Clinical Work and Supervision

Goals of Supervision

There are also several related goals in how I supervise. First and foremost, I feel that it is my job to help the supervisee move toward a point of self-supervision (Todd, 1997). I want the supervisee to be able to monitor him or herself, both during the session and in reviewing the case afterward. This is the ultimate goal because, much of the time, the supervisor will not be able to follow the supervisee's every move. The great deal of time that the supervisor is not available, the therapist still has to write case notes, plan for the next session, and work within the session to determine the best way to facilitate change.

A second goal of mine, inspired by the integrative supervisory models (Rigazio-DiGilio, 1997), is to broaden the perspective of the supervisee. I know that the supervisee and I will probably hypothesize about cases differently, and, consequently, have differing ideas about intervention. Both of these perspectives can be valid. Because one of the constraints a supervisee may experience might be seeing a case in one, rigid manner, my goal in supervision is to open up options and create the context for the supervisee to entertain other ideas/hypotheses. In this way, the supervisee experiences more options, anxiety may be reduced, and the supervisee will feel more free to use their individual strengths in the cases.

Part of this broadening is not only related to anxiety, but also means that the process of supervision should be sensitive to multilevel implications of developmental, biological, socio-cultural, gender, and family of origin issues (Leitch, 2000). The supervisor should call attention to factors that affect the therapy as well as factors that impact the process of supervision. For example, as a supervisor I encourage my supervisee to explore gender roles in client systems with which they are working. Additionally, what were the gender roles in the supervisee's family of origin? If the supervisee experienced abuse at the hands of their father, is it then difficult for the supervisee to work effectively with families with a history of abuse? Supervision that is sensitive to these factors potentially affecting a supervisee's work will help therapists to provide more effective therapy for their clients.

How I Supervise

My supervision is influenced by systems theory (Yingling, 2000). I help the supervisee to explore their theoretical orientation, patterns through generations and through different systems, and use an integration of theories.

In general, I tend to conduct therapy through theory -- developing a hypothesis about a case and then generating interventions based on my hypothesis. In supervision, I tend to generate a hypothesis about the supervisee, my supervision, or our relationship. One example was when a supervisee was working with a case in which the client was not connecting with his emotions. In a parallel process, the supervisee also admitted to difficulty accessing emotions. When I was able to disclose my hypothesis about how his process was blocking the therapy, he was able to intervene in a more effective manner.

I tend to supervise in the way that I perform therapy insofar as I integrate many models. The supervisory models identified as integrative are based on the metaframeworks, systemic-developmental cognitive therapy, integrative problem centered, and that based on a mythological perspective (Rigazio-DiGilio, 1997). I tend to integrate each of these into my work when appropriate. For example, when a supervisee might need to develop a treatment plan, I would use the problem-centered model; but if the supervisee is having a difficult time developing a treatment plan because of something blocking his/her work, I would then integrate the metaframework and mythological perspectives.

Specific principles that guide my work include those of Bowen family systems theory (1978) and the sequences metaframeworks (Breunlin, Schwartz, & Mac Kune-Karrer, 1992). In both therapy and supervision, following the family systems model, I look for patterns and sequences, tie them to anxiety management, explore potential patterns with the supervisee, and examine how the supervisee resolves those issues. I feel that this is appropriate in supervision as the supervisee, like clients, may be engaging in emotionally reactive behavior in their cases. One specific example is the therapist who, as a result of his anxiety, avoids discussing feelings and shame in session and stays with cognitive and behavioral interventions, even when it may be less effective to do so. The emotional pattern, then, may be to intellectualize. I would call attention to this pattern of the therapist, both in the case at hand but also across all cases. One of the benefits of working through this model is that any patterns that are observed may be happening in many cases as opposed to just one, and supervision can move from case-specific supervision to supervision of the supervisee's work across a multitude of cases. Another benefit is that it encourages self-supervision. Rather than having to be able to work with the variety of content in every case, the supervisee explores his/her processes over a number of cases.

Following the metaframeworks perspective, I believe that supervisees who are stuck are experiencing a constraint. Supervision, then, becomes about exploring what that the constraint is that is blocking the supervisee from doing their work. At times, these constraints may be easily identified; in other times, these constraints are difficult to identify, or might also be difficult to introduce to the supervisee. This is where the supervisee-supervisor relationship is important: the relationship should be strong enough so that these issues may be discussed.

The principles of behaviorism are also integrated into my supervision. Through operant conditioning and shaping, I reinforce what I like in supervision and de-emphasize what I think is not as critical. For example, if I am working with a supervisee who has difficulty getting to the emotional level when it is important to do so with their client, I will reinforce when I see the supervisee getting to the emotional level in the supervision session and try to not reinforce the times in which the supervisee intellectualizes when inappropriate. Related to this, I also see the importance of the role of supervisor as a model to my supervisees. The supervisor can be a model in a variety of ways.

Another important influence to my supervision style is the idea of power in the supervision relationship. I believe that supervision should in some ways be a collaborative effort between supervisee and supervisor (Fine & Turner, 1997). Reflecting on my own supervision experience, I found supervision more rewarding when my hypothesis about a case was considered as opposed to being given directives from a supervisor who only saw things from their perspective. I do believe, however, that there are times in which the supervisor needs to take a directive role, specifically when there are legal implications, since the supervisors is the one ultimately responsible.

Self of Supervisor

I think as a supervisor it is important to understand how my personal history as a supervisee, family members' beliefs, and theoretical assumptions impact my work with supervisees. Just as I think it is important for the supervisee to be able to identify patterns in their past that affect their hypothesis and interventions in cases, the supervisor should be a model for that. I think part of being a model is for the supervisor to be open to recognizing limitations they experience. There are times that the supervisor should seek supervision about how his or her style is interacting with that of the supervisee.

Pragmatics of Supervision

Becuase I try to broaden my perspectives within supervision, it is important to me to consider a variety of modalities within supervision and be able to effectively use each modality when appropriate. I have thus far participated in live supervision, video supervision, as recommended by Jordan (2000) and case note supervision. Each has its benefits and has a place within therapeutic supervision. Live supervision is important because it provides the supervisor a chance to obtain a feeling for the work of the therapist and the relationship, but it is limited in the sense that the focus is on the case rather than across-cases. One main benefit of video tape supervision is the ability to freeze a frame, rewind, or review in other ways events that are directly happening in the room. Progress note supervision might provide an easier way for the supervisor and supervisee to focus across cases as opposed to just one, but the supervisor does not get to see the case. Reflecting teams are beneficial in that it can focus on patterns of interaction within the supervisory relationship.

As my style of supervision has evolved just over the course of this candidacy, it is bound to evolve over my career as a supervisor. It will be interesting to see how, as my supervisees' needs change, how I will change and adapt to their needs. I attempt to continue in the future my broadening of perspectives, collaborating with the supervisee, directing when appropriate, exploring the role of anxiety within the therapist and uncovering any constraints.

References

Bowen, M. (1978). Family therapy in clinical practice. Hillsdale, NJ: Aronson.

Bruenlin, D., Schwartz, R., & MacKune-Karrer, B. (1992). Metaframeworks: Transcending the models of family therapy. San Francisco: Jossey-Bass.

Fine, M., & Turner, J. (1997). Collaborative supervision: Minding the power. In T. C. Todd & C. L. Storm's (Eds.). The complete systemic supervisor (pp. 229-240). Needham Heights, MA: Allyn & Bacon.

Jordan, K. B. (2000). Live supervision of all therapy sessions: A must for beginning therapists in clinical practica. In AAMFT's Readings in family therapy supervision (p. 116). AAMFT: Washington, D. C.

Leitch, M. L. (2000). Explicitly recognizing contextual influence broadens our scope and inquiry. In AAMFT's Readings in family therapy supervision (pp. 181-182). AAMFT: Washington, D.C.

Rigazio-DiGilio. S. A. (1997). Integrative supervision: Approaches to tailoring the supervisory process. In T. C. Todd & C. L. Storm's (Eds.). The complete systemic supervisor (pp. 195-216). Needham Heights, MA: Allyn & Bacon.

Todd. T. C. (1997). Self-supervision as a universal supervisory goal. In T. C. Todd & C. L. Storm's (Eds.). The complete systemic supervisor (pp. 17-25). Needham Heights, MA: Allyn & Bacon.

Yingling, L. C. (2000). What is a systemic orientation -- really? In AAMFT's Readings in family therapy supervision (pp. 36-38). AAMFT: Washington, D. C.

Clinical Theory of Change

Major assumptions that guide my work

As the clients move through different stages of motivation, I as a therapist have different ways that I can meet them where they are and move the motivation level. I have learned that there are different levels of motivation based on the environment I which I am working as well. Prochaska and DiClemente (1982) delineate several stages of motivation and determine therapist tasks at these various stages:

1. Precomtemplation stage. Client is not aware there is a problem.
Therapist's role: Move clients to action

2. Contemplation. Client thinks s/he may need help but are not certain.
Therapist's role: discuss negative consequences of change and explore further options for change; give hope to the client and tell them that you think change can occur.

3. Determination. Client musters up the energy to change. The client decides how they are going to handle their problem with the help of the therapist.
Therapist's role: Facilitate decision-making process; supports the client in their endeavors.

4. Action stage.
Therapist's role: Help the client to make those changes s/he desires.

5. Maintenance stage.
Therapist's role: Therapist and client discuss strategies to maintain the behavior and keep it from happening again.

Context and Constraints

There are several major assumptions that guide my work. The overarching assumption is that individuals and families live within a context. Another is that I believe individuals and families get into sequences of interaction that can become difficult to change from time to time.

Based on the notion of constraints, and that sequences are embedded in context, and also being influenced by the work of the MRI group in regard to the ideas of first-and second-order change (Watzlawick, Weakland, & Fisch, 1974), I tend to work from a sequences metaframework standpoint. Sequences metaframework is the manner in which I typically envision a case. I see the role of the therapist as the individual who can help to family to remove the roadblock and allow the wheels of the family to freely turn again. Pathology in this model is remaining constrained and engaging in sequences. I see the removal of constraint as the way to free the family. In this way, I view the family as capable to solve their own problems once the constraint is removed (Breunlin, Schwartz, & Kune-Karrer, 2001).

The therapist can assist with the removal of the constraint in several ways. The therapist can be very directive about the removal of the constraint, and even as directive enough about pointing out what the constraint for a family might be, and other times the therapist can facilitate conversation so the family will be able to determine what the constraint is for themselves and be able to work from there. My framework, then, is directive at times and client-centered at other times, depending on the appropriateness for the case.

One of the benefits of using a sequences metaframework is the freedom to use several models along the sequences. Within the specific sequences, I use several models. Models used fit as to the reason why sequences are occurring. Examples include EFT (Greenberg & Johnson, 1988), Bowen family systems theory, structural, etc. For example, if I believe a particular sequence is occurring between a couple as a result of each partner not feeling safe with the other and lacking a secure attachment, EFT will guide the manner in which I provide treatment to this sequence. Additionally, if I believe a sequence is occurring as a result of continued anxiety in a system and that anxiety can reach to proportions where it becomes constraining to families, I will use Bowen's family systems theory to guide my interventions.

The sequences metaframework provides the clinician with four ways to examine processes. S1 interactions refer to those fact-to-face interactions that last a few seconds to several minutes. They define characteristic styles of relating. S1 interactions are fairly easy to observe and therefore are available for intervention. S1 interactions also include the range of non-verbal behavior.

Behavioral therapies and structural family therapy (Minuchin, 1974) are what I am most likely to use as a first shot at working with S1 interactions. Another type of intervention I may also use at this point (from strategic school of therapy) is paradoxical interventions (Haley, 1987). If S1 interactions are not sufficient to for resolving the problem to the satisfaction of the client, S2 interactions are assessed and explored. S2 interactions show the daily routine of a family. Rather than examining one sequence of interaction repeatedly, the therapist examines routines that usually occur over a one-day period of time. For example, a therapist may choose to explore family rules or to assess other information to gain an understanding of the family's organization and functioning. Questioning is critical to eliciting a family's S2 interactional sequence. The family members should be able to report what they do on a daily basis. Altering these sequences can include the aforementioned models for assessment and intervention, but I also tend to use circular questioning from the Milan group more frequently for assessment and intervention in this stage than I do in previous stages. Questioning the family is partly influenced by portions of a postmodern (collaborative language and narrative) philosophy (Anderson, 1997). Although I might have a hypothesis about what is going on with a family, I also allow the questioning to reveal how each family members experience the problem and gain insight into each's narratives.

When I need to go beyond S2 interaction, the metaframework provides for me to examine another interactional sequence with S3 interactions. S3 interactions represent the ebb and flow of some condition or problem in the family. These time periods might range from several weeks to a year. They may include important events as well as the aftermath of these events. Families may or may not be aware of S3 interactions. They can, however, be used as a metaphor in my therapy, or also as a way of measuring outcome. As aforementioned, structural, strategic, and other approaches are acceptable and appropriate during this stage. The added part of this sequence is the increased focused on the solution-focused model (de Shazer, 1991). As families become aware of S3 interactions, the sequences become more overt. But just as families can see the sequence, they can also see progress they have made. As a result, it is important to pull out the exceptions and help them to see their successes.

S4 sequences are those transmitted across generations. I believe that family members attempt to connect each other and their lineage. One way in which to do this is to engage in family-sanctioned behavior. Examples might include alcoholism transmitted across the generations or patterns of anger management (or lack thereof). This is what Nagy terms "invisible loyalties": actions that keep us connected with one another. Based on the nature of the reason for the connection I will either use contextual family therapy (Boszormenyi-Nagy & Krasner, 1986) or Bowen's family systems theory (Bowen, 1978).

Self-of-the-therapist is a concept with which I continue to work and strengthen my skills. I see the self-of-the- therapist piece as accomplishing several things, but I specifically want to discuss how it impacts sequences. Isomorphism in the therapy room can in fact be another sequence. Just as the family is embedded in sequence, the therapy room and the interactions between therapist and client can also constitute a sequence and feed into the system. It is important as the therapist that I keep aware of how my part in sequences is affecting the therapy work. I have the freedom to use isomorphism to accomplish a task, or to reflect on my isomorphism to give myself more information about what is happening in a room.

Theoretical Origin of Each Assumption

The theoretical origin of my work comes from several places. Overall, general systems theory and cybernetics guide my use of the sequences metaframework. Systems, according to de Shazer (1991) have certain properties allowing for change: circularity, equi- and multifinality, and the fact that a change in one part of the system affects the whole system. Equifinality refers to the property by which one end result can be achieved through different paths. Multifinality refers to the property that similar paths may actually lead to different end states. This is important because I can use these concepts and change is implemented, observing the results in the sequences. Other concepts related to GST a family's ability to self-correct. As a result, it makes sense that I practice a sequences metaframework, upon which removal of the constraint, the family has the ability to solve its own problems (Keeney, 1983).

I also use a modified scientific method. I have a tendency to hypothesize about a family, test my hypothesis, then revise it as necessary and with more information, test again, etc. It is modified in the sense that I do not use a strict scientific methodology is in a positivist fashion, where the researcher has the responsibility in developing the hypothesis; I am post-positivist in that I encourage the family's experience and hypothesis as part of the hypothesis revision stage.

As aforementioned, postmodernism also guides my work in how I think about families. Specifically, sequences metaframework helps me feel more comfortable with moving from model to model and integrating models into a therapy that fits the family. Rather than sticking with the positivist view of the family, my post-positivist view allows me more options. Likewise, two major postmodern themes underwrite my work with families: acknowledgment of history and tradition, and a certain emphasis on individual experience. This is present in my work with some aspects of collaborative language theory and narrative approaches, for example, in the role of hypothesis revision and development of intervention.

Diversity in clinical work

In my clinical work, the families I see are very diverse, from varied financial backgrounds to varied cultural and religious backgrounds. I began my clinical work when I began my master's in MFT program at Purdue University Calumet. In addition to completing clinical hours at the campus MFT clinic, I was also assigned to a local mental health agency. The population at the MFT clinic was composed primarily of individuals, couples, and families from Northwest Indiana. The clients were typically employed in the steel plants located in a nearby town, Caucasian, and of lower socioeconomic status. The local mental health agency, in contrast, served clients primarily in the south suburbs of Chicago. Clients were typically African American with a variety of different issues bringing them to counseling. It was at this location that I also had the opportunity to provide both in-home and outpatient therapy. For my second internship in my master's program, I was placed at a Christian counseling center. This internship was significantly different from the first internship at the community agency due to the nature of the work and the clientele. The clientele at the center were from Munster, Indiana, a fairly affluent town in Northwest Indiana. Unlike the clientele of the community counseling center, the clientele in Munster were typically those who commuted to Chicago to work. The couples and families were often seeking solutions to a variety of problems, and seeking those solutions through a faith-based lens. I also learned to integrate faith in session, whether that is in the form of prayer with my clients or in other ways.

Coming to Virginia Tech to pursue my PhD in MFT exposed me to another group of clients that were diverse from my previous clinical experiences. Many of the couples and families were those who were from rural Virginia, about as different as possible from urban Chicago. I also had an opportunity to continue to see families from a variety of ethnic or minority backgrounds such as Muslim families. Finally, I am currently working at Family Service of Roanoke Valley for my PhD internship. Here, I am focusing on my work with multi-problem families, particularly with families with young children. I am primarily doing non-directive child-centered play therapy with the children and helping parents to co-parent these children.