Sanctioned supervision: voices from the experts.

This qualitative study took an initial step in gathering ideas from professionals and academics in the counseling field regarding the efficacy of sanctioned supervision as an intervention for counselor impairment. The results of the focus group suggest that sanctioned supervision is a worthwhile endeavor but needs improved structure, organization, and clarity. Based on feedback from study participants, the authors developed a preliminary model as to how sanctioned supervision could work more effectively.

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Counselor impairment has been a significant concern for the mental health profession over the past decade (Forrest, Elman, Gizara, & Vacha-Haase, 1999). Several studies have pointed to an alarming number of ethical and legal violations among mental health practitioners (Pope & Veter, 1992). Moreover, the rate of impairment in academic training programs is estimated to be around 5% of students in training (Mearns & Allen, 1991; Olkin & Gaughen, 1991). The results of these studies suggest that clinical training programs are regularly faced with cases of impairment (Forrest et al., 1999). Clearly, dealing with an impaired practitioner is of utmost importance in the maintenance and continuation of all mental health professions.

The counseling profession has recognized the importance of identifying and intervening when counselors may be providing sub-standard care to clients (American Mental Health Counselors Association, 2000; Anderson, 1992; Emerson & Markos, 1996; Hazier & Kottler, 1996; Kottler & Hazier, 1996; Stadler, Willing, Eberhage, & Ward, 1988). Several recommendations have been advocated including: encouragement of counselor educators to renew their efforts as gatekeepers to the profession, attention to reducing workplace stress, support in taking action when signs of impairment are demonstrated, monitoring impaired counselors, and increased research in the area of impairment (Cobia & Pipes, 2002; Stadler et al., 1988; Thomas, 2005). Prevention efforts have been proposed as well (Witmer & Young, 1996).

Clearly, a central responsibility of licensure boards is the identification, investigation, and discipline of impaired counselors. Included in disciplinary procedures used by licensing boards is the mandated monitoring of disciplined providers, often termed as sanctioned supervision or mandated supervision. Sanctioned supervision usually involves the identified impaired mental health provider being monitored and supervised by specified colleagues (Thomas, 2005; Walzer & Miltimore, 1993). Sanctioned supervision has been described as a mechanism for helping the disciplined professional develop in areas that had been defined as lacking or impaired (Cobia & Pipes, 2002).

The literature on counselor impairment has supported the use of supervision as part of an appropriate intervention for counselor impairment (Cobia & Pipes, 2002; Schoener & Gonsiorek, 1988). Yet, little data are available on the effectiveness of this method of intervention. There is, however, conceptual and theoretical support for the use of sanctioned supervision based on developmental models of supervision, as well as constructs in social learning theory and social psychology (Cobia & Pipes, 2002). It makes some intuitive and perhaps logical sense that impaired professionals need to be "watched," at least for a while, to ensure remediation and rehabilitation efforts are successful. Yet, the manner in which sanctioned supervision should be carried out is still undefined.

There are clearly challenging ethical and legal considerations related to sanctioned supervision that are confusing and perhaps intimidating (Cobia & Boes, 2000; Getz, 1999; Strein & Hershenson, 1991; Thomas, 2005). More research is needed to determine if sanctioned supervision is an appropriate and effective intervention for the impaired counselor. If it is deemed effective, data are then needed to establish the most effective manner of providing sanctioned supervision. Thus, this qualitative study took an initial step in gathering ideas and thoughts from professionals and academics in the counseling field as to the efficacy of sanctioned supervision as an intervention for impairment. Our goal was to generate interventions leading to an improved sanctioned supervision process and provide direction for more empirical research.

METHOD

Participants and Procedure

Individual interviews with supervisors who have worked with sanctioned counselors. Our initial plan for this study was to conduct individual interviews with supervisors in Ohio who have conducted sanctioned supervision over the past few years. We contacted the Ohio counseling licensure board (The State of Ohio Counselor, Social Worker, and Marriage and Family Therapist Board) and a representative from the board agreed to send out letters describing our project to all of the supervisors in Ohio who had conducted sanctioned supervision since 2000 (N= approximately 7). The board representative would not release the names of these supervisors or any identifying information such as race, ethnicity, or gender to us due to confidentiality issues. We forwarded to the representative a letter describing our project and information as to how the supervisors could contact us (i.e., phone and e-mail) to participate in the interviews. We offered $50 for the supervisors' time. Our board contact then forwarded the letters to the supervisors. Disappointingly, none of the supervisors contacted us. We then proceeded to move on to the second phase of our project.

Focus group with experts in supervision. We chose the focus group format, as focus groups are considered appropriate when gathering initial data, especially when little information on a specific topic is known. Focus groups can provide an exploratory approach that is also time efficient (Greenbaum, 1993; Krueger, 1994). Moreover, the group synergy can foster a creative process where new thoughts, ideas and experiences can be shared (Vaughn, Schumm, & Sinagub, 1996).

In selecting our sample for the focus group, typical case sampling, a form of purposive sampling, was used. We were interested in including participants that represented experienced supervisors, counselor educators with expertise in supervision, counselor educators with expertise in ethics, counselor educators with experience on a licensing board, and supervisees. Fifteen professionals and academics were invited to attend a two-hour focus group. Four professionals and four academics agreed to participate. The mean age of the one male and seven female participants was 51 years old (range of ages was 30 to 62 years). Although the group members were Caucasian, every participant had experience working with culturally diverse supervisees. Every participant had completed formal education at the doctoral level. The professionals were all seasoned supervisors in the field of counseling. The academics all had expertise in the areas of supervision and ethics, and one had served on a state counseling board. The group of participants had overall means of 22.3 years of counseling experience (range of experience was 10 to 37 years) and 11.5 years of counseling supervision experience (range of counseling supervision experience was four to 24 years). The principal researchers of this study were a doctoral student intern in counselor education and a professor in a master's level community counseling program.

The focus group was moderated by the principal researchers as an overall understanding of the study was necessary in order to keep the group on task. The moderators began the focus group by obtaining informed consent from the participants for their participation in the study as well as permission to audiotape the group discussion. The moderators briefly described the purpose of the focus group, discussed the first part of the research which was to individually interview supervisors of sanctioned counselors, and the lack of response from the supervisors to participate in the interviews. Next, they provided an overall structure for the group which followed a set of prepared questions as an outline. Participants were encouraged to brainstorm and relay ideas even if they seemed preliminary. The questions were meant to guide the discussion, but participants were encouraged to present and discuss any thoughts they deemed relevant to the topic. The moderators' main role was to help them stay on task and be responsible for time management. The participants introduced themselves and briefly described their experience in counseling and counseling supervision and then began to discuss the questions.

The researchers had identified seven questions based on the current literature and discussion to structure the focus group. Participants were given a paper copy of the following questions:

1. What are your thoughts/hypotheses regarding the lack of response from supervisors of sanctioned counselors in Ohio to our invitation for an interview?

2. Overall, what is your reaction to the concept of sanctioned supervision? What do you see as the challenges and obstacles? What are some of the ethical issues?

3. How do you think the mandatory nature of sanctioned supervision would impact the supervisory relationship?

4. What do you think about the sanctioned counselor being allowed to choose his/her supervisor?

5. With which knowledge base (theories/techniques) is it important for supervisors of sanctioned counselors to be familiar?

6. What are the implications for training?

7. What ideas do you have to improve the process of sanctioned supervision?

Data Analysis

The focus group interview was transcribed and disseminated to research team members. Researchers independently read the transcripts and identified significant themes from which to develop a coding system. Researchers then met to discuss the themes. Axial coding (Neuman, 1997; Strauss, 1987) was applied, which involved re-reading the transcripts and identifying categories of data under each theme. Selective coding was implemented, involving again re-reading transcripts and entering codes in the margins. Raters reached a consensus and were in agreement over the themes. Representative quotations were identified.

RESULTS

Themes Emerging from Focus Group

Throughout the focus group process, the participants discussed their reactions to the concept of sanctioned supervision. They focused on several themes including: the supervisory relationship, liability, payment for supervision, lack of training, access to information, evaluation of supervision, and the importance of sanctioned supervision to the counseling field.

Supervisory relationship. Participants discussed that the sanctioned supervision relationship may not be ethical because as one participant said, "There is an impulse to pick somebody that you know and feel comfortable with." Another participant said, "People might say, 'Oh, I'll just get my best buddy to sign off for me.'" One participant described the sanctioned supervisory relationship as "... particularly complicated ... if I was sanctioned, I would probably call somebody that I knew and you can see a lot of people calling a friend who is a counselor and saying, 'Can you help me out?'"

The second area of supervisory relationship discussed by the focus group was how the attitude of the sanctioned counselor could impact the working relationship with the supervisor. Members of the group felt that if the sanctioned counselor had a negative attitude regarding the process, it could create a very challenging environment and one not conducive to remediation and growth. This is illustrated with the following quote: "part of the problem is the attitude of the counselor ... I think it's probably going to be not very helpful at best and at worst could really create a big mess."

Liability. Participants discussed concerns about protection for the supervisor who conducts sanctioned supervision. They wondered what would be the legal risk if the sanctioned counselor would continue an impaired behavior or re-offend. This was reflected in such statements as: "They're [sanctioned counselor] a good person, and say good things but then they [supervisor] also have to worry about what this letter on record means if this person offends again in a more serious way." and "I've signed off [supervisor], they're remediated, they're fine, and three months later another complaint comes in ... It's such a hard place to be."

Several participants stated that their willingness to be a supervisor would depend on their liability and whether there would be some protection from the counseling licensure board. "If someone approached me to be a supervisor, one of my questions would be, 'What would my liability be?' Another participant stated that conducting sanctioned supervision would "depend on the liability and how protected I would feel by the board and what kind of back-up they would provide."

Payment for supervision. Participants expressed concern for the structure of sanctioned supervision that calls for the sanctioned counselor to pay the supervisor directly for supervision services. One participant said "Here's my check, and that is the issue, to who is this person loyal?" Another participant stated "you know you give me [supervisor] a check and it's hard to tell you [sanctioned counselor] 'you're terrible, thank you. I don't think you should do this anymore, so you want to come next Thursday?'" Adding on to this was the quote from a participant who said, "It's very, it's awkward, even for people who are well-intentioned, so I think it's a whole problem with counseling supervision."

Lack of training. The majority of the participants agreed that there was not enough training around this type of supervision. They wondered how much training, if any, the counseling licensure board provided to supervisors of sanctioned counselors. One participant stated, "The supervisors don't have enough guidance in dealing with these issues and it's one of those good, safe efforts." Another participant questioned, "Exactly how trained is the supervisor in supervision ... and the kind of supervision that is offered?"

Access to information regarding the impaired counselor. Focus group participants discussed what would be needed to have an accurate sense of the sanctioned counselor's work during supervision. They discussed the importance of having access to clinical records as well as additional supportive material to supplement the reports from the sanctioned counselor. A participant discussed these points in the following quote: "One of the dilemmas in supervision is what do you [supervisor] know about what I'm [sanctioned counselor] really doing with my client? If you don't have access to in vivo supervision, or tapes, or any direct feedback about counseling, then is the public interest really being protected by this?"

Evaluation of supervision. Focus group participants discussed the requirement of the supervisor to evaluate the sanctioned counselor. They reflected on the lack of clear, objective, evaluation criteria and evidence of remediation. Participants expressed concern over the difficulty of planning and documenting the remedial process. One participant commented, "And what will be the evidence that you see it happening? It needs to be cited, and that evidence needs to be collected."

Importance of sanctioned supervision to the counseling field. The focus group participants reflected on the importance of sanctioned supervision to the counseling field in helping to work with impaired counselors. Participants were quoted as saying "it's an important issue to support professionals who can be rehabilitated ...", and "it's important to intervene and to be really helpful to them so that they can be helpful to the public."

Recommendations

Overall, the focus group participants expressed a need for more structure and organization to the entire sanctioned supervision process. The general consensus was that the process was too loose. Many felt there needed to be clarity as to the manner in which supervisors conducted the sanctioned supervision and how they documented the process. Furthermore, they reported that specifics were needed related to how supervisors should evaluate the sanctioned counselor and how that evaluation should be reported to the board. Below are recommendations that surfaced from the discussion.

Need for assignment and payment of the supervisor from a statewide fund. Most participants reported concerns about sanctioned counselors choosing their own supervisor. Several suggested that there be a statewide fund to pay the supervisors. Some participants felt the fund could be built from additional renewal dues for licensure. This was illustrated by one of the participants who said, "We all have an obligation to keep our profession clean and do our part so if you don't want to do the supervision you don't have to but ... but you throw in an extra $10 for the license."

Others felt a fund could be developed from the money sanctioned counselors pay for their supervision. Instead of paying the supervisor directly, the money would go to the statewide fund that would pay the supervisor.

Use of the term clinical monitoring. The group also engaged in a discussion of the appropriateness of the term "sanctioned supervision." Several participants liked the idea of using the term "clinical monitoring" in place of sanctioned supervision. One participant described the point saying, "Supervision refers to a growth and development, and a positive thing, and yet here they [licensure board] are saying, 'You're in trouble, now you have to go to supervision.' which kind of destroys the whole thing."

Supervisors of sanctioned counselors need support and protection. Several participants felt that supervisors needed on-going consultation and support. They were quoted saying, "And the benefit for me saying, 'Okay, I'll be one of those supervisors,' is that not only do I get paid, but I get training and I have some support and I feel like I have backing. If I have a question, I have somebody to call."

Participants offered suggestions around the liability risks for supervisors of sanctioned counselors. Several recommended that the supervisor prepare an evaluation that goes to the board, but it would be the board's responsibility to implement the recommendations. They felt this process would provide more protection to the supervisor. As one participant said, "The final responsibility lies in the board's hands to determine whether or not this person has been rehabilitated." Others suggested that the board offer and pay for specific liability insurance to the supervisors of sanctioned counselors for this task.

Additional and specific training is needed. Participants noted that training in legal and ethical issues was very important. One participant felt that the training should include clarifying and communicating mutual responsibilities. This was shown in the following quote: "Going to structuring something that could be in writing is part of the training, part of the responsibilities of the supervisor to the sanctioned counselor. What are the responsibilities of the sanctioned counselor to the supervisor, and when you put the sanctioned counselor's clients in there, who's responsible for whom about what? So as much criteria or guidelines could be written down so that everyone was on the same page and it is concrete." This idea was supported by a participant who said, "I would want to contract ... and develop an individualized service plan or individualized education plan, with goals and objectives and what we're trying to accomplish."

Another participant suggested some kind of training model be developed. This is illustrated in the following quotes: "I can imagine some kind of manual being developed. It would included target specific behaviors and appropriate interventions. It would help if people could see examples ..."; "I do think there should be freedom. And I don't think you should micro-manage too much what people do in supervision, but I get a little nervous when it's totally open."

State licensing boards would benefit from consultation on how sanctioned supervision should be implemented and monitored. Participants expressed empathy for licensing boards, but also relayed that boards may need help in making these kinds of decisions and most felt that additional guidance was needed. The following quotes illustrate this: "People volunteer to be on Boards and it's a really good thing that they do that and it's a huge commitment of time and energy ... but ... there needs to be more systematic ... help for board members about making ethics decisions and adjudicating cases"; "When you are on a board there is so much to do and they get in the mindset of 'doing what you can, go where the pressure is'"; "It might help to have a third party consultant come in to help make that assessment of what level is this person at and are they appropriate for sanctioned supervision or do they need something different."

DISCUSSION

The results of the focus group, overall, suggest that sanctioned supervision is a worthwhile endeavor but needs improved structure, organization, and clarity. All participants felt that the topic was timely and relevant. They were all in agreement with further development of the sanctioned supervision process and supported our efforts in continuing research and planning on the topic.

From the results of the focus group, we have put together a preliminary model as to how sanctioned supervision could work more effectively. We recommend a statewide process be developed to provide training, structure and support for supervisors of sanctioned counselors. This process would be under the control of the counseling licensure board for each state. The board would elect one non-board member to be the coordinator of the process.

Interested supervisors would apply to be a supervisor of sanctioned counselors and if chosen, would receive statewide training on the process. The coordinator would be responsible for developing and providing the training. The training would be regulated and include legal and ethical issues. It would also include supervision theory and interventions applicable to counselor impairment. A manual would be developed and used as a training guide.

Documentation and evaluation forms would be developed and included in the manual. An initial contract would also be used to set up the supervision. Supervisors would be trained in the use of all forms. Supervisors would be required to send quarterly reports to the board. This would provide all parties involved, including the sanctioned counselor and the board, with the sanctioned counselor's ongoing progress assessment. The supervisor would complete a final evaluation of the sanctioned counselor including recommendations for the board; however, the final disposition would be the board's responsibility.

Sanctioned counselors would then get assigned one of these trained supervisors based on their reason for discipline. Supervisors would receive ongoing group support through a secure electronic format designed to maximize confidentiality, monitored by the coordinator. Biyearly statewide meetings would also allow the supervisors to process their concerns and receive their own supervision for the sanctioned supervision they have provided. The supervisors would get paid out of a statewide fund. This fund would be built from fines paid by the sanctioned counselor and from additional monies collected at renewal. The fund would finance the training and pay for specific liability insurance for the supervisors of sanctioned counselors.

The coordinator would also serve as consultant to the board. When impaired counselors are brought to the board for adjudication, the coordinator would assist the board in making recommendations around sanctioned supervision. An individualized plan would be created for the impaired counselor and specifics regarding the sanctioned supervision would be outlined including measurable goals and expected outcomes.

This model would provide the counseling profession an opportunity to become more sophisticated and accountable when dealing with counselor impairment. In this era of litigation and increased vulnerability, counselors need to consciously search for improved ways to monitor the quality of professional services and effectively identify, discipline, and manage those who present with sub-standard or impaired professional behaviors.

LIMITATIONS AND RECOMMENDATIONS FOR FUTURE RESEARCH

This was a preliminary project and limited by a small sample size and a single focus group. More research capturing a larger database, including master's level counselors and multiple geographical locations is encouraged. Moreover, interviewing supervisors who have provided sanctioned supervision regarding their experiences would verify and expand our findings. Our model is in its initial stages and needs assessment and ongoing modifications but begins the process of structuring and monitoring sanctioned supervision.

Authors' Note: The authors would like to particularly thank Pam Peters, M.A. for her personal assistance in preparing this manuscript.

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Clarrice A. Rapisarda is affiliated with the University of North Carolina at Charlotte

Paula J. Britton is affiliated with John Carroll University. Correspondence concerning this article should be addressed to Clarrice A. Rapisarda, Department of Counseling, the University of NorthCarolina at Charlotte, 9201 University City Blvd., Charlotte, North Carolina, 28223, E-mail: [e-mail].