Which clients are you brushing your teeth with?
by Dr. Danna Bodenheimer, LCSW. author of Real World Clinical Social Work: Find Your Voice and Find Your Way
Given that it is impossible to advance one’s level of licensure without substantial supervision, the import of the subject of supervision is inarguable. Despite this reality, discussions on what constitutes “good” supervision are scant, at best. This is largely because the pressure of managed care and decreased agency funding has led many to use supervision as a space for the management of administrative tasks, reflecting the powerful scarcity of time and resources. The multiple pressures on all social workers has forced dedicated clinical supervision to fall by the wayside. Thus, supervision has lost its sacred standing in our field.
Although there might be a dwindling focus on the essential nature of supervision, that does not change the sheer necessity of it. For supervisors and supervisees alike, the need to honor the supervision process is vital. Supervision is actually the underlying life force that keeps our field ethical, evolving, and intentional. Supervision ought to be where wisdom is shared, clinical voices are cultivated, and cases are conceptualized.
Given this inarguable level of import, let’s talk about what makes supervision good and what makes supervision bad. I say it that plainly because there is a lot of good supervision that happens. There is also a lot of mediocre supervision that happens, and that is a fact that must be examined.
Let’s start with the mediocre. Mediocre supervision is, first and foremost, co-created. The forces that underlie mediocre supervision are intricately intertwined. There is the over-burdened supervisor, the chaotic agency setting, and the supervisee who is inhibited about clearly articulating needs. No one wants supervision to become mediocre, but it is hard to keep it alive. Pressures for precise paperwork, audits by insurance companies, and high caseloads leave supervisors depleted and supervision deadened. This deadening leads to supervision that is largely superficial, thereby neglecting the depth of the clinical work. Amidst this depletion and deadening, supervisees tend to put their needs aside in the hopes of making everyone’s job easier, avoiding the obstructive role of the squeaky/needy wheel.
Supervisees often feel pressured to come to supervision prepared with a set of questions in order to support the efficacy of the meeting. Supervisees also feel responsible for presenting the ways in which they are smoothly adhering to the agency’s treatment modality. For example, if an agency strictly practices and bills for trauma focused cognitive behavioral therapy (TF-CBT), then most of the questions will be about how to use this technique and how to get clients to become more responsive to the technique. While preparedness for supervision makes sense, as does adherence to agency modalities, these constructs can render supervision inauthentic and performative. This performativity stunts the growth of both the clinician and the supervisor and leaves the truth and grit of clinical work outside of the supervision room.
In clear opposition to this performativity, the very real and rich possibility of authentic (good) supervision remains powerfully possible. Good supervision is actually a great thing. Our field was basically founded on the power of supervision, identifying it as the site at which practice wisdom was imparted and social work neophytes became social work magicians. Rather than a focus on model adherence or administrative tasks, supervision was a place where the expertise of a seasoned supervisor brought these magicians to life. Of course, this still occurs quite a bit, but not enough.
Good supervision requires openness and vulnerability by the clinician and the supervisor. Many supervisors are legitimately frightened by the weight of the responsibility of supervising. They are essentially taking on the caseload of a younger clinician in the hopes that the clinician is making sound decisions. Every time supervision happens, a license is on the line. This requires a certain bravery that needs to be mutually recognized. However, this bravery can not be managed through a false sense of authority. Instead, it is the vulnerability of a supervisor that can allow for the transformation of a clinician and, subsequently, for their clients. For example, a clinician might present a case of a client in a dangerous domestic violence situation. The clinician has almost habituated to the stories of abuse, losing their sense of alarm. The supervisor can come in and offer authentic fear for the client and empathy for the desensitized clinician. This fear and empathy, once transmitted, can allow a social worker to reawaken the client, feeling more fueled by the tender witnessing of a supervisor.
The presence of a supervisor’s vulnerability lessens the very real threat of shame for the clinician. Endemic to many supervision dynamics is a simultaneous avoidance and experience of shame. Supervisees often assume that they are being rigorously judged. And, supervisors feel a level of responsibility that can lead them to act authoritatively certain of right from wrong. Rather than remaining entrenched in this polarization, a supervisor’s vulnerablity invariably lifts this shame and opens up clinicians to more clearly see their own blind spots. This vulnerability also allows the supervisee to open more purely and honestly around their internal processes.
Good supervision requires the steady knowledge of parallel processes. What happens in a supervisee dyad almost always shows up in a clinical dyad. In other words, if there is shame in the supervision, there will be shame in the clinical work. If there is a toleration of vulnerability in the supervision, this will also trickle down. If a supervisee is withholding information from the supervisor, this likely means that clinical information is also being withheld in the treatment. There is no supervisory dynamic that operates in a vacuum, though this is something that is often forgotten in our work to stay afloat in high pressured, high volume settings.
The Blur Between Therapy & Supervision
Further, underlying effective supervision, an understanding of the inevitable blur between therapy and supervision must be tolerated. Much of what is brought up in supervision touches on the deepest parts of the clinician who is sharing it. In good supervision, we often bring up what rubs us most intimately. I had a supervisee discussing a client’s history of sexual abuse recently. He was brought to tears hearing about the details of the vicious experiences of his client. While I know that he is clearly moved by his client’s story, the resonance of the story felt deeper than that. We started to talk about his fears for his own son and the ways that this client reminds him of his child. If we had only talked about the client, the undue amount of emotion would have remained displaced onto the clinical work. By allowing for the blur between therapy and supervision, we create the possibility of clearer delineations in the actual treatment.
Most social workers feel a decent amount of haunting by the lives and stories of their clients. I have a question that I ask most supervisees: Which clients are you brushing your teeth with? It is a strange question, but what I am aiming to discern is what clients are most deeply penetrating the psyches of my supervisees. I ask this question, first to normalize how much we keep our clients with us. I also ask this question because I sincerely believe that the hold our clients have on us is lessened in the presence of supervision. While supervision is not designed to dilute intense clinical relationships, it is intended to create enough psychic space for the supervisee to clearly think.
If a clinical relationship feels like a pressure cooker, supervision is the space where the steam can be let off. The relief of letting out steam is often supported by the supervisor’s reminder of theory, attachment patterns, and clear signs of countertransference. The supervisee might be driving with their low lights on; the supervisor helps with finding their brights, too. The internalization of a decent supervisory relationship allows the clinician to create impulse control around the crafting of interventions. Ideally, an intervention comes to mind, and before immediately acting on it, many will take the idea to supervision. Together, a solid choice can be made. The internalization of supervision helps the supervisee to feel safer in the decision-making, knowing that there is a clear space for them to carefully consider all of their options, and to reflect on their choices in retrospect.
The Messiness & the Magic
Supervision requires a certain messiness to be effective. In supervision, clinicians are asked to look within in order to better understand their role in their clinical efforts. Deepened self knowledge can only occur in the presence of a safe and non-judgmental relationship. It is also reasonable for supervisees to demonstrate fears about not having any idea what they are doing. A large part of the supervisor’s job is to help the clinician develop language to better identify their own thinking and clinical choices. A clinician might say, “I had no idea what to say, so I just sat there.” A supervisor can healthfully respond by saying, “It sounds like you were working to tolerate the silence your client needed.” Supervisees need to be able to give voice to their terror around incompetence and inefficacy. Supervisors can tolerate and normalize these fears, while helping clinicians to find their own voice, wisdom, magic.
There is certainly no one right way to do supervision or to be in supervision. But consistent, carved out time for supervision that happens reliably is central to the growth of any social worker. Further, good supervision ought to be crafted to tolerate ambiguity and confusion, allowing a social worker to ultimately find the way toward ethical, curative, and theory based interventions.
Yes, administrative tasks and crafted agencies are a valuable use of supervisory time. But it is worth considering that these agendas are often attended to as a defense against the mutual vulnerability it takes to engage in transformative supervision. A good, great, not mediocre, supervision can transform a supervisor, a supervisee, and our clients.
Dr. Danna R. Bodenheimer, LCSW, is in private practice at Walnut Psychotherapy Center in Philadelphia, PA, and teaches at Bryn Mawr College Graduate School of Social Work and Social Research. Read more about clinical supervision in her book, Real World Clinical Social Work: Find Your Voice and Find Your Way.