Monthly Archives: November 2014

Behind the Book: DSM-5 Learning Companion for Counselors

By Bethany Bray November 10, 2014

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), often referred to as the “psychiatric bible,” occupies a mandatory spot on the bookshelves of many counselors.

The American Psychiatric Association released this most recent version of the DSM in May 2013, after more than 12 years of planning, research and review.

The ability to confidently navigate the DSM-5’s nearly 1,000 pages of material is of the utmost importance to counselors of all types, says Stephanie Dailey, co-author of DSM-5 Learning DSM5Companion for Counselors, newly published by the American Counseling Association.

Dailey and co-authors Carman Gill, Shannon Karl and Casey Barrio Minton collaborated on the book to bring counselors up to speed on the new manual and highlight how it applies to their day-to-day work.

Their goal, says Dailey, was to make the DSM-5 accessible to counselors.

“Even professionals who are not traditionally responsible for diagnosis as a part of their counseling services, such as school or career counselors, should understand the DSM so they can recognize diagnostic problems or complaints and participate in discussions and treatment regarding these issues,” the authors write in the book’s introduction.

“Despite widespread guidance encouraging counselors to be familiar with the DSM, utilization of the manual is not without challenges and controversy. … As counselors are only too aware, clients cannot be encapsulated into fixed categories. Each client comes to counseling with numerous sociocultural issues that the counselor must consider prior to making a diagnosis and putting together an approach for treatment.”


Q+A: DSM-5 Learning Companion for Counselors

Responses from co-author Stephanie Dailey


At 947 pages, you and your co-authors had a lot of ground to cover. Please explain the thought process that went into the way you broke the DSM-5’s subject matter up in your book.

We wrote this Learning Companion to make the DSM-5 accessible to professional counselors. Given the huge implications of changes to diagnostic nomenclature, our primary goal was to break down the changes and additions found within the revised manual. We used language that was applicable to the work that counselors do and, after reviewing major philosophical and structural changes, organized the book by disorders counselors most frequently diagnose. The learning companion is divided into four parts grouped by diagnostic similarity and relevance to the counseling profession. In each of the four parts, we provide a basic description of the diagnostic classification and an overview of the specific disorders covered, highlighting essential features as they relate to the counseling profession. We also provide a comprehensive review of specific changes, when applicable, from the DSM-IV-TR to the DSM-5. When specific or significant changes to a diagnostic category or diagnosis have not been made, we provide a general review of either the category or the diagnosis, but we refrain from providing the reader with too much detail because the purpose of this Learning Companion is to focus on changes from the DSM-IV-TR to the DSM-5.


Having spent so much time delving into the DSM-5, what are some key takeaways you would want counselors to know about it?

This is a tough question because of the multiple roles that counselors play. However, if I had to choose five “must know” takeaways, I would select the following:

  1. Removal of the multiaxial system, including the Global Assessment of Functioning (GAF): When writing up disorders, counselors should combine Axes I, II and III and include Axis IV with clinical disorders, either as a notation or as a V Code. The WHODAS 2.0 has replaced the GAF (see int/classifications/icf/whodasii/en/)
  2. Emerging measures: The American Psychiatric Association has published on its website measures which counselors can use, provided they are knowledgeable about the measure and can ethically incorporate them into their work. There are two different types of measures — cross-cutting and disorder specific. Measures are not required for diagnosis, but some counselors may find them useful (see org/practice/dsm/dsm5/online-assessment-measures).
  3. Other specified and unspecified diagnoses: To reduce overreliance on NOS (not otherwise specified) diagnoses, clinicians who work with individuals who do not meet full criteria for more specific disorders within the DSM-5 now have two options: “other specified” and “unspecified” diagnoses. Clinicians will use other specified diagnosis to record a concern within a specific diagnostic category and a reason why a more specific diagnosis is not provided. Clinicians will use unspecified diagnoses when they are certain about the category of diagnosis but unable or unwilling to provide additional details.
  4. Start using the DSM-5 now (or when it makes sense to do so): Counselors may begin using the updated manual and diagnostic criteria as soon as they are ready to do so. However, insurance companies, other third-party payers and community agencies may need time to adjust reporting systems from multiaxial to nonaxial formats. At the time the DSM-5 was published, the American Psychiatric Association predicted that the insurance industry would transition to DSM-5 by December 31, 2013. However, this estimate was optimistic, as most third-party billing systems and government agencies are unlikely to formally switch over to the DSM-5 until October 1, 2015, when a nationwide mandate for the use of ICD (International Classification of Diseases)-10-CM codes goes into effect.
  5. Coding changes and specifiers: The DSM-5 includes ICD-9-CM codes for current billing use as well as ICD-10-CM codes for use after the October 1, 2015, nationwide conversion to ICD-10 In the DSM-5, ICD-9-CM codes appear first, are in black print and generally include three digits or begin with V. In contrast, ICD-10-CM codes appear in parenthesis, are in gray print and generally begin with a letter. Psychosocial and environmental factors often begin with Z. There are more specifiers in this edition, many of which indicate symptom severity, than any other DSM to date. Counselors should pay particular attention to these when recording diagnoses.


Although ACA advocated for counselors throughout the DSM-5 revision process, no professional counselors served on its task force. Is one of the goals of your book to provide a counseling “translation” of a volume written for and by psychiatrists?

One of the major frustrations of mine is that counselors have yet to be included in the development process of any iteration of the DSM. That said, ACA served as an important advocate for professional counselors during the revision process. Through advocacy efforts of ACA’s Professional Affairs Office and the ACA DSM-5 Revision Task Force, two ACA presidents sent letters to the American Psychiatric Association indicating concern over proposed changes. The first was sent by Lynn Linde, ACA 2009–2010 president, to David Kupfer, [American Psychiatric Association] DSM-5 Task Force chair. The letter indicated that ACA members had concerns regarding five areas of particular importance to professional counselors. The second letter was sent by Don Locke, ACA 2011–2012 president, informing John Oldham, American Psychiatric Association president, that licensed professional counselors were the second largest group to routinely use the DSM-IV-TR. He noted uncertainty among professional counselors about the quality and credibility of the DSM-5 and included a prioritized list of concerns the American Psychiatric Association should consider before publishing the DSM-5.

So, yes, it was our goal to help counselors transition to the new manual but, more importantly, we also believe it is imperative that counselors have a place at the table when future iterations of the manual are developed. By pointing out strengths and weaknesses of the DSM-5 as they pertain to the work that counselors do, we hope this book will help facilitate future advocacy efforts.


Do you feel counselors refer to the DSM-5 too often or not enough (or neither)?

The DSM-5 is simply a part of the work that counselors do, its use specific to the role that each professional plays. Professional counselors who provide services in mental health centers, psychiatric hospitals, employee assistance programs, detention centers, private practice or other community settings must be well versed in client conceptualization and diagnostic assessment. For those in private practice, agencies and hospitals, a diagnosis using DSM criteria is necessary for third-party payments and for certain types of record keeping and reporting. Even professionals who are not traditionally responsible for diagnosis as a part of their counseling services, such as school or career counselors, should understand the DSM so they can recognize diagnostic problems or complaints and participate in discussions and treatment regarding these issues.


Do you think the DSM-5 is something counselors sometimes feel overwhelmed or frustrated by? If so, how?

No, counselors should not feel overwhelmed. Although many advocates voiced concerns that the DSM-5 would lead to a rather drastic shift in conceptualization of mental disorders, assessment procedures and diagnostic thresholds, this version of the psychiatric bible looks remarkably like its predecessor.


What inspired you and your co-authors to collaborate and write this book?

We wrote this Learning Companion to make the DSM-5 accessible to professional counselors by breaking down the complexity of the changes and additions found within the revised manual. Because the CACREP 2009 Standards require that programs “provide an understanding of the nature and needs of persons at all developmental levels and in multicultural contexts … including an understanding of psychopathology and situational and environmental factors that affect both normal and abnormal behavior,” we believe it is essential that new and seasoned professional counselors, counselor educators and counseling students have easily accessible and accurate information regarding the DSM-5 and implications of changes for current counseling practice.


What do you hope counselors take away from the book?

The ability to navigate and use the DSM-5 so they can recognize diagnostic problems or complaints and participate in discussions, treatment and research regarding these issues. Most importantly, we wanted to describe how these changes translate to current counseling practices.




78087The DSM-5 Learning Companion for Counselors is available from the American Counseling Association bookstore at or by calling 800-422-2648 x 222








About the authors

  • Stephanie Dailey is a licensed professional counselor and assistant professor of counseling at Argosy University in Washington, D.C.
  • Carman Gill is a licensed professional counselor and associate professor and chair of the counselor education program at Argosy University. She served on ACA’s DSM-5 Revision Task Force.
  • Shannon Karl is a licensed mental health counselor and associate professor with the Center for Psychological Studies at Nova Southeastern University in Florida. She was a member of ACA’s DSM-5 Revision Task Force from 2011 to 2013.
  • Casey Barrio Minton is an associate professor and counseling program coordinator at the University of North Texas.






Bethany Bray is a staff writer for Counseling Today. Contact her at


Follow Counseling Today on Twitter @ACA_CTonline and on Facebook:


Progress on the path to somewhere over the rainbow

By Mark Pope November 5, 2014

The Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling (ALGBTIC) held the first national conference in the history of the organization on Sept. 19-21. And what a conference it was! New Orleans was such a fitting place to hold this first conference because the city was where the founders of this American Counseling Association division first met and birthed ALGBTIC (or the Caucus of Gay Counselors, as it was called back then). Joe Norton, a counseling professor at the

The Association for Lesbian, Gay, Bisexual & Transgender Issues in Counseling (ALGBTIC) recently held their first conference in New Orleans.

The Association for Lesbian, Gay, Bisexual & Transgender Issues in Counseling (ALGBTIC) held their first conference in New Orleans this fall.

State University of New York–Albany, had called for a meeting of “gay counselors” in March 1974 during the national convention of the American Personnel and Guidance Association (now ACA). And people came.

Out of that meeting, a plan was developed to propose a workshop at the next APGA convention that was to be held in New York City in 1975. Only a few individuals were able to put their names on the proposal for fear of being “outed.” The convention program committee accepted the proposal, and the workshop was assigned to a room that was supposed to hold about 90 people. Instead, it ended up being standing room only. We had to close the doors to the room, not because it was too crowded, but because some of those who attended that first workshop were simply afraid — afraid that they would be fired by their school district or college or community-based organization for even being seen attending this type of workshop. Such were the times.

Fast forward to 2014. Expecting 100 attendees for this inaugural conference, almost 300 showed up. Organized in part by ALGBTIC President Jane Rheineck, the conference was a rich feast for those who specialize or merely have interest in this area of the counseling profession. At the opening session, several of us had tears in our eyes.

It is rare for me to go to a professional conference and find too many programs that I want to attend, no matter how large the conference. Let’s just say that I’ve been around awhile. But this conference

ACA President-Elect Thelma Duffey speaks at the opening session of the ALGBTIC conference in September.

ACA President-Elect Thelma Duffey speaks at the opening session of the ALGBTIC conference in September.

was so very different for me. In my life, I’ve never been to such a conference where I literally wanted to go to every program on the schedule. A special energy was present among the attendees as we packed into each session to listen, learn and talk about our passion for counseling with LGBTQQIAA people (yes, we have a growing acronym and community).

This conference was also well supported by the leadership of our profession, with ACA President-elect Thelma Duffey and three former ACA presidents (Patricia Arredondo, Colleen Logan and myself) in attendance. The buzz throughout this conference was that there has to be another one. Whether it is in one year or two years is the only question. Not if, but when. But attending the very first one after 40 years in our profession was so

Mark Pope and Patricia Arredondo at the ALGBTIC conference.

Mark Pope and Patricia Arredondo at the ALGBTIC conference.

emotional for all of us who have been around for all those years. It’s been a long road. I think that I speak for all of us who have been here from the beginning when I say that we were just glad to have this happen in our lifetime.

As Sam Gladding might have said at one of his many speeches, quoting the lyrics of Sam Cooke, “It’s been a long time coming, but I know a change gonna come.” I was so thrilled to be there for this one.





Mark Pope is professor and chair of the Department of Counseling and Family Therapy at the University of Missouri – Saint Louis. He is also a past president of the predecessor to ALGBTIC (Caucus of Gay Counselors/National Caucus of Gay and Lesbian Counselors), the National Career Development Association and the American Counseling Association.




For more information on ALGBTIC, or to see a slideshow of photos from conference,



A steadying hand

By Laurie Meyers November 1, 2014

Receiving supervision is an experience common to all counselors. Some view it as little more than an experience to be endured — another box to be ticked off the list in pursuit of a counseling degree or counselor licensure. Perhaps that’s because securing the proper supervision can be a frustrating, time-consuming and expensive proposition, especially at the beginning of a counseling career when Bird landing on an outstretched handthe paychecks are low and the burden of student loan debt is heavy.

Many other counselors, however, possess a different perspective, believing that all the “gains” achieved through supervision are worth the potential “pains” that accompany the process. Professionals who study and provide counselor supervision contend that the supervisory experience is critical to a counselor’s development. Many of these professionals also think that supervision is something counselors should seek throughout their careers — not just at the beginning of a career — from senior colleagues and peers.

Counseling Today recently spoke with several counselors about what makes a supervisory relationship work, as well as some of the challenges inherent in supervision.

A reflection of the counselor-client relationship

In a recent small study, American Counseling Association members M. Kristina DePue and Glenn Lambie found that effective supervision is more about the relationship itself than the particular methods or strategies used during supervision (studies have found, of course, that the same holds true with the counseling process). Lambie and DePue examined satisfaction ratings by supervisees and supervisors and found that high satisfaction ratings correlated with greater competency levels during the practicum process.

As with the counselor-client relationship, the supervisor-supervisee relationship should include trust and acceptance, says DePue, an assistant professor of counselor education at the University of Florida. As a constructivist, she believes the supervision process is (or should be) a holding environment — one of support, challenge and continuity.

“I know that might sound odd to many people,” DePue says, “but when we think about it, counseling serves the purpose of providing a safe space for growth and change. In reality, supervision does the same thing. Therefore, we should expect to see very similar patterns in these relationships.”

In fact, DePue thinks that in order to provide understanding and effective supervision, those who supervise must keep the therapeutic relationship in mind.

“Students aren’t that dissimilar [from] our clients,” she points out. “They are attracted to this profession for various reasons, but oftentimes they come to training with a history of wounds that need healing. Supervisors should know what to expect from trainees at a particular developmental stage. For example, if we are working with practicum students, skill acquisition and self-awareness may be drastically less than [it is in] a person in their first year of licensure. It is important to consistently think about the individual student and what they need at this point in the trajectory of their career. Always be mindful that students are developing skills and developing personally. We can help or harm their development, and I think having realistic expectations is a huge part of not being too critical or harsh on students.”

Lambie, a professor of counselor education and chair of the Department of Child, Family and Community Sciences at the University of Central Florida, agrees about the importance of maintaining an environment in which supervisees are able to be themselves and feel comfortable trying different things.

Referring to his supervision of students, Lambie says, “We don’t want it to be just sink or swim. When you’re new you need feedback, and we want to provide you with that feedback.”

Lambie’s advice to other supervisors is to remain mindful throughout the process. “Be purposeful in trying to develop a strong supervisory bond. Don’t just take it for granted,” he urges. “It’s important for a supervisor to model what he or she wants to support in his or her supervisees. If I want you to be more empathetic but I’m yelling at you, I don’t think that’s going to be a good experience.”

Critical support

During their professional journeys, many counselors experience critical incidents — specific moments or cases that cause them to question the path they’re on. Oftentimes, these critical incidents can be positive, serving as turning points that deepen a counselor’s sense of professional identity, says Ruthann Smith Anderson, an ACA member and past president of the Ohio Mental Health Counselors Association. However, when a supervisee experiences a critical incident, the encounter can be overwhelming. Supervisors need to recognize when supervisees have had a critical incident so they can help guide the supervisee through it.

“There are moments when counselors-in-training come up against something they don’t expect in terms of who they are in counseling and what counseling is. It can cause them to question themselves, their qualifications and capabilities,” says Anderson, a licensed professional clinical counselor supervisor (LPCC-S) and an assistant professor of counseling and human development at Walsh University in North Canton, Ohio.

Critical incidents among supervisees often involve questioning professional identity, difficulty with the complexity of real-life cases and even struggling with the supervision process itself, Anderson says. In some cases, supervisees are dealing with a sense of disappointment because they are not as professionally competent as they assumed, she adds.

“One of the things that supervisors have to do is provide a safe environment,” Anderson says. “Supervisees frequently feel insecure and full of self-doubt, and they need to feel that they can come to the supervisor and express that. You [the supervisor] have to find a way to give feedback that is clear, concrete and immediate, and you want it to be sandwiched with feedback about what the supervisee has done well. Supervisors need to remember how vulnerable supervisees are and to help normalize it — tell them that these reactions are common. In talking with students, they have consistently said that if they don’t feel safe [in the supervisory relationship], they won’t bring up their doubts.”

Providing consistent feedback requires close supervision. In Anderson’s program, all supervisee sessions are taped so that the supervisor can later review the session with the supervisee. Supervisors also watch some sessions live from another office.

Going over the session tapes with supervisees helps Anderson track their professional development and provide guidance in areas in which they need more help. For example, perhaps the supervisee didn’t stop to note that what the client was saying didn’t match his or her affect — maybe the person was smiling or laughing while talking about something sad. Anderson can jump to that spot in the session tape and ask what the supervisee was thinking at that moment and what the supervisee might say now. If the supervisee still doesn’t recognize the problem, Anderson will explain it and ask why the supervisee thinks he or she missed it. The supervisee can then bring the issue up with the client in the next session and also will have learned to watch for similar reactions with other clients.

Working with and teaching supervisees, not just telling them what they did wrong, is part of successful and supportive supervision, Anderson says. “When [providing] supervision, hopefully you are doing supervision on several levels — developing skills, deepening the ability to hypothesize or conceptualize, and exploring who the supervisee is as an individual and how that influences [his or her] work,” she explains.

When supervising closely on all three of those levels, Anderson says, supervisors are likely to catch a supervisee’s critical incidents and any other issues that need to be addressed.

Protecting against client suicide

Among the most difficult circumstances any counselor will face is a client’s death by suicide. Now imagine confronting that reality in the supervision process. Although it is not a common occurrence, it can and does happen, says Daniel Weigel, a licensed professional counselor (LPC) and ACA member. To protect supervisees, clients and themselves, supervisors must observe caseloads closely, teach supervisees how to assess for clients who may be suicidal and build a strong supervisory relationship that encourages novice counselors to ask for help anytime they are working with a client who is potentially suicidal.

Such clients aren’t likely to come in to counseling and announce that they’re feeling suicidal. Instead, counselors must be on the alert for subtle signs, including behavioral or verbal clues that novice counselors and counseling students might overlook, says Weigel, a counseling professor and the practicum and internship coordinator for the counseling programs at Southeastern Oklahoma State University. As an example, he mentions clients who avoid using a future orientation in conversation, such as discussing plans for the weekend or talking about what they’ll do after graduation, or who speak almost exclusively in the past tense.

Because not all clients will have been diagnosed previously, supervisors also need to teach their supervisees to recognize signs of disorders such as depressive disorders, bipolar disorders, substance abuse and schizophrenia that commonly accompany suicide attempts, Weigel says. Other signs supervisees should be taught to probe for are a previous history of suicide attempts (which Weigel identifies as perhaps the best predictor of future attempts); isolation from social supports such as family members, a partner, friends or a religious community; abuse of alcohol or drugs; and addictive behaviors such as gambling, among many other potential signs.

“Counselors-in-training require education in recognizing these clues and trusting their instincts to ask the necessary questions if such situations arise with a client,” Weigel says. Supervisors can help supervisees by observing or shadowing actual suicide assessments (if clients give their permission). As supervisees become more experienced, they can also learn by co-participating with supervisors or taking the lead (under live supervision) in conducting suicide assessments and interventions.

Providing close and collaborative supervision is likely the only way for a supervisor to accurately determine whether the supervisee’s client is at risk for suicide, Weigel says. “To rely solely on information presented by a supervisee verbally or in written form, as opposed to the raw data presented in recorded sessions, live supervision or co-counseling supervision strategies, is unlikely to reveal the subtle clues of client suicide risk,” he says.

Weigel acknowledges that much of the supervision being provided in the field is not live, in part because many supervisors don’t have the time necessary to see their own clients and observe live counseling sessions conducted by their supervisees. In addition, many supervision sites don’t have the capability to tape sessions for later review. So Weigel stresses the importance of developing a strong supervisory relationship, particularly if supervision must be based solely on verbal or written reports from the supervisee. Otherwise, supervisees may be tempted to hold back and present only that information they think will “please” the supervisor. According to Weigel, this is very common behavior.

Weigel advises supervisors to screen clients carefully before pairing them up with a counseling student or novice counselor to determine if they are an appropriate match. He also directly discusses the possibility of client suicide with his supervisees.

“Allowing supervisees who are not carefully oriented and trained in suicide assessment to see clients is a very dangerous position in which to place everyone. The first step in handling a potential crisis between a supervisee and his or her client is to educate [the supervisee] on the process before clients are ever seen,” says Weigel. He explains that preparation involves carefully reviewing the signs of suicide risk with supervisees, while also encouraging them to tune in to their own feelings and trust their instincts.

“Many novice counselors feel like impostors or feel unprepared to see clients,” he says. “Part of the role of the supervisor is to help supervisees feel empowered to trust the skills they have learned and the instincts they carry. This is especially true regarding skills related to crisis intervention.”

At Southeastern Oklahoma State, if a supervisee at the practicum or internship level suspects a client may be suicidal, he or she must bring the supervisor in immediately. Supervisors should establish a procedure for this circumstance ahead of time because suicidal clients should never be left alone, even for a moment, Weigel emphasizes. Once the supervisor is called in, he or she will typically take over the suicide assessment and ideally give the counselor-in-training the opportunity to observe the assessment and intervention in real time, he says.

Preparing supervisees for the possibility of client suicide is an incredibly difficult part of supervision, Weigel says. “[It] can, quite frankly, become overwhelming at times. Any client with whom we work is at risk of death by suicide, just as any supervisee’s clients might be at risk of the same. For me, the scariest part of clinical supervision is the fact that one of my supervisee’s clients might die by suicide, and I may never have had a chance to meet with that client.”

Multicultural competence

The United States has long been a nation of many cultures, and its population continues to grow more diverse. Yet most counseling programs offer only one course specifically devoted to multiculturalism, notes ACA member Kevin Feisthamel, director of counseling, health and disability services at Hiram College in Ohio. He doesn’t believe that’s enough.

“We need to become aware of our biases and become competent,” asserts Feisthamel, an LPCC-S and national certified counselor. “As supervisors, we need to be up to date on the latest [multicultural] research. [But] we get complacent or get so busy that we don’t have time. We forget that we have an ethical mandate [to teach multicultural skills].”

Being multiculturally competent as a counselor doesn’t automatically make you multiculturally competent as a supervisor, says Paula Britton, an ACA member and professional clinical counselor supervisor who runs a multicultural workshop for supervisors in Ohio. “In many states, you don’t need any additional multicultural training to become a supervisor,” she notes. When supervisors aren’t multiculturally competent, they are really doing their supervisees a disservice, contends Britton, who believes that supervision is the best place to learn multicultural competence.

Multicultural awareness in supervision doesn’t just concern clients; it may also be an issue within the supervisory relationship itself, says Britton, a professor of clinical mental health counseling at John Carroll University. “People who come from oppressed cultures often have trouble with trusting people in power, and supervisors are people in power,” she points out.

If a supervisor doesn’t take the time to understand a supervisee’s personal cultural background, the supervisor may make assumptions that further impede trust being established in the supervisory relationship, Britton says. And if a supervisee doesn’t trust the supervisor, he or she will be less likely to ask questions or bring up concerns, which can have a negative effect on the counselor’s professional development and, ultimately, the quality of care provided to clients.

Britton offers the example of a white supervisor with a supervisee who is African American. The supervisor might make the assumption that the supervisee comes from a low-income background. “Then the supervisee feels misunderstood but doesn’t want to say anything because [he or she is] being evaluated,” Britton says.

The best way for supervisors to start building a relationship of trust is to genuinely get to know their supervisees by asking about their culture. “I see a lot of supervisors who are worried that they will offend someone, so they just don’t say anything [about cultural differences],” Britton says. “We know from literature that that is the worst thing you can do. The more questions you ask, the better. The supervisor can [also] say [something like], ‘I’m aware that I’m white and you are Latino. I want to be sensitive, but if I say something insensitive, let me know.’”

Counselors need to educate themselves, but that doesn’t mean they have to be experts on every culture, either with their supervisees or with their clients, Britton says. Rather, she explains, they simply need to speak up and acknowledge when there are holes in their cultural understanding.

“Say to your supervisee, ‘I don’t know a lot about this culture. Let’s explore it more,’” she urges. By doing that, a supervisor shows the supervisee that learning is a career-long process and that even veteran counselors don’t have all the answers, she says.

Feisthamel sits down with his interns whenever they will be working with a client from another culture and asks them how knowledgeable or comfortable they feel about that particular culture. “They [the supervisee] might say, ‘Well, I’m not too familiar with the culture in India,’ and I’ll say, ‘OK, what are your questions? Let’s look at the research and find out what’s working for Indian people.’”

Feisthamel also encourages his supervisees to ask questions. “I think sometimes students don’t ask questions because they’re afraid to be wrong,” he says. The supervisor needs to make sure that the supervisee feels comfortable enough to ask questions — even if they seem stupid, asserts Feisthamel.

Britton agrees. “The best thing you can do as a supervisor with any supervisee is make them feel safe instead of making them feel like they have to pretend.”

Helping counselors-in-training and the community

Counseling students at Indiana State University receive assistance with internship placement, but the program staff there also wanted students to get more experience under live supervision. So the staff lobbied to reopen a community mental health clinic, associated with the university since the 1970s, that had recently fallen by the wayside.

“We have an underserved community,” says Catherine Tucker, director of the clinical mental health counseling program at Indiana State. “We also have a highly service-oriented program.”

The clinic is staffed by three of the department’s counselor educators, as well as outside clinicians and the students themselves. Students begin work there during their practicum and stay on during the summer between practicum and internship. Although they are placed outside the clinic for internship, they still put in hours at the clinic.

But the clinic isn’t just convenient for the community and students; it’s essential to the supervisory process, says Tucker, a member of ACA. Instead of reviewing tapes from supervised sessions off campus, as the program used to do, all supervision at the clinic is live. Each consultation room has a camera with a live feed that is monitored by staff and other students in a main control room. The camera also records all sessions so that students can review them later. In addition to being observed from the control room, students come out halfway through their counseling sessions for a brief consultation on what is going well, what isn’t and what they might try next.

“It is so much better [than before] because they [the supervisees] can go back in and, if they missed something, they can ask questions,” Tucker says. “Or if they need to change techniques, they can do it then. If they are just bringing in a tape or discussing it [afterward], it’s too late. They can make a change the next week, but the opportunity for immediate change [and learning] is gone. I think all the skills develop more rapidly when you have the chance to go back and correct in real time.”

How do supervisees react to being watched by multiple observers? “They’re very self-conscious at the beginning,” Tucker acknowledges. “It’s strange [for them] to think that they’re being taped and watched.”

But the faculty reassures supervisees that the purpose of the observation is not to catalog all their faults. “We see this as a developmental process,” Tucker explains. “Other students also observe. If you don’t have another client, you are expected to watch another session. At first [the supervisees’ reaction is] kind of deer in the headlights. We talk a lot about that in practicum and let them know that it’s normal to be strung out and anxious the first few times.”

“Starting out, we want to make sure basic skills are solid and that they can do an interview,” Tucker continues. “As time goes on, we want to make sure they are solid on diagnosis and that they can pull in their [chosen] technique. We also want them to know that they are in a developmental role. Growth happens over the length of a career, not just in one process. We don’t expect perfection, but we always expect to see progress.”

The supervisees and the program also benefit from the participation of counselors from outside the university. These counselors not only provide an outside perspective but also help students gain an understanding of the nuts and bolts of private practice, such as billing practices and issues (the clinic charges a nominal fee and doesn’t bill), and all the documentation that practitioners need to keep. “They [the outside practitioners] also have access to outside referral services that we don’t have,” Tucker adds.

The clinic serves individual adults, children, families and couples. The faculty uses this variety to push supervisees out of their comfort zones.

“If they say that children make them nervous, we’ll stick them with a 4-year-old,” says Tucker, noting that several of her supervisees initially voiced feeling uncomfortable counseling children, only to later decide that they wanted to become play therapists.

But the main point of the clinic is to give the students experience counseling a wide variety of clients. “They need to become generalists, because in the beginning [of a counseling career], you need to be able to handle whatever comes through the door,” she says.

Tucker believes live supervision is the key to getting counselors-in-training ready for internship and beyond. Therefore, she urges other counselor educators to find a way to incorporate at least a few live supervision sessions into practicum or internships.

“The growth we see is absolutely exponential when compared with the other model [of just reviewing session tapes],” she says. “The thing that really strikes me is that when internships start, they [the counseling students] say they feel really comfortable walking into a meeting and saying, ‘This is my treatment plan, and this is how I’m going to implement it.’ … Seeing the growth firsthand has been really exciting.”

Peer-to-peer supervision

How do you find supervision when you’re in an area with very few providers? And if you’re one of those providers, how do you learn to supervise novice counselors? These are among the challenges that Lauren Paulson, an LPC and ACA member, has faced while working as a clinician and supervisor in a rural area outside of Pittsburgh.

“Many rural environments are lacking a lot of services, and counselors have to work as generalists,” she notes, adding that practitioners in these small, sometimes remote communities often have to fill most or all of the community’s counseling needs. Not only are these practitioners juggling roles and a wide range of counseling issues; they are often doing so without the assistance of colleagues.

“I had this feeling of isolation, and then I became a supervisor and felt even more isolated,” says Paulson, who is also an assistant professor of psychology at Allegheny College in Meadville, Pennsylvania. “I really wasn’t trained to supervise, and rural communities have unique and specific needs.”

For instance, she says, boundary issues are very common. In a small rural community, it’s harder for counselors to draw the line between personal and professional interactions.

“People have multiple roles in the community, and sometimes they may conflict with your role as counselor,” Paulson explains. “You might be sitting on a school committee, and a client’s parent might be working with you.”

Counselors are also more likely to run into clients outside of the office, Paulson notes. “I work out at the local YMCA, and I often see one of my clients in the locker room,” she says.

So on the one hand, Paulson felt like she had little privacy in her role as a counselor. On the other hand, she felt very isolated professionally. “I wanted to connect with others, but it was hard to find [fellow helping professionals] to connect with,” she says.

Those experiences sparked Paulson’s interest in peer-to-peer supervision, which she currently researches. In her research, she has found that other counselors who practice in rural areas mention having the same kinds of challenges — and a desire for community.

Bill Casile acknowledges the difficulty of finding supervision in the comparative isolation of a rural environment, but he says living in an urban environment doesn’t guarantee that counselors-in-training and prelicensed counselors will secure quality supervision either.

“When I talk to graduates, it’s scary the minimal supervision they’re getting,” says Casile, an ACA member and associate professor in the counseling, psychology and special education program at Duquesne University in Pittsburgh. Too often, he says, supervisees working toward their licensure are learning mainly about administrative tasks such as completing paperwork. While these novice counselors are logging hours and getting clinical experience, no one is attending to their skill development, he says.

Casile was initially drawn to the study of supervision because he was dissatisfied with how counselor education programs were performing supervision during the practicum process. He thought the evaluation process was getting in the way of the functional educational purpose of supervision. In other words, supervisors were too busy grading and critiquing to truly teach their students real-life counseling skills.

Casile has long been interested in group supervision and currently teaches a supervision class inTeacher and student which he tries to create a collaborative environment. His work with group supervision and collaboration led him to believe that peer-to-peer supervision might be a useful supplement to counselors’ other supervision experiences.

Casile and Paulson have now teamed up to research peer-to-peer supervision. Their first study involved bringing counselors together just to talk face to face. “It wasn’t hierarchical, just an exchange of information,” Paulson says. The participants thought the experience was helpful, but most had to drive a considerable distance to meet their peers.

So, Paulson and Casile decided to test online peer-to-peer supervision. They recruited area mental health professionals and established an online group through Google Hangouts, a platform that enables online group interaction through audio, video and a chatlike comments box. After the initial meeting to set everything up, the group met twice a month at first and then scaled back to once a month. The group was diverse and included family counselors, school counselors, private practitioners and even a psychologist.

“Initially, Bill and I led the group, but we wanted the group to take over,” Paulson says. “They decided the structure would be that each meeting, one person would present a case [while maintaining client confidentiality], and then we would all discuss it.” The group also reserved time at the end of each session to discuss any concerns its members might have.

Group members also wanted to learn more about supervision itself, Casile says, so they used different models, including “reflecting teams,” which is a structured way of providing feedback to the person presenting the case. One person assumes the role of supervisor, and the rest of the group listens to the dialogue between the “supervisor” and “supervisee.” Once their dialogue stops, the rest of the group members talk about what they heard, with the supervisor and supervisee now remaining silent. The group repeats this pattern until it has finished discussing all aspects of the case. Casile says this form of supervision helps to keep the presenting counselor from getting defensive when receiving feedback.

The group also engaged in another type of supervision in which each participant played a role in the presented case, such as counselor, client, client family member and so on. This allowed group members to explore the case from multiple viewpoints, Casile notes.

Participants found value in the peer-to-peer supervision group because it allowed for diverse perspectives. And unlike with one-on-one supervision, the group members didn’t feel pressured to demonstrate competence, Paulson and Casile say. Instead, the environment made it safe for members to ask “silly” questions they may have been embarrassed or scared to ask an individual supervisor.

Paulson and Casile emphasize that peer-to-peer supervision is not a replacement for the regular one-on-one supervision that counselors should be accessing throughout their careers. They emphasize that even veteran counselors need the benefit of an outside perspective. At the same time, they realize that many counselors aren’t securing individual supervision for one reason or another, and they believe that some kind of supervision is essential throughout a counselor’s career. Participants in peer-to-peer groups may even end up finding individual supervision opportunities through the peer contacts they make, as happened with some of the members of Paulson and Casile’s group.

To find a group of peers, Paulson and Casile advise counselors to join local professional networks, participate on Listservs or explore an ACA Interest Network (see

Counselors searching for peer-to-peer supervision might also want to avoid putting too many restrictions on their definition of a peer. “Peers need not all be LPCs,” Paulson advises. “Others like school counselors or anyone in the helping professions can provide interesting perspectives. With peers, I don’t think you need to limit yourself.”


To contact the individuals interviewed for this article, email:


Laurie Meyers is the senior writer for Counseling Today. Contact her at

Letters to the


Related reading: See “Unethical supervision practices and student vulnerability,” the story of one counselor’s experience with unethical supervision practices during her practicum and internship: