Moments of overwhelming emotion and boundary maintenance dilemmas with clients predictably occur across one's professional life. Practitioners need a shame-free, trusting relationship with peers or a supervisor to sort out such dilemmas to protect the client as well as the practitioner. Safe clinical practice for all professionals includes self-awareness, self-monitoring, and ongoing review of challenging or difficult cases with peers or a clinical supervisor.
Supervision creates a setting for self care, support, and nurturance. It is the right place to receive appreciation for the good and useful work a practitioner is doing. Supervision assists practitioners to maintain ethical practices and reduce burnout. The management of boundaries in professional relationships is a complex area of practice. With increasing attention to boundaries, boundary violations, and professional misconduct in the practice of all health care professionals, and particularly in the touch professions, the fundamental importance of clinical supervision is clear.
The crucial role of supervision in the training of all health care professionals has been widely acknowledged by practitioners and supported in professional literature for the past 15 years. Yet the core curricula in most training programs often neglect to teach practitioners how to deal with the intense feelings that arise in the therapeutic relationship. When the body is touched as a part of the therapeutic relationship, feelings can become intensified. These feelings may be confusing and troubling, and at times diminish the practitioner's ability to deliver quality care. Without solid models or communication tools, practitioners have to figure out by trial and error how to best manage the complex interpersonal dilemmas that arise when working with clients.
The clients who come for care and treatment have wide-ranging vulnerabilities, multiple needs, past relationship troubles, unrealistic hopes, and personal traumas. An important and integral aspect of being a health care professional includes tolerating and managing feelings that arise in our professional relationships with these clients. This can be very stressful and difficult at times.
Practitioners need to be involved enough to feel for and care for clients, yet distant enough to decide objectively and implement the best course of treatment . Inevitably, feelings toward certain clients move us closer, push us away, confuse or irritate us as professionals. Particular clients may challenge our capacity to manage our feelings, expose professional "blind spots," or touch on areas of personal vulnerability. This hampers our efforts to communicate directly and effectively which impacts our ability to deliver the best care. Discussing these issues in a supervision setting helps diffuse residual emotions and creates balance.
Clinical supervision has long been the "primary professional training model for mental health clinicians" and more recently other somatic professionals have begun to recognize and use this forum to teach students. Clinical supervision is a valuable and necessary form of continuing education for all wellness professionals, and it's particularly important for practitioners who perform ongoing body therapy. Les Kertay, Ph.D. states, "If you're interested in doing work that has emotional and spiritual impact on your clients, then the most powerful way of dealing with the questions involved is to utilize ongoing professional supervision. Supervision isn't about being told how to do your job, rather it's a place to process your clients' work and your experiences of being with them."
Supervision can be done on a one-on-one basis or in a group. It is often useful to have supervision in a small group of practitioners who are doing the same kind of work. This broadens the base of learning and creates an additional support system for each member. If the practitioner is in a group situation where she can learn from other's experiences, it's possible to master the fundamentals of practice through witnessing other's learning and not relying exclusively upon her own professional trial and error. Hearing the fears and doubts of other practitioners who are feeling challenged by unusual client situations can help practitioners feel less isolated and alone
In a group setting clinical supervision undertakes four functions:
Clinical supervision provides an opportunity to discuss with a more experienced, psychologically savvy practitioner how to best help a client while promoting increased self-observation and awareness. In a group setting the supervisor will often invite other members to help navigate a colleague towards the core issue underlying the problem. Practitioners may increase their tolerance and understanding and learn how to manage feelings in themselves and their clients through clinical supervision. Supervision may be a nourishing, protective, creative endeavor that greatly benefits the practitioner, client, and supervisor.
Identifying and understanding intense, sometimes objectionable, feelings in professional relationships is central to the management of professional boundaries. With inadequate preparation for managing intense, often startling feelings, practitioners run the risk of over-identification, engaging in destructive behavior, or developing restricted practice styles that don't benefit themselves or their clients. Supervisors are well suited to assist practitioners with identification and management of their feelings around these boundary dilemmas. Consultations may assist practitioners in sorting out clinical and interpersonal dilemmas, thereby protecting competent care of the client.
The clinical supervisor helps the practitioner define his problems and questions. This can be a surprisingly difficult job for both supervisor and practitioner. When a practitioner feels disturbed by something, the task becomes naming that something precisely and figuring out what kind of help is wanted. There is an important distinction between how the practitioner sees the problem and how the supervisor sees it. Rather than offering advice and telling the practitioner what to do, a good supervisor helps the practitioner to explore what's happening internally, define where the appropriate boundary is for the practitioner and the client, and determine what action might correct the situation. In general these techniques, which draw on and validate the practitioner's problem-solving skills, lead to a more effective and empowering resolution.
Peer group supervision is a valuable model of supervision for massage therapists at any phase of professional life. Beginning practitioners may find it beneficial to engage in both individual and peer group supervision. Mid- and late-career practitioners often participate regularly in peer group supervision and seek individual consultations as required. Each practitioner designs a network of supervision that suits the demands and needs of her practice, phase of professional development and her personality.
Peer group supervision has easily identifiable advantages and some potential disadvantages. The strengths, limitations, and success of peer groups rest with the composition of the individual members and the clarity of the peer group contract. Members must agree upon the time, location, and frequency of meetings. The organizational structure and goals of the meeting, and limits of confidentiality need to be defined and agreed upon. Vague, ambiguous, overly ambitious or ambivalent goals and structure often lead to difficulties. As with individual or clinical supervision, an interpersonal atmosphere of reasonable safety, including respect, warmth, honesty and a collaborative openness, is critical. Competitiveness, criticism, inconsistency of members, absence of support and warmth all diminish the effectiveness of the group and the pleasure for the members. Potential disadvantages of peer group supervision include the varying commitment and inconsistency of attendance of members.
Peer group supervision decreases professional isolation, increases professional support and networking, normalizes the stress and strain of professional life, and offers multiple perspectives on any concern or problem. Peer supervision has the added benefit of being free of charge, intellectually stimulating and fun.
A brief, start-up consultation with a clinical supervisor or group specialist is helpful to define and establish the contract and framework for successful peer group supervision. When successful, peer group supervision far exceeds other forms of supervision and continuing education for individualized learning, intimacy, support, pleasure, and a sense of belonging that anchors professional work. Many peer groups opt to have a clinical supervisor moderate meetings on a regular basis, such as quarterly or twice a year. This supervisor also might be appropriate to meet with individually when additional support is requested.
A skillful supervisor is like a guide in unfamiliar territory, enhancing understanding and helping direct the practitioner toward constructive solutions, if necessary. A supervisor often helps by asking a variety of questions about what is needed and what the practitioner was thinking and feeling during the time s/he didn't know what to do. In appropriate situations advice can be offered as to what to do with a client. The most important aspect of supervision, however, is the opportunity to explore and work through a problem.
Finding a supervisor is often not an easy task, particularly in small, out of the way places where there are few therapists familiar with somatic practices. Psychotherapy disciplines have the longest tradition of providing clinical supervision and thus psychotherapists are fruitful sources. Psychiatrists, nurses, social workers, psychologists, and counselors are likely to be experienced supervisors. Personal recommendations by a colleague or a valued teacher are also fine ways to secure names of potential supervisors. If a referral by a colleague or instructor is difficult to obtain, it's possible to contact state or national professional organizations to obtain names of professionals in good standing.
Julie Onofrio is a massage practitioner in Seattle, Washington. She has been in business full time since 1989. She attended a workshop with Jack Blackburn at the AMTA- Washington convention in April 2002 and has been working with him regularly since then.
Onofrio shares that her supervision sessions help her get more in touch with herself and her clients. "I wish now that I had started supervision earlier, but then again I probably wasn't ready. I was too busy trying to figure out how to massage and run a business. When I first heard the term 'supervision,' I thought it meant that someone was going to tell me what to do. That of course is not what supervision is about at all. Supervision is looking at yourself and your practice and how you feel about the process. It doesn't involve judging -- saying what is right or wrong. Each individual has to find that out for themselves."
She is also starting a small peer supervision group. One of the major goals is learning how to listen and not try to fix, which, according to Onofrio, "Is much harder than I ever imagined!" She believes that the future of our profession lies in supervision.