Supervision Topics : Clinical Guidance Simplified

A Fact-Based Approach to Working Through Any Supervisee Dilemma

Supervisees present us with cases that involve complex decision making. When a supervisee is overwhelmed, they can have difficulty formulating the case in a coherent manner. Often there are numerous situations converging upon the case and it can be difficult to determine which are the most important to address. We are required to reconcile these challenges in order to reach the goals of promoting clinical skills, professional development, confidence building and ethical decision making. Some of the challenges we face as clinical supervisors are:

1) these cases can present us with ethical dilemmas,
2) the case can have disastrous implications,
3) the case may be beyond the skill level and experience of the supervisee,
4) helping the supervisee prioritize interventions,
5) supervisor’s feelings of helplessness and countertransference, and
6) helping them formulate the case in a manner which is useful for problem solving.

A supervisee’s clinical dilemmas are often a result of:

1) inadequate case information,
2) faulty assumptions made about the case,
3) insufficient clinical experience, and
3) impaired insight due to intrapersonal struggles.

A Fact Based Approach: Crime Scene Investigation

Having investigated over 200 licensing board complaints, it became apparent that similar principles can be quite effectively applied to client case formulation and problem resolution. In essence, the case presentation and feedback/advice process is approached as a crime investigation:

1) facts upon initial discovery,
2) determining which direction to take the investigation,
3) discovery of more facts,
4) evaluating all information,
5) making recommendations,
6) return to step 1.

The following is an actual example of a complex case and the application of an investigative process. All identities have been concealed.

Case Vignette

The Supervisee:

27 year old female with an LAPC and 2 years of therapist licensing requirementscounseling experience. She is working in an intensive outpatient addiction program. Many are dually diagnosed with a mood disorder but rarely severe mental illness or functional psychotic disorders. Most clients are survivors of significant childhood trauma. She recently began work in a private practice setting under the direction of the owner of the counseling practice. No other work mental health work experience. Psychologically she is functioning on a scale of 1-10, about 8. No history of acute depression. Mild/moderate struggles with assertiveness, boundaries and confidence in her therapy.

The Case:

A 25 year old male. The supervisee has provided the following information: Client takes Adderal, is addicted to internet pornography, and discouraged about whether he will ever complete his bachelor degree. No suicidal ideation. Last year he was hospitalized in an inpatient psychiatric facility for 6 weeks and discharged to a intensive outpatient program that he did not attend. His stated goal is to get back into school. He does not feel he has any other problems for which he would like help.

The Dilemma:

She feels lost and does not have a clear picture of this client’s struggles. She therefore doesn’t know where to begin to help the client. She has given the client advice and helped him set goals for returning to school. After 5 months, she feels the client has made little progress.

The Investigation:

Known Facts:

Of the clients own admission, takes Adderal, was hospitalized, wants to get back in school.

Determining Direction and Evidence Collection:

We can conclude this supervisee is inexperienced particularly in clinical mental health and the spectrum of mental illness. They are new in the counseling field. They have some knowledge about addiction, depression and trauma. The supervisee is likely confused because there is a great deal of missing information; many unknowns. In other words, they have not completed a comprehensive assessment. In your opinion what are the ‘great unknowns’?

Helping the Supervisee Determine which Information/Evidence to Collect and How to Collect It

Part of being overwhelmed is that we often can’t see the forest for the trees. Your first objective should be to help them see what is most obvious. How does a supervisor accomplish that?

I often use allegory and other non-counseling metaphor and illustration in supervision:

“Imagine you are called to investigate a missing person. You identify and question witnesses. This leads you to the home of an individual who was possibly the last to see the missing person. When you arrive, the individual answers the door, you enter the home and have a brief discussion. You briefly make notice of a splatter on the wall and doorway leading to the kitchen that appears to be blood. The individual stated that another person came to the home and departed with the missing person; that they were not the last individual to see the missing person. A second elderly person appears from a bedroom in the home. She is obviously frightened and confirms the report of the missing person’s departure earlier that week. She states that according to police the person who departed with the missing person has a lengthy criminal record. She provides you the name of the individual. You call your police precinct and the elderly woman’s report is confirmed. You leave the home. What should be your next step? Which step is most likely to render the most relevant information?”

Hopefully at this point, your supervisee will conclude that inquiring about the hospitalization will render the most useful clinical information: the hospitalization is the blood splatter on the wall. Some of the questions the supervisee should ask the client are:

1) I’d like you to share with me your hospitalization last year? How did you get to the hospital? Did you drive yourself or did someone bring you?
2) Did you voluntarily admit yourself?
3) What was the hospital’s stated reason for hospitalizing you?
4) Did you express thoughts of suicide either prior to or during the hospital intake interview?
5) What did the drug test show positive for?
6) What happened immediately prior to the decision that you would go to the hospital?
7) Did you go to a general hospital emergency room? If so, were you hospitalized there?

Data Collected: The client made a suicide attempt by mixing a significant quantity of Xanax and Alcohol. They stayed in the emergency room for 48 hours prior to discharge to a psychiatric facility. The hospital said she was hospitalized for severe depression, and Xanax dependence. The drug test rendered positive results for Adderal, Xanax, and Hydrocodone. Now you have a much clearer clinical picture.

We now have more facts:

1) Confirmed substance dependence on Xanax.
2) Confirmed history of an acute and severe major depressive episode.
3) At least one prior suicide attempt which was severe enough to require medical stabilization.
4) The above make them a high risk for major depression and suicidal thoughts.

Reevaluation/Prioritization

The immediate and short-term goal of therapy should now shift from advisement on academics to stabilizing the client and reducing risk for another major depressive episode, and a comprehensive substance use assessment. Interventions aimed at increasing insight into severity of depression and substance abuse. Restating the desire to return to school as being almost entirely dependent upon first addressing substance abuse and depression.

Supervision Goals Accomplished

The supervisor now has proactive mechanisms supervision topicsin place that cover most major ethical and other concerns. It would also be prudent to recommend the supervisee seek additional work experience that will enable them to work with a population with severe clinical illness. It is important to articulate to them there is no educational substitute for that experience and the risk involved with working in a practice environment with no physician or other medical staff on-site is formidable. It is a good indicator that this supervisee is eager to learn and apply recommendations. Please follow my blog series on supervision topics. I also enjoy providing ethics in supervision workshops.

Get That LPC Application Approved

This post will help you get that lpc application approved – the first time. How do I find a qualified LPC clinical supervisor? How do I know if the board will approve my work setting? How do I know how many hours or years I need to complete? I’m sure our readers would like to know the answers to these questions.

Introduction

LPC Educational Requirements

GA Composite board rules require a graduate degree that is “…primarily counseling in content”. A masters degree in Sociology is not acceptable to the board because it is not primarily counseling in content. A degree in Professional Counseling is acceptable.

Masters in Psychology or Special Education could be eligible. It largely depends on the titles and content of the courses required. It must be a program in applied counseling not experimental or theoretical knowledge. For example, a course “Group Counseling” is acceptable whereas “Cultural Anthropology and Groups” is not. Why? The latter is not applied counseling. For more details read rules “Definitions”, paragraph 8. You also must pass a national exam further explained in “Requirements for Licensure, paragraph 3.  As you read further, you may want to read my The Art of Reading Board Rules. The page will open in a new browser window.

Years of Required Directed Experience Under Clinical Supervision

One year: 600 hours of directed experience and 30 hours of Supervision over a period of minimum 12 and maximum 20 months. 800 hours in 11 months is not acceptable. You can’t reduce or accelerate the calendar year requirement. Must be minimum 12 calendar months. You have up to 20 months to complete that one year. After September 30 2018, these requirements increase: One year is minimum 1000 hours directed experience and 35 hours Supervision. Very important: only months which you are under Direction and Supervision simultaneously will be eligible. You cannot practice if you are not under supervision.

Supervision

A: The rules state that you have until September 30th 2018 to obtain a clinical supervisor under the current requirements–generally, the supervisor must have 3 years post-licensure experience and no additional credential. In other words, any current board eligible supervisor you execute a contract with prior to that date will be acceptable throughout your supervision with them. Hypothetically, if you enter into a supervision agreement on September 30, 2018 you may stay with them as long as you like. However, if you change supervisorson October 1, 2018 that new supervisor will need either the Licensed Professional Counselors Association of Georgia Certified Professional Clinical Supervisor (CPCS) or the National Board for Certified Counselors Approved Clinical Supervisor (ACS) credential.

 

How do I Know if My Job Will be accepted by the Board

A: There are no guarantees your work setting will be accepted by the board. First, try to find a work setting or organization that has a track record with the board. Ask the director if they have had any problems with the board approving their work setting. Most employment or contract work in government settings is acceptable. Private treatment programs that have been historically accepted include Rebecca Beaton’s Anxiety and Stress Management Institute and Peachford Hospital. There are many other private treatment programs which are acceptable. Private psychiatric practices in which you receive either a W2 or 1099 are often acceptable. Smaller private practice organizations can be acceptable to the board. You CAN find that perfect therapy work site.

For any of the sites above, you must document on the duties section of the directed experience form that you are doing psychotherapy. Whether your site is acceptable to the board is very much dependent upon you demonstrating the site has structure, a comprehensive system for monitoring your work and policies/procedures for discipline and intervention with your client work. This is critical.

Can I Work in Practice Practice Psychotherapy as an LPC?

A: It is possible. Remember: In Georgia, LAPC (Licensed Associate Professional Counselor or in some states, ALPC license) and LPC are governed under the same scope of practice. The difference is that as an LAPC, you must be under direction and supervision simultaneously. That is critical.

A private practice setting in which you are working on your own without any structure or intervention, bears no resemblance to employment or you are not receiving training and administrative oversight will likely be denied as an acceptable work setting.

Q: What do you recommend for a work setting?

Where Can I Find The Best LPC Jobs and Work Settings?

A: How to find a counseling job. Your goal should be to find a site that provides clinical mental health experience. Severe mental illness. Addiction. Facilities such as Grady Memorial Hospital Psychiatry in Atlanta, Ridgeview Institute in Smyrna Georgia or a community service board are excellent training grounds. In the absence of this type of training, it may limit your skills. If you must, seek this training post-licensure. This also applies totherapist licensing requirements social workers and marriage and family therapists.

Q. How do I find a qualified supervisor?

A. Interview several. Determine if their approach provides a level structure suited to you. A supervising relationship should consist of authority, mentoring, and someone you want to learn from. Seek a supervisor that wants to help develop you clinically, personally and professionally. One of the greatest challenges of having a job where your supervisor is also your boss is that you cannot be open with them. If you have an offsite independent clinical supervisor, that conflict of interest can be eliminated.

Q.What happens in a supervision session? It seems shrouded in mystery!

A. Supervisors will highlight areas that need improvement. You being a student you will have discussions with your supervisor about your clients, and your supervisor will question you. The supervisor will give you notes and ideas and you should apply these suggestions. It should be an interactive relationship. In addition, you should be open to constructive feedback on personal issues which may be interfering with your counseling and psychotherapy. Your supervisor may inquire about childhood trauma and abuse to determine if these are unresolved and therefore negatively impacting your work. They may require you see a therapist. Generally, your supervisor should be supportive, confident, reliable and consistent.

Q. How do I know if I am cut out for this work? For example, How do I even know if I will be a qualified counselor?

A. You have to decide whether you enjoy counseling people. You will find this work frustrating if you believe clients are not changing quickly. The work will be hazardous if you become involved with a client’s matters that are outside the scope of psychotherapy. This is referred to as boundary issues. Blurred boundaries include trying to find them a job, transacting other business or any advocacy work that is not directly related to treatment. Remember: we are licensed to treat mental disorders through psychotherapy. Also, if you are not comfortable with diversity you may be more content in a different career. If you can separate your personal life from work and view it as a vocation. If you are self aware and don’t have a rigid coping style. If you understand that you can learn from other therapists–even those less experienced. If you understand that a client drives personal change- not you.

Q. Finally, what would you say to graduate level counselors pursuing state licensing on how to have a successful career?

A. Acquire and be eager to learn business skills. Be able to reconcile that even though you are helping someone, you need to seek at least the average income for counselors or social workers. Be open to learning and criticism. Seeing a therapist as a therapist is almost required. You cannot sell a product you do not believe in yourself. Find a specialty. Don’t be a generalist. Seek training in that specialty and obtain a credential. Strive to be the best at that specialty so you can become an expert in it.

If you really want to be a great therapist, cover these 3 bases:

1. Obtain solid training in clinical mental health and addiction.

2. Remember that your practice is a business.

3. Find your own therapist and work very hard. You can only help a client through their emotional struggles if you are actively working on your own struggles.

Eric Groh has worked in the mental field in Georgia or 30 years. For 16 years he has maintained a thriving Atlanta psychotherapy and ethics consultant practice. He processed over 7000 LPC applications and 200 licensee complaints while serving a 7 year governors appointment to the Composite Board of Professional Counselors, Social Workers, and Marriage and Family Therapists. He specializes in the treatment of dissociative disorders and gambling disorder .