Why Supervision Matters
“Do not pick a job, pick a supervisor.”
I’ve been telling that to my social work students, interns and supervisees since 2011.
Neither the pay, nor the job title, nor the commute, nor the work-from-home policy should determine where you work. The driving variable is the supervisor.
That’s a difficult sell. It may mean taking a harder job, for less money, farther from home. It runs against a professional culture that prioritizes short-term comfort over long-term formation.
Supervision functions much like parenting. If you train under a good supervisor, you are far more likely to become a competent and grounded clinician. Strong clinicians can emerge from poor supervision, but it is rare. Poor supervisors, on the other hand, reliably produce underprepared and often embittered clinicians.
Before defining good supervision, it helps to understand what bad supervision looks like.
Bad Supervision
I recently read an evaluation where the clinician didn’t give a basis for the diagnosis, misspelled names, got dates wrong and provided laughable recommendations.
Bad supervisors fail in predictable ways. They often:
- assign work but don’t tell you how to do it, then get angry when they don’t like what you did, discourage questions
- load work on employees and do little themselves, take credit for your work
- are unavailable, frequently cancel, rush supervision or multitasks
- do not review paperwork line-by-line
- exist only on paper
- over-validate without correction
- react defensively to questions or mistakes, collapse when challenged from above or by outside forces
My first supervisor at Integrity got high after I was there for three days. Four months later, I got my second supervisor. He liked to yell. He didn’t like that I had good relationships with the clients; he wanted them to fear me. These were the values of someone who had never been responsible for other people. I quit eight months later.
A good supervisor is not enough if the institution itself is unethical. No supervisor can permanently compensate for a corrupt system.
How Supervision Is Conducted
Supervision is the act of watching, training, directing, correcting and protecting a worker to make sure they complete tasks safely, ethically, properly and efficiently. Supervision is far more layered than just one-on-one work. A good supervisor will use at least a few of the following methods to train their employees:
- Individual supervision
- Group supervision. You learn from listening to co-workers present and get feedback
- Trainings on areas of expertise. I recently trained a bunch of new supervisees on ethics, suicide, social isolation, documentation, sports gambling and how to run group.
- Observation of supervisees in individual and group work. A supervisor should never just rely on the self-report of employees in the beginning
- Supervisees observe the supervisor and other clinicians in order to develop their own style
- Article reading and discussion
- Case Presentations. This should be done without notes. This is best in group supervision.
- Caseload Reviews
- Live note review. Clinicians should get direct, in-person feedback regarding DAP notes and treatment plans so they are time focused and have specific behavioral interventions.
- Video a clinician’s work and then watch it together. This is the only one I don’t do. Dave Erickson did this for decades and it was quite effective.
In most states, individual supervision must take place at least twice a month. Group supervision can fill the other weeks. I believe it is best for supervisees to bring an agenda. A good supervisor teaches triaging work. A great supervisor uses their own mistakes as teaching moments.
Reviewing paperwork is the area of supervision I like the least, but it is extremely important. It allows another clinician to understand what happened, it legally protects the worker/supervisor/company, third party payers require it and it is one of the only ways states monitor what has happened in treatment. Paperwork includes intake forms, treatment plans, individual notes, group notes and correspondence with referral sources including courts, jobs and schools. A good supervisor teaches clinicians how to write.
Three important aspects of supervision that I touch upon every month are scope of practice, countertransference and professional development.
Scope of practice refers to the area a licensed medical professional has been educated, trained and supervised in. An ophthalmologist doesn’t work on feet. Yes, they are a doctor but their scope of practice is the eyes. A supervisee’s scope of practice should not exceed their supervisor’s. If I am not competent in an area, I cannot supervise it safely. Expansion requires additional training and appropriate consultation.
Countertransference is when a clinician has an emotional reaction to the client. They could like them, hate them, dread them or overly root for them. Substance misuse counselors in recovery occasionally fall into a trap of wanting their client to get sober more than the client does and getting upset when it doesn’t work out. Countertransference tends to hit workers earlier in their career. Sometimes, countertransference should be discussed with a supervisor; other times, with a therapist. For example, if a clinician is treating someone whose disastrous romantic relationship reminds them of their own marriage, it may not be something they want to share with their supervisor. But, that supervisor should have taught them enough about countertransference that the worker knows to discuss it in therapy.
Professional development is pretty self-explanatory. I teach and review skills with workers, such as diagnosing, running groups, writing reports or conducting trainings. It also includes getting more education, pursuing new credentials and earning advanced licenses. It involves working with different demographics and on different types of cases. From the start, I explicitly prepare workers to either (a) get promoted with the company or (b) become strong enough to find a better job somewhere else. It is good for them, the field, society and in the meantime, I get great work out of them because they know they are moving forward towards something better.
Supervision must be modeled, not just taught.
Administration and Environment
When most Americans go to a doctor’s office, they are handed a clipboard and told to fill out a bunch of forms, including what might be a very in-depth medical history.
Do not hand clients a clipboard of paperwork. Walk them through it. They will take it more seriously and you will learn a lot more about them. Because you explain each form, sometimes apologizing for the duplicate nature, you will begin to build trust. During an intake several years ago, a cop told me that a paver ran over his foot when he was 18 and working on a road crew. He couldn’t walk for almost a year. It was important for me to know and I wouldn’t have found out if not for doing the intake paperwork with him and asking additional questions.
Individual and group rooms should be safe and interesting. There should be art on the walls to look at. I believe that clinicians should have something about their favorite sports team or musician or movie on the wall. It can spark a conversation, or at the very least, show the client you have your own life (although it can be annoying for other people who use your office when you aren’t there; one part-time worker got so frustrated by being asked about Bob Dylan because of the concert poster in my office that she thought about quitting).
A good supervisor makes sure the clinician eats during the day and takes regular time off.
Relationship and Alliance Building
I teach clinicians to acknowledge differences with their clients during the first session, particularly age, (most important), race and gender. One must explicitly state why you can work with them anyway. Invite questions or concerns.
I want clinicians to find common interests with clients: places visited, books read, favorite movies, sports, hiking, restaurants, television, music, video games, aquariums and any other hobbies that you have in common.
If you don’t know much about their job or hobby, ask them. A recent client educated me about meteorology. A fifteen year old taught me about Oxycontin in 2005 and another one of my clients at Rutgers informed me about fentanyl back in 2009. My work on the opiate epidemic was informed and inspired by my early clients.
If it is possible to leave the office, I think going for a walk with a client can be incredibly effective. A park is best, but not required. To be clear, one should follow agency policy, know the area and trust the client.
Clinical Standards
Diagnosis
The core rules in the DSM are that one does not diagnose when a medical condition or substances can explain the symptoms; and that only the most pervasive disorder in a clinical tree gets diagnosed (not bipolar disorder and depression, just bipolar disorder, as depression is an aspect of it). In 2009, a young woman from Connecticut walked into my office at Rutgers and told me, “I’m bipolar. I’m borderline. I’m addicted to alcohol and marijuana and mushrooms and LSD. I’m also anxious, depressed and have ADHD.” I told her to slow down and start with her name. She had been hit with so many diagnostic labels that it became her identity.
Clinicians should never simply reaffirm prior diagnoses. I tell my students and workers, “Even if you saw that I did it, I want you to review my work.” Once a diagnosis exists, professionals often stop checking. This is a known problem in physical medicine and mental health. A young soldier once walked into my office with a diagnosis of bipolar disorder. She had gone to a hospital because she couldn’t sleep for days and had difficulty concentrating. This was because she had caught her live-in boyfriend with another woman in their bed when she came home from the Army and was justifiably incredibly upset. When she went to the ER, the doctor hit her with the bipolar diagnosis. The Army was going to kick her out until I met with her. I was enraged. I had to write a detailed report about how her symptoms were consistent with someone who had been horrifically betrayed by a romantic partner and not bipolar disorder. Her life was almost irreversibly worsened by a bad diagnosis.
A good clinician teaches clients: how the diagnosis was reached, what criteria were met and what treatment options exist.
A good supervisor teaches clinicians to place clients in the appropriate stage of change, especially when stuck or frustrated.
A good supervisor teaches clinicians that “If you don’t know something, say you don’t know.”
A good supervisor teaches clinicians to recognize when something is outside their scope and consult or refer out and to also recognize when a higher level of care is needed.
Individual and Group Practice Standards
Confidentiality must be explained at the start of individual work, as well as the five exceptions to confidentiality (record release, medical emergency, suspected abuse of elder/minor/disabled people, homicidal or suicidal ideation, court orders). Confidentiality should be stated at the start of every group, even if everyone in group has been there before. It reinforces the rules and structure.
Every session should end with reviewing what was discussed. That also signals that time is up. I believe that clients should be given one to five things to do before the next time you meet, with a particular focus on behaviors.
Individual sessions should not exceed one hour. Group sessions should not exceed 90 minutes. Do not tell people not to cry. Normalize distress when appropriate. Let people know reactions can be typical and healthy. Use humor if you have it. Confront and challenge only after trust is established. Use their words. Do not use blank facial neutrality. Be sad with them. Be angry for them. Do not be shocked.
Documentation and Ethics
Document everything: phone calls, emails, texts and random meetings. If someone provides information about a client by phone, email, letter or in-person, tell the client what was said and by whom, even if it is uncomfortable. Back in 2004, I didn’t keep a fax receipt for some paperwork I sent to the Orange County NY court regarding one of my clients at Integrity House. When I went with him, his probation officer claimed they never got the report. I couldn’t produce the fax receipt so the judge threw my client in jail. I went to my car and cried.
Supervisees must carry adequate malpractice insurance. It is strongly advised the supervisors and their clinicians use the same carrier, lest one’s insurance company sues the other and the case gets tied up for years. Do not skimp on coverage.
It is the supervisor’s job to teach the ten most common ethical problems and the eight most common punishments. Those are basic. There are much more in-depth ethical conversations to be had.
Lessons From My Supervisors
I want to tell you about my three supervisors, Joe Butler, Jass Pelland and Lisa Laitman. And I want to share three great lessons from each of them (there are more, but all you get are three).
I met Joe Butler in 2004. He led group clinical supervision on a weekly basis at Integrity House. He was a great listener. He asked probing questions of the other counselors and helped them to see what they should do next with their clients. I had been working there less than a month when he suggested that I go get my MSW. That was on January 27th and I got my application in before the February 1st deadline. My earliest exposure to family work was watching Joe run family education groups before visits.
Joe told me to stop talking about my teenage arrests and recovery background as a way of bonding and treating clients. “You are an outstanding peer but you want to be a clinician. You need to develop counseling skills. If you rely on your biography and personality, it’ll work, but you’ll never really get better.” I stopped talking about my background for two years. Joe taught me about clinical skill development.
I did my first year Master’s Internship at Integrity House. Joe had me work with women, people with HIV, people with sexual trauma and teenagers. New populations, new types of problems. During my second week in graduate school, a teenage boy told me during the intake that his neighbor had molested him for a few years. I told Joe, thinking that he would take care of it. Instead, he told me to have the Mom come in and I would tell her with her son in the room. “Joe, I’ve only been in school for two weeks.” He told me that it was my responsibility. Joe taught me to have hard conversations early.
During my time at Integrity House, my caseload had far better outcomes than any other counselor. Around the ninth month there, one of my clients left and got high. I was devastated. I was angry at him but also blamed myself. “You can’t wear your clients’ successes and failures. You didn’t get them sober and you can’t get them drunk. You are part of their process. That’s it. You control what you do with them; they are responsible for what happens. If you wear their successes and failure, you will emotionally burn out.” I became a process guy. Joe taught me that I am responsible for my work, not my clients’ outcomes.
I started working for Jass Pelland at Hunterdon Drug Awareness in 2005, shortly after I had left Integrity House. I was originally hired to run multi-family group on Friday nights. Despite only working five hours a week, she made sure to give me weekly supervision. I soon started working there about 25 hours a week. I ran six groups, conducted intakes and had a few individual clients. No matter how busy we were, I got individual supervision every Monday at 4 pm and took part in group supervision every Tuesday at 5 pm.
In late 2006, I conducted an intake on a late-thirty-something-year-old white male. He thought it was important for me to know his sexist, racist and homophobic beliefs. You know the type. I have almost always been able to find something to like or some way to bond with a client. I found him to be distasteful and deplorable. I didn’t want to work with him. I told Jass that I completed it and that he needed treatment but I didn’t want to work with him. She asked me why. I told her that he was racist and sexist and spewed bile the whole time and I didn’t like him. She said, “I don’t care about that. He needs treatment, so you treat him.” I told her that he also hated gay people. Jass is a lesbian, so I figured that would do the trick. “So what? He needs treatment. We provide treatment. So you will provide treatment.” And I worked very hard at providing him quality treatment despite my personal difficulties with him. Jass taught me that treatment is not contingent on liking the client.
In 2008, we admitted a trans woman into our program. She had been kicked out of Sunrise House Detox because they didn’t know where to put her. Jass made all of us take a half day course on providing substance misuse treatment to trans people. I asked her why we were spending so much time learning how to work with just one client from a very rare population. She raised her voice, not in anger, but to emphasize how important her next words were: “We need to be able to provide quality treatment to any individual in the community, but particularly to people who can’t get it anywhere else. We are not here to just treat the most common people and the most common cases.” She taught me that competence must extend to the margins.
More than any individual lesson though, what stands out most about Jass is that she was a role model. Every month, she reviewed every current client file. This meant she looked at between 120 and 150 charts during the last three days of the month. I would get two to five pages in red ink about all the things I needed to fix. There were no shortcuts, no cut and paste. Our notes were so good that our agency was used by the state as a model of what an Intensive Outpatient Program’s (IOP) paperwork should look like. She taught me to write every document like it would appear in court or on the front page of the Star Ledger. Other clinicians and I would complain about intakes, caseloads and paperwork. Then we would glance down the hall and see Jass working at 9 pm. She did intakes herself, carried a caseload, ran groups, took urines, supervised us and reviewed all of our paperwork. No matter how hard she pushed us, she demanded more from herself. And, as I write this I have a lump in my throat, that is how I am now. Despite the long drive during rush hour traffic, I worked part-time under her for six years.
I met Lisa Laitman when I arrived at Rutgers in 1997. She oversaw the Alcohol and Other Drug Assistance Program and ran the Recovery House. I had decided to live in the transfer dorm my first year but I made sure to get to know her. I moved into the Recovery House my second year at Rutgers and found her to be an incredible mentor.
Lisa came to Rutgers in 1983 and created an early recovery group in 1984. In 1988, Rutgers became the first school in the world to have specialized housing for students in recovery. She was a trailblazer of the first order. In 2009, Lisa hired me to be the Recovery Counselor on both the New Brunswick and Newark Campuses. I met with students individually, ran group, trained resident advisors (RA’s) all over campus, took students to meetings, organized activities, found new students, coerced alumni to attend events and handled small and big crises.
Despite the Recovery House being her life’s work, she handed me the proverbial keys soon after I was hired. We met weekly and I kept her apprised with what I was doing, but she let me run with it all. She trusted my abilities, work ethic, values and judgement. She was confident enough to give me autonomy. She taught me that trust produces responsibility.
Lisa emphasized emotional regulation over success and criticism. When I worked at Rutgers, we had tremendous institutional support from the President and extra funding from the State. Lisa was happy about it but she had a long view of things. “A few years earlier, the former Dean of Student Affairs wanted to get rid of Recovery Housing. He didn’t think we were serving enough students and that our population was a giant potential liability.” She rode out that rough time and kept the Recovery House going. “When you are disliked and disregarded, just keep doing the work. It’ll turn. And when you are praised and celebrated, don’t get too full of yourself or let your guard down, because it’ll turn.” Stay frosty. Lisa taught me to regulate my ego before I regulated anyone else.
The last story is too long to retell, but you can read about it here. Basically, there were some students who said some bad things about the recovery students. I wanted to punish them. Lisa saw another way. And she was right.
The wildest part?
I picked all three to be my supervisors.
Burnout
I teach my students, interns and clinicians to watch for when they are irritable. Or, in some case, more irritable than usual. I watch them for cynicism, which can be tricky, because I fall into societal-level cynicism on occasion. I tell them to beware of over-identifying with clients and to avoid rescue fantasies. But to also not wall themselves off with detachment or rule rigidity. Watch out for moral superiority, I tell them (this is another trap I can fall into). And don’t become numb.
Burnout is not avoided by affirmative signs (“happiness” or the absolute worst, “gather”) and going to yoga (I love yoga, to be clear). Burnout is prevented by having reasonable caseloads, a clear scope of practice, access to consultation, time off without guilt, leaders who model restraint and humility and weekly quality supervision.
I regularly review clinicians’ cases. I check in on countertransference. I tell them about my mistakes and how to avoid them. I model saying “I don’t know” and “I’m not sure.” I am aware of my scope of practice and refer to other clinicians and programs without shame. I take breaks for coffee and meals. I take time off, both long weekends and extended vacations.
There is an extremely important caveat here. A good supervisor isn’t the be-all and end-all. A good supervisor cannot permanently compensate for a corrupt institution.
Non-negotiables for New Clinicians
- Do not wear client outcomes.
- Do not diagnose when substances or medical conditions can explain symptoms.
- Reassess diagnoses even when they come from good clinicians.
- Teach clients how diagnoses were reached.
- Explain confidentiality every time.
- End sessions with review and next steps.
- Eat during the work day.
- Document everything.
Putting It all Together
Early supervision protects clients first. It protects clinicians second. It protects institutions third. It accelerates development and prevents bad habits from hardening into character.
Jobs come and go. Titles change. Salaries fluctuate.
Do not pick a job. Pick a supervisor.
