptom reduction and completed cases (Lyon et al., 2018; Rieck et al., 2015).

Supervision impacts therapist competence. Supervision itself can be more impactful than training as it promotes behavioral change in employees (Lyon et al., 2018). Structured supervision is not widely utilized because most supervision practice focuses on case conceptualization, interventions, and administrative tasks (Lyon et al., 2018). Supervision outcomes are typically not measured; however, it is known that quality supervision focuses some sort of standardization such as focus on session review, treatment model fidelity, and supervisee skill building (Lyon et al., 2018; Rieck et al., 2015).

Quality supervision can reinforce practices that increase employee well-being. Making workplace detachment at home allows for recovery from work (Sonnentag & Fritz, 2015). A supervisor’s promotion of work-life balance and relaxation can decrease emotional exhaustion, a core component of burnout (Hutchins, 2018). Supervisors who coach their employees to use active coping strategies opposed to avoidance coping can increase job satisfaction and organizational commitment (Hutchins, 2018). Quality supervision can increase employee job satisfaction, reduce turnover intention, and lead to increased organizational commitment (Mathieu et al., 2016). Perceived supervisor support increases employee social relations, which is protective against burnout (Arici, 2018). Employees who have higher levels of perceived supervisor support tend to have higher levels of perceived organizational support, a factor known to decrease burnout (Arici, 2018). Supervisors serve as a protective factor in this way; however, supervisors can also serve as a risk factor for burnout if employees focus on the negative aspects of their supervisor (Arici, 2018). When an employee experiences burnout or secondary traumatic stress, they are placed in a position in which they do not feel empowered. Supervision that has a leadership component (agenda setting, guiding the session, teaching and development of the supervisee) can be protective when a supervisee’s ability to advocate, engage, and collaborate effectively is compromised (Martin & Milne, 2018).

Supervisors who provide frequent constructive feedback and direct, immediate support can affect employee engagement, job satisfaction, and organizational commitment (Shuck, et al., 2014). While not directly correlated with quality supervision, the effects of on work engagement can lead to decrease absenteeism, burnout, and turnover intention (Shuck et al., 2014). Supervisors can also provide feedback that enhances job embeddedness, which represents employee’s skills and job fit; employee job embeddedness decreases turnover intention (Shuck et al., 2014). Clinical supervision does have an impact on coping; it serves as a supportive activity for coworkers, and it provides long-term influence on job satisfaction and competence (Hyrkas et al., 2005).

In addition, it may be helpful to understand the bi-directional impact of supervision on organizational climate (employees’ perception of their workplace environment) and culture (norms and expectations in an organization) (Glisson, 2002). Supervisors often serve as middle managers, who supervise frontline employees and are supervised by top organization leaders (Birken et al., 2012). Middle managers play the important role of communicating and implementing the policies and practices established by organization leaders and are therefore essential in creating and maintaining organizational climate and culture conducive to employee performance and well-being (Birken et al., 2012). When particularly focusing clinician EBP use, supervision is theorized to increase EBP use through influencing EBP implementation climate, the perception that EBP use is expected, supported, and rewarded in one’s organization. One study found that supervisors engage in four specific behaviors (diffusing, adapting, mediating, and selling) all related to communicating information about EBP use to clinicians in order to shape and improve implementation climate (Bunger et al., 2019). Another study found that when supervisors frequently engage in specific implementation leadership behaviors, organizational implementation climate improves, and clinician EBP use increases (Williams et al., 2020). However, implementation climate may also influence supervisor behaviors. One study found that implementation climate strongly predicted the amount of time supervisors spent discussing EBPs content, accounting for about 37% of supervisor-level variance (Dorsey et al., 2017). In this case, messaging from top organization leaders, through explicit communication or allocation of financial resources to EBPs, may be important in encouraging supervisors to engage in EBP specific supervision. Therefore, attending to this bi-directional relationship may help clinicians understand how and where they can best receive EBP support from within their workplaces.

Values and Principles of Supervision

When we think about the various roles of the supervisor, the value is not in a prescriptive description of what to do, but how to do it. In this section, we focus on the how of supervision. A critical first step in discussing supervision is grounding our practice in SAMHSA’s Six Principles of Trauma-Informed Care (SAMHSA, 2014): safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment, voice, and choice; and cultural, historical, and gender issues. Trauma-informed organizations infuse these principles in all their policies and practices. This section describes how these principles are implemented in supervision. By utilizing these principles in clinical supervision with a trauma-informed lens, we positively impact staff and improve the quality of care provided to clients. These principles not only apply to our clients but should be woven throughout all aspects of the organization.

Supervisory Value: Safety

As a supervisor, one of our primary goals is to increase safety for our staff. We must prioritize both physical and psychological safety. In thinking about physical safety, we must consider the physical space staff are working in (in homes, communities, office settings), their access to resources and safety plans in times of crisis, and their personal sense of safety working with certain populations. We must consider whether staff feel respected by clients and families that they work with as well as peers, colleagues, and administrators. It is important to have discussions with staff to better understand their sense of safety in their work.

Psychological safety is essential to the relationship between supervisor and supervisee. Supervision should be a place where staff can come to feel heard, respected, understood, and supported. Supervisors need to invest time and effort into trying to create spaces that are inviting and free of judgment. There are many ways to accomplish this, beginning with recognizing our staff as human beings who come to this work with their own personal feelings, beliefs, and histories. Infusing the importance of safety when we speak is paramount. It is our responsibility as supervisors to partner with staff to enhance their sense of safety and to implement policies and protocols to mitigate any safety issues.

Supervisory Value: Trustworthiness and Transparency

A positive relationship and connection between you and your supervisee create the foundation for trust and a strong professional relationship. By prioritizing the relationship, supervisees will begin to trust that we, as supervisors, will have their back. The goal of supervision is not to prevent staff from making mistakes but to allow staff to make mistakes, seek support, and learn from those mistakes. While we ask for our staff to trust us, and we work to build that trust, we must also trust our supervisees. We must trust that they have the best intentions for their clients, which will allow space for supervisees to function independently without micro-management. It is critical that staff know that you, as a supervisor, believe in them, support them, and will stand by them when they’re doing great work, as well as when they make mistakes. Our responsibility is not perfection, but it is to help supervisees learn and grow to provide the best care to clients.

Providing honest and clear feedback in a constructive, not punitive way, is another way to maintain transparency. In addition to being a source of support for staff, we must be consistent with that support. Holding our supervision time as scheduled, not frequently rescheduling, is one way to show consistency. We must also be accountable, following up on tasks and ensuring that staff have access to the information and resources to do their jobs. The supervision space should remain confidential, except when staff ask for assistance in advocating on their behalf. In addition to the trust and transparency between supervisor and staff, that transparency should also include openness about agency-level decisions, changes, or policy updates that impact staff and clients.

Supervisory Value: Peer Support 

The supervisor is one of many forms of support to supervisees. As supervisors, it is important to encourage staff to seek out different forms of support. While supervisors must recognize their own impact on staff performance and wellness, they must also recognize the limits of individual supervision and the benefits of peer support. Catherall (1995, p. 86) states that “peer support can often clarify colleagues’ insights, listen for and correct cognitive distortions, offer perspective/reframing, and relate to the emotional state of the therapist”. In order to build a strong cohesive team, it is essential to recognize and create opportunities for staff to give and receive peer support and mutual aid. Similarly, supervisors should seek their own peer support, to learn from other supervisors and engage in collaborative learning.

Supervisory Value: Collaboration and Mutuality

As a trauma-informed supervisor, our goal is to reduce hierarchical structures to enhance mutuality and collaboration. It is essential that we, as supervisors, work to level the power differences in supervisory relationships. We must recognize our power and position and be mindful of that power and privilege in all the spaces we operate, as well as in the decisions we make. Our supervision time with staff should be collaborative in which the supervisor and staff join in sharing perspectives, problem solving, and making decisions. It is important for staff to model vulnerability at times and to be authentic when they may not have the solution to an issue. Just as we understand the impact of an authentic relationship between clinicians and clients, the context of relationships between supervisor and supervisee is the foundation for healing and empowerment.

Supervisory Value: Empowerment, Voice and Choice

Utilizing this pillar in the supervisory relationship helps us acknowledge that each supervisee has unique experiences, skills, and needs and will require different things from us as supervisors. Approaching supervision by using the strengths perspective will help us identify the assets of each individual staff member and be able to flex our style of supervision to meet their needs. While some staff may appreciate and utilize processing in the context of supervision, others may have alternate ways outside of supervision that allow them to process. Similarly, some supervisees are able to voice when they are struggling or need additional support, while other staff require the supervisor to create the opportunity for staff to feel safe enough to share it. It is important to have discussions to get to know what each staff needs from you as a supervisor. Supervisors should encourage staff to utilize multiple means of communication to share feedback, such as supervision meetings, email, or Slack.

Supervisory Value: Cultural, Historic, and Gender Issues

As supervisors, we must recognize our own biases. We must recognize the histories and experiences that our staff may have, including those related to race, gender, socioeconomic status, geography, sexual orientation, religion, and abilities; we must also recognize how these experiences impact their work and their relationship with us as supervisor. It is essential to recognize and acknowledge historical and present-day abuses of power and privilege and how these behaviors contribute to structural racism and discrimination that affect our clients, families, and staff. As a supervisor, it is imperative to hold space to acknowledge these experiences in the context of trauma in staff’s personal and professional lives. In addition, it is also essential to understand that staff often bring their individual cultural practices and ways of healing, and that is an asset and can improve care to clients.

SAMHSA’s Six Principles of Trauma-Informed Care provide the values and beliefs that can guide supervisors in how to create authentic professional relationships and safe spaces for their staff. In addition to these principles, it is also important to recognize the different roles that supervisors play within the organization. Supervisors can take on the roles of counselor, educator, consultant, wellness coach, and/or advocate. When we know our staff and their needs, it will help us know when we need to shift into these different roles to best support them and ultimately enhance the quality of care provided to clients.

Roles and Responsibilities of a Supervisor

The previous section gave the context of the approach to supervision, and this section will discuss the specific roles or implementation of those core policies. Supervisors may have different styles, such as a developmental approach that focuses on the continual growth areas; an integrated model that understands the eclectic approach to counseling and therapy; and an orientation specific model of supervision, like behavioral supervision or systemic therapy (Leddic, 1994). There are many other models and considerations for supervisory practice (Westefeld, 2009; Mitchell & Butler, 2021; Li & Peters, 2022), so we will glean common elements from these approaches. We start out considering the bigger picture for our supervisees, and then we will work towards the delivery of service.

Wellness Coach Role

Supervisors have an ethical imperative to discuss aspects of burnout or secondary traumatic stress with their direct reports. It is helpful to understand these concepts and how they can enter the supervisory relationship. Burnout comprises the specific cognitive, emotional, and behavioral changes an employee faces after cumulative stress, and its features include emotional exhaustion, depersonalization, cynicism, diminished sense of personal accomplishment, and the overwhelming feeling of increased difficulty to perform work tasks effectively (Stamm, 2010; Ahola, Toppinen-Tanner, Seppänen, 2017). Burnout can be seen through an organizational lens, in which burnout arises from the conflict of job demands and resources to meet demands; typically, this stress load is characterized by deficits in resources and surpluses of demands (Ahola et al., 2017). On an individual level, an employee’s appraisal of their stress also mediates the relationship of both the job-demands conflict and the resulting burnout (Ahola et al., 2017). This appraisal pattern can create a negative feedback loop that perpetuates and exacerbates burnout symptoms.

Secondary traumatic stress results from the emotional responses when a helper is exposed to first-hand traumatic experiences of their clients (Stamm, 2010), and it often resembles the symptoms of post-traumatic stress disorder (PTSD). Employees can have intrusive thoughts about their clients’ experience, undergo changes in mood and cognition, suffer sleep disruption, and, lastly, avoid their client or content related to their clients’ experiences (Stamm, 2010; Osofsky et al., 2008; Figley, 1995). Secondary traumatic stress goes beyond burnout, as there can be drastic and lasting changes in a helper’s belief system in which they feel helpless, detach from their work, and experience physical and psychological isolation (Stamm, 2010; Figley, 1995, 2002; Osofsky et al., 2008). STS, if left untreated, can lead to problems for employees in both occupational and personal domains (e.g., employees can experience physical ailments, and poor interpersonal relationships, along with diminished work quality, performance, and productivity) (Pryce et al., 2007). Both STS and burnout in their respective presentations of stress provide challenges for human service organizations with a seriousness that can signal an occupational hazard.

In addition to the negative sequela in individual workers, STS impacts the care provided to clients and families. Dutton and Rubinstein (1995) assert that defense mechanisms, such as detachment and non-empathic distancing used by workers to deal with client’s traumatic experiences, lead to clients feeling emotionally isolated and detached from those workers who are trying to help them. STS also contributes to victim blaming and the disruption of empathic abilities (Pearlman & Saakvitne, 1995). Bride (2007) found that 31.6 % of workers endorsed client avoidance (reduced interactions or visits with clients) which was the second most frequently reported symptom. Bride’s findings are particularly alarming considering how such symptoms not only affect workers but also directly impact the quality of care provided to clients. Compromised care may negatively impact vulnerable children and families and may also increase risks related to safety for staff, clients, and the organization (Vega, 2019).

STS also correlates with low rates of job satisfaction, retention, employee engagement, decreased agency efficiency, morale, quality of work, increase in staff turnover, and economic loss to the agency associated with hiring and training rates (Joyce et al., 2015). Mental health is an increasingly important topic in the workplace with common psychological disorders now recognized as the leading cause of sickness, absence, and long-term work disability in most developed countries (Cattrell et al., 2011; Moncrieff & Pomerleau, 2000). Stress-related health conditions contribute to substantial economic costs to employers and disruptions in quality services provided to vulnerable children and families.

The physical, psychological, cognitive, and behavioral manifestations of STS also interfere with worker productivity as workers perform their job duties, while also trying to address their own health needs. STS is pervasive and increases the risk for negative psychosocial and health outcomes for workers, negatively impacts client safety and wellbeing, and poses great economic strain on the organization. Abounding risk factors in multiple domains highlight the need for a holistic and comprehensive understanding of the interrelated factors that increase risk for STS.

One of the greatest protective factors that we can control organizationally to support staff and mitigate STS is the quality of supervision. Social support plays an essential role in the lives of individuals who work with clients who have experienced trauma. Kassam-Adams (1995) conducted a study on 100 psychotherapists who worked in outpatient mental health agencies. Approximately 50% of the participants reported STS symptoms, including symptoms of avoidance and intrusive thoughts. The participants’ stress levels were found to be inversely related to the levels of social support they had in their personal and professional lives.

In addition, the use, availability, and quality of supervision has been shown to decrease the negative effects of STS and VT (Brady et al., 1999). Dalton (2001) found that the number of hours of supervision received but also the number of times a social worker received supervision were positively related to low levels of STS. Organizations seeking to prevent or reduce the impact of STS must employ interventions that focus on increasing peer, supervisor, and organizational support that can improve the quality of work and preserve the overall effectiveness of the organization (Dunkley & Whelan, 2006). STS is a serious work hazard, and administrators should pay more attention to the negative outcomes and implications of failing to address STS.  Supervisors must understand that STS is a structural problem, and individual solutions may only buffer the negative outcomes. This can result in both physical and psychological impairment of staff, decreased quality of services to clients, and greater attrition rates and costs to the organization.

Advocate or Change Agent Role

As we have learned, the addition of supervisor support serves to reduce or alleviate concrete work stressors and/or workload. Ideally, the supervisor becomes a buffer to address the organizational and systemic factors that are increasing stress reactions (by diversifying tasks, reducing caseload, halting intakes, permitting time off, escalating client or organizational concerns, providing encouragement and recognition, etc.). The supervisor’s role is to advocate for staff wellness (balancing that with client safety and needs) and think through creative solutions to mitigate the systemic sources of stress. Many of these organizational resolutions are often temporarily enacted to give staff enough time and space to cope effectively. This approach fosters the supervisory relationship as a protective factor to promote longevity of staff and quality care to clients.

Identification of STS as a systemic issue encourages those in the profession to reexamine the relationship between trauma and this type of employment stress. Evidence demonstrates the need for administrators and supervisors to implement organizational responses, such as reducing workloads, diversifying tasks, and increasing vacation or sick time to address employee health and safety. Other organizational responses, such as ongoing peer support, increased supervision, and creating a culture that acknowledges the potential for STS can serve to prevent or decrease symptoms (Vega, 2019).

Counselor Role

One of the roles that supervisors play is that of a counselor. While supervision is not therapy, a supervisee must feel that they can voice their concerns, ask for help, be vulnerable, and seek guidance. The counselor role resembles aspects of reflective supervision, where the supervisor utilizes active listening and thoughtful questioning to support the supervisee with decision-making. By providing space and silence in supervision, we allow supervisees to think and reflect before expressing their thoughts and feelings. In our role as counselors within the context of supervision, the goal is to try to create a safe space for our supervisees to feel supported and heard.

In this counselor role, we support our staff by helping them be able to process client experiences and the way those experiences impact them. In the same way a client may experience a persistent fight or flight response, there exists a parallel process in which staff can experience the same response as a result of their increased and chronic exposure to traumatic stress (Vega, 2019). It is important that staff are able to utilize supervision to receive social support and tips on how to manage this impact. The supervisor explores the thoughts, feelings, reaction(s) of the supervisee in this role as counselor. By engaging in reflective supervision, the supervisee can increase observational capacity and become more aware of their own reactions to the client and the change process. In addition, reflective supervision can help supervisees become aware of their own biases and thought processes which can, in turn, enhance the quality of therapy provided to clients.

Educator Role 

Supervisors often function as educators within the supervisory relationship. Educational supervision helps supervisees better understand their role while refining their knowledge and skills. Supervisors provide skills development, share resources and deliver content. Within supervision, there may be activities that guide the supervisee to better understand assessment, treatment, intervention, and evaluation. In certain specializations or areas, supervisors may share specific skills related to job responsibilities or tasks to help the supervisee grow. Supervisors are responsible for helping to close gaps in knowledge from both a clinical and administrative perspective. While educational supervision can provide new skills related to clinical practice, supervisors as educators also provide education around employee benefits, stress relief, or self-care strategies.

Consultant Role

For more advanced clinicians, we may enter into the role of consultant. A clinician may feel competent in delivering an EBP, so the role may be less about teaching or reviewing aspects of the EBP and more about monitoring the fidelity of the model. In such cases, a supervisor should have a clearly laid out information system, such as a system of feedback loops that can guide a consultant’s work to understand and maintain model fidelity. This work may feel less dyadic and more of a collaborative relationship that encourages a different type of problem-solving process in which advice and knowledge are shared. In the consultant role, a supervisor may have specialized knowledge, and this can be helpful to identify gaps/barriers to a therapist’s knowledge. Supervisors often play the role of consultant when trying to enhance fidelity in delivering EBPs within a new setting or with a new population. The supervisor will be able to support staff in shifting expectations or trying new strategies while maintaining fidelity to the EBP model.

Architecture of a Supervisory Hour

Given the various roles of the supervisor, there are many things to consider in a supervisory session. Structuring supervision can maximize use of time and ensure that key treatment needs are being addressed. The supervisory hour has time constraints, and supervisors have a multifaceted role in supporting clinicians, facilitating implementation of EBP, and addressing other miscellaneous issues that arise. Because of this, it is important to be intentional in structuring the supervision hour. Doing so will maximize the utility of the supervision hour.

When considering how to best align supervision with gold standard recommendations, it is important to consider the supervision content (i.e., what is talked about), supervision process (i.e., how it is talked about), and the relationship between the supervisor and supervisee, particularly as it relates to cultural humility (Schriger et al., 2021; Hook et al., 2016; Patallo, 2019). Supervision content will ensure that clinicians have the content knowledge and skills they need to implement EBPs with fidelity. Supervision processes allow for supervisors to ascertain that supervisees have this knowledge; it also allows a supervisor to foster a clinician’s growth and learning through strategies that promote their development. Finally, attention to the positionality of supervisors and supervisees allows supervisors to model cultural humility with supervisees, which can then be enacted with clients.

Supervision Content

The content that is discussed in supervision is highly related to what is discussed in therapy, and thus should be considered when carrying out supervision. This can be addressed using an agenda, much like what is done within therapy sessions. It is important that key evidence-based content areas are addressed during supervision to ensure that they are being brought into therapy. These core EBP elements should be prioritized during supervision to maximize the likelihood that they will be implemented with the client (Bearman et al., 2013). While the key EBP components will differ across interventions, there are many components that cut across interventions, such as psychoeducation (across most interventions), exposure (particularly for anxiety treatments), and behavioral activation (most often for treatments targeting depression).

In addition to core EBP elements, there are often other content areas that may need to be addressed during supervision, including administrative tasks, case management, crisis assessment, and risk management. In some cases, it may also be important to briefly discuss each client and to review any questions that arose since the previous supervision meeting. However, spending even a few minutes of review on each client can quickly use up the supervision hour, and this breadth must be weighed against depth in other areas.

Content areas unrelated to EBP implementation are often addressed during supervision out of necessity, as there may not be an additional dedicated time to address them. However, time spent in these areas will diminish the time that can be spent addressing core EBP components, and thus, if possible, it is best to address them outside of the supervision hour. This will maximize supervision as a time to support clinicians in solidifying therapeutic technique and to facilitate EBP implementation. There are several creative strategies that can be used to retain individual supervision as a time for carrying out these goals, particularly through the use of group supervision and “drop in” supervision (Schriger et al., 2021).

Group Supervision. Recent work suggests that these administrative and logistical issues can be successfully addressed during group supervision, which maximizes efficiency by allowing multiple supervisees to gain information at the same time. Group supervision can create greater efficiency for common challenges that may arise across supervisees, and it has been shown to be as effective as individual supervision (Dorsey et al., 2013; Stirman et al., 2017). In addition to discussing administrative and regulatory content in group supervision, some studies have suggested that in-depth case reviews can be utilized to teach skills to supervisees that they can then use with their own clients (Dorsey et al., 2017).

Drop-in Supervision. Other alternative solutions include creating a drop-in supervision hour during which supervisees can ask non-clinical questions to supervisors during a designated hour, much like office hours. (Schriger et al., in press). Drop-in supervision may be optimized by using an online platform, as it allows supervisees to drop-in even when not in the office or when they have a quick question that would otherwise not warrant a full meeting.

Supervision Process

The strategies used within clinical supervision are essential in fostering high quality clinical care and ensuring that EBPs are implemented with fidelity. There are a number of supervisory strategies that can be used to carry this out, including strategies that are more active in nature and others that are more passive (Schriger et al., 2021). Though both sets of strategies are important, the active strategies are crucial in facilitating specific skill development (particularly around delivery of core EBP content areas) and are often underutilized (Schriger et al., 2021; Bailin et al., 2018). Key active strategies include experiential learning techniques such as role playing, modeling, and direct observation of live or recorded therapy sessions. Direct observation (and subsequent feedback) is a particularly crucial element for increasing clinician competency and has been shown to be underutilized (Milne, 2009; Schriger et al., 2021). Other core active strategies include agenda setting, feedback provision, and didactic skills training.

In addition to active supervision strategies, it is important to attend to the relationship between supervisor and supervisee to facilitate trust and honesty and, in turn, to maximize the utility and impact of the supervision hour. Passive supervision strategies include actively listening to the supervisee, receiving feedback from them, and validating their experience. Additionally, supervision should attend to cultural humility, which is one aspect of culturally responsive care (Hook et al., 2016; Patallo, 2019). Although the literature on cultural humility in the context of clinical supervision is relatively limited, strategies have been developed to best foster cultural humility and address issues pertaining to diversity within the supervisory relationship (Hook et al., 2016).

Bringing It All Together

Given the multidimensional nature of clinical supervision, it can be challenging to know how to structure the supervision hour. While each supervisor-supervisee relationship is different, and each supervisee’s caseload is different, below we provide a list of recommendations to maximize utility of the supervision hour.

1. Set an agenda at the start of the hour to provide a roadmap for what will be discussed.

2. Prioritize discussion of key EBP content areas (e.g., psychoeducation, exposure, behavioral activation) to facilitate clinician competency and EBP implementation.

3. Utilize active supervision strategies (e.g., direct observation, role-playing) to bolster clinicians’ experiential learning and to generate feedback for clinicians.

4. Leverage passive supervision strategies and enhance relationship with supervisee.

5. Adopt techniques (e.g., initiate invite instill approach described by Hook et al., 2016) used to model cultural humility to promote culturally responsive clinical care.

6. Whenever possible, free up the individual supervision hour by discussing administrative and regulatory issues that affect multiple supervisees in alternative settings, such as group supervision or drop-in supervision.

7. Encourage supervisees to come to supervision with questions to guide agenda setting and maximize usefulness.

This chapter shows the balance between the what and the how of supervision, as well as the technical aspects of supervision and the values and attitudes needed for a supervisor to effectively work alongside their supervisee. Our work is challenging, but it does not mean that it is not feasible or that there are not ways to mitigate those challenges. Quality supervision matters to clinicians, their clients, and their organizations, and there is an ethical responsibility for supervisors to ensure that their supervisees can be set up for success.

Clinical Dialogues: Talking About Stress in Supervision with Dr. Laura Vega, DSW and  Caroline Glavin, MSW

Sean E. Snyder, LCSW: Supervision is one of the most important ways that an organization can support clinicians to support patient care and to sustain therapeutic services. That requires us to juggle many different professional roles and tasks. So, starting with Laura, how do you view your role as a supervisor? And what types of roles do you occupy as a supervisor?

Laura Vega, LCSW: In my role as a supervisor, I first take a holistic approach to working with staff and view them first as human beings working with incredibly challenging settings with at times a challenging caseload. I look at the supervisor almost as a change agent or a buffer to those stressors, to advocate for policies and practices that both support wellbeing but also support the quality of services provided to our patients and clients. One of the roles is a supporter and an advocate. Another role is helping somebody grow professionally through sharing feedback or providing safe spaces for feedback, for staff to ask questions and admit if they make mistakes.

Snyder: I heard you say that it’s a big picture thing with supervision, about connection to the organization locally and at large, about the person’s development, their personal growth, and all those kinds of things that fit into that holistic perspective. Caroline, I’d love to hear your perspective on how you view your role supervisor, knowing that you’ve had a lot of clinical experience (Laura does, too) and supervising clinical folks recently for your program.

Caroline Glavin, LCSW: I have a lot of the same views as Laura, and I had the opportunity to learn from her about important aspects of supervision, especially from a traumainformed approach, from learning and understanding myself as a clinician. I strive to provide my supervisees with the understanding of how this work can impact us, and so, taking that holistic approach, acknowledging that the work that we do is so challenging, and that there are times that we may be impacted by it. As Laura said, creating the safe space for vulnerability to be shared and discussed, can help me to validate and normalize experiences for supervisees. The hope is that they do feel that they can turn to me for support when they are struggling with, secondary traumatic stress or compassion fatigue on top of their regular clinical activities. If we are not taking care of ourselves, or acknowledging how this work is affecting us, it’s going to impact the service delivery, and the quality of work that we are engaging in and that we’re able to provide to our clients and families.

Snyder: If you’re burned out, if you’re stressed, it is very easy to stray from the EBP you are delivering or the modality that has been shown to be helpful for your population. You can’t even engage with a client if you’re burned out yourself. All those things moderate the relationships we have with providing services. Knowing that’s all in the background, how do you balance that with the delivery of the service, like providing trauma focused cognitive behavioral therapy intensive case management as well? How do you balance the clinician needs with the more direct clinical supervision tasks like case conceptualization, behavior rehearsal or other technical aspects of doing clinical supervision?

Vega: To be honest, once you prioritize somebody’s wellness, as a person in supervision, the rest falls into place. I feel people carry so much with them. A lot of people come into this work with their own personal experiences of trauma. I do think that making it a priority to check in with how your staff is doing first in supervision because it does set the stage for the other parts of our job. People will be in a better place to have conversations about the other administrative or case-related things that need to get done, and staff can generalize those knowledge gains. But if that is absent, oftentimes, we’re actually contributing more stress, and potentially, secondary trauma to our staff, if we’re not responsive or creating spaces where people can share about how they’re doing, both personally and professionally. So, it is helpful to enter into supervision with this. Let me meet you where you’re at; let me see how I can support you with all the things you’re doing. And let me try to advocate from an organizational standpoint if there are huge policies and practices that are going against your wellness and positive delivery of quality services to clients.

Snyder: If you think about when we deliver EBPs, we always go back to that rationale. For instance with trauma treatments, we consider how we are going to get the client to buy him into what we’re doing when we know it’s helpful for them in the long run (sorry if that seems paternalistic). What’s our rationale? Why are we doing this, how can I get buy-in to provide the service? It’s because we care about you as a person, and we care about you as the provider of services to the clients that you care about. Is that rationale of supervision? We keep tying it back to that. And then over time, our organizations will benefit. Systems benefit and patients benefit.

Now, Caroline, what’s your perspective on this, especially because I know you’ve been trained in many different things like the Child and Family Traumatic Stress Intervention, Attachment-based Family Therapy, and TF CBT.

Glavin: I view the relationship between supervisor and supervisee similar to the way that I view relationship between a clinician and the patient, in that their relationship is the foundation, and there has to be a strong relationship between the two before you can make progress in other areas. So, setting the stage early on, having that strong foundation of that relationship where the other person feels safe is the priority and is something that is so important in both areas. The relationship isn’t necessarily the intervention, but it’s the context for the change to happen.

Snyder: Yes, relational intelligence is so key. So, in the chapter, we’ll talk about how to structure and how to do the work in the clinical hour. I want to spend a little more time talking about the organizational context for supervision. It really does take an organizational approach, when we think about staff wellness and about supporting clinicians.

Laura, I know there’s a backstory about the Stress Less Initiative you developed at Children’s Hospital of Philadelphia. Could you tell us a little about what Stress Less is? It responds to that organizational piece.

Vega: The Stress Less Initiative is a trauma-informed group model for staff to enhance personal and team resilience and to reduce or prevent secondary traumatic stress. The overarching goal is to reduce the stigma associated with secondary trauma, to normalize our experiences as clinicians and social workers and researchers in the field that are working with trauma survivors, that this is normal experience. Secondary trauma is a normal thing that happens within our work settings, and so, the more we can come together and talk about those things, and validate and support one another, the more successful we’ll be.

A lot of it came about, honestly, because of my own personal experience with vicarious trauma and also being in a supervisor role and seeing many of my own staff having trouble sleeping, having worries about their own safety, being hyper vigilant, having their own trauma symptoms. The model takes those insights into thinking about how hard it has been for me personally, but also for my staff. They were struggling in silos with these symptoms. The model aims to think about what it would look like organizationally to come together, to be authentic about these challenges, to talk about them and figure out how we can support each other. It was built out of an unmet need. We’ve been running it now for six years in our own program, which has been a great asset to both making sure that people have the support they need, but also that as an organization, we are being responsive to the wellness and the needs of staff.

Snyder: Later I’m going to ask you about the nuances of what it is, but I want to pivot back to something you mentioned about who this affects. The Center for Violence Prevention provides clinical services but there’s also this research arm of the center. When you talked about staff and the people doing the work, you mentioned research staff. Can you tell me about that? That’s an interesting piece, when we think about what about research staff and secondary trauma.

Vega: We’ve learned so much about trauma. We know it’s subjective, and we know that it reaches everyone. There are researchers and research assistants on our team. You don’t often think of researchers being impacted by secondary trauma. This reminds me of an example of when I was in my office one day, and there was a research project going on that required our research assistants to go through client encounter notes. It was a qualitative project and they had to read through notes, and one of the research assistants came into my office crying from being impacted by someone’s story, one of the children who had extensive trauma history and had so many different challenges. We recognize that you don’t have to be somebody who is in direct service or on the frontline to be impacted on hearing stories; seeing or hearing or witnessing the different aspects of our work can be challenging.

Snyder: I appreciate you sharing that because when we think about a trauma-informed organization, it’s not only the clinicians; it’s folks at the front desk of a clinic, or security officers in the building. Everybody can have exposure to this occupational hazard! Your example was a unique situation.

Ok, I’d love to hear how you developed it, as well as the nuances and what’s happening now in Stress Less, I know the development of Stress Less was embedded in your coursework towards your Doctor of Social Work degree. A lot of thoughtful planning went into this, from reviewing the literature, getting expert consultation from child trauma experts at NCTSN or other research centers. What are some of the common elements you pulled from the literature for Stress Less?

Vega: The Stress Less model is 12 sessions, done over a year. We meet monthly for 90 minutes, and it’s embedded within our staff meeting. The tone is important to set as a way for people to come together and have time and space for themselves to talk about how this work is impacting them both personally and professionally and then get support. I developed a logic model based on the risk and protective factors that I found in the literature on secondary trauma. There’s a lot of research that still needs to be done on effective interventions for secondary trauma; there’s  a huge gap with what is currently out there. I pulled from that and from what has been working in trauma treatments, so, things like mindfulness, recognizing power and control issues and how we as providers often are faced with limitations and systems that can impede progress. The elements are meant to foster team resilience.

Another element is regular assessment, almost like measurement-based care. We start each Stress Less group by assessing where we are from a mind-body-behavior-cognition perspective, and that gives us a way to check in with ourselves regularly to stay connected to those four domains of stress. Awareness can help introduce our strategies for stress management, coping, and getting support sooner. The goal is that the more we become attuned with ourselves, the quicker we’ll be able to use our tools in our toolbox or to reach out for support. A philosophical component of Stress Less is about the onus for care and support not being on the individual, but it’s about the people around you. It’s about having a culture where you can be able to ask for support when you need it, being able to help each other, being able to recognize any issues in each other when people are stressed and say, “Hey, what are concrete things that I can do to take off your plate?” There’s a lot of beautiful things that weren’t anticipated when I first developed it that are now happening, and that has been wonderful to see over the years. It’s building team morale, and team cohesion. It’s been a wonderful experience.

Snyder: It sounds like it’s a very iterative project, where it’s focused on really listening in and working with those core concepts, and then listening to folks to see what’s working, what’s not working, and what their lived experience is. People inform the model. You’ve made me think about your experience doing TF CBT and thinking of a wellness promotion mindset. There are so many things in our treatments where I think, “This stuff can benefit us too, not just the clients!” Mindfulness can help clinicians and affect regulation and interpersonal skills; it all helps.

There’s two parts to my next thought. One is that sometimes we need the skills, and we need to learn that as a group. But also, what are the things that get in the way of using those skills (for instance, stress)? So the group can cover both the learning problem or the problem with learning or about learning. Caroline, what was it like being on the receiving end of Stress Less and your trajectory as a supervisor? It’s so common; we start out as a direct service provider and then eventually become a supervisor. So, what was it on the receiving end, and what is it now being in that supervisory role?

Glavin: There are so many things that I’ve gained through experiencing Stress Less and that our team has gained. One of them that I never experienced in any other position was this connection between the work and how it impacts us, specifically with the symptoms we can experience. Laura talked about the frequent assessments, so checking in with our bodies, and acknowledging and recognizing if we have a headache every single day after work, that may be related to stress, or, if we’re having stomach problems, these very specific things that I never received any information or training around, this connection between the work and our bodies, and how our bodies can manifest stress.

The regular check-in is so important on those four different domains, but along with that, the normalization, the validation, and the opportunity to come together with people who truly understand what you do in that space to discuss that shared experience. It has been very challenging for me to have conversations about this work or how it impacts me outside of work, because with people who don’t do this work it’s a very particular conversation. I end up explaining all the different systems and definitions, and it’s not helpful for you or a very therapeutic experience to explain all those things to someone who doesn’t do the work. The shared experience has been the most powerful for me: the opportunity to be with other people who truly understand not only the work but how this work can impact us and being able to receive some validation about that or receive some comfort. That has been huge. That in turn has created an incredible culture among our team that Laura spoke of, this sense of trust and team cohesion.

Everybody on our team is always willing to pitch in and take something off someone else’s plate if they’re struggling. That is because of this foundation that we created with Stress Less and the normalization of having these conversations and that it’s okay among our team to express when you’re struggling. And so, there have been so many things that I’ve gained as a participant of Stress Less. And those are things that I hope to continue to instill in the new team members who joined Stress Less now that I am part of leading the group, creating that safe space for people to share, normalizing, validating and helping them understand the connections that can be between stress and our bodies and our minds and how this work can impact us.

Vega: Thank you Caroline, because that was so well said. Stress Less was designed to be a mitigation strategy for secondary trauma, the other side is that we come together to talk about the great things we’re seeing. We’re celebrating victories within the work because we wouldn’t be doing this work if there wasn’t both sides. This work with families is challenging, but because it is challenging, it’s also powerful and wonderful. It provides the opportunity to be part of something so powerful and transforming when we see healing and recovery. So, we also share those experiences in Stress Less as well.

Snyder: I come back to this notion in DBT, when we think about cultivating positive experiences. How do we cultivate positive experiences in the midst of a lot of stress, where it feels like climbing a metal ladder in a fire pit (that’s the DBT metaphor)? What undercuts everything from both of what I heard you say is that stress is part of our work. It shouldn’t be the thing that defines our work, so we should be celebrating those successes and putting the change that we influence at the center of it and not necessarily the stress that comes from the changes we try to make. Let’s define our work through the change. I appreciate that idea of wellness promotion being at the center of all the things that we do, and your supervisory model does that.

Let’s talk now about the implementation of your model. There are so many things to consider like organizational culture, organizational climate, internal leadership, and we know all of these things influence EBP implementation and also sustainability. That’s the point of your model, to make our work sustainable. If we’re all burned out, then no one’s doing the work that our families need. So, there are two things in there: how do you try to sustain your model, and how has your model been able to keep your program at large sustainable?

Vega: The research shows how much turnover there is with clinicians. I know in Philadelphia currently, it’s a huge issue, and we need to think about ways to respond. A lot of people leave prematurely, without feeling supported or getting the resources they need to feel better in their role. I do look at Stress Less definitely as a way to sustain people within the field and get the support that they need. As an example, too, of internal sustainability, Caroline has been a great advocate and champion of the work, and it has been great now to step aside and see other people facilitate Stress Less within our organization.

To help us with spread and scale, we had an opportunity recently to partner with the Netter Center, a wonderful organization, through University of Pennsylvania, that is a bridge between academic institutions and the community. They asked for some support in two after-school programs for two Philadelphia schools. They’ve been implementing Stress Less to their after-school teams, and that has been amazing to be part of this partnership. We are learning too about where we can do Stress Less. I wasn’t thinking about educators with development of Stress Less. Teachers don’t have a lot of support, especially with COVID and the impact of COVID, how much has that been the challenge for teachers to be there for children in the hybrid school model. So, we are learning and attempting to adapt beyond just organizations doing mental health treatment; it goes into anyone providing a therapeutic service.

Snyder: That’s a great example of how an intermediary/purveyor organization can be a way to sustain things or get things to people. Also, I heard you say your team is tailoring Stress Less based on local knowledge, it’s adapting to those local contexts, considering that lived experience. What are some other things with your pilot?

Vega: Effective implementation involves training, of course, but in our training we talk about secondary trauma, and then I do a second training for facilitators. The idea is that it needs to be somebody within the organization within the team that runs Stress Less. It’s not me coming in or some other entity outside of the organization to have these sessions. The facilitator should be internal to the organization; often a supervisor is the one leading it. In that facilitator training, there’s a whole section on being able to be vulnerable in front of people you supervise and how powerful that can be to set the stage for staff being able to share and being able to be a support and be authentic. The organization needs to own Stress Less, and the model gives them the space to take that on.

Snyder: When we lose people with turnover, the organization experiences knowledge loss; there’s loss of resources because then orgs have to train new people. So, the start-up costs of doing an intervention like Stress Less, there is a return on investment if employees stay, if there’s improved client outcomes. Taking care of people is the best organizational medicine. Any parting words for us?

Vega: We’re always growing and changing, and even as a supervisor, I see things new each day. The piece that is most powerful for supervisors is sometimes that we feel that we get pressure from above and from below. That pressure can create conditions that supervisors maybe want to micromanage or want to control more. My advice would be to do that less: trust your staff more and give people freedom and independence. Supervisors may try to control more, but actually, we need to let go more.

Snyder: It is constantly evolving and iterative. It’s paying attention to that stress yourself because it is such a parallel process. Thanks for sharing all of your knowledge and wisdom!

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