CRISIS MANAGEMENT DURING "LIVE" SUPERVISION: CLINICAL AND INSTRUCTIONAL MATTERS

Journal of Marital and Family Therapy, Jul 2005 by Charl�s, Laurie L, Ticheli-Kallikas, Michele, Tyner, Kelly, Barber-Stephens, Brandi

In this article, we illustrate two examples of "live" supervision with marriage and family therapy trainees whose clients presented in the therapy room in immediate crisis. The case examples, one a client with suicidal thoughts and the other a parent who had struck her child, demonstrate how the university-based therapy team managed the recursive clinical and supervision processes that unfolded during the sessions. We present the case examples from the perspective of both supervisees and supervisor, discussing how our different experiences of the supervision unfolded in real time. Case discussion and reflections later in the article illustrate the need for an open, transparent, dialogical process throughout supervision. A case is made for supervisory participants to create alternative formats in which multiple supervisory voices can be heard.

INTRODUCTION

In marriage and family therapy (MFT) training programs, clinical supervision has been shown to be a generative and invaluable method of promoting a therapy trainee's clinical development (Liddle & Schwartz, 1983; Montalvo 1973; Storm, Todd, Sprenkle, & Morgan, 2001; Storm & Sprenkle, 1997; Todd & Storm, 1997). Clinical supervision is the primary way new clinicians develop skills and build theoretical understanding, as well as learn values and norms about the MFT culture (Everett, 1980; Lee, Nichols, Nichols, & Odom, 2004; Nichols & Lee, 1999). In particular, the intensity of live supervision can be an extremely generative learning platform for both supervisor and supervisee. Indeed, the intense focus on cases in "live" supervision (i.e., when a supervisor is observing from behind a one-way mirror) is a routine process in many MFT programs and institutes. It is both a distinguishing feature and hallmark of the field (Storm et al., 2001).

Conducting live supervision with therapy trainees who find themselves in the midst of a client crisis adds even more complexity to the supervision process. The supervisor/supervisee relationship, a therapy team's synergy, and the context in which the supervision takes place are all variables that influence how the crisis is handled. Further, a supervisor's theoretical views of therapy and model of supervision are critical elements that also shape how a trainee manages a crisis intervention process. The team context and supervisory relationships can determine how effective any intervention might be. A supervisor's guidance can either help or hinder how a clinical trainee manages the crisis in the room.

In this article, the authors (an American Association for Marriage and Family Therapy [AAMFT] approved supervisor [LLC] and three MFT supervisees, [MTK, KT, and BBS]) discuss how crisis interventions were handled during the live supervision of two clinical situations. The cases took place during two separate practica, the first of which was master's, and the second, doctoral. In the first example, a client revealed thoughts of slashing her wrists and ending her life. In the second, a father revealed to the therapist that his wife had hit their 10-year-old child in the face, bloodying her nose. In this article, we will illustrate how the therapists and supervisor on the case managed, discussed, and reflected on the clinical decision-making process in these cases as they occurred in real time. We present our perspectives in a narrative format, from the voices of both supervisees and supervisor in each case.

The case narratives provided will illustrate how a collaborative supervision model (Anderson, 1997; Flemons, Green, & Rambo, 1996; Green, Shilts, & Bacigalupe, 2001) influenced the clinical and instructional matters in both cases. In addition, we will discuss how systemic thinking informed the clinical management of these potentially life-threatening situations (Bobele, 1987), and how systemic questioning elicited difficult and highly emotionally charged information from clients. We also discuss how the team met legal and ethical standards and provided a reasonable standard of care.

SYSTEMIC UNDERSTANDINGS OF CRISIS INTERVENTION

The systemic management of crisis is a topic that has received notable, but limited, attention in the field of MFT. Yet, Bobele (1987) noted that "life-threatening behavior is a relatively common encounter in the day-to-day practice of many clinicians" (pp. 225-226). Thus, instruction on how to manage crisis events that occur in a clinical context is necessary for new and developing MFT trainees. Considering the systemic elements of how crises begin and develop is an important part of the learning process. As Bobele suggested (1987), "interventions designed to prevent the dangerous behavior without taking into account the interactional context of the threat run the risk of actually increasing the likelihood that tragedy will occur" (p. 225).

A systemic approach considers how a crisis makes sense in the context in which it occurs (Bateson, 1972; Everstine & Everstine, 1983). A therapist operating from this perspective must be prepared to deal with the clinical information generated by a systemic exploration into the details of a client's crisis. However, it is less clear how clinical supervisors guide trainees through the management of a client's crisis as it unfolds in the therapy room.