Judith F. Esposito, Elon University
Hildy G. Getz, Virginia Polytechnic Institute and State University
Counselor educators and supervisors are often challenged to find efficient methods for providing quality supervision to individual students, while managing multiple students during their practicum and internship experiences. This article describes the use of in-the-room supervision, a modality which is underrepresented in the clinical supervision literature. The experiences of this supervision modality for the supervisors, supervisees, and clients were examined t hr ough both written and oral questionnaires. A thematic analysis produced perceived advantages and disadvantages for all t hr ee levels of participants involved. Recommendations for implementing this modality in practicum and internship experiences are discussed.
A variety of ethical and legal issues arise when students enter their first clinical experience seeing "real" clients, versus mock clients. Supervision of student clinicians is at the forefront of these issues. Clearly, in order to provide ethical, professional, and effective practice and to guard against the possibility of litigation, there is a need for an experienced supervisor to be available when students are seeing clients.
The researchers in this study became involved with in-the-room supervision when they were developing a practicum course for students in a counselor education program. Practicum was to be the middle step between didactic classes, in which students worked with mock clients, and internship, where students were placed in school or community agencies. The authors were faced with the task of providing appropriate supervision of the students as they proceeded t hr ough this crucial part of their training.
Much like in other student field experiences, it was determined that the trainees in this study were not yet clinically prepared to see clients independently. Supervision then assumed the vital position of helping students increase their effectiveness while minimizing client risk. Because this counselor education facility had no counseling lab with one-way mirrors and because many counseling students were sent out to see clients in community settings during which all supervision was provided by the university, the internship supervisors had to be creative in providing the extensive supervision their students needed. It was determined that in-the-room supervision was the only available format suitable for monitoring and evaluating the trainees' work. This study focuses on the use of in-the-room supervision as a modality, as well as the reactions of supervisors, supervisees, and their clients, to this modality.
Varying forms of live supervision have been discussed and practiced, especially in the marriage and family therapy field, since it was pioneered by the Structural and Strategic schools of family therapy (Haley, 1976; Malcom, 1978; Montalvo, 1973). The premise of live supervision is that a supervisor who observes a therapist in action will have better information about the therapist's strengths and weaknesses and therefore provide better training. It also allows the supervisor to have more influence about therapeutic strategies and direction. The most practiced form of live supervision takes place behind a one-way mirror. Communication can occur by telephoning the trainee during the session, using a bug-in-the-ear, walking into the session, using computer monitors, and taking consultation breaks.With advanced technology there is also the possibility of two-way video transmission in order to conduct live supervision from campus to off-campus sites (Johnson & Combs, 1997). Taping is often combined with live supervision to maximize learning.
Goodman (1985) supported the use of live supervision as a way to protect the welfare of the client, while promoting learning on the part of the supervisee. However, he also listed five potential problems in using live supervision: (a) the supervisor may attempt to do too much for the trainee or monopolize the therapy process; (b) the supervisor may attempt to make dramatic, yet inappropriate, interventions; (c) the supervisor may try to dominate the trainee thus failing to allow the trainee freedom of choice; (d) the necessity of evaluating a trainee may interfere with the collaborative nature of the supervisor/trainee relationship; and (e) because of the natural hierarchical arrangement between supervisor and trainee, issues of power, dependency, control, and competency may surface.
Bowman (1980) noted that live supervision might contribute to increased anxiety levels of supervisees. Costa (1994) agreed, saying that so much is riding on the supervisory evaluation, that supervisee anxiety is an inevitable part of live supervision. Others have believed that the initial anxiety in live supervision will eventually be replaced by enthusiasm of being watched and learning from the process (Kaplan, 1987; Liddle & Schwartz, 1983; Wong, 1997). Wark (1995) described an exploratory study in which five supervisory dyads examined their views of the most important incidents of live supervision related to skill development of the supervisee. The findings revealed that both supervisors and supervisees found instruction and support to be helpful. The supervisees also appreciated the autonomy they were given to set their own therapeutic approach. The author called for more research on first-person perceptions of supervisors and supervisees doing live supervision. These pros and cons of live supervision, while applicable to many modalities of supervision, are focused solely on the use of the one-way mirror, and have not focused on what happens when the supervisor stays in the same room with supervisee and client.
Taibbi (1995) believed that in-the-room supervision is not used enough because there is an assumption that the client will be distracted. He also discussed the anxiety of the supervisor, but stated that this anxiety can be overcome and may be related to the level of supervisor involvement in the session. The least active and intrusive level requires that the supervisor be introduced as an observer, that permission be obtained from the client and that the supervisor remain silent. The next level of involvement would be when the supervisor is used as a consultant, especially when the clinician and/or client are feeling stuck. The supervisor may occasionally provide feedback about the process, assist to shift the direction or summarize at the end what he or she has observed, and make recommendations for changes to both the client and the clinician. The supervisor can also conduct the session, a process that models therapeutic work for the clinician and the client and encourages thoughtful reflection on the treatment (Taibbi, 1995).
In examining methods of live supervision, a major focus of research has concentrated on how each method of supervision affects the supervisor, the counselor (trainee or supervisee), and the supervisory relationship (Bernard & Goodyear, 2004). Very few studies have focused on the impact of in-the-room supervision on individual clients. One research study of families' reactions to live supervision found that family members were generally positive about the experience and believed that it provided better services as a result of having more than one therapist in the room (Piercy, Sprenkle, & Constantine, 1986). Locke and McCollum (2001) examined clients' perceptions of in-the-room supervision and their satisfaction with therapy in a university-based training program for marriage and family therapists. Results concluded that clients found live supervision to be satisfactory as long as the perceived helpfulness of it outweighed its perceived intrusiveness. However, these studies were conducted in marriage and family therapy training programs, while the same topic in other fields remains underrepresented in the literature.
There does not appear to be much clarity or consensus from the literature about conducting in-the-room supervision, and no research about the combined reactions of supervisors, supervisees, and clients to this method of supervision. This article responds to that gap in the supervision literature by describing the use of in-the-room supervision in practicum and the reactions of the supervisors, supervisees, and clients to this supervision approach.
The participants in this study consisted of counselor education master's students enrolled for credit in the practicum portion of a counselor education masters program in the eastern United States . The data were collected from t hr ee consecutive courses, thus including three separate groups of practicum students. Practicum students were supervised by current doctoral students in the counselor education program who had either previously taken, or were currently enrolled in a clinical supervision course. All of the supervisors were therapists with at least two years of counseling experience, and all received regular supervision from university faculty for the duration of this study.
The first class consisted of fourteen supervisees between the ages of 24 and 49, five of them European American males, two African American females, and the rest European American females. There were seven supervisors for this class, between the ages of 31 to 43, including one European American male, one Hispanic male, and five European American females. The second class consisted of eleven supervisees between the ages of 26 and 58, all female, t hr ee African American, and the rest European American. This class had seven supervisors between the ages of 27 and 34, one European American male, two African American females, one Hispanic female, and the rest European American females. The third class consisted of twelve supervisees between the ages of 24 and 72, one African American male, and the rest European American females. There were six supervisors for this class, all European Americans between the ages of 27 and 54, with one male and the rest female. There were fifty undergraduate clients between the ages of 17 and 30 participating with each class, which resulted in a total of 150 clients.Procedure
Doctoral student supervisors were assigned practicum supervisees by the professor and graduate assistants for the supervision and practicum classes. The supervisors received preliminary instruction about beginning a supervisory relationship with the use of an informed consent agreement. Supervisors held initial supervision sessions discussing the terms of the informed consent agreement with their supervisees, and preparing for the first session with a client. Clients were solicited from announcements in undergraduate classes and from advertisements posted in dormitories. These notices described the training and supervision of the trainees who would be seeing clients. A graduate assistant gathered intake information from interested clients and coordinated the appointments with the trainees. This method helped screen for client problems that might be beyond a trainee's ability, such as serious psychological or psychiatric disorders. Appropriate referrals were then made to the university's counseling center or to the respective agencies where practicum students were placed.
The practicum students saw clients t hr oughout the course of the semester. The majority of the counseling/in-the-room supervision sessions took place in assigned rooms within the counselor education department. The remaining sessions took place at the respective practicum sites, where clients were already receiving services (i.e. no client solicitation was needed). At the beginning of the first session, each client was introduced to the student counselor and his or her respective supervisor. An explanation of the supervisor's role followed. Each client was given the opportunity to decline participation prior to beginning the counseling relationship, and advised that his or her participation was voluntary thereafter. The supervisors remained in the room for the counseling sessions, delivering in-the-room supervision in the manner most comfortable to them (i.e., offering suggestions and intervening when necessary, or serving as silent observers and having a consultation meeting with the student counselor after the client left).Data collection
At the end of the counseling relationship, each client, counselor, and supervisor, completed a questionnaire in which they described their perceptions of the in-the-room supervision experience. Specific questions focused on what it was like to have a supervisor in the room during the session, the advantages and disadvantages of in-the-room supervision, and suggested changes for improvement of supervision.Analysis
Responses to the in-the-room supervision sessions were analyzed by organizing them into categories according to thematic content. Both authors and two graduate assistants worked independently to group the data and then compared their results. The data was then compiled into matrix displays for further analysis, in which the most common responses were determined. The final categories were compiled into the present format, with quotes from the respondents supporting each category.
The findings are presented in terms of the advantages and disadvantages of in-the-room supervision for supervisors, supervisees and clients. Table 1 provides percentages of the most common themes reported.
Most Common Advantages to In-The-Room Supervision: Percentage of Responses to Survey
Supervisee Supervisor Client_ ___________________
Liked immediate help 43 Valued immediate 30 Valued support for counselor 10
available when stuck feedback opportunities
Felt supported and
comforted 48 Time-efficient 20 Liked having more than one 10
Appreciated having a 21 Valued being able to 25
different perspective monitor and interject
Most Common Disadvantages to In-The Room Supervision: Percentage of Responses to Survey
Supervisee Supervisor Client_____________________
Made the supervisee 21 Felt as though presence 20 Felt increased anxiety and 13
nervous may hinder client intimidated about disclosing
Felt inhibited due to 10 Unsure when to 20 Distraction for counselor 8
being observed intervene in the
Concerned that the 25
supervisee may be
nervous to the point
of ineffective counseling
Supervisees' perceptions of advantages
1. Immediate help . The following comments made regarding the students' sense of security reflected their novice status, the fact that they were seeing clients for the first time: "I liked the supervisor being there to interject when necessary." "I knew I had a back up so I went ahead fearlessly." "It was a great comfort during the first sessions." "I think that the clients may have felt more secure knowing someone with experience can be involved in the session." Several students referred to it as a "safety net" for them and their clients. Forty-t hr ee (43) percent of the students reported having a supervisor with them seemed to reduce anxiety about client welfare and client perceptions about the value of counseling.
2. Support . Students liked the support offered by having their supervisor in the room. Some described feeling encouraged, being part of a team, and feeling comforted by the supervisor's presence. Forty-eight (48) percent mentioned the immediacy of the support by having the supervisor in the room.
3. Different perspective . Twenty-one percent (21) of supervisees noted that they appreciated having a different perspective. One student described her supervisor in the room as "a valuable ally in my quest to learn counseling." Some students mentioned having confidence to try new techniques and approaches with their clients. When the supervisors did intervene, the students seemed to experience the intervention as good direction and modeling. As one supervisee said, "Moments when I was stuck, it was very helpful for me to have my supervisor intervene and guide me t hr ough the counseling session by demonstrating innovative techniques." Another supervisee stated that having the supervisor in the room resulted in better understanding of the counselor-client dynamics involved and therefore enabled the supervisee to receive better feedback.
Clients' perceptions of advantages
1. Support for the counselor . Ten (10) percent of the clients reported believing that the supervisors were of significant support to the new counselors.
2. More than one viewpoint . Ten (10) percent of the clients regarded having "two viewpoints" as the predominant advantage of having a supervisor in the room. When the supervisor did become involved, clients saw this as helpful feedback.
Supervisors' perceptions of advantages
1. Providing immediate feedback. The supervisors liked the immediacy of the feedback they could give while in a session with their supervisees. They also liked the first-hand experiencing of the counselor and the client. One said, "In-the-room supervision felt comfortable, and provided excellent observation of the supervisee's communication and relationship skills." Another comment was "It has been helpful for me personally to be in the room to hear the clients first-hand." The supervisors liked the convenience of being able to comment and provide feedback regarding the process. These comments were represented by thirty (30) percent of the supervisors.
2. Time efficient modeling . Twenty (20) percent of the supervisors saw in-the-room supervision as a time-efficient method of modeling appropriate skills and interventions for the supervisees and providing co-therapy as needed.
3. Monitoring and interjecting . In attending to the responsibility that supervisors have for client welfare and their supervisee's growth, twenty-five (25) percent of the supervisors saw in-the-room supervision as a safety net. One said that she felt "comfort that comes with knowing exactly what went on in a session and closely witnessing all of a supervisee's performance." Supervisors agreed that having a supervisor in the room would potentially allow beginning counselors the opportunity to see clients who have serious diagnoses and who would otherwise not be considered appropriate for a lab setting.Disadvantages
Supervisees' perceptions of disadvantages
1. Nervousness . Twenty-one (21) percent of the supervisees expressed some discomfort and nervousness about having a supervisor in the room. They used terms like "being watched," "inspected," "pressure to perform as a counselor" and "inhibited having someone watch me so closely."
2. Inhibition and distraction . Some supervisees (10 %) reported the experience as inhibiting and a "distraction" interfering in their concentration. Several believed that it was also a distraction for the clients to watch the supervisors, and to have two people focusing on them. Some supervisees believed that when the supervisor was in the room, that he or she was most likely to "take over" parts of the session. One "disliked feeling pressured to do what I thought the supervisor wanted rather than trusting my own instincts."
Clients' perceptions of disadvantages
1. Inhibited self-disclosure . Several (13%) of the clients gave feedback pertaining to their anxiety and inhibition due to having a supervisor in the room. For example, one client stated: "I would have preferred not to share my personal concerns with two people." Another said it was "nerve-wracking" and a third client described it as "invasive."
2. Distraction for the counselor . Some clients (8%) expressed an issue of distractibility. One client said that for him it was not a problem but "for my counselor it was a distraction." Another said the she "felt it was less private and made the counselor nervous." Several commented that it was a distraction when the supervisor was taking notes.
Many of the disadvantages were cited as problematic only at the beginning of the counseling relationship. It seems, then, that often the clients became accustomed to having a supervisor in the room.
Supervisors' perceptions of disadvantages
1. Hindering client disclosure . Just as the supervisees expressed a concern about overwhelming the client with two people in the room, so did some of the supervisors. Twenty (20) percent reported worrying about inhibiting client self-disclosure.
2. Unsure when to intervene . Twenty (20) percent of the supervisors reported struggling with their level of involvement in the sessions. "I had difficulty knowing at what point it would be advantageous for me to add to the counseling process." Many worried about "taking over," "getting too involved," or "rescuing" in the session. There was a concern, too, that the supervisees could become too dependent on them. For example, one supervisor stated, "I feel like I am a crutch for my supervisee and that she would try more things on her own if I were not in the room." Several comments from supervisors described their feelings of self-consciousness: "I often don't know where to look. I question how long I should look at the client or the supervisee/counselor. I find myself looking down. I feel awkward when I want to write something down."
3. Nervousness and ineffectiveness . Supervisors were very sensitive to the anxiety of their supervisees. Twenty-five (25) percent reported concerns about this anxiety interfering with the supervisee's effectiveness: "I know that my supervisee is aware of all my movements and gestures, so I am anxious about that." "Because supervisees are kept on their therapeutic toes as a result of in-the-room supervision, I wonder to what extent they are more anxious." "My supervisee was more nervous, appeared to perform as if having test anxiety, forgetting everything she had learned."
Summary and Discussion
Several limitations were present in this study. The participants were from a purposive sample, which limits the ability to generalize the findings. The supervisors and supervisees were in the same university program, although at different degree levels, and there may have been other contacts with one another that resulted in bias. Other factors that may have affected the results include compatibility of supervisor/supervisee dyads and the level of supervision training completed by the supervisor.
Despite limitations, however, the current results support many of the advantages of live supervision in general as presented in the literature. In agreement with Wark (1995), this research showed that for supervisees, instruction, support, and autonomy were important in live supervision. Supervisors valued immediate feedback and modeling opportunities. Some of the supervisors' and supervisees' responses supported the idea that in-the-room supervision provided direct access to client dynamics, something that they could not achieve otherwise. Many clients appreciated in-the-room supervision, as cited in research (Piercy, Sprenkle, and Constantine (1986); and Locke and McCollum, (2001)), finding it to be additional help with their issues.
The general disadvantages of live supervision as cited in the literature were also supported in these findings about in-the-room supervision. Some supervisors, supervisees, and clients experienced increased anxiety that was in some cases very problematic. This finding supports the findings of Bowman (1980) and Costa (1994). Supervisors frequently reported role confusion as to their level of involvement in the session. Some clients expressed feelings of intrusion, distraction, and uneasiness about being observed by a third party.
The researchers concluded that the advantages of in-the-room supervision were very beneficial, particularly when training novice counselors. This modality of supervision will continue to be used for supervisees seeing clients in settings where there is no one-way mirror and taping technology. Moreover, this modality will continue to be used in the program's new lab facility where observation and taping technology is now available. Unlike other forms of supervision, in-the-room supervision provides a unique opportunity for the supervisor to observe, support, and model interventions within the flow of the therapy session. For some clients, it provides reassurance of having the feedback of an advanced therapist along with that of a novice therapist, an aspect which may become increasingly important in order to recruit clients for training programs. To improve the manner in which in-the-room supervision is conducted, the authors have learned that much more preparation needs to be given to the supervisor and the supervisee. It is important to develop a clear understanding of the purpose of observation and intervention of the supervisor. Taibbi (1995) raises the following important questions that may be used to guide preliminary discussions: Does the supervisor want to see how the clinician works with a particular case? Does the clinician want another assessment or suggestions about a client? When is modeling important to do? Future research in clinical supervision of counselors in training should focus on the roles and goals of supervisors conducting in-the-room supervision as they monitor and observe their supervisees. Clearly, the manner in which in-the-room supervision is conducted affects the perceptions of all involved. More quantitative methods measuring such domains as anxiety, support, and role confusion of the supervisor, may be helpful in determining how supervisors choose their levels of involvement, interventions, and style of in-the-room supervision. Perhaps another survey aimed at assessing forms of live supervision employed in clinical training programs would provide some insight as well. Future research may focus on ways to alleviate client issues during this method of supervision.
Bernard, J.M. & Goodyear, R.K. (2004). Fundamentals of clinical supervision (3 rd ed.). Needham Heights , MA : Allyn & Bacon.
Bowman, J. T. (1980). Effect of supervisory evaluation on counselor trainees' anxiety. Psychological Reports, 46 , 754.
Costa, L. (1994). Reducing anxiety in live supervision. Counselor Education and Supervision, 34 , 30-40.
Goodman, R. K. (1985). The live supervision model in clinical training. The Clinical Supervisor, 3 , 43-49.
Haley, J. (1976). Problem solving therapy . San Francisco : Jossey Bass.
Johnson, S. W. & Combs, D. C. (1997) The use of interactive television in live supervision . Texas Counseling Association Journal, 28 (1) 4-10.
Jordan, K. (1999). Live supervision for beginning therapists in practicum: Crucial for quality counseling and avoiding litigation. Family Therapy, 26 (2) 81-86.
Kaplan, R. (1987). The current use of live supervision within marriage and family therapy training programs. The Clinical Supervisor, 5, 43-52.
Liddle, H. A., & Schwartz, R. C. (Eds.). (1983). Live supervision/consultation: Conceptual and pragmatic guidelines for family therapy trainers. Family Process, 22 , 477-490.
Locke, L. D., & McCollum, E. E. (2001). Clients' views of live supervision and satisfaction with therapy. Journal of Marital and Family Therapy, 27 , 129-133.
Malcom, J. (1978, May 15). A reporter at large (family therapy). The New Yorker, 39, 55-61.
Montalvo, B. (1973). Aspects of live supervision. Family Process, 12 , 343-359.
Piercy, F. P., Sprenkle, D. H., & Constantine, J. A. (1986). Family members' perceptions of live observation/supervision: An exploratory study. Contemporary Family Therapy, 8 , 171- 187.
Taibbi, R. (1995). Clinical supervision. Milwaukee : Families International, Inc.
Wark, L. (1995). Defining the territory of live supervision in family therapy training: A qualitative study and theoretical discussion. The Clinical Supervisor, 13 , 145-162.
Wong, Y. S. (1997). Live supervision in family therapy: Trainee perspectives. The Clinical Supervisor, 15, 145-157.