Essay Grade

The Clinical Supervisor
ISSN: 0732-5223 (Print) 1545-231X (Online) Journal homepage: https://www.tandfonline.com/loi/wcsu20
Models and Methods in Hospital Social Work
Supervision
Goldie Kadushin , Candyce Berger , Carlean Gilbert & Mark de St. Aubin
To cite this article: Goldie Kadushin , Candyce Berger , Carlean Gilbert & Mark de St. Aubin
(2009) Models and Methods in Hospital Social Work Supervision, The Clinical Supervisor, 28:2,
180-199, DOI: 10.1080/07325220903324660
To link to this article: https://doi.org/10.1080/07325220903324660
Published online: 10 Nov 2009.
Submit your article to this journal
Article views: 2023
Citing articles: 9 View citing articles
Full Terms & Conditions of access and use can be found at
https://www.tandfonline.com/action/journalInformation?journalCode=wcsu20
The Clinical Supervisor, 28:180–199, 2009
Copyright # Taylor & Francis Group, LLC
ISSN: 0732-5223 print=1545-231X online
DOI: 10.1080/07325220903324660
Models and Methods in Hospital
Social Work Supervision
GOLDIE KADUSHIN
University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, United States
CANDYCE BERGER
University of Texas at El Paso, El Paso, Texas, United States
CARLEAN GILBERT
Loyola University School of Social Work, Chicago, Illinois, United States
MARK DE ST. AUBIN
University of Utah, Salt Lake City, Utah, United States
This is the first qualitative study of the perceptions of hospital-based
social work supervisees regarding their hospital supervision.
Seventeen social workers were recruited using a national listserv
and snowball sampling techniques. According to the perception
of the clinical social workers participating in the study, hospital
social work supervision is organizationally driven rather than
worker-focused. Implications for social work education and
research are discussed.
KEYWORDS hospital, managed care, models of supervision,
organizational re-structuring
INTRODUCTION
Social work supervision has played an important but changing role in the
development of the profession. Supervisors are agency managers who
have been delegated authority to maintain the job performance of supervisees.
In assuming this responsibility, the supervisor performs educational, administrative, and supportive functions in a positive relationship with the supervisee.
Address correspondence to Goldie Kadushin, Professor, Helen Bader School of Social
Work, University of Wisconsin-Milwaukee, PO Box 786, Milwaukee, WI 53201. E-mail:
Kadushin@uwm.edu
180
Hospital Social Work Supervision
181
The long-term objective of supervision is to prepare the supervisee to deliver
effective, efficient services to clients, consistent with the agency’s mandate and
professional practice standards (Kadushin & Harkness, 2002; Tsui, 2005). The
administrative function of supervision is to organize the work of the supervisees to achieve agency objectives. This is the basic supervisory function. Educational or clinical supervision improves the knowledge and skills of workers
within the mandate of the agency. Supportive supervision reduces job-related
stress and fosters worker self-awareness to cope with stress (Bogo & McKnight,
2005; Kadushin & Harkness, 2002; Tsui, 2005). These functions apply to any
supervisor in any social work agency.
This paper focuses on social work supervision in hospitals. The
sustainability of supervision in hospital settings is threatened by the elimination of middle management and supervisory positions in favor of leaner,
cost-effective structures. This reorganization reflects the influence of managed care and capitated methods of financing that are reducing the hospitals’
access to revenue (Berger & Mizrahi, 2001; Globerman, McKenzie-Davies, &
Walsh, 1996; Weissman & Rosenberg, 2002; Schmid, 2002). Consistent
with these findings, a recent survey of licensed health care social workers
reported increased job stress in the context of reduced access to supervision
(Center for Health Workforce Studies, 2006).
The influence of managed care and capitated financing systems on hospital supervision has not been examined by social work researchers since
1996, the last year of data collection in a longitudinal study conducted by Berger and her colleagues (Berger, Robbins, Lewis, Mizrahi, & Fleit, 2003; Berger
& Mizrahi, 2001; Berger et al., 1996.) The existing research is also limited by an
exclusive focus on the perceptions of supervisors. No research has examined
hospital supervision from the perspective of the supervisee. An understanding
of the supervisee’s views is necessary to inform the profession of unmet
worker needs for oversight, support, and education in the social work health
care labor force (Center for Health Workforce Studies, 2006). To begin to
address this gap in the literature, a pilot study was conducted to answer the
following question: What are the perceptions of supervisees about the current
models and functions of social work supervision in hospitals? The hospital
agency was the setting for this pilot study because previous research on supervision in health care has been hospital-based, providing a knowledge base for
the development of the study questions and instruments.
LITERATURE REVIEW
Hospital Reorganization: Impact on Social Work
Hospital Supervision
Many theories explain the relationship between the hospital and the environment (Netting, Kettner, & McMurtry, 2004) or those ‘‘external conditions
182
G. Kadushin et al.
that may affect the organization’’ (Schmid, 2002, p. 133). The merits of different
theories are still debated, but all theories assume environmental circumstances
influence organizational processes (Schmid, 2002). In particular, the immediate
or task environment is assumed to affect organizational strategies and structures (Schmid, 2002; Netting et al., 2004). The task environment includes
patient populations, revenues, in-kind resources, competitive institutions,
and federal and state regulators (Netting et al., 2004; Schmid, 2002).
In the early 1980s, health care delivery and funding underwent a radical
change in the United States with the introduction of a Medicare capitated
payment system for hospital care. Capitated payment is a form of managed
care. Managed care can be defined as a payment and health care delivery system that regulates, monitors, and coordinates resources to contain costs and
increase efficiency. Introduced into the United States to reduce spiraling
health care spending in the early 1980s, managed care is now the dominant
arrangement in both public and private sectors.
Because a capitated payment system transfers risk from payer to provider, the Medicare prospective payment system reduced hospital revenues.
Aware of the risk of cost-shifting, private and public third-party payers also
adopted managed care payment and delivery procedures. Hospitals were
confronted with an unstable, rapidly changing environment in which fierce
competition for scarce resources and patients existed. In this context, theories predict that organizations will revise strategies and structures to reassert
control over actors in the task environment (Schmid, 2002).
Hospitals responded by developing alliances with multi-hospital systems, merging with competitive institutions, and separating functions into
independent, decentralized programs or teams (Lee & Alexander, 1999;
Bazzoli, Dynan, Burns, & Yap, 2004; Weil, 2003). The effect of hospital reorganization was to reduce operating costs by consolidating management and
duplicative services. However, this strategy also eliminated the positions of
middle managers and social work directors who provided supervision,
decreasing institutional resources to support this function (Kadushin &
Harkness, 2002; Weissman & Rosenberg, 2002).
A government-mandated managed care program implemented in the
1990s in Canadian hospitals is suggestive of the effect of hospital restructuring
on social work supervision. The introduction of managed care was the impetus
for the dismantling of Canada’s hospital social work departments. Social work
supervision decreased in the absence of an administrative structure (e.g., social
work directors and supervisors). Canadian hospital workers organized peer
groups to provide clinical and supportive consultation but they had no
access to formal supervision (Globerman et al., 1996; Globerman, White, &
McDonald, 2002; Globerman, White, Mullings, & McKenzie-Davies, 2003;
Michalski, Creighton, & Jackson, 1999). While this research is specific to the
Canadian health care system, it is suggestive of the potential impact of managed care and hospital restructuring on worker access to formal supervision.
Hospital Social Work Supervision
183
Kadushin and Harkness (2002) hypothesize that clinical and supportive
supervision, which are resource-intensive, non-revenue-generating functions,
may be assigned a low priority by hospitals impacted by managed care. They
suggest, however, that because administrative supervision directly benefits
the organization, it may be the sole form of supervision recognized by hospitals within an environment of cost containment (Kadushin & Harkness, 2002).
Models of Social Work Supervision
Models of social work supervision can be differentiated by levels of agency
control. At one extreme is the ‘‘casework model’’ or scheduled one-on-one
individual social work supervision, which is based on high levels of administrative accountability. At the other extreme is the autonomous practice
model, which is characterized by professional autonomy of the supervisee.
Between these extremes on the continuum of administrative accountability
are group, team, and peer supervision models (Bogo & McKnight, 2005;
Kadushin & Harkness, 2002; Tsui, 2005).
Individual supervision is the most widely used model of supervision,
particularly for unlicensed or inexperienced (less than two to six years of
practice in the same setting) workers (Kadushin & Harkness, 2002). It is
delivered in a one-on-one tutorial session scheduled weekly for at least an
hour. The demands of time and effort required by this model may be challenging to hospital-based social work supervisors who have corporate or wideranging administrative responsibilities.
Group supervision is the second most widely adopted model of
supervision. It is characterized by the presence of a formal social work
supervisor who performs the functions of supervision—administrative,
educational, and supportive—in a group format. Group supervision is a
supplement to, not a substitute for, casework supervision.
The introduction of group supervision is ideally preceded by worker
preparation for the change and agreement by the staff. The advantages of
the group modality are conservation of time and resources; lateral peer learning; and sharing and normalization of job-related stress (Bogo & McKnight,
2005; Kadushin & Harkness, 2002; Sulman, Savage, Vrooman, & McGillivray,
2004; Tsui, 2005).
Peer supervision is supervision led by a peer group; in this situation, no
supervisory oversight or authority exists. All participants hold equal status in
terms of accountability and responsibility for their own practice. The purpose
of peer group supervision is to provide educational=clinical supervision
through case conferences and the exchange of clinical expertise and guidance.
Peer supervision is a supplement to, or a substitute for, educational=
clinical supervision (Brashears, 1995; Barretta-Herman, 1993; Hardcastle,
1991; Kadushin & Harkness, 2002; Sulman et al., 2004; Tsui, 2005). Team
supervision is led by a team leader who may or may not be a social worker.
184
G. Kadushin et al.
In team supervision, intradisciplinary workers may exercise autonomy,
collectively make decisions about work assignments, case dispositions, performance checks, and professional development, providing educational=clinical
guidance and oversight and allocating work assignments. The supervisor is a
team member but retains administrative accountability for team performance
(Kadushin & Harkness, 2002; Tsui, 2005). On interdisciplinary teams, the leader
may be a physician, nurse, or other medical professional who assumes supervisory authority over the other team members (Kadushin & Harkness, 2002).
The question of the prevalence of supervision models in hospital-based
social work has generally been ignored by social work research. Berger and
Mizrahi (2001) examined supervision from the perspective of supervisors in a
national sample of hospitals in 1992, 1994, and 1996. They found that in the early
to late 1990s, individual and group supervision were the most frequent models
(these models were collapsed into the category ‘‘formal supervision’’). Peer
supervision (consultation) was the second-most frequent model. The use of
non-social work supervision significantly increased over all time periods.
Health care social workers speculate that as hospitals restructure and
eliminate social work managers and departments, the resources to support
the traditional individual supervision model will decline. Workers will have
to take the initiative in finding support for supervision outside the hospital
or by creating group or peer models that use collective resources efficiently.
The caution is the need for thoughtful planning, implementation, and a
mechanism for training and evaluation to accumulate research to inform
the profession regarding the efficacy of innovative supervision models
(Berger & Mizrahi, 2001; Kadushin & Harkness, 2002).
METHODOLOGY
This qualitative study was implemented using telephone focus group
interviews. Focus groups have been widely used as a data collection method
in qualitative research, and growing evidence supports the efficacy of
telephone focus groups or ‘‘telegroups’’ as an alternative to face-to-face focus
groups (Cooper, Jorgensen, & Merritt, 2003; Appleton, Fry, Rees, Rush, &
Cull, 2000). Using the Society for Social Work Leadership in Health Care
membership as a sampling frame, researchers employed purposive and
snowball sampling techniques. Social work directors=managers were
contacted by electronic mail using the organization’s listserv. The e-mail
explained the purpose and method of the study and encouraged social work
directors=managers to share the attached flyer with their staffs. Inclusion=
exclusion criteria were as follows: graduate-level social work staff (i.e.,
MSW, PhD, DSW); 50% currently employed in an inpatient or outpatient
hospital setting; one or more year working in clinical practice; at least one
year of experience in the current setting; and English-speaking.
Hospital Social Work Supervision
185
Eligible staff members e-mailed the Principal Investigator (PI) to indicate
their willingness to participate. The PI responded to the e-mail and screened
the subject for eligibility. If he or she qualified for the study, the PI sent an
electronic version of the consent form that was approved by the institutional
review boards (IRBs) of every member of the research team. A waiver of
signature for consent was obtained from the IRBs in order to ensure anonymity of the participants. In developing the focus groups, every attempt was
made to ensure that subjects from the same setting did not participate in
the same focus group to prevent voice identification.
The PI contacted the individuals by phone to discuss the study, answer
questions, and confirm their willingness to participate. Subjects were also
encouraged to share information about the study with their colleagues within
their own and other health care settings. Given the use of the listserv and the
snowball sampling technique, it was not possible to calculate how many
social work clinicians in health care settings were informed of the study to
produce a response rate.
The subjects were made aware of scheduled times for the focus groups
and selected a group. The subjects were asked to adopt fictitious names to
be used during the telegroup; these same names are also used in the data
presentation that follows. The intention in using fabricated names was not only
to increase the level of confidentiality, but also to ensure that each person in
the telegroup session had a distinguishable name. An e-mail was subsequently
sent to the participants confirming the time of the telegroup, the phone number that the participants called to access the focus group, the conference call
identification number to be used, and the fictitious name that they selected
for use during the telegroup and additional flyers advertising the study to share
with colleagues. This e-mail also contained the fictitious names of the other
participants and the focus group leader. A similar e-mail was sent to the group
facilitators. Focus group facilitators were aware only of the fictitious names and
geographic location of the participants; they were not given any other identifying information about the participants in their groups. The day before the telegroup, the PI sent an e-mail reminder to each participant with the same
information contained in the previous e-mail.
Once this reminder e-mail was sent, the PI erased any electronic
information required in setting up the conference calls in order to ensure
anonymity within the actual focus groups. If a participant did not call the
access number for the telegroup, it was impossible to contact him or her
since all identifying information was erased. However, most of the participants who were not able to attend their assigned focus group did contact
the PI to reschedule another time to participate. A private teleconferencing
company was used to set up the conference calls for the focus groups.
The members of the research team served as the facilitators of the focus
groups; the focus groups took about 60 minutes. Telegroup members were
instructed to use only their fictitious names in identifying themselves.
186
G. Kadushin et al.
A semi-structured interview schedule was finalized following a literature
review and the consensus of the four researchers who contributed both
academic knowledge and practice experience in supervision. The interview
schedule consisted of a series of six open-ended questions and accompanying
probes related to the following topics:
1.
2.
3.
4.
5.
6.
access to individual educational=clinical supervision;
access to different models of supervision (e.g., group, peer);
supervisors’ professional discipline;
administrative supervision and accountability for job performance;
use of outside supervisors; and
organizational changes affecting supervision.
This semi-structured interview schedule was followed in each focus
group to ensure some comparability. Major topic questions were presented
to each group separately to maintain a focus on the topic, but group leaders
had the flexibility to explore issues raised that did not coincide with the topic
questions. The topic questions were read aloud by the facilitator, who then
prompted the group for responses. Once discussion was underway, the facilitators intervened only as necessary to guide, probe, or provide support. This
procedure aided in conducting groups that were focused, without excessive
and counterproductive constraints on their interaction.
All interviews were audio-recorded and then transcribed by members of
the research team or by the teleconferencing company. The focus group
sessions began with an assignment of a study identification number. Only
the study identification numbers appeared on the transcripts. Any identifying
information on the tape (e.g., names of individuals, institutions, and locations
used in the discussion) were deleted from the transcript. Once the transcript
was checked for accuracy, the audiotapes were destroyed.
Using a grounded theory approach to data analysis, the narrative data was
pre-coded into conceptual categories. Content was then grouped into broad
categories to detect patterns and relationships. Through further coding, these
categories were reduced to reveal consistencies and inconsistencies in the data.
When codes fit well with old and new data, they were reviewed again in order to
identify focused themes to enhance understanding. This paper will focus on two
key themes that appeared to influence the participants’ perceptions of supervision: the organizational context and the multimodal approach to supervision.
FINDINGS
Sample Characteristics
The majority of the 17 focus group participants were licensed; 5 subjects
were not licensed. In general, the participants were experienced workers;
Hospital Social Work Supervision
187
five had supervisory responsibilities and also carried caseloads. All
participants were employed in hospitals as social workers and, with one
exception, all were women. One participant was employed in a psychiatric
hospital; the remaining sample was employed in medical hospitals.
Organizational Context and Sanction for Social Work Supervision
One of the dominant themes related to the organizational context was the
amount of change that the practitioners were experiencing in their settings.
For some, the change had more to do with roles, while for others restructuring and resizing strategies led to the elimination of social work directors,
transfer of reporting relationships to non-social work personnel, and=or
implementation of matrix models for organizational structure. These matrix
structures retained a social worker as one of the managers, but the supervisor
could be a nurse, a social work department director, or a social worker at the
corporate level. Lisa, an unlicensed social worker in an outpatient dialysis
unit, described a matrix structure of supervision in her setting.
It’s just been a very large growth boom within this organization. So, right
now my clinical supervisor is the only director for all social work departments in the corporation. So that does limit her availability with that
change. I receive clinical supervision monthly by phone and we meet
every three months as a group. I have a direct supervisor at the center
and she is an RN. For, you know, more of the actual clinical needs with
the patients that I’m seeing day in and day out, my tasks, the issues that
come up within my actual work setting, it’s really underneath the RN
clinical manager. But the corporate director of social work and the direct
clinical manager do communicate when they need to.
Abigail, a licensed social worker in a large hospital in a corporate
system, describes a matrix organization in discussing her supervision:
I meet with my director two times a month now, and then I have a manager [nurse] here that I have access to whenever I need to talk to someone.
Other workers experienced the loss of their social work supervisor and
had to advocate for supervision by an MSW.
Previously we had a social work supervisor and there was more clinical
supervision, but she was replaced by a nurse because she did not have
the medical knowledge that the hospital wanted. There is no understanding of the social work role in this setting. (Jan)
In one hospital, the social workers acted more proactively in response to
the elimination of their social work director. The director had been demoted,
and they were then expected to report to a nurse. The social workers began
188
G. Kadushin et al.
meeting as a group to provide peer support and supervision, and this led to
political action. They were successful in getting the hospital to allow a licensed
social worker to be a consultant in order to provide supervision to staff.
Our previous social work supervisor was demoted and replaced by
a nurse supervisor. The new supervisor does not know much about
social work. After this happened we advocated for a social work supervisor, and the hospital hired a social worker who is a consultant for
supervision. (Will)
Organizational changes and the exponential increase in the scope of
the managers’ responsibilities made access to supervision problematic. The
participants reported that many social work supervisors carried wide-ranging
administrative responsibilities for corporate social work systems, entire
geographic areas, or several hospital departments. Even when the participants had social workers as managers or supervisors, some reported that
their ability to obtain supervision was eroded by the increased administrative
demands of their supervisor, particularly if the social work supervisor was
the department director. Many described ad hoc supervision based on the
supervisor’s availability rather than the workers’ needs. When they met with
their supervisor, the sessions were often described as shorter:
Our company was bought out by a larger company. Now it is harder to
communicate with higher people in the company . . . . Previously we had
access to social work supervision but the supervisor is less accessible
now and the quality of supervision is not as good. (Dodie)
One of the other things that might be a limitation is that we have overtaken many other centers throughout the United States and it’s just been
a very large growth boom within this organization. So, right now she [the
social work supervisor] is the only supervisor for the entire area. She is
the director of the entire department nationwide. So that does limit her
availability with that change. (Lisa)
He’s [the director] on a lot of different boards at the hospital. And the hospital is going through some changes where the person who is the head of
the hospital is going to be stepping down and they’re going into a search
committee to be looking for a new president of the hospital. He’s
involved a lot in that type of thing. So, I think that, where you don’t have
a time that’s set up, sometimes it’s difficult . . . versus if you have a supervisor who’s more accessible around the hospital. (Barb)
Others reported the presence of licensed clinical supervisors within
their work unit who provided supervision.
[Supervision] was by an RN because it was also under the offices of the
case management department. And what the social workers did, we
Hospital Social Work Supervision
189
actually fought to have a clinical supervisor. So, the most senior social
worker who was an LCSW took on the role of supervising us . . . . (Cathy)
Another factor that seemed to influence the frequency and mode of
supervision related to the status of the worker. In some but not all hospitals
new workers to the organization or service, or those who were preparing for
licensure, reported that they were more likely to receive scheduled, frequent
clinical supervision. This access may have been influenced by variations
between states’ licensure requirements.
The first six months on this job, I am way past licensure, we are supervised once a week. Then after six months, it is once a month . . . or as
needed. (Judy)
. . . in order to keep their licensure, they need to meet with the director of
social service once a week. (Debbie)
As supervisors assumed responsibilities for oversight of entire geographic regions or director positions over all social work departments in a
corporate system, communication technology appeared to be an essential
tool to facilitate access to supervision. Participants reported the use of cell
phones, pagers, e-mail, and the Internet as helpful tools to ensuring access
to clinical supervision or consultation.
Pretty much on a daily basis, several times a day . . . we’re on the Internet
so we have a direct e-mail access to each other all day long. I do mostly
[supervision] by phone about 20% clinical and the rest is administrative,
and we have a quarterly meeting with the supervisor every month. (Lisa)
I have access to clinical supervision as needed basically. I like the flexibility of being able to call him on a whim if I’m in the middle of something
and it’s stumping me or whatever I need to—or if something’s really bothered me that’s happened that I need to talk about . . . . I have that ability
then to page them and they’ll get back with me and so forth. (Elizabeth)
Ultimately, the strongest factor influencing the availability, frequency,
and models of supervision was organizational sanction. The participants
reported an array of scenarios ranging from complete disbanding of the
social work program with social workers reporting to non-social work leaders to centralized social work departments with social work managers
and supervisors. Organizational recognition and sanction for the importance
of social work supervision and the allocation of resources to the supervisory
function seemed to define the organizational context for supervision. Tracy,
a licensed social worker in a mental health hospital, attributed her access to
190
G. Kadushin et al.
supervision to the organization’s recognition of the salience of social work
supervision.
The flexibility of having access to individual supervision pretty much
whenever I need it is pretty useful. Like someone who said that their
licensure doesn’t require supervision, nor does mine, but my unit
supports it, my director supports it and her director supports it.
Administrative sanction is poignantly captured in the following scenario.
Although supervisory staff existed, they were unwilling to provide clinical
supervision to non-licensed workers. This finding suggests that the organization has no commitment to making these resources available to ensure their
workers achieve licensure.
[The participant] . . . as for licensure, that’s pretty frustrating . . . we have a
couple of people who are licensed who are not willing to provide
one-on-one supervision . . . . (Cathy)
The lack of commitment to licensure is also captured in the following
two quotes. The first participant describes how she chose to leave the
organization after the clinical supervisor position was not replaced. While
some chose to seek their supervisory hours outside of the organization, many
accepted positions that included available supervision. The provision of
supervision could have a significant impact on a health care setting’s ability
to recruit and retain competent social work practitioners.
And when she [the supervisor] left, that was actually the reason I left.
When she left, they didn’t make an effort to get a new clinical supervisor . . . I was losing about 30 hours a week of supervised hours [toward
licensure]. (Barb)
Will reported another example of sanction. He stated that after the
elimination of the social work manager=supervisor positions in his hospital,
the social work staff advocated for the provision of clinical supervision. The
organization agreed to have a consultant come to provide the supervision but
did not make it a requirement for all staff to obtain licensure. Will reported
that not all non-licensed staff took advantage of the clinical supervisor.
Again, this finding supports the concern that without administrative sanction,
the quality of social work services and the skill development of the staff
can be compromised, particularly in situations where supervision may be
provided by non-social workers.
And for the clinical supervision it’s an LCSW, I believe PhD, from outside
who really is just volunteering, it’s not, an LCSW is definitely not needed for
our position. It’s really just something that if you personally want to take
the time to help yourself out then that person is volunteering to do that.
Hospital Social Work Supervision
191
The system-driven nature of individual social work supervision was also
reflected in workers’ statements about the emphasis of their work on
discharge planning, length of stay, and cost control, and how this emphasis
shaped their supervision. However, workers who were seeking licensure, in
particular, and some of the licensed workers, mentioned wanting more
clinical insight from their supervision.
It’s getting everybody, no matter what your background is, it’s focused on
shortening length of stay and identifying discharge barriers early on . . . it
takes up a lot of everybody’s space and time, it is the top priority and so
all the energy is being spent in that direction and what gets left over you
might . . . be able to squeeze in some clinical. It’s just a matter of space
and time. (Abigail)
I could benefit from more clinical supervision. The work has a
psychosocial component but there is too much emphasis on concrete
services and supervision that is task-focused to get the job done. The
current emphasis is on length of stay and discharge planning. There is
more focus in supervision on these issues than clinical content. (Judy)
The presence of organizational sanction set the tone for the types of
supervisory models apparent within the organization. Both licensed and
unlicensed work