UPDATE October 20, 2008: University of Buffalo School of Social Work published a very engaging and informative interview with Dr. Lawrence Shulman about parallel process and honest relationships in supervision. Dr. Shulman's interview was full of practical tips for supervisors and clinicians in the field. You can hear this excellent podcast at the University of Buffalo School of Social Work Living Proof website.
Download MP3 [19:32]
In the mid-1990s I worked for an outpatient crisis unit for children and adolescents. We provided assessment, intervention and short-term stabilization therapy for children who were suicidal, homicidal or actively psychotic. Because of the severity of the presenting problems and the risk for imminent harm, we would consult with each other and the psychiatrist on every case. Case consultation was a daily, sometimes hourly, event. In these case consultations we talked about what was going on with the kid, the family, the other agencies, organizations or groups with which they might be involved. We staffed cases in real time in order to make sure that we were getting all of the information we needed to keep this kid alive. We also got feedback on what we might have missed in our assessment or what information might be useful for treatment planning and next steps.
Once a week for two hours the agency hired relief workers to cover the phones and take care of drop-ins so that the full-time staff could attend a weekly staff meeting. When I started working on the crisis unit, I expected that in these weekly staff meetings we would get in depth clinical supervision and direction for the treatment of our cases. Instead we talked about billing codes, 90-day review cycles, which signatures were required on which pieces of paper, and which new assessment was required by the state to qualify for reimbursement. Although it seems obvious now, it wasn’t until I had spent some time in this agency that I realized that we had scheduled administrative supervision and informal clinical supervision. In order to qualify for my advanced clinical license I had to seek outside clinical supervision because there are important differences between administrative and clinical supervision. There is also a difference between clinical supervision for licensure and on-going post-license clinical consultation. In an excellent article on supervision, Mirean Coleman distinguishes between consultation and supervision. Consultation, she writes, may involve some of the same functions as supervision but lacks the administrative responsibility and accountability. Consultants can make recommendations but have no power to sanctions against a social worker when problems arise.
The 2005 NASW Standards for Clinical Social Work states that Clinical social workers shall maintain access to professional supervision and/or consultation. The standards stipulate that social workers should receive supervision for the first five years of their professional experience. After five years, social workers are expected to receive supervision and consultation on an as-needed basis. When social workers have their clinical licenses, the NASW guidelines recommend that social workers offer training and mentoring opportunities to beginning social workers. In social work, supervision is seen as a continuous and meaningful part of the profession.
So what is supervision? According to the NASW, “Supervision is the relationship between the supervisor and the supervisee that promotes the development of responsibility, skill, knowledge, attitudes, and ethical standards in the practice of clinical social work. The priority in the supervision process is accountability for client care within the parameters and ethical standards of the social work profession” (NASW, 1994)
There are three types of supervision: administrative, clinical (also called educational supervision) and supportive supervision.
The most basic function of administrative supervision is to ensure that work is performed. Most social workers receive administrative supervision at their agencies. How do you know if you’re receiving administrative supervision? Your supervisor talks with you about paperwork compliance, billing, administrative procedures for changes in codes and categories. Administrative supervision is crucial in maintaining agency functioning. Every time my supervisor talked about billing codes, she was making sure that our agency would be reimbursed for services rendered. Without proper attention to billing and compliance with the myriad of oversight agencies (and funding sources), most social service agencies couldn’t survive audits or pay the bills. Administrative supervision is not concerned about the quality of the services provided – that is the function of clinical supervision.
Clinical (also known as educational supervision)
Clinical supervision is concerned with teaching the knowledge, skills, and attitudes important to clinical tasks. Some social workers receive clinical supervision at their agencies. How do you know if you’re receiving clinical supervision? You meet on a regular basis with your supervisor to discuss client issues such as assessment, diagnosis, treatment options, barriers to care, medication support, etc.
Clinical supervision, like the therapeutic relationship itself, starts with rapport building, establishes a purpose for supervision, and determines when the relationship will be over. Clinical supervisors can and should use all of the skills they have developed as clinicians in a supervisory context.
Supervision looks different based on setting, clinician needs and supervisor orientation. For example, if you are receiving supervision for work in the addictions field, it might be that your supervisor will ask you to identify which stage of change your client is in. In contrast, if you are working in a child and family treatment agency, your supervisor might ask you to identify your client’s developmental stage, or the stage of the family life cycle.
Although there are different approaches to supervision, including formal case presentation, technique-specific approaches, etc., some common clinical supervisory questions include:
1. What is your role with the client?
2. What goals have you and your client established for treatment?
3. What challenges do you have with treatment right now?
This type of supervision is typically not separate from administrative or clinical but has the function of increasing job performance and decreasing burnout.
Supervision, whether administrative, clinical or supportive, has traditionally occurred in person. Because of advances in technology, more and more people are using the phone and Internet technologies like chat rooms and email to obtain supervision. Regardless of the medium, supervision can occur individually or in groups. Each state has different regulations about what counts towards supervision. In Pennsylvania, social workers can receive no more than 50% of their supervision towards advanced clinical licensure in a group setting.
Uses of supervision across the career
In this next section, I’m going to talk about how supervision can be used at three different stages of a social work career – student, professional working towards advanced clinical license, and finally independent practitioner. I will also reference relevant standards and guidelines developed by the National Association of Social Workers (NASW) and the Counsel on Social Work Education (CSWE). For social workers at all stages of their career, good supervision prevents burnout, improves the quality of clinical care, and reduces liability.
The Council on Social Work Education’s 2004 Educational Policy and Accreditation Standards (also known as EPAS) state that that supervision is essential to social work practice. Graduates of either BSW or MSW programs are expected to demonstrate 12 abilities, one of which is the use of supervision and consultation (EPAS, 2001, 3.0, p. 7). Students are required to receive supervision in field placements (EPAS, 2.1.6, p. 13). Field supervision has an educational focus and is expected to accomplish a number of goals. One goal is to ensure that students are providing ethical and clinically appropriate services. Another goal is to help students to develop into professionals. A third purpose is to help students understand how coursework is translated into practice. In any give class students are provided with more information than they can be expected to grasp, and certainly more than they are expected to implement in the field. Good field supervision allows students to bounce ideas off of supervisors that they learned about in class and to gain insight into how those ideas or theories actually work in the “real world.”
Supervision is important after graduation as well. Supervision is also important for obtaining advanced clinical licenses that are often required for third-party reimbursement, whether that be federal insurance like Medicaid, medicare or SCHiP, or private insurance like BC/BS. Before you enter a supervisory relationship towards advanced clinical licensure, it is important to make sure that your supervisor has all of the credentials necessary to sign off on your supervision. I know this sounds obvious, but the rules and regulations for clinical supervision differ from state to state. Here’s a recent example from New Jersey. An article in the January 11, 2008 edition of the Asbury Park Press reported that 5 social workers in New Jersey were suing their employer, Meridian Health System, for misrepresenting their supervisor’s credentials to provide their supervision towards advanced clinical licensure. According to the article, in the State of New Jersey, clinical supervisors must have an LCSW and have completed 20 continuing education credits of post-graduate course work related to supervision. Here’s where it is important to be clear on your supervisor’s credentials. Although the plaintiff’s supervisor was an LCSW he did not have the 20 CEU hours. So, what do you do if your agency supervisor does not have the credentials? You seek outside supervision like I did at the crisis unit. Because of social work’s unique focus on the person-in-environment, it is usually preferred to have a social worker as your clinical supervisor. If, however, you are unable to find a clinical social worker, some states allow approved psychologists and licensed professional counselors to provide supervision.
Supervision is expected of social workers who have achieved their advanced clinical license and are able to practice independently and receive third-party reimbursement. The NASW Standards for Clinical Social Work stipulate that Clinical social workers shall maintain access to professional supervision and/or consultation. Most social workers work in settings that expect them to provide services to a wide variety of clients with a wide variety of problems. The social work axiom of “starting where the client is” sometimes means that social workers are presented with problems that are outside of their area of expertise. Supervision and consultation becomes a way for social workers to acquire additional knowledge and skills required to provide excellent clinical care. Supervision helps social workers to recognize when they are practicing beyond the scope of their expertise and need to refer to someone else. For example, when I was working at a small private social service agency in Austin, Texas I was assigned a woman whose husband of 50 years had recently died. Her stated reason for seeking services was to deal with the overwhelming sadness she was experiencing. Although I had experience working with grief and loss issues with children, I had never worked with adult grief and loss. I spoke with the director of the agency about my concerns. He provided administrative supervision and asked that I complete the intake and then refer if necessary. According to the NASW guidelines, it is appropriate for me to provide services to this client, as long as I let her know that I do not have expertise in working with adults with grief and loss issues and as long as I seek clinical supervision and consultation about all areas of treatment, including assessment, diagnosis, course of treatment, best practices, issues of transference and countertransference and termination and referral. By providing this information, the client can consent to services knowing what I can and cannot do. This is called “informed consent." After the intake assessment I met with my clinical supervisor (who was different than my administrative supervisor) and it became clear to me that I would be unable to provide the type of clinical care that this woman deserved, so I referred out. Through a combination of administrative and clinical consultation I was able to provide the appropriate level of clinical care. Had I been in a situation where there were no referral options, I would have needed to obtain intensive supervision and outside education in order to provide services.
Supervision is important not only to ensure quality clinical care, but also as a way of reducing liability. Social workers are increasingly the targets of malpractice lawsuits. Although courts do not require social workers to be perfect, they do require social workers to be professional. How do the courts know what professional services look like? Well, they can look at the NASW standards for clinical practice and see if you have been following them. They can also call in social workers who perform the same kind of work as you and ask them to review your documentation to determine whether or not you were providing a reasonable standard of care. That is, they want to know if you were doing what any other reasonable social worker would have done in your place. Documented supervision is a way of showing the courts that you were following NASW guidelines and that your treatment decisions were reviewed by others and modifications were made, if appropriate. In other words, documenting your supervision is a way of making sure that you are providing a reasonable standard of care.
Social workers who provide supervision are expected to uphold certain ethical standards outlined in the NASW code of ethics. These can be found on the NASW website at socialworkers.org. The four ethical responsibilities for supervision and consultation are:
(a) Social workers who provide supervision or consultation should have the necessary knowledge and skill to supervise or consult appropriately and should do so only within their areas of knowledge and competence.
(b) Social workers who provide supervision or consultation are responsible for setting clear, appropriate, and culturally sensitive boundaries.
(c) Social workers should not engage in any dual or multiple relationships with supervisees in which there is a risk of exploitation of or potential harm to the supervisee.
(d) Social workers who provide supervision should evaluate supervisees' performance in a manner that is fair and respectful.
Summary and Conclusion
Supervision is relationship between a supervisor and supervisee. Social workers typically receive both administrative and clinical supervision. According to the standards set by the Counsel on Social work Education and the National Association of Social workers, social workers are required to receive supervision during their social work program and for five years after graduation. For ethical, clinical and liability reasons, ongoing clinical supervision and consultation is strongly recommended for social workers with advanced clinical licenses. Supervision can be face to face, over the phone or even over email and can occur individually or in a group setting. For social workers who find themselves working with a problem area or population for which they have little training, or for social workers who are in agencies or geographic locations where clinical supervision is not available, phone and email supervision are important alternatives to traditional face to face supervision. Because the issue of phone and web-based social work services is increasingly important, the next few podcast will address phone supervision, both from the supervisors’ and supervisees point of view.
- Coleman, M. (2003, June). Supervision and the clinical social worker. Clinical Social Work: Practice Update, 3(4).Retrieved on January 11, 2008 at http://www.socialworkers.org/practice/clinical/csw0703b.pdf
- Counsel on Social Work Education. (2001). Educational Policies and Accreditation Standards. Retrieved online January 11, 2008 at http://www.cswe.org/NR/rdonlyres/111833A0-C4F5-475C-8FEB-EA740FF4D9F1/0/EPAS.pdf
- National Association of Social Workers. (1999). 3.01 Supervision and Consultation. NASW Code of Ethics. Washington, D.C.: Author. Retrieved online January 11, 2008 at http://www.socialworkers.org/pubs/code/code.asp.
- NASW standards for clinical social work in social work practice. Washington, D.C.: Author. Retrieved online January 11, 2008 at http://www.socialworkers.org/practice/standards/NASWClinicalSWStandards.pdf
- Stofle, G. S., & Hamilton, S. (1998). Online Supervision for Social Workers. The New Social Worker, 5(4).Retrieved online January 11, 2008 at http://www.socialworker.com/onlinesu.htm.
- Webster, C. (2008, January 11). Social workers sue over supervisor's credentials: Claim boss didn't have necessary credits. Asbury Park Press.Retreived online January 11, 2007 at http://www.app.com/apps/pbcs.dll/article?AID=/20080111/NEWS01/801110413/1004/NEWS01
Singer, J. B. (Host). (2008, January 14). Supervision for social workers [Episode 30]. Social Work Podcast. Podcast retrieved Month Day, Year, from http://socialworkpodcast.com/2008/01/supervision-for-social-workers.html