Clinical Supervision

Emily St. Amant:

Welcome to the Voice of Counseling from the American Counseling Association. I'm Emily St. Amant, and co-hosting with me today is Christa Butler. Today's guest is Rachel McCrinkard, who is here to talk about clinical supervision. Before we jump into the interview, we want to let our listeners know about some great resources offered by the ACA, including the books "Clinical Supervision in the Helping Professions: A Practical Guide, Third Edition," as well as "Gatekeeping in the Mental Health Professions."

Emily St. Amant:

To find these books and online courses about supervision, check out counseling.org in the publication section, and look for the category supervision. We'll put some links in the description below as well. Rachel McCrinkard is the CEO and co-founder of Motivo Health. A licensed marriage and family therapist herself, Rachel withstood a weekly two-hour commute to complete her required clinical supervision hours over the course of two years. That experience gave her a front seat view to the geographic boundaries that preclude behavioral health professionals from serving rural areas.

Emily St. Amant:

When states began changing laws to allow supervision to occur virtually, Rachel was galvanized to take action. Thank you so much for joining us today, Rachel. How are you?

Rachel McCrinkard:

I'm good. Yeah, so glad to be here with you, Emily and Christa. Thanks for having me.

Emily St. Amant:

Yeah, thank you so much for joining us today. We are so excited to have you and so grateful to be able to share your expertise. To jump right into it, what is clinical supervision, and how does it differ from other types of supervision, like administrative, or sort of other types? You might have a manager that monitors other things, but what is clinical supervision?

Rachel McCrinkard:

Yeah, great question. Clinical supervision are the years in between graduate school and getting your full clinical licensure. Usually, that's about two years, can take a little bit longer. It's almost never shorter than that, where you are meeting with another licensed professional in the field who you've chosen as your clinical supervisor. They meet the state requirements to provide clinical supervision. Really, the purpose of it is to just talk about your cases, do some own work on what might be coming up for you in self of the therapist type ways of working with your clients, sometimes getting ready for the licensing exam, examining some of the rules that are required for licensure in your state.

Rachel McCrinkard:

It's basically your mentor and guide through the licensure process, the person who helps you become a clinician that's ready to serve independently. Then how that differs from an administrative supervision, I would say administrative supervision is more a term that we hear used in community mental health settings, where you have a boss or a supervisor who's meeting with you to make sure that you are getting all the hours that you're required to get in order to meet your billable time, or making sure that your documentation, your clinical notes meets the organization's standards or the payer, be it Medicaid or commercial insurance, their standards for documentation.

Rachel McCrinkard:

It's more focused on what do we need in order to bill for this time, and what do we need from you from an organization perspective, in terms of productivity and producing client hours, than it is what we call more restorative supervision. That's very focused on the clinician, how they're doing, what they're learning, how they're growing, so that they can be a better clinician.

Emily St. Amant:

Okay. I think that makes sense. It's more focused on the personal growth and development of that clinician, and the skills that they need, the support they need to, like you said, practice independently. There's only so much you can do in graduate school. There's so much to learn. That's really important to have that support after graduation.

Rachel McCrinkard:

That's exactly right. Yeah. If I can say this, I would love to just give a little bit of history real briefly about even how clinical supervision came to be. I think this is very interesting. It's from, I learned this in Ben Caldwell's book "Saving Psychotherapy." If you were to read that, you'd get the full history there, but it talked about where did this even come from, this two years that a clinician needs to be under supervision in order to become a licensed clinician? It really dates back to more when doctors were going through this same process, and it was after a war or something like that. They were all returning home. A lot of doctors were going through the process of becoming a medical doctor, and they needed to slow down the influx of new healthcare professionals into the field.

Rachel McCrinkard:

They said, "Okay, well, we'll give them this two year training period called residency for a doctor in order to slow down how quickly they're coming into the field." Then when mental health began to evolve and become more standard practice, they were like, "Well, how long should someone be under the supervision process?" They're like, "Well, let's just do two years," same as a doctor, which I think is just very interesting. Then Dr. Caldwell points this out in his book. There's no real research or study that says after two years, you are ready. It's like, you need to be learning and growing your entire time as a clinician, but that is the standard of our field today.

Christa Butler:

Yes, that's a really good point that you need to be growing throughout your practice as a clinician. While we have those two initial years leading up to our licensure, that doesn't mean that you've reached a point where you just, "I'm good, I know it all." No, there's always new information, and best practices, and research that helps to inform and to update how we serve our clients. I think it's very important that beyond those two years, that you continue to seek consultations and support in building your skills as a clinician.

Christa Butler:

Rachel, we were just talking about how clinical supervision is different from administrative supervision. Can we also talk about what is the difference between the clinical supervision that one might undergo in graduate school? For example, when you're doing your internship, when you're doing your practicum, you're going to be provided onsite supervision as well as some supervision from your professor, but that's also a bit different. Can you share with us how that differs from the supervision that's required for licensure?

Rachel McCrinkard:

In terms of what's covered during supervision, it's largely the same. Yeah, it's just counted differently from a state's perspective, from the licensing board. It's governed differently in the sense that usually, your university is setting what your requirements are based on the accreditation body of the school, be that CACREP or COAMFTE or something like that, that are setting those, how long do they need to be in supervision? How many hours do they need to collect in order to graduate, that sort of thing. Largely, what you're doing during supervision is the same.

Rachel McCrinkard:

I'd say the only difference is that there is usually a requirement around raw data, which means that you need to record sessions, video or audio sessions of your time with clients, and listen to them with your supervisor. That is something that's recommended. Even I think North Carolina board actually has a requirement that you do that when you're in the postgraduate phase. It's definitely required almost always when you're in the graduate phase, just to get a little bit closer eye on how you're developing in those early days.

Christa Butler:

Yeah, thank you for bringing that up. That's a good point, that depending on the state that you reside in, some of those requirements are going to be a little bit different. The recordings that you do in graduate school, depending on your license and the state that you're in, your state may also require some postgraduate observations of the services that you're rendering as well. Yeah, thanks for providing that explanation on those two things.

Emily St. Amant:

I think a lot of what is different is developmentally, too. When you graduate, you're in a much different position as a clinician versus when you're just starting. I just remember that first week of seeing clients was a deer in headlights feeling, right? As you develop, the nature of clinical supervision developments, because it's all a developmental process.

Emily St. Amant:

Those hours that you spend with your supervisor, it's a big part of what we're required to do for licensure. Can you talk a little bit about why that's so important to spend that time with the supervisor, or even after graduation before you were able to practice independently?

Rachel McCrinkard:

Yeah, I would say the most important tool that you have as a clinician is you as the clinician, how healthy you are, how much of your own self-work that you've done around examining privilege and bias, and your own family history, and what's triggering you? For example, maybe you are seeing a patient who's an eight-year-old boy who has begun to wet the bed because their parents are getting a divorce. Then maybe you're a clinician whose parents got divorced when you were eight years old. That's definitely going to bring some stuff up for you as the clinician, as you're doing your work with them.

Rachel McCrinkard:

Being able to be mindful of that, to examine it, to have someone to talk to about it, either in personal therapy or in clinical supervision. I think we get this idea that you're not supposed to talk about any personal stuff when you're in clinical supervision, that that's for therapy. I don't necessarily believe that. I think anything that is about your development as a clinician is something that is important to be discussing in clinical supervision, that clinical supervisors should even prompt people to do so.

Rachel McCrinkard:

To Christa's point earlier, that doesn't just go away when you get licensed. There's really a need for ongoing consultation, supervision, and support to guide you on your journey, whether it be a new population that you're working with that you don't have any experience in, that's a great time to get additional supervision. It's vital, and I would say, critical in the early years of becoming a clinician to be under supervision. It's also just helpful the whole entire way through.

Christa Butler:

I think what you're speaking to, Rachel, is the self of the therapist and how you are, again, doing your own work and also doing that professional development work, that there's a clear correlation between the two. As a clinician in the room, you're going to be showing up as your whole self. I know in grad school, they talk about compartmentalizing and doing all of that, but I think that's a skill that for some people, depending on where you are, developmentally, and just counselors have personalized too. I think what you're speaking to as far as the consultation piece, the supervision piece, no matter where you are in your career, it's important to do.

Christa Butler:

Then Emily, you talked about developmentally, right? Depending on the different focus area and the different population, your developmental skillsets are going to differ across the board as well. There may be some areas that yes, you're highly skilled in, then there are going to be some areas where you perhaps need to have a little bit more support to really grow and nurture your skillset.

Rachel McCrinkard:

Yeah, that too, because obviously, other people are depending on you to remain healthy. We don't have one of those professions where you can just phone it in for a day. People's lives are impacted if you are not examining your own self, staying healthy. I think about this very similarly to my work now as the CEO of Motivo. When I'm exercising, I'm thinking of it as part of my job description. I'm like, "It is important for me to be doing these things to invest in my own health, so that I can show up every day better." I think that's just so true for a clinician as well.

Christa Butler:

In addition to the specific supervision requirements that are established by one state, what are some additional benefits or supports that could be helpful for folks that are working towards their license?

Rachel McCrinkard:

Yeah. I think that people thinking about supervision in a little bit of a wider lens, of not just what do I need? I think a lot of people approach supervision, I know I certainly did, as this check the box, just get it done. Here's another hour to go into my bank of hours. I was very excited to update my spreadsheet and be like, "I'm closer, I'm closer, I'm closer." You just get so excited about this idea of getting licensed, and that's going to maybe more opportunities, different career paths, that sort of thing once you get licensed.

Rachel McCrinkard:

Really investing in that time and making sure that you're using it as a way to do the hard work of learning how to become a clinician. I think to that point earlier around the examination of raw data and observation and that sort of stuff, I think as a clinical supervisor, obviously, it's not necessarily mandated that you continue to have your supervisor - supervisees do that, but I think it's one of the most helpful things that you can do. I tend to be a bit of a perfectionist. I can remember going to my supervisor and just telling them all the stuff that I did really well, "And I did this, and I think I changed this person's life forever, because then I said this, and it was super powerful."

Rachel McCrinkard:

It was harder for me to bring this stuff that was like, "I really messed up here. This was not easy for me. This was not a good session." My supervisor would really urge me, "Bring me the hard stuff. How did you really miss this week?" I think when you can bring some of that raw data, it gives you a little bit of an insider's look as a supervisor to how are you really doing? I would just say, one of the main things that you can do with supervision is take it seriously, and really utilize it. You got to be there anyways, so why not utilize it as a time to really invest in your growth and development?

Christa Butler:

You need to know it. It's not just a checklist. These are things you need to do in terms of being able to serve your clients with the highest level of ethics, the highest level of competency. It is, obviously, there's a certain benchmark you got to reach. However, these are things that you absolutely need to know in best serving our clients.

Emily St. Amant:

Yeah. I think that that requires certain level of safety and a good relationship with your supervisor, because I think there's some little overlap between the relationship between supervisor, supervisee, client, therapist. It's different, but still it needs to be a place where you're challenged and pushed, and you get that outside perspective on, like you said, things that you didn't do so well. In order for that to happen, it needs to be a good fit, you need to be able to have someone that really has not only the skillset, but I guess the character, the personality, like the compassion and the empathy to work with a supervisee as well.

Emily St. Amant:

That can be hard to determine. What's some advice for people who are maybe looking for a supervisor, where they do want to get the most out of that time with that supervisor? What are some things to look for?

Rachel McCrinkard:

Yeah, I think it's similar to finding a therapist as well. It's not just interviewing one and being like, "All right, this is the one. The LCSW in Montana meets the requirements, so they're the one for me." It's really examining what clinical setting have they worked in? Is it community mental health, or private practice? Hospitals, like health plans, how does this align with the kind of clinical setting that you want to work in someday? What type of population?

Rachel McCrinkard:

Obviously, I think race, ethnicity, gender, identity, all of those things play in to not just how it might align with you, but how it would align with the population that you want to serve, and how you want to grow and develop. That could be either one. I tell this story sometimes about this very early supervisor that we had, and he lived in south Georgia. He was a minister. He is one of my favorite people. He is this great guy. He came to Motivo in the very, very early days, and he was like, "I want to meet with a black woman supervisor because I want to learn more about how to work with all people, and I am surrounded by white 50 year old men just like me."

Rachel McCrinkard:

He really went into it more intentionally of wanting to utilize supervision as a way to grow his competency, sensitivity, understanding, all of those types of things, versus finding someone who aligned directly with his background and experience as a white, cisgendered man living in south Georgia. I think you could go either way, find someone who, it's kind of personal preference there. What do you want to learn? What is the situation where you're going to feel like the most safe, the most able to examine what you want to during supervision?

Christa Butler:

Yeah. Yeah, absolutely. I think finding the right fit, it might require you to do a little bit of trial and error, and I think it's okay to change supervisors if you need to, but having some intentionality behind what it is that you're looking for, what your preferences are, what you're hoping to get out of supervision beyond those requirements, in terms of specific areas of focus, or skillsets that you feel that you're able to find with the person that you perhaps chosen to work with. I think it's important to think beyond the requirements, and really think about this person as your mentor and someone that's going to help you to really learn and acquire some of those skills that you might use throughout your entire career.

Christa Butler:

Yeah. Let me just say, I think that this is one of the great things about Motivo is that you have the option to work with folks across the state. With the option for tele-supervision, it certainly does open up some of those options. I'm thinking about folks that live in rural areas, for example. You might not have as many options depending on where you're located. You might not have as much variation in terms of one supervisor to the other. I think, Rachel, that's one of the beautiful things about Motivo.

Christa Butler:

It certainly does open the doors for people to have more access to meeting supervisors from various backgrounds and clinical specialties and interests, which is absolutely, I think, a gift to have that option to find when you're in clinical supervision.

Rachel McCrinkard:

Maybe I too, Christa, I can just briefly speak to the people who might not have a choice of who their clinical supervisor is, because it's definitely a privilege to be able to pay extra for outside supervision and find someone that I really want to meet with. A lot of people who are working in the early days of their profession are working in community mental health, and someone is assigned to their supervisor. They have no choice on who it is.

Rachel McCrinkard:

I think that it's obviously a good opportunity to get what you can from that, but it's also an opportunity to advocate for yourself with the organization and say, "This is why I would really benefit from having a supervisor that's either external from my organization, or that can give me a different outlook. This is why it's going to help me be a better clinician. This is how it's going to help me stay at the organization longer." One of the main issues that community mental health organizations face is turnover, having people who leave because they get burnt out. It's very under, if I can just say for a second here, even this idea of just invest in your own clinical supervision and your growth and development. That's not the full story. I just want to say that.

Rachel McCrinkard:

Part of the story is a bit of a broken system on the mental health care side of the fact that we use our greenest clinician to serve the most vulnerable populations. My first job post-grad school, I went to grad school in LA, and it was working in skid row with chronically homeless adults. I was like 22 years old, and I didn't have enough life experience or clinical experience to really know how to handle a very vulnerable, underserved population. I didn't have good clinical supervision at all. I really struggled. We recently put out a white paper that ACA also contributed to about the fact that 57% of the people who get a master's degree in counseling never complete clinical licensure.

Rachel McCrinkard:

It's not just a problem of get good clinical supervision, it's a problem of that we need to look at as from the industry perspective as a whole, and think about what is the clinical setting of pre-licensed clinicians, and how can we invest more in training and support, and days off, and less productivity, higher reimbursement rates, all of those more policy type issues, that can result in more clinicians making it through the process? I'm little on my soapbox there, but that's how I feel.

Christa Butler:

Yes. No, I couldn't agree more that this goes beyond just finding a supervisor. Honestly, it goes beyond just self-care as well. While self-care is certainly important for us to do, there's, there are systemic and structural issues that perpetuate and reinforce marginalization, and frankly, burnout. I also come from community mental health. I've been in that same situation where it's like, "Here's your clinical supervisor," and having the privilege to say, "No, thank you, I'm going to go ahead and just pay for it out of pocket," was definitely something that I am thankful that I had the option to do that.

Christa Butler:

Absolutely, I think there's so many areas beyond just, again, the checkbox and the bases that we're talking about here, that feeds into the larger issues and the systemic issues that feed into that, contribute to the fact that so many folks get a master's degree and don't go on to work in the field. The times that we're in now, we need more clinicians than ever. You think about the mental health and the healthcare provider shortages. We need better access and better, like you said, legislation and policy change, and frankly, financial, finances to go towards mental health, and to go towards benefiting folks that are in process of earning their license, and the full nine yards.

Christa Butler:

All of that needs to be better served so that we can best serve our clients, and be able to respond to the healthcare shortage and all of that.

Rachel McCrinkard:

100%, yeah. ACA is doing such important work around that too, with the counseling compact. There's another big reason that people don't achieve licensure is that they might be halfway through the process, and then move to another state. Maybe their education or experience doesn't line up, or something like that, and they just give up, or they're already licensed, they don't want to go through the process again. That licensure reciprocity piece that ACA is working on is it's really, it's another important piece of this puzzle of investing in the clinicians that we already have, or that are in the last mile of their journey to become a licensed clinician.

Christa Butler:

What about for those who are thinking about becoming a clinical supervisor, or maybe they haven't thought about it, but they're looking to set some goals for their career? What are some reasons to become a clinical supervisor?

Rachel McCrinkard:

Yeah. I think it gives you as a clinician, a different way to use your skillset and maybe a variation in your practice, because it's not the same thing as doing client work. With your client work, it's a total different process. Clinical supervision I think kind of stretches a different side of your brain and your kind of clinical experience of knowing not just how to be like, "This is how, do it like this, do it like I would do it." This is what you say. That's what I would do. Sometimes as a very early clinical supervisor, I'd be like, "Oh, don't say it that. Say it like this."

Rachel McCrinkard:

I was realizing after that, oh no. Part of my job as a clinical supervisor is helped them become the best clinician that they can be on their own. It's not about giving them those easy answers of, "Just do it like this." It's, "How can I guide them in their path to discovering the kind of clinician that they want to be?" I think that's just kind of exciting work for a clinician who might be in seeing client after client, just to have a different type of clinical work that they're doing in their day. I think giving back to the profession is a really big one.

Rachel McCrinkard:

When you think about that statistic of how many people don't make it through the licensure process, it's kind of a all hands on deck situation of how can we all help give these early clinicians maybe what we didn't have? I rarely speak to someone who's like, "I had a great clinical supervision experience. It was wonderful." Most of the time, I hear people say like, "No, it was lacking. It left me wanting more." I think really being able to be part of the solution to that, say, "I'm going to give something that's better than I got myself," or maybe you had a great experience and you just wanted to give that to somebody else as well, I think it can be a very wonderful ... it can bring you a lot of value into your clinical practice, I think.

Emily St. Amant:

Yeah. I think that's one of the biggest things that we benefit from is that quote, we rise by lifting others. By supporting the next generation of counselors and therapists, that's a way, like you said, to give back to the profession, but then also you're a part of something bigger than yourself. You're sort of fostering that other person's growth, development, and it's a big part of their success. If they have that support, you just think about how much better of a clinician they are, how much more successful they can be if they have that foundation of having that support, someone that really cares and believes in them, and how much of a difference that can make.

Emily St. Amant:

That just makes me think of how supervision is not just about the clinical care that you provide, it's about also promoting diversity, equity, inclusion, and justice in the field as a whole. Can you maybe speak to that, about how supervision can be one of those vehicles for some of those needed changes?

Rachel McCrinkard:

Yeah, I think so much of that is a willingness on the clinician's part to do the work of examining themselves. I'll share this example from Motivo in the sense that we used to have this core value that was something like, celebrate what makes us unique, or something like that. All people are welcome here. We actually recently changed it to be more action-oriented, and we changed it to dig deep, which means that you are taking responsibility and ownership over examining your own privilege, bias, racism, all of those types, homophobia, transphobia, where does that exist in you, in yourself, and being willing to do that work.

Rachel McCrinkard:

I think it's kind of reformatory, or it's easy to just be like, "Everybody's welcome here," but I think the harder work is doing the work yourself. I think that is a very necessary part of the clinical supervision experience. If I was picking a clinical supervisor today, I would want to pick someone who I could even ask them in a supervision interview, "How are you going to help me? What questions are you going to ask me that's going to help me examine these parts of myself that might be uncomfortable to look at, but that are essential to becoming a really good clinician?" That's what I would say about that.

Christa Butler:

Could you also share with us before we wrap up, this has been great, Rachel, by the way. There's so much information and wealth of knowledge that you've shared that we wish we had more time to get into. Before we wrap up, could you share with us any additional suggestions that you would have for clinical supervisors on the importance of continuing to invest in their own personal and professional development as they invest in that of their supervisee?

Rachel McCrinkard:

Yeah, I think there's a lot of different other opportunities in the sense of, we host a few peer groups at Motivo. That's helpful for licensed clinicians to join and be a part of. Obviously, continuing education, being very mindful about what types of CEs picking and how they ... CEs can also be one of those check the box things, where we're just like, "Oh, just get it done. Give me another hour," but really being mindful and planning ahead to what kinds of CEs that you need. I think the other thing that, this isn't very widely known, but NBCC allows you to use an hour of supervision as a CE.

Rachel McCrinkard:

You have to look in there, what qualifies as CEs, One of them is just an hour of consultation with another licensed clinician. As long as the person gives you some sort of documentation to sign off, you can utilize that as an hour of a CE. I, for one, I think would find a lot more value in just an hour speaking to another professional about a specific specialty area. Then maybe another conference or another long webinar on some particular topic. Being intentional about your own growth in the development.

Rachel McCrinkard:

Obviously, staying in therapy or getting in therapy yourself. I'm a lifelong, I'll always have a therapist, I think, and a couple's therapist for me and my husband. I just value what I learn in therapy and how I'm able to continue to grow. Yeah.

Christa Butler:

For those who would like to find you, your website, your email, your socials, can you share with us how can people reach out to you?

Rachel McCrinkard:

For sure. Yeah, I'd love to chat, especially about all things clinical supervision. My email is Rachel@motivohealth.com. Then you can find me on socials, mostly on LinkedIn. I don't do much many of the other socials these days, but I'm on LinkedIn. Then our website for Motivo is motivohealth.com, so would love to chat.

Christa Butler:

Awesome. Thank you, Rachel, for joining us. This has been great. Be sure to subscribe to the Voice of Counseling on Apple and Google podcast, and you can follow ACA on social media. To join the ACA and to get exclusive access to all member benefits, check out counseling.org.

Speaker 4:

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