Article 10. The Lived Experience of Supervisors in Rural Settings

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Article 10. The Lived Experience of Supervisors in Rural Settings

Ideas and Research You Can Use: VISTAS 2013supervisors. Inclusion criteria required participants to have worked in a rural mentalhealth setting and have provided clinical supervision for at least five years. Initialcontacts were made via telephone and e-mail and pre-interview forms were mailed toparticipants to gather information about their experiences and training. This studyinvolved 10 supervisors (7 female and 3 male) working in community mental health andprivate practice. Creswell (2007) identified 6-10 participants as an appropriate numberfor phenomenological research. The supervisors reported between 8-45 years working inthe field (M=24, SD=14) and 8-38 years working as a supervisor (M=15, SD=8). Thesupervisors reported providing both clinical and administrative supervision to a case loadranging from 1-65 clinicians.Data CollectionParticipants working in community mental health took part in 1 of 2 focus groupinterviews (n=4 each). The focus and individual interviews were conducted at fourseparate mental health offices throughout one county. Focus groups are unique in thatthey allow members to construct meaning based on each other’s comments, ideas, orsuggestions, and become energized (Kress & Shoffner, 2007; Patton, 2002). To enhancecredibility, two additional individual interviews, using snow ball sampling, wereconducted with supervisors working in private practice. All interviews were digitallyrecorded and included the same set of 10 interview questions (see Appendix). Eachquestion was intended to be open-ended, neutral, and developed based on an extensivereview of literature, the researcher’s 12 years of experience working as a rural counselorand supervisor, the conceptual framework of the study, and in consultation with an expertin the field. The focus groups and individual interviews lasted between 60-90 and 45-60minutes in length, respectively.Data AnalysisThis study used a phenomenological perspective to examine the personalmeanings and lived experience of rural supervisors and followed Patton’s (2002)guidelines for qualitative data analysis. First, all interviews were immediately transcribedverbatim and reviewed as a whole by the researcher. Second, analysis focused onindividual descriptions to grasp the lived experiences of each supervisor. This processincluded horizontalization, which allowed equal credence of all statements produced byindividual participants (Creswell, 2007). Third, the researcher identified common themesor structures within the narratives (Wertz, 2005). Next, member-checking was used witha focus group member to review the results and verify the descriptions andinterpretations. The group member and research co-constructed the definition of one subtheme(i.e., wording and clarity). At this time, two auditors, who served as supervisors ofthis researcher, reviewed the interpretations and suggested additional individualinterviews to ensure the credibility of the research. Last, the data were synthesized into aholistic understanding and provided the psychological structure of the participants’experience (Wertz, 2005).TrustworthinessTrustworthiness can be established through credibility, confirmability,dependability, and transferability (Denzin & Lincoln, 2011). Credibility methods used to3


Ideas and Research You Can Use: VISTAS 2013generalist as a challenge voicing, “Working with supervisees who have very differentbackgrounds, life experiences, values, cultures, and education and training… it is achallenge to provide supervision to diverse supervisees.”Cultural competence and boundaries. Supervisors discussed the challenge ofdealing with cultural differences, managing boundaries and multiple relationships, andless anonymity. A supervisor shared,There is a distinct cultural difference in rural areas when you talk aboutdiversity. Being rural is a special client group. The value systems are justdifferent… it is important to know the culture and community you workwith and make sure supervisees know the community. [Supervisees] haveto get used to going into dirty homes and be comfortable when working inrural areas.Lack of supervisee appreciation and understanding of the rural culture was a consistenttheme with all the supervisors. One supervisor commented,Sometimes supervisees do not understand that a way of life for someclients may be completely normal for the client, such as not havingrunning water. Encouraging supervisees’ understanding and appreciationof the Amish culture, that it’s going to take them extra time to get therebecause they’re bringing a horse and buggy and not driving a car.Supervisors reported that urban training programs do not prepare counselors for ruralwork and supervisees sometimes experience culture shock. Rural supervisors need tounderstand how to navigate and support supervisees within the rural context.The challenge of blurred boundaries and multiple relationships were revealed as acommon concern. As illustrated by one supervisor, “You can be sitting in church, or youare at the Y[MCA] naked, the boundaries are blurred so easily here.” Another added,It does place boundaries on what we do in a lot more ways. I feltuncomfortable going to dinner and having wine with dinner, because whatif somebody saw me? What if someone saw me drinking wine, were theygoing to confront me.In addition to vague boundaries, a supervisor commented, “One encounters dualrelationship conflicts more readily in a rural area, the question is how do you steer yourway amid dual relationships?” Another supervisor added, “As a supervisor in a rural area,you are continually redefining, or reminding might be a better word, [supervisees] whatproper boundaries are and what is ethical versus unethical.”Life on an island. Life on an island represents the general sense of isolation experiencedby supervisors and the expressed need for professional support and continuing educationopportunities. Overall, supervisors did not feel adequately or developmentally prepared towork as a supervisor. Comments included, “I was just kind of like thrown in [to thesupervisor role]” and “I would like to have had more training as a supervisor.” Anotheradded,6


Ideas and Research You Can Use: VISTAS 2013You take and develop expertise in the clinical situation or the field work,whatever, and you do that for 20 years and then get promoted tosupervisor and you haven’t had supervisor training. And they’ve assumedbecause you’ve done field work that you can be a supervisor and the skillsets are very different.The need for support was a prominent concern expressed by all supervisors. Commentsincluded, “You have to be careful who you vent to,” and “Working in a rural area is veryisolating. There are not a lot of professionals around.” Finally, lack of trainingopportunities and the need to travel great distances to access continuing education wascited as a challenge.DiscussionThe purpose of this study was to examine the lived experience of clinicalsupervisors working in rural mental health settings. This study provided the opportunityfor rural supervisors, in their own words, to share the benefits and challenges ofproviding supervision. The findings provide a basis to discuss practical recommendationsto improve supervisor functioning and development in rural areas.Findings suggest rural supervisors need to use the strengths of rural communitiesto their advantage in their work. These strengths can act as a buffer and promote thedevelopment and functioning of the supervisor, supervisee, and rural client. Perceivedcultural strengths found in this study, also described by Stamm (2003), include tight-knitcommunities, rich collaboration with professionals, pragmatism, and informalprofessional support networks. Whether the relationship was with other mental healthproviders, family practitioners, or county or school administrators, all relationships wereperceived as important to the functioning of a rural supervisor. This finding reveals theimportance of training in interdisciplinary communication and collaboration skills foroutsiders who want to move into a rural area.In contrast, the supervisors shared multiple risk factors in the rural context thathave a rippling effect on their development and functioning. It is important to note thatmany of the supervisors’ perceived assumptions of working in an urban area may beinaccurate; however, urban areas do have multiple libraries, increased social networks,diverse mental health providers, and referral sources to help support supervisors and theirsupervisees (Morrissette, 2000). Similar to the findings in psychology (Barbopoulos &Clark, 2003; Helbok, 2003), school counseling (Morrissette, 2000), social work(Riebschleger, 2007), and family counseling (Weigel & Baker, 2002), the supervisorsreport the challenge of working from a generalist perspective. Supervisors need to have abroad range of training and knowledge, beyond that of their supervisees, in diversemental health issues with multiple populations, such as children, adolescents, adults, andfamilies (ACA, 2005; AMHCA, 2010). This can exacerbate supervisor anxiety, andincrease burnout and legal responsibilities, thereby suggesting the need for additionaltraining and support. Finally, rural counselors face numerous ethical challenges, such asdual relationships and boundary issues (Barbopoulos & Clark, 2003; Helbok, 2003;Weigel & Baker, 2002). In order to minimize the liability and risk, supervisors must betrained in supervision, risk management, and ethical decision making (Bernard &7


Ideas and Research You Can Use: VISTAS 2013Goodyear, 2009). What follows are practical implications to enhance the preparation,training, and support of rural supervisors.Enhance Rural Culture CompetenciesA consistent theme found in the current study included supervisees’ lack ofappreciation and understanding of the unique and diverse rural culture. Many superviseesare trained from an urban model (Helbok, 2003) and have not been exposed to ruralpopulations. The literature on rural school counselors highlights the need for specifictraining to deal with each unique rural culture and associated ethical issues (Weigel &Baker, 2002). Counselor educators can prepare mental health workers by introducingrural issues in existing classes or through a formal rural counseling course. This courseshould include training from a generalist framework, a review of ethical and legal issuesinherent in rural work, awareness of social issues, interdisciplinary communication, andfield experiences in rural settings (Ginsberg, 2005).Rural Supervisor Training and Continuing EducationSupervisors reported feeling ill-prepared, citing their own supervision educationprimarily through workshops and continuing education credits. Many of the supervisorsearned their degrees before supervision was considered a specialty. Mental healthcounselors promoted to supervisor roles, who are not developmentally prepared, canexperience anxiety, confusion, and low self-confidence (Stoltenberg, McNeill, &Delworth, 1998). A senior counselor promoted to supervisor, with no or little supervisorytraining, may not adequately assess the developmental level of the supervisee and fail toimplement appropriate strategies to promote growth and development (Pearson, 2001).As witnessed in this study, rural workers transition differently, or more rapidly, throughdevelopmental levels due to the nature of rural work. The findings support the need forinitial and continued education and training for rural workers. However, rural counselorshave low rates of professional memberships and attend few conferences (Coll et al.,2007) and finding and accessing continuing education and training opportunities is oftena barrier (Morrissette, 2000).Building Sidewalks: Supporting Rural SupervisorsThe need for peer support and collaboration to reduce feelings of isolation wasshared by all supervisors and is portrayed in related literature (Morrissette, 2000; Weigel& Baker, 2002). However, supervision of supervisors is not a priority in clinical settings(Casile, Gruber, & Rosenblatt, 2007). Peer supervision is a way rural supervisors canreceive supervision of their own services (Stamm, 2003; Weigel & Baker, 2002) and mayalleviate the stressors. The economy, failing industry, and managed care restrictions havean effect on those living in rural areas and service providers are struggling financially tosurvive. The comment, “Mental health gets the short end of the stick!” seemed toreverberate throughout all of the findings in this study. Systems, such as managed carecompanies, need to invest in supervision in order to improve rural clinical services(Stoltenberg et al., 1998). Agencies need to support regular supervision, training, andprofessional development opportunities through financial support and time off. A ruralsymposium for supervisors can be implemented that follows the general curriculumpresented by Riess and Fishel (2000). Finally, technology can be used to support rural8


Ideas and Research You Can Use: VISTAS 2013supervisors. Examples include: on-line discussion forums, videoconferencing, and webbasedsupervision (Sampson, Kolodinsky, & Greeno, 1997).Limitations and Research RecommendationsDue to the philosophical underpinnings of qualitative research, one cannotguarantee that the results of this study may be transferable. The current sample lackeddiversity and may not be representative of all rural supervisors. Researcher biases andpresuppositions may affect the outcomes of this qualitative study (Berg, 2007). Forexample, the formulation of research questions and data analysis may have beeninfluenced by the researcher’s perspective. Specifically, a few of the research questionsmay have been leading and needed to be more open-ended. Interviews can be a limitationin qualitative research as the researcher may influence the direction of the interview. Inaddition, the auditors in this study served in dual roles and were not completelyunattached to the study. The present study should be replicated in other rural locationswith a larger and more diverse sample. Further studies need to examine the assumptionsshared by rural supervisors, examining the effect of the rural context on rural mentalhealth counselors compared to their urban counterparts. Future research should use otherqualitative methods, such as case studies or ethnography to illuminate rural supervisors’experiences. Finally, the use of technology to enhance rural supervision should beexplored.An analysis of relevant themes that emerged from interviews with ten ruralsupervisors provided a rich description of the experience of rural supervisors. The resultsdemonstrate that working in rural mental health settings provides unique challenges.Rural supervisors expressed the challenges of working in multiple roles, lack of culturalcompetence, and working from a generalist perspective, while lacking training andsupport. There is a need for counselor educators to provide specific training and fieldexperiences to prepare supervisors for rural work and for enhanced support of ruralsupervisors.ReferencesAmerican Counseling Association [ACA]. (2005). Code of ethics and standards ofpractice. Alexandria, VA: Author.American Mental Health Counseling Association [AMHCA]. (2010). AMHCA Code ofEthics. Alexandria, VA: Author.Barbopoulos, A., & Clark, J. M. (2003). Practicing psychology in rural settings: Issuesand guidelines. Canadian Psychology, 44(4), 410-424.Berg, B. L. (2007). Qualitative research methods for the social sciences (6th ed.).Boston, MA: Pearson-Allyn.Bernard, J. M., & Goodyear, R. K. (2009). Fundamentals of clinical supervision (4thed.). Boston, MA: Merrill.Campbell, J. M. (2006). Essentials of clinical supervision. Hoboken, NJ: Wiley.Campbell, C. D., & Gordon, M. C. (2003). Acknowledging the inevitable: Multiplerelationships in rural practice. Professional Psychology: Research and Practice,34(4), 430-434.9


Ideas and Research You Can Use: VISTAS 2013Casile, W, J., Gruber, E. A., & Rosenblatt, S. N. (2007). Collaborative supervision for thenovice supervisor. In J. Gregoire and C. M. Jungers (Eds.), The counselor’scompanion (pp. 86-109). Mahwah, NJ: Lawrence Erlbaum Associates, Inc.Coll, K. M., Kovach, T., Cutler, M. M., & Smith, M. (2007). Exploring wellness and therural mental health counselor. Journal of Rural Community Psychology, 10(2)Retrieved from http://www.marshall.edu/jrcp/V10%20N2/coll.pdfCouncil for Accreditation of Counseling and Related Educational Programs [CACREP].(2001). CACREP accreditation standards and procedures manual. Alexandria,VA: Author.Creswell, J. W. (2007). Qualitative inquiry and research design: Choosing among fivetraditions (2 nd ed.). Thousand Oaks, CA: Sage.Denzin, N. K., & Lincoln, Y. S. (Eds.) (2011). Handbook of qualitative research (4thed.). Thousand Oaks, CA: Sage PublicationsErickson, S. H. (2001). Multiple relationships in rural counseling. The Family Journal, 9,302-304.Gale, J. A., & Deprez, R. D. (2003). A public health approach to the challenges of ruralmental health service integration. In B.H. Stamm (Ed.), Rural behavioral healthcare: An interdisciplinary guide (pp. 95-108). Washington, DC: APA Books.Ginsberg, L. H. (Ed.). (2005). Social work in rural communities (4th ed.). Alexandria,VA: Council on Social Work Education.Glense, C. (2006). Becoming qualitative researchers: An introduction (3rd ed.). Boston,MA: Pearson Allyn & Beacon.Helbok, C. M. (2003). The practice of psychology in rural communities: Potential ethicaldilemmas. Ethics and Behavior, 13(4), 367-384.Johnson, M., & Dunbar, E. (2005). Culturally relevant social work practice in diverserural communities. In L. H. Ginsberg (Ed.), Social work in rural communities (pp.175-188). Alexandria: VA: Council on Social Work Education,Kress, V. E., & Shoffner, M. F. (2007). Focus groups: A practical and applied researchapproach for counselors [Electronic version]. Journal of Counseling andDevelopment, 85(2), 189-196.Kruse, S. J., & Aten, J. D. (2007). Preparing psychologists to work with underservedpopulations: A faith-based pre-doctoral training model [Electronic version].Journal of Psychology and Theology, 35(2), 123-132.Morrissette, P. J. (2000). The experiences of the rural school counselor [Electronicversion]. Professional School Counseling, 3(3), 197-210.Moustakas, C. (1994). Phenomenological research methods. Thousand Oaks, CA: Sage.Patton, M. Q. (2002). Qualitative research and evaluation methods (3rd ed.). ThousandOaks, CA: Sage.Pearson, Q. M. (2001). A case in clinical supervision: A framework for putting theoryinto practice [Electronic version]. Journal of Mental Health Counseling, 23(2),174-184.Riebschleger, J. (2007). Social counselors’ suggestions for effective rural practice.Families in Society, 88(2), 203-213.Riess, H., & Fishel, A. K. (2000). The necessity of continuing education forpsychotherapy supervisors [Electronic version]. Academic Psychiatry, 24(3), 147-156.10


Ideas and Research You Can Use: VISTAS 2013Sampson, J. P., Kolodinsky, R. W., & Greeno, B. P. (1997). Counseling on theinformation highway: Future possibilities and potential problems [Electronicversion]. Journal of Counseling Development, 75(3), 203-213.Schank, J. A., & Skovholt, T. M. (1997). Dual-relationship dilemmas of rural and smallcommunitypsychologists. Professional Psychology: Research and Practice,28(1), 44-49.Stamm, B. H. (2003). Rural behavioral health care. Washington, DC: AmericanPsychological Association.Stoltenberg, C. D., McNeill, B., & Delworth, U. (1998). IDM Supervision: An integrateddevelopmental model of supervising counselors and therapists. San Francisco,CA: Jossey-Bass.Stoltenberg, C. D., & McNeill, B. (2009). IDM Supervision: An integrated developmentalmodel of supervising counselors and therapists (3rd ed.). New York, NY: Taylor& Francis.Sutton, J. M., Jr. (2002). The practice of school counseling in rural and small townschools [Electronic version]. Professional School Counselor, 5(4), 266-277.U. S. Census Bureau. (2010). Unites States Census Bureau (2010) Census 2010 Urbanand Rural Classification. Retrieved from http://www.census.gov/geo/www/ua/2010urbanruralclass.htmlU. S. Census Bureau. (2012). Unites States Census Bureau (2011) State and CountyQuick Facts. Retrieved from http://quickfacts.census.gov/qfd/states/42/42121.htmlVan Manen, M. (1990). Researching lived experience: Human science for an actionsensitive pedagogy. Ontario, Canada: The Althouse Press.Weigel, D. J., & Baker, B. G. (2002). Unique issues in rural couple and familycounseling. The Family Journal: Counseling and Therapy for Couples andFamilies, 10, 61-69.Wertz, F. J. (2005). Phenomenological research methods for counseling psychology.Journal of Counseling Psychology, 52, 167-177.Note: This paper is part of the annual VISTAS project sponsored by the American Counseling Association.Find more information on the project at: http://counselingoutfitters.com/vistas/VISTAS_Home.htm11


Ideas and Research You Can Use: VISTAS 2013AppendixInterview Questions1. What is your experience working as a supervisor in a rural area?2. How have you been prepared to provide supervision in rural areas?3. How do you supervise a counselor in rural mental health settings?4. What are your needs as a supervisor in rural mental health settings?5. Are there any factors that affect your performance as a supervisor in rural mentalhealth settings?6. What preventive or self-care strategies do you employ?7. Why do you choose to work in rural areas?8. What are the advantages and disadvantages of working in rural areas?9. What recommendations do you make for preparation and support of supervisorsworking in rural areas?10. What should I have asked you that I did not ask that would help me betterunderstand the experience of supervisors in rural settings?12

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