Tuesday, December 11, 2012

Supervision Addressing Counselor-Client Sexual Attraction

Kelli E. Scanlon, The University of North Carolina at Greensboro

What was the purpose of this literature review?
This literature review examined both empirical and conceptual articles concerning the attraction between counselor and client, the use of supervision for managing such feelings, and practitioners’ opinions of the training they received concerning counselor-client attraction.

Major findings or points:
Seminal research on counselor-client attraction indicates that more than 84% of mental health practitioners will experience sexual attraction to a client at some point in their career (Pope et al., 1986).   More recent studies suggest that the number may be higher.  At the same time, counselors-in training consistently report that they feel ill-prepared by their graduate programs to manage sexual dilemmas in real-world settings.  Consequently, helping trainees normalize and navigate attraction within the counseling relationship is a critical component of comprehensive and ethical supervision. 
The most common feeling among counselors who experience counselor-client attraction is discomfort, which may take the form of fear, guilt, shame, anxiety, or caution.   Counselors largely that believe that their clients are not aware of the attraction their counselor may have for them, and it is common for practitioners to terminate counseling without feeling “resolved” about the attraction.  Given trainees’ discomfort with such feelings and experiences, making meaning of the client and/or therapist attractions/responses is an often overlooked —albeit central—step to managing future attraction and fostering trainee self-efficacy.

What does this research mean for counseling practice, settings, and/or training?
Use of clinical supervision to address feelings of counselor-client attraction is critical. By and large, it is incumbent upon the supervisor to raise the issue of sexual attraction with supervisees. Researchers have found that if these issues are not adequately addressed, both the supervisory and counselor-client relationships are likely to suffer.  As such, supervisors would do well to discuss their trainees’ thoughts, beliefs, and concerns about counselor-client sexual attraction before such issues even arise.   Moreover, since peer support is essential in helping to normalize the attraction and reduce the stigma surrounding professional disclosure of sexual attraction, group supervision is one of the best venues for addressing issues of counselor-client attraction.
Fear of being judged by supervisors and concerns about a supervisor’s professional opinion have been shown to be principal barriers to counselors making use of supervision for this need.  Clinician shame is another significant reason why practitioners don’t disclose to their supervisors. Unfortunately, experiencing or perceiving a supervisor’s discomfort with the topic is another deciding factor for supervisees.  Numerous study respondents have suggested that their supervisors either chose not to address sexual attraction to clients or appeared uncomfortable with such conversations.  Since trainees are generally reluctant to raise the issue themselves in supervision, important discussions about sexual dilemmas are often avoided.  Not only do trainees need safe places to discuss experiences of attraction, but supervisors’ disclosure of their own experiences of client attraction tops the list of things that trainees believe would improve their levels of competency and comfort with such experiences. 
Facilitating trainees’ understanding of the differences between sexual attraction (a normal experience) and sexual contact (an ethical violation) is also imperative. Acting upon client attraction happens much less frequently than the experience of feeling attracted, but still more often than it should, suggesting that clinicians-in-training require ongoing clinical supervision in this area.  Both loneliness and overall lack of social support have been shown to be factors that set clinicians at risk for boundary violations and romantic attraction to clients, and should be monitored.  Furthermore, since male therapists are more likely than females to engage in sexual contact with clients, male trainees may require additional supervisory support.
Although research concerning therapist-client attraction in the field of counseling lags behind other clinical disciplines, the literature in this area is growing.  In the meanwhile, counselors can look to research from other helping professions as well as our own Code of Ethics for instruction.  Hamilton and Spruill (1999) offered a comprehensive risk management checklist for use in supervision (Appendix A).  The “Checklist for Trainees and Supervisor” serves as a gauge of appropriate clinical boundaries for trainees and seasoned counselors alike, and provides supervisors with guidelines for comprehensive conversations with their trainees in this area.

supervision, counselor-client relationship, disclosure, training

For Further Reading:

American Counseling Association. (2005). ACA Code of Ethics. Alexandria, VA: American Counseling Association.
Hamilton, J. C., & Spruill, J. (1999). Identifying and reducing risk factors related to trainee-client sexual misconduct. Professional Psychology: Research & Practice, 30, 318-327.
Hartl, T. L., Zeiss, R. A., Marino, C. M., Zeiss, A. M., Regev, L. G., & Leontis, C. (2007). Clients' sexually inappropriate behaviors directed toward clinicians: Conceptualization and management. Professional Psychology: Research & Practice, 38, 674-681.
Ladany, N., & Melincoff, D. S. (1997). Sexual attraction toward clients, use of supervision, and prior training: A qualitative study of predoctoral psychology interns. Journal of Counseling Psychology, 44, 413-424.
Pope, K., Keith-Speigel, P., & Tabachnik, B. (1986).  Sexual attraction to clients: The human therapist and the (sometimes) inhuman training system.  American Psychologist, 41, 147-158.
Rodolfa, E., Hall, T., Holms, V., Davena, A., Komatz, D., Antunez, M., & Hall, A. (1994). The management of sexual feelings in therapy.  Professional Psychology: Research and Practice, 25, 168-172.

Appendix A: Risk Management - A Checklist for Trainees and Supervisors

Therapist Response to Clients

       Do you find it difficult to set limits on the demands your client makes of you?
       Do you accept phone calls from your client at home or your office when the client needs you to (a) help with a “crisis,” (b) deal with minor problems, or (c) alleviate his or her loneliness or meet his or her need to talk to someone who “understands”?
       Do you make statements such as “This is not my usual practice; I ordinarily don't do this, but, in your case … ” or “Under the circumstances, it seems OK to … ”?
       Do you find yourself wanting to rescue your client from some situation or behavior that is detrimental to him or her?
       Do you find yourself talking about your client to others?
       Does your client occupy your thoughts outside office hours?
       Do you hope you will “run into” your client at the grocery store, social settings, and so forth?
       Is it becoming progressively easier and more satisfying to share intimate details of your own life with your client?
       Do you find opportunities to talk about nontherapy issues with your client?
       Do you take care to dress or look more attractive than usual for a particular client?
       Do you find yourself wondering what the client thinks about you?
       Do you make excuses to talk with your client by phone?
       Do you accept friends of your client as therapy clients, and then find yourself spending a lot of the session talking about the original client to the current client rather than focusing on the current client's problems?
       Do you find yourself looking forward to seeing a particular client (or type of client) and feeling disappointed if he or she cancels the session?

Therapist Needs

       Does your primary satisfaction come from your work with therapy clients?
       Do you have more clients than required or more than your fellow practicum students?
       Are you lonely and feeling as if your needs are not being met by anyone?
       Do you have a circle of friends with whom you engage in pleasurable social activities?
       Do you have a circle of friends to whom you can turn for support?
       Do you have one or more close friends in whom you could confide about fears, anxieties, and self-doubts?
       What are the important stressors in your life, and what steps are you taking to resolve or to cope with them?

Session Characteristics

       Do you regularly extend the session for one client but not for others?
       Do you regularly start the session early, end it late, or both for one client?
       Do you schedule a particular client at times that afford the opportunity to linger, or to walk out of the clinic together, and so forth?
       Do you schedule the client after regular office hours because your schedule or the client's schedule does not permit regular office hours?


       Do you find yourself forgetting to document phone calls from your client?
       Do you find yourself getting defensive about particular clients or certain issues (e.g., you bristle when a supervisor suggests that there is no progress being made and a referral is in order)?
       Are you reluctant to talk about transference or boundary issues, particularly feelings related to sexual attraction by or to the client?
       Do you find it difficult to tell your treatment team or supervisor some details related to your client?
       Is there anything that you “try not to talk about” concerning a particular client?
       Do you find yourself putting off seeking supervision or consultation about a particular client or issue?
       Does the tape always run out or mess up at a “sensitive” point in the session? Does the therapy session regularly extend beyond the length of the tape?
       If you make phone calls, extend sessions, and so forth, how much of this information is recorded in the client's file? Do you find yourself unwilling, or “forgetting,” to document information with regard to a particular client?


       Have the secretaries or other people commented about your behavior toward a client?
       Have you offered to do such things as give the client a ride home, give tutoring in a difficult class, or arrange a meeting outside the therapy hour or place?
       Are you concerned about the client's feelings toward you, or your feelings toward the client?

Checklist for Supervisors

       Have I discussed how to establish a professional therapist–client relationship with my practicum students?
       Have I reviewed the issue of sexual attraction to clients and shared my own experiences with my practicum students? If I am unwilling to share my own feelings, what have I done about this?
       Have I created an atmosphere of openness and willingness to discuss the fears, uncertainties, and so forth of my practicum students?
       Do my practicum students know about boundary violations and the reasons for establishing boundaries?
       Have I discussed the checklist for students with them?

Hamilton, J. C., & Spruill, J. (1999). Identifying and reducing risk factors related to trainee-client sexual misconduct. Professional Psychology: Research & Practice, 30, 318-327.

Supervision of Counselors Working with Clients in Crisis: A Review for Supervision Practitioners

Allison C. Marsh, The University of North Carolina at Greensboro

What was the purpose of this literature review?
            The purpose of this review was to summarize the existing literature on supervision of client crisis and to offer useful tips to practicing supervisors as they guide counselors through challenging client situations. Crisis intervention is becoming an increasingly common part of many counselors’ practice. Among the numerous responsibilities we assume in meeting the needs of our clients, it is one of the most impactful and anxiety producing. Many counselors report feeling underprepared for intervening in client crisis. Yet crisis is a very real part of many of our clients’ lives. Counselors are frequently told of the importance of consultation and supervision – “Whenever in doubt, consult!” These resources are particularly vital in cases of client crisis when powerful emotions and the need for quick decision-making can feel overwhelming.

Major findings or points:
            Researchers have indicated that counseling clients in crisis can have a significant impact on the personal and professional lives of counselors, and lead to feelings of anxiety, shock, anger, frustration, helplessness, sadness, and responsibility (McAdams & Foster, 2000; Richards, 2000; Smith, Kleijn, & Hutschemaekers, 2007). Patterns of stress, burnout, and impairment in functioning highlight the vital importance of external support, particularly from counselor supervision. In fact, supervisory support has been rated the most useful resource for counselors working through a client crisis (McAdams & Foster, 2002).
            The following are some basic recommendations, based on research findings, for supervising counselors in working with client crisis:
1)    Supervisors should work with counselors from the beginning of the supervisory relationship to assess competence and confidence in working with clients in crisis, and to identify challenge areas.
2)    Supervisors should talk openly with counselors about the potential impact of working with clients in crisis and the range of reactions they may experience, including but not limited to those mentioned above.
3)    Both supervisors and counselors should be knowledgeable about agency policies and procedures regarding client crisis intervention, as well as area resources for referral.
4)    Supervisors should encourage counselors to consult when making decisions that affect a client in crisis and to seek more frequent supervision during these times.
5)    Counselors should also be encouraged to seek support beyond the supervisory relationship, including personal therapy as needed.
            In addition, some models exist that provide a framework for supervisors to use in addressing client crisis with their supervisees. The Preparation, Action, Recovery (PAR) model breaks crisis intervention down into three stages and outlines steps for thorough and ethical practice at each stage, as well as potential threats to effective counselor intervention (McAdams & Keener, 2008). The Cube Model (McGlothlin, Rainey, & Kindsvatter, 2005) incorporates two well-known and established models for supervision into a comprehensive framework for supervising counselors as they work through client crisis at various levels of severity. This model is particularly useful in helping supervisors gauge interventions that are appropriate to a counselor’s developmental level and to the specific needs of the client.

Major caveats:
            The onus of consultation in working with client crisis does not end with the counselor. Remember that it is important for supervisors to consult as well, particularly with other professionals who have experience supervising during client crisis. It is also important to remember that, although these basic guidelines may be helpful, each situation is unique and should be approached with consideration for the individual needs of the client as well as the counselor involved.

What does this research mean for counseling practice, settings, and/or training?
            Although working with clients in crisis can feel overwhelming and confusing for both the counselor and supervisor, these guidelines and models provide some structure for approaching these challenging situations in supervision. By remaining aware of the unique demands of working with client crisis and by maintaining best practices in supervision, counselor supervisors can maximize the effectiveness of their support and interventions and minimize negative outcomes for practitioners.

Supervision of client crisis, client crisis, suicidal ideation

For Further Reading:
*Most recommended for supervisor practitioners
*Hipple, J., & Beamish, P. M. (2007). Supervision of counselor trainees with clients in crisis. Journal of Professional Counseling: Practice, Theory, and Research, 35(2), 1–16.
McAdams, C. R., & Foster, V. A. (2000). Client suicide: Its frequency and impact on counselors. Journal of Mental Health Counseling, 22(2), 107–121.
McAdams, C. R., & Foster, V. A. (2002). An assessment of resources for counselor coping and recovery in the aftermath of client suicide. Journal of Humanistic Counseling, Education and Development, 41, 232–241.
*McAdams, C. R., & Keener, H. J. (2008). Practice & preparation, action, recovery: Preparation and response in client crises. Journal of Counseling and Development, 86, 388–398.
*McGlothlin, J. M., Rainey, S., & Kindsvatter, A. (2005). Suicidal clients and supervisees : A model for considering supervisor roles. Counselor Education and Supervision, 45, 135–146.
Miller, G. D., Iverson, K. M., Kemmelmeier, M., Maclane, C., Pistorello, J., Fruzzetti, A. E., Watkins, M. M., et al. (2011). A preliminary examination of burnout among counselor trainees treating clients with recent suicidal ideation and borderline traits. Counselor Education and Supervision, 50, 344–359.
Richards, B. M. (2000). Impact upon therapy and the therapist when working with suicidal patients : Some transference and countertransference aspects. British Journal of Guidance and Counselling, 28(3), 325–337.
Smith, A. J. M., Kleijn, W. C., & Hutschemaekers, G. J. M. (2007). Therapist reactions in self-experienced difficult situations: An exploration. Counselling and Psychotherapy Research, 7(1), 34–41. doi:10.1080/14733140601140865

Tuesday, December 4, 2012

Supervision Via Video-counseling

Mark P. Eades, The University of North Carolina at Greensboro

What was the purpose of this literature review?
This literature review examines what articles have been written on using video conferencing in supervision.  This review critiques current literature and identifies areas for further research.

Major findings or points:
Video conferencing has the potential to link counselors in remote places to skilled supervisors over the internet, allowing supervisees the ability to reflect on, adjust, and refine their counseling skills in the hopes of becoming better at their craft.  This is true for many supervisees in a variety of disciplines.  Teachers, nurse practitioners, psychiatrists, and counselors alike who have experienced videoconferencing supervision report many positive aspects of their experiences.  They enjoy the freedom to schedule supervision at their work site, the ability to create a strong working alliance with their supervisors, and they felt that video-supervision promoted autonomous functioning and personal growth.  Most authors who write on video mediated supervision use these positive findings to forecast video-supervision as a means of connecting isolated counselors to qualified supervisors, creating a means of making the supervision process available to counselors across the country and throughout the world.

Major caveats:
The technological problems associated with using video cameras have proven to be the biggest hurdle in advancing video supervision.  In every article written on using video in supervision, participants and authors commented that they didn’t feel prepared to operate, adjust, or fix current hardware or software.  This was by far the biggest frustration voiced by supervisors and supervisees; when technical problems arose it was enough to ruin entire supervision sessions.  Supervisees commented that even small technical glitches would lead to stifled interactions with supervisors, causing supervisees to hold back on emotional conversations associated with working with clients and instead focus on only factual information when in supervision.  Even lawmakers are weary of counselors’ inability to work with video systems, as 19 states currently have laws in place forbidding the use of video-supervision, citing inadequate education and preparation of supervisors as the reason for enforcing such laws.

What does this research mean for counseling practice, settings, and/or training?
When all of this information is taken together, it would appear that creating and providing trainings in using video in supervision is the main roadblock before true advances in the field can be made.  When supervisors feel confident that they can successfully operate video-supervision technology, not only will video supervision sessions run more smoothly, but state lawmakers will have to revisit their current stand on the subject.  Future researchers could focus on this area, pulling information from the video production education literature to create informed educational trainings for supervisors and testing their effectiveness.  Once proper training is established, then revisiting the idea of testing the effectiveness of video-supervision can more logically be executed.

Video supervision, video conferencing, technology in counseling, video counseling supervision

For Further Reading:

Conn, S. R., Roberts, R. L., & Powell, B. M.  (2009).  Attitudes and satisfaction with a    hybrid             model of counseling supervision.  Educational Technology & Society, 12,       298-306.
Dymond, S. K., Renzaglia, A., Halle, J. W., Chadsey, J., & Bentz, J. L. (2008). An            evaluation of   videoconferencing as a supportive technology for practicum        supervision.  Teacher             Education and Special Education, 31, 243-256.
Gammon, D., Sorlie, T., Bergvik, S., & Hoifodt, T. S. (1998).  Psychotherapy supervision            conducted via videoconferencing:  A qualitative study of users’ experiences.      Nord J Psychiatry, 52, 411-421.
Marrow, C. E., Hollyoake, K., Hamer, D., & Kenrick, C. (2002). Clinical supervision        using video-     conferencing technology: A reflective account, Journal of Nursing      Management, 10, 275-282.
McAdams, C. R., & Wyatt, K. L. (2010). The regulation of technology assisted distance   counseling and supervision in the United States: An analysis of current and      extent, trends,             and implications.  Counselors Education and Supervision, 49, 179- 192.
Olson, M. M., Russell, C. S., & White, M. B. (2008).  Technological implications for        clinical supervision and practice.  The Clinical Supervisor, 20, 201-215.
Van Horn, S. D. (2001).  Computer technology and the 21st century school counselor.       Professional School Counseling, 5, 124-130.
Wright, J., & Griffiths, F. (2010).  Reflective practice at a distance: Using technology in    counseling supervision.  Reflective Practice, 11, 693-703.