#76831: Clinical Supervision for Mental Health Professionals in Florida

Individuals who wish to supervise interns and other practitioners must work within the limits of their competence and practiced techniques. Supervisors should be qualified to hold the position, either by demonstrating the ability to supervise or by receiving training [1]. The National Association of Social Workers (NASW), the American Psychology Association (APA), the American Association for Marriage and Family Therapy (AAMFT), the American Counseling Association (ACA), and the National Board for Certified Counselors (NBCC) all include standards in their respective code of ethics that require mental health professionals to work within their limits of knowledge [14,15,16,17,23]. While this is most clear in work with clients, it also pertains to work with other practitioners or interns as a supervisor. When using technology in their work and for supervisory purposes, mental health professionals should have the required knowledge and tools to use the technology safely and competently. When an individual uses new techniques, tools, or plans to provide services, he or she should seek additional education or supervision from a more experienced practitioner [14,15,16,17,23].

According to the APA's Code of Ethics, psychologists who require professional knowledge related to age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, or socioeconomic status in order to effectively provide services should seek training, consultation, or supervision, or they must make a referral to a psychologist who has the required knowledge or experience [15].

Mental health practitioners who accept the role of supervisor also accept the responsibility of helping to further the professional development of their supervisees. This includes providing supervisees with opportunities for learning, giving evaluations promptly, and providing constructive feedback during sessions. Lack of timely feedback is reported to be one of the main ethical complaints against supervisors [1]. Supervisees who are not performing at an acceptable level should first be given a plan for improvement. If a poor evaluation is given, it should not come as a surprise to the supervisee; rather, it should be the result of not meeting the terms of a previously discussed plan [1].

It is important that supervisors have basic information about the supervisee's clients in order to make and monitor treatment plans. Supervisors should be available for emergencies regarding clients and for client interventions, if needed. Keeping in mind the fact that the well-being of the client is ultimately the responsibility of the supervisor, supervisors should not supervise more interns than they can responsibly manage [1].

A supervisor holds a position of trust and is expected to always consider the well-being of his or her supervisee. Because of the power dynamics that exist between supervisor and supervisee, entering into dual relationships with supervisees is discouraged, as this could affect the supervisory relationship, as well as the supervisor's professional judgement [1,2,19,23]. Examples of dual relationships include when a supervisor is also a friend, family member, therapist, business partner, or romantic partner, or enters a sexual relationship with his or her supervisee.

The risk of establishing a dual relationship of supervisor and therapist is increased because many strategies used in supervision are derived from strategies used in therapy [2]. Teaching supervisees how to use such strategies in clinical sessions and working through personal issues can result in a blurring of boundaries. Studies show that supervision is less effective for the supervisee when the supervisor takes on a therapist role rather than using deliberate instruction of new skills. One of the most significant grievances that supervisees have about supervisors is regarding the dual relationship of supervisor and therapist [2,19].

Supervisors should never enter sexual or romantic relationships of any kind with students, interns, or supervisees. This includes verbal, written, electronic, or physical contact [14]. Further, no person should agree to supervise a person with whom they have had a romantic or sexual relationship. Students not only include those under direct supervision but also any intern in a clinician's department, agency, or center or any student who the individual may have need to evaluate in the future [15].

Supervisors have the responsibility to ensure that clients are informed when students, interns, or individuals in trainings are providing client services [1,14,15,17]. Clients have the right to choose a more experienced practitioner if they do not feel comfortable receiving services from an individual in training [1]. Failure to inform a client could result in legal action against the supervisor or supervisee [1].

Clients should give their informed consent to supervision of their case, as the supervisee will share certain details of the client sessions with his or her supervisor. While the supervisee has the responsibility to maintain client confidentiality, there are some limits to confidentiality because of possible vicarious liability to the supervisor [19]. This will be discussed later in this course.

There are specific payment and advertisement issues faced by supervisors and supervisees. First, supervisees are not allowed to advertise their services. Payments for services must be made directly to the supervisor or the agency at which the supervisee is working. Any business cards with the supervisee's name should make their status as an intern, trainee, or student clear. It should not appear that an uncredentialed individual provides services independently [1].

Supervisors may be exposed to charges of direct liability if their action or inaction is found to have caused injury to a client. For example, direct liability can occur when supervisors are negligent in their duties and do not properly plan and supervise client outcomes. Also, as supervisors are required to have sufficient knowledge of clients, direct liability can occur if the supervisor gives inaccurate or inappropriate advice, which is then used in therapy to the detriment of the client. This is also true if the supervisor did not fully understand the supervisee's description of the client's needs because they failed to listen carefully. Similarly, direct liability can occur if the supervisor gives tasks to the supervisee that are inappropriate for his or her level of skill. Supervisors should have good knowledge of the abilities of their supervisees and should not assign tasks outside of supervisees' training and ability [1,19,23].

Because of their position, supervisors are responsible for the actions of their employees or supervisees. If a client suffers harm or injury because of the actions of a supervisee performing regular work duties, supervisors may be held responsible for those injuries. An individual in training cannot assume final responsibility for a client; a credentialed professional must carry decision-making roles and responsibilities [1].

As a result of the case of Tarasoff v. Regents of the University of California of 1976, in which it was found that a psychologist should have done more to prevent a murder committed by his client, it was established that mental health professionals are required to warn and protect when a client appears to be a danger to others. Even though their training may not be complete, interns, students, and trainees still have the responsibility to provide the same standard of care as a licensed mental health professional. This includes the possibility of needing to violate client confidentiality in order to protect others from harm. A supervisor must intervene to protect a client from harm when the supervisee is deemed to be incompetent [23]. Supervisors and their supervisees can be held responsible for harm done to a person that could have been prevented by reporting [1].

Supervisors and agencies should have policies in place to guide supervisees in situations in which they are required to issue a warning, as supervisors can also be held responsible for actions taken by clients because a trainee failed to warn and protect [1].

As mentioned, clients deserve the same standard of care regardless of whether they receive service from a licensed practitioner or from interns, students, or trainees. Supervisors who believe that clients are not receiving adequate care are required to act to protect the client. This includes thoroughly investigating complaints that clients may make about supervisees [1].

In 2016, CS/HB 373 Mental Health Counseling Interns was signed into law by the Governor of Florida. The law sets new requirements for mental health interns, including in the fields of social work, marriage and family therapy, and mental health counseling. Individuals who do not meet the postgraduate or post-Master's level experience requirements must register as an intern in the field for which he or she is seeking licensure. Individuals must complete the application form and pay an application fee, which should not exceed $200 [4].

In addition to meeting certain education requirements, applicants must present a plan for supervision, including identifying a qualified supervisor and remaining under supervision for the entirety of his or her internship. Hours worked before registering as an intern do not count toward the internship requirement. Intern registration is valid for five years. CS/HB 373 also requires that a licensed mental health professional be on the premises when clinical services are provided by a registered intern in a private practice setting [4].

Rule 64B4-2.002 defines the role of supervisor in the fields of clinical social work, marriage and family therapy, and mental health counseling. The rule defines supervision as [5]:

Rule 64B4-2.002 states that interns will be credited for the time of supervision if the intern received at least 100 hours of supervision in no less than 100 weeks, provided at least 1,500 hours of face-to-face psychotherapy with clients, and received at least one hour of supervision every two weeks [5].

Supervision should be focused on data from the intern's face-to-face psychotherapy with clients, for example, from written clinical materials, direct observation, or video and audio recordings. Supervisors and interns may use face-to-face electronic methods for supervisory sessions but not telephone-only communication. At least 50% of all sessions must be in-person meetings. Before using any online or electronic method, the supervisor and intern must have at least one in-person meeting. Both the supervisor and intern are responsible for maintaining client confidentiality during supervision [5].

Interns may receive group supervision; however, each hour of group supervision must alternate with an hour of individual supervision. Group supervision must be conducted with all participants present in-person. Individual supervision is defined as one qualified supervisor supervising no more than two interns, and group supervision is defined as one qualified supervisor supervising more than two and up to a maximum of six interns per group [5].

Clinical supervisors have several roles in their work with interns. The SAMHSA describes clinical supervision as having four functions: teacher, consultant, coach, and mentor/role model [19]. Supervisors serve as teachers by helping interns to develop knowledge and skills. Supervisors teach, train, and serve as professional role models for their supervisee. As consultants, supervisors have the responsibilities of case consultation, performance monitoring, giving feedback about job performance, and assessment. The supervisor also assumes the role of coach by providing moral support, assessing supervisee's needs and strengths, suggesting clinical approaches, and providing role plays for modeling, encouraging, and preventing burnout. As a mentor/role model, a supervisor teaches through modeling and helps to facilitate his or her supervisee's professional identity [19].

The role of a supervisor is of utmost importance in the development of the supervisee's ethical practice. He or she can also be considered a gatekeeper to the profession and must maintain professional standards while also being sure that clients are receiving the best care. Because of the importance of this role, new supervisors may find it beneficial to find a mentor. A talented clinician does not always take to his or her new role as supervisor easily [19]. The SAMHSA TIP series provides helpful reminders for supervisors [19]:

Internship has been referred to as the professional adolescence of the mental health professions [20]. As a period of growth and new experiences, common stressors include adjusting to a new organization or program and developing relationships with new colleagues/staff in charge of training. In addition, interns are gaining new skills to work with clients and/or groups, assessing personal strengths and weaknesses, evaluating their competence with clients, and planning for a professional career after the internship has ended.

It is important for the supervisee or intern to maintain an open mind in order to learn from experiences during his or her internship. An internship gives a practitioner the opportunity to practice new skills. Interns should take advantage of the expertise, not only of his or her supervisor, but of all mental health professionals he or she may encounter at the organization. If an intern feels that he or she is not being sufficiently challenged by a supervisor or if he or she is having difficulty at the placement, he or she should be vocal and ask for help or for more challenging opportunities [21].

Both the supervisor and the supervisee have the responsibility to properly document supervisory sessions, as well as to provide the necessary documentation required by administrative and human resources (HR) personnel, including emergency contact information and profiles for each supervisee, a supervisory logging sheet, supervision notes, and case reviews [19]. Supervisors are also responsible for informal and formal evaluations of their supervisees [19].

While some documentation is available for HR to access, supervision notes, especially notes related to work with clients, should be held separately and kept confidential to protect the identity of the supervisee and client. Supervisory notes may include a summary of the topics that were discussed during supervision, comments about the strengths and weaknesses of the supervisee, actions to be taken by either the supervisor or supervisee before the next session, and other comments that any party may wish to note. The purpose of supervision notes should be to help the supervisee to improve clinical skills and to ensure quality in patient care. Wording should be specific regarding plans for follow-up about particular clients while also maintaining client confidentiality [19]. It is the responsibility of the supervisor to provide supervisees with documentation of supervised sessions within a reasonable time [22].

Upon the completion of supervisory hours (or termination of the supervisory relationship) as required by the Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling, qualified supervisors must complete the Verification of Clinical Experience form, available at https://floridasmentalhealthprofessions.gov/forms/clinical-exp-verification.pdf.

Florida Department of Health Rule 64B4-2.002 states that supervisory meetings may be held using video conferencing, so long as the first meeting between supervisor and supervisee occurs in person and that in-person meetings make up at least 50% of all total meetings [5]. Also, using the telephone without video is not to be counted toward supervision hours.

One ethical concern regarding the use of technology in supervision is the fact that phones, computers, and electronic devices are designed to share information, sometimes automatically without the knowledge of the user. For example, photos or videos may be automatically shared from a smart phone at work to a tablet at home. Devices may also automatically share the user's location, documents, emails, and contacts, creating possible breaches in confidentiality of both the supervisee and the client [28].

Similarly, electronic devices are often constantly on, in some cases with listening devices that can respond to requested information, play music, control other smart devices, and record what they hear. This is a stark change from electronic devices of the past (e.g., tape recorders or video recorders), which were turned on manually and only when the user required them. The fact that some devices or apps may perpetually be "on" in the background is an ethical concern when considering the confidentiality of supervisees and clients [28].

Many devices are programmed to update automatically, which may affect the competency with which the user may operate the app, as system updates may change the location of commands or information. Downloading apps or programs often requires that the user accept the terms of use, which can contain permissions to automatically share information to third party apps or companies [28].

Another ethical concern in terms of confidentiality of supervisees and clients is the use of cloud storage to save documents, photos, and general information. While cloud storage is more efficient, both in terms of space and cost, it poses a risk to confidentiality because companies rent cloud storage from third parties, in some cases internationally, and data may be stored in more than one place. This makes it more difficult for users to ensure that their confidential files are kept safe [28].

The general recommendation to supervisors using electronic devices in supervision is to avoid using cloud storage with client or supervisee information. If cloud storage must be used, supervisors should encrypt documents, use strong passwords, and use cloud storage that is HIPAA compliant. Use of cloud storage should be disclosed to clients and supervisees [28]. HIPAA-aligned cloud storage websites include [28]:

Supervisors may be asked to internally supervise current colleagues or may externally supervise interns from other organizations. Both cases offer special challenges. Supervising current colleagues can be difficult when professional relationships, and in some cases personal relationships, change. Because of the proximity, both supervisor and supervisee may take for granted the ease of supervisory meetings and therefore take such meetings less seriously. On the other hand, external supervision of an intern can lead to conflicts between the organizational standards and the advice of the supervisor. Initially, an external supervisor may not be as familiar with the work of a supervisee [24].

Another challenge in supervision is balancing clinical and administrative duties, and the time commitment is often a first barrier for busy professionals. Supervisors who are responsible for supervising clinical sessions of their supervisees while also scheduling, hiring, and delegating tasks may find it challenging to juggle such a heavy load. It is important for supervisors to find time to fulfill both roles and remember which role they are taking on at any specific time [19]. Supervisors who are also practitioners with their own clients will need to find time to supervise while also keeping up with client sessions and documentation. As mentioned, supervisors should not take on more supervisees than can be effectively handled [19].

In some cases, professionals may resent being supervised, which can present in a variety of ways. Older professionals who have been working in human services in some capacity for many years but are moving into a new area of service are likely to feel some level of resentment. This resentment can be more significant if they are being supervised by younger professionals (contingent, of course, upon personal variables). Professionals are more likely to experience resentment or be resistant to supervision if they feel they know more about therapy/counseling, obtained through life experiences, compared with a supervisor who has less real-world experience. Excellent students may be prone to entering an internship or work feeling that they know it all and could be sensitive to correction. Inferiority fears can also be a major reason for resisting supervision and the corrective feedback that comes with it. Supervisors may even find that the agency or organization itself is resistant to clinical supervision [19].

Most supervisory relationships have aspects of a power dynamic between the supervisor and the supervisee. Issues of race, gender, sexuality, age, ability, and/or social class may further affect the already existing power dynamic [2]. Research indicates that when supervisor and supervisee are matched by background, supervision can be more beneficial, although more research is needed [2]. There is a general agreement that supervisors should be aware of systemic and social power dynamics that may arise in supervision as well as the need for culturally sensitive supervision [2].

A culturally competent supervisor is actively engaged in the process of becoming aware of his or her assumptions about human behavior, values, biases, preconceived notions, and personal limitations [25]. This is an ongoing process of self-discovery that requires a willingness to address any issues that may arise. For example, because the concept of boundaries varies across cultures, therapeutic elements related to boundaries should be modified to adapt to this variance (within ethical and legal boundaries) [25].

The expectation of confidentiality varies, and in many cultures, confidentiality is neither expected nor therapeutic [26]. As such, supervisors should resist assuming that confidentiality is implicitly restricted to the supervisor and supervisee. Being culturally competent requires vigilance and an understanding that referral to another supervisor might be necessary in some circumstances (e.g., when working with a supervisee is beyond the supervisor's boundaries of competence) [25].

A culturally competent supervisor actively attempts to understand the worldview of a culturally different supervisee by employing empathy and avoiding negative judgments [25]. This involves becoming familiar with the culture, subculture, and political history of the supervisee when these differ from those of the supervisor. Seeking continuing education yields valuable rewards and is useful in avoiding the common therapeutic blunder of overgeneralization [26]. For example, knowing a supervisee's ethnicity, political affiliation in their country of origin, religious beliefs, and expectations of gender roles contributes to the supervisor's ability to create a more precise framework from which supervision can be applied. Supervisees usually recognize and appreciate supervisors' attempts to learn about their culture, which can enhance the supervisory alliance [26]. It is also important to recognize that the supervisee is part of a larger cultural system that may include family members, societal elders, or others of significance. These others can impact the supervisee's therapy, with positive or negative outcomes, depending on whether they are enlisted as allies or alienated [26].

A culturally competent supervisor also actively develops and practices appropriate, relevant, and sensitive intervention strategies and skills when working with culturally different supervisees. In order to keep abreast of new interventions and strategies, the supervisor may acquire additional education, training, and supervised experience [25].

Common issues in the supervisory relationship (e.g., gifts, touch, eye contact, medication compliance, choice of vocabulary) are all influenced by culture. Rather than adhering to a rigid theoretical approach when dealing with these issues, it is best to seek out their cultural meaning on a case-by-case basis. Enlist the expertise of a cultural informant, if one is available. This person is generally from the same culture as the supervisee, is not an active participant in the therapy, and functions as a consultant to the professional by interpreting or identifying culture-specific issues. The Department of Health and Human Services offers trainings in cultural competence. A list of these courses is available online at https://thinkculturalhealth.hhs.gov/education/behavioral-health.