Supervision Topics : Clinical Guidance Simplified

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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.