Clinical Supervision in
a Rural / Frontier State
Clinical supervision in rural areas has a number of characteristics that differentiate it from supervision in more populated areas. While these differences do not necessarily mean that the quality of supervision received is inferior to that received in more urban areas, they can place quality at risk for the supervisor who is not aware of the pitfalls inherent in the realities of rural supervision and does not make compensation for them.
The author writes from Wyoming, the smallest state in the country in terms of population. Only 8 communities in the state have more than 10,000 people. The population clusters that do exist are separated by many miles of virtually uninhabited terrain. The state has 17 Clinical Members of AAMFT in residence. The author has been a mental health practitioner in the state for 35 years and is one of only two AAMFT Approved Supervisors in the entire state. The observations about supervision in sparsely populated regions that follow are based on her many years of supervisory experience, as well as the results of a survey that she recently conducted with 84 licensed clinical social workers in the state about their personal supervision experiences. The following characteristics about clinical supervision in a very rural state emerged:
1. Many clinicians receive little or no supervision of their work. In 1985, the author found that out of a group of practitioners who received intensive training in family therapy, only 29% were able to find any supervision of their work. In 1987, in a study of rural mental health practice, only 40% of the multi-disciplinary practitioners participating in the study received supervision of their work. This figure improved only slightly in 1999. Only 42% of the author’s survey group of social workers reported receiving supervision of their work.
2. Clinical supervision received by possibly the majority of practitioners is from a clinician outside of their discipline. Opportunities for socialization into their profession (a major goal of supervision) are addressed minimally, if at all, by such supervision. Of the practitioners receiving supervision in the author’s recent survey, 62% of them received supervision from someone outside of their discipline of social work. This situation is exacerbated by the state’s licensing law for mental health professionals (social workers, marriage & family therapists, counselors and addictions therapists) which states that supervision for any candidate for licensure may be provided by a licensed social worker, marriage and family therapist, counselor, addictions therapist, psychologist, psychiatrist or psychiatric nurse who has been licensed in their specialty for two years.
3. Supervision of a practitioner’s clinical work, cited by many as the cornerstone of professional development, is not experienced as their primary source of professional development by the majority of practitioners in Wyoming. Only 22% of the author’s survey population rated it as such. The overwhelming majority of those surveyed mentioned conferences and workshops, professional publications and information, peer consultation and review as primary professional development resources. This is undoubtedly an inevitable outcome of the unavailability of supervision in many areas, particularly that of one’s own profession.
4. A significant number of practitioners receiving supervision of their work have to travel some distance to receive it. The author has provided supervision for individuals living as far away as 300 miles. Nineteen percent of her survey population reported traveling 28 to 200 miles to receive supervision. This has obvious implications in terms of frequency of supervision.
5. There is little formal training in skills for the provision of competent clinical supervision available. Only the doctoral program in counseling at the state’s single university offers a course in supervision and workshops on this subject are extremely rare. Considerable travel is usually involved for those practitioners wanting more training in supervision. In the author’s survey group, 88% of the respondents who wanted more training in supervision listed a lack of training opportunities in the state as a major barrier for them receiving same. The author had to travel 350 miles to receive supervision of her work to become an Approved Supervisor. She is currently supervising two candidates for the Approved Supervisor designation who travel 185 and 150 miles respectively for their supervision and she previously supervised a candidate from Montana who traveled 300 miles for his supervision.
6. The range of modalities utilized in providing clinical supervision is extremely limited. Ninety-one percent of the respondents in the author’s survey group reported that all of the supervision they received was discussion of case materials based on self report (the validity of which is based heavily on the supervisee’s observational and conceptual abilities) and process notes. Clinical training at Wyoming’s one university in marriage and family therapy and counseling utilizes videotaping and live observation extensively but these supervision modalities become extremely rare in clinical supervision in the field.
7. Dual relationships, with all their inherent pitfalls, are common in clinical supervision. Thirty-nine percent of the respondents to the author’s survey reported that their supervisor and agency administrator were the same person.
Attempts to provide quality clinical supervision in sparsely settled regions of the country must include the provision for more intensive training opportunities in supervision skills within a geographical area accessible to practitioners. Perhaps professional organizations such as AAMFT, NASW or ACA might take the initiative to sponsor these training opportunities. Wyoming’s small AAMFT chapter made a beginning effort in this area at their state conference last fall. Such training should focus on utilization of modalities in the supervision experience besides self report or process notes on case materials such as audio & video taping of sessions and live observation (which can offer the supervisor a more accurate picture of what is happening in the supervisee’s work). Face to face supervision on a weekly or biweekly basis is simply not feasible for a number of practitioners who live a considerable distance from their supervisor and supervisors need training in using modalities that could help them supplement their face to face meetings with supervisees such as compressed video, online supervision, etc. Participation in supervisory training for practitioners who supervise might be encouraged by a provision of some minimal requirements in supervision training in the state licensing law. This, however, is not a uniquely rural problem, for a number of professions (e.g. social work) do not clearly state qualifications or credentials that a supervisor should possess.
Some attention needs to be paid to the problem of so many supervisees in a state such as Wyoming receiving supervision from someone outside of their professional discipline. This state of affairs robs the supervisee of the opportunity to be socialized into their profession through ongoing supervision and robs the profession of the benefits of the gate keeping into the profession that can only be provided through supervision. Perhaps an amendment to licensing laws similar to those of Wyoming’s, which would require (as many states do) that at least some portion of a practitioner’s supervision be given by a supervisor from their profession, would begin to address this very important benefit of supervision that many practitioners in states like Wyoming are missing.
Patricia Boyer, LCSW, LMFT, is an AAMFT Approved Supervisor and an Associate Professor Emerita of Social Work at the University of Wyoming. She has authored a number of articles on rural mental health practice and is a co-author of the book, A Guide for the Family Therapist. She currently maintains a private mental health practice in therapy, supervision, and consultation.
Wicks, Leone. (1978). Rural social work supervision: An exploratory study. Doctoral Dissertation. University of Utah.