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Article 10

The Lived Experience of Supervisors in Rural Settings

Lauren Paulson

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Paper based on a program presented at the 2010 ACA Conference, Pittsburgh, PA, March 21.

The Lived Experience of Supervisors in Rural Settings

Supervisors are to be competent when working with diverse clients (American Counseling Association [ACA], 2005; American Mental Health Counseling Association [AMHCA], 2010; Campbell, 2006), and supervising those within a rural population requires an awareness and understanding of its distinctive culture, values, and lifestyle (Johnson & Dunbar, 2005; Stamm, 2003, Sutton, 2002). Rural is defined as individuals located outside of urbanized areas and urban clusters and includes approximately 21% of the US population (U.S. Census Bureau, 2010). The rural community faces stressors specific to the context of rural settings such as higher unemployment, poverty, financial stressors (Barbopoulos & Clark, 2003), and lack of health insurance (Gale & Deprez, 2003). Due to these stressors, rural residents are at greater risk of mental health and adjustment issues (Stamm, 2003).

There is some literature available concerning mental health counselors’ experiences in rural settings. Rural counselors face a myriad of unique challenges including geographical and accessibility issues, working from a generalist perspective, boundary issues and dual relationships, lack of professional support, multiple and diverse roles, lack of privacy, and professional isolation (Erickson, 2001; Morrissette, 2000; Schank & Skovholt, 1997). Mental health counselors tend to be trained to adhere to a Western value of individualism commonly assumed for urban settings (Kruse & Aten, 2007), although rural communities tend to be interdependent (Stamm, 2003). Further, rural communities are often tight-knit and may be suspicious of others; thus, counselors are challenged to collaborate with these communities to gain acceptance (Campbell & Gordon, 2003; Ginsberg, 2005).

Based on these reported challenges and considerations, rural counselors are often expected to work beyond their level of competency (Weigel & Baker, 2002) and desire more clinical supervision (Coll, Kovach, Cutler, & Smith, 2007). Rural supervisors, however, may similarly lack specific competencies and require additional training (Morrissette, 2000; Weigel & Baker, 2002). To date, there is limited research on rural supervision (Weigel & Baker, 2002) and no available published literature on the experiences of providing supervision in rural settings.

This research draws upon the theoretical framework of the Integrated Developmental Model (IDM) of Supervision (Stoltenberg & McNeill, 2009) to understand factors that influence supervisor development. The IDM of Supervision indicates that, over time, the supervisor, supervisee, and their relationship changes. Both supervisors and supervisees are influenced by individual experiences, cultural backgrounds, and the context in which they interact. Supervisors need to know how to assess supervisees’ developmental level, implement appropriate strategies, and recognize relationship dynamics that may affect the supervisory relationship (Pearson, 2001).

Due to the lack of understanding and no research in the mental health counseling field on the experiences of rural supervisors, a qualitative method was selected. Qualitative research examines how people create their social realities and make sense of their world (Berg, 2007). The purpose of this phenomenological study was to investigate the experiences of supervisors working in rural settings to examine contextual variables that influence supervisor development. Phenomenology as a research tradition allows researchers to understand how individuals make sense of personal experiences and examine any essence, or meaning, of those experiences (Creswell, 2007; Van Manen, 1990; Wertz, 2005).

Method

Study Context

The participants in this study were dispersed throughout three rural counties in the mid-Atlantic region. The researcher chose this environment due to personal experiences working in the community and having access to professional contacts. This particular rural area is predominantly White and as much as 16% of the population is living below the poverty level (U. S. Census Bureau, 2012). The population range among all three counties is 54,984-116,638.

Participants and Procedures

To gather a representative and information-rich sample, criterion sampling using the researcher’s personal contacts, followed by snowball sampling was used to recruit supervisors. Inclusion criteria required participants to have worked in a rural mental health setting and have provided clinical supervision for at least five years. Initial contacts were made via telephone and e-mail and pre-interview forms were mailed to participants to gather information about their experiences and training. This study involved 10 supervisors (7 female and 3 male) working in community mental health and private practice. Creswell (2007) identified 6-10 participants as an appropriate number for phenomenological research. The supervisors reported between 8-45 years working in the field (M=24, SD=14) and 8-38 years working as a supervisor (M=15, SD=8). The supervisors reported providing both clinical and administrative supervision to a case load ranging from 1-65 clinicians.

Data Collection

Participants working in community mental health took part in 1 of 2 focus group interviews (n=4 each). The focus and individual interviews were conducted at four separate mental health offices throughout one county. Focus groups are unique in that they allow members to construct meaning based on each other’s comments, ideas, or suggestions, and become energized (Kress & Shoffner, 2007; Patton, 2002). To enhance credibility, two additional individual interviews, using snow ball sampling, were conducted with supervisors working in private practice. All interviews were digitally recorded and included the same set of 10 interview questions (see Appendix). Each question was intended to be open-ended, neutral, and developed based on an extensive review of literature, the researcher’s 12 years of experience working as a rural counselor and supervisor, the conceptual framework of the study, and in consultation with an expert in the field. The focus groups and individual interviews lasted between 60-90 and 45-60 minutes in length, respectively.

Data Analysis

This study used a phenomenological perspective to examine the personal meanings and lived experience of rural supervisors and followed Patton’s (2002) guidelines for qualitative data analysis. First, all interviews were immediately transcribed verbatim and reviewed as a whole by the researcher. Second, analysis focused on individual descriptions to grasp the lived experiences of each supervisor. This process included horizontalization, which allowed equal credence of all statements produced by individual participants (Creswell, 2007). Third, the researcher identified common themes or structures within the narratives (Wertz, 2005). Next, member-checking was used with a focus group member to review the results and verify the descriptions and interpretations. The group member and research co-constructed the definition of one sub- theme (i.e., wording and clarity). At this time, two auditors, who served as supervisors of this researcher, reviewed the interpretations and suggested additional individual interviews to ensure the credibility of the research. Last, the data were synthesized into a holistic understanding and provided the psychological structure of the participants’ experience (Wertz, 2005).

Trustworthiness

Trustworthiness can be established through credibility, confirmability, dependability, and transferability (Denzin & Lincoln, 2011). Credibility methods used to enhance this study included peer debriefing during the interviews and member-checking. In addition to multiple data sources, confirmability strategies included using two auditors, experts in the field of counseling and supervision, who reviewed the raw data, summary notes, interpretations, and reflexive journal (Denzin & Lincoln, 2011). Next, dependability and transferability were established through the use of focus group and individual interviews with community and private practice supervisors to provide a more representative group of informants. Additionally, to enhance trustworthiness, the following were implemented during data collection and analysis to reduce researcher bias: epoche, phenomenological reductions or bracketing, and structural synthesis (Moustakas, 1994). For example, reflexivity allows the researcher to discern the essence of the phenomena by evaluating his or her own voice in addition to the voice of the participants. In a reflective field journal, the following questions were considered: What is the purpose of the study? What do I observe? What do I fail to observe? How do I know that I am right (Glense, 2006)?

Researcher Identity

As the researcher, I am an instrument in qualitative study and my interests, experience, and assumptions can influence the study (Creswell, 2007). In my 12 years of experience working as a rural counselor and supervisor, I felt ill-equipped in the role of supervisor. Receiving minimal training and clinical support in the work setting resulted in feelings of isolation and frustration. I wanted to gain a better understanding of the lives of other rural supervisors and provide suggestions to better prepare and support rural supervisors.

Findings

The purpose of this study was to examine the lived experiences of rural supervisors. The focus was to understand the impact of internal and external forces on the supervisor’s development and functioning in the rural context. After final data analysis, the identified themes were framed within the theoretical structure of the study and collapsed into protective factors and risk factors. Protective factors serve as a buffer to protect supervisors and enhance their development and functioning, whereas risk factors can be seen as barriers, “frustrations,” or “challenges” to supervisors’ development. The themes, along with related sub-themes, are presented in the following section.

Theme 1: Protective Factors to Rural Supervisors’ Development and Functioning Sidewalks.

Sidewalks describe the general sense of connectedness shared as a benefit to living and working in rural communities. Facilitating networks and collaborative relationships is necessary for effective counselor functioning (Council for Accreditation of Counseling and Related Educational Programs [CACREP], 2001) and may be more apparent in smaller communities where, “everyone knows everyone.” The findings suggest that relationships in rural areas are important. For example, one supervisor commented, “The most important thing is to form relationships with other providers [in order to] ease client access to services.” The ability to be creative with services and develop unique, collaborative programming opportunities was another benefit that emerged.

Interdependence. Supervisors discussed the rural culture noting the advantage of “informal networks” and “rich collaboration” and that “others” are always willing to help out. One supervisor commented, “There is a [sense] of pragmatism to being in a rural culture. If there was a felt need among people it would happen. Barriers are much more quickly overcome when there is a need.” Rural communities have strong family ties and tend to be interdependent by taking care of problems within their in-group (Stamm, 2003; Weigel & Baker, 2002). The supervisors’ comments including, “[Rural areas are] just a friendlier atmosphere in general,” “People seem to get along pretty well,” “It’s a little more neighborly,” and “There is more family connection,” all demonstrate a sense of connectedness and interdependence. In contrast to the aforementioned protective factors, the participants spent the majority of the time identifying risk factors that serve as barriers to their functioning and development.

Theme 2: Risk Factors to Rural Supervisors’ Development and Functioning

Show me the money. Show me the money represents the sentiment shared in all interviews that funding and resources are insufficient in rural areas. Supervisors reported concerns with lower wages, difficulty recruiting and retaining qualified staff, lack of resources and financial supports, and lack of transportation. “We all probably deal with people that really need mental health services but can’t afford the co-pays and rural areas tend to be less economically stable.” Another supervisor added the negative impact of the lack of industry on mental health, “There was a cut-throat competition… or goal displacement for resources among providers. Generating revenue became more important than providing services.” The supervisors discussed the challenge of lack of funding stating,

Someone [in an urban area] doing the same job we do would probably get a much higher salary than we do and we’re doing probably more than they are because we have double duty with the other stuff we have to do. Sometimes that’s a little irritating.

Another supervisor added, “In a rural area, you were so desperate to find people who have the degree and the education to do the job.” Finally, the supervisors expressed “frustration” guiding supervisees to understand challenges specific to rural areas, such as transportation and infrastructure concerns. One supervisor shared,

Understanding that maybe their clients are coming from miles away because there aren’t a lot of resources close to them. Public transportation for our clients is a nightmare. You know, these people sit in the waiting room for hours! They’re late for appointments, you know, things like that… it’s not even their fault.

Wearing many hats. The theme Wearing many hats was represented in the statement, “I don’t think there’s enough time in the day to do what you want to do.” Supervisors reported work overload, multiple roles, lack of administrative support, and the challenge of working from a generalist perspective. Most worked in the dual role of clinical and administrative supervisor, “Working in a small rural agency, you are expected to do everything.” “Part of the job description of supervisor is the administrative piece in rural areas. If you worked in an urban area with five clinical supervisors, you would probably have more administrative support.” Supervisors shared working as a generalist as a challenge voicing, “Working with supervisees who have very different backgrounds, life experiences, values, cultures, and education and training… it is a challenge to provide supervision to diverse supervisees.”

Cultural competence and boundaries. Supervisors discussed the challenge of dealing with cultural differences, managing boundaries and multiple relationships, and less anonymity. A supervisor shared,

There is a distinct cultural difference in rural areas when you talk about diversity. Being rural is a special client group. The value systems are just different… it is important to know the culture and community you work with and make sure supervisees know the community. [Supervisees] have to get used to going into dirty homes and be comfortable when working in rural areas.

Lack of supervisee appreciation and understanding of the rural culture was a consistent theme with all the supervisors. One supervisor commented,

Sometimes supervisees do not understand that a way of life for some clients may be completely normal for the client, such as not having running water. Encouraging supervisees’ understanding and appreciation of the Amish culture, that it’s going to take them extra time to get there because they’re bringing a horse and buggy and not driving a car.

Supervisors reported that urban training programs do not prepare counselors for rural work and supervisees sometimes experience culture shock. Rural supervisors need to understand how to navigate and support supervisees within the rural context.

The challenge of blurred boundaries and multiple relationships were revealed as a common concern. As illustrated by one supervisor, “You can be sitting in church, or you are 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 felt uncomfortable going to dinner and having wine with dinner, because what if somebody saw me? What if someone saw me drinking wine, were they going to confront me.

In addition to vague boundaries, a supervisor commented, “One encounters dual relationship conflicts more readily in a rural area, the question is how do you steer your way 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] what proper boundaries are and what is ethical versus unethical.”

Life on an island. Life on an island represents the general sense of isolation experienced by supervisors and the expressed need for professional support and continuing education opportunities. Overall, supervisors did not feel adequately or developmentally prepared to work as a supervisor. Comments included, “I was just kind of like thrown in [to the supervisor role]” and “I would like to have had more training as a supervisor.” Another added,

You take and develop expertise in the clinical situation or the field work, whatever, and you do that for 20 years and then get promoted to supervisor and you haven’t had supervisor training. And they’ve assumed because you’ve done field work that you can be a supervisor and the skill sets are very different.

The need for support was a prominent concern expressed by all supervisors. Comments included, “You have to be careful who you vent to,” and “Working in a rural area is very isolating. There are not a lot of professionals around.” Finally, lack of training opportunities and the need to travel great distances to access continuing education was cited as a challenge.

Discussion

The purpose of this study was to examine the lived experience of clinical supervisors working in rural mental health settings. This study provided the opportunity for rural supervisors, in their own words, to share the benefits and challenges of providing supervision. The findings provide a basis to discuss practical recommendations to improve supervisor functioning and development in rural areas.

Findings suggest rural supervisors need to use the strengths of rural communities to their advantage in their work. These strengths can act as a buffer and promote the development and functioning of the supervisor, supervisee, and rural client. Perceived cultural strengths found in this study, also described by Stamm (2003), include tight-knit communities, rich collaboration with professionals, pragmatism, and informal professional support networks. Whether the relationship was with other mental health providers, family practitioners, or county or school administrators, all relationships were perceived as important to the functioning of a rural supervisor. This finding reveals the importance of training in interdisciplinary communication and collaboration skills for outsiders who want to move into a rural area.

In contrast, the supervisors shared multiple risk factors in the rural context that have a rippling effect on their development and functioning. It is important to note that many of the supervisors’ perceived assumptions of working in an urban area may be inaccurate; however, urban areas do have multiple libraries, increased social networks, diverse mental health providers, and referral sources to help support supervisors and their supervisees (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 supervisors report the challenge of working from a generalist perspective. Supervisors need to have a broad range of training and knowledge, beyond that of their supervisees, in diverse mental health issues with multiple populations, such as children, adolescents, adults, and families (ACA, 2005; AMHCA, 2010). This can exacerbate supervisor anxiety, and increase burnout and legal responsibilities, thereby suggesting the need for additional training and support. Finally, rural counselors face numerous ethical challenges, such as dual relationships and boundary issues (Barbopoulos & Clark, 2003; Helbok, 2003; Weigel & Baker, 2002). In order to minimize the liability and risk, supervisors must be trained in supervision, risk management, and ethical decision making (Bernard & Goodyear, 2009). What follows are practical implications to enhance the preparation, training, and support of rural supervisors.

Enhance Rural Culture Competencies

A consistent theme found in the current study included supervisees’ lack of appreciation and understanding of the unique and diverse rural culture. Many supervisees are trained from an urban model (Helbok, 2003) and have not been exposed to rural populations. The literature on rural school counselors highlights the need for specific training to deal with each unique rural culture and associated ethical issues (Weigel & Baker, 2002). Counselor educators can prepare mental health workers by introducing rural issues in existing classes or through a formal rural counseling course. This course should include training from a generalist framework, a review of ethical and legal issues inherent in rural work, awareness of social issues, interdisciplinary communication, and field experiences in rural settings (Ginsberg, 2005).

Rural Supervisor Training and Continuing Education

Supervisors reported feeling ill-prepared, citing their own supervision education primarily through workshops and continuing education credits. Many of the supervisors earned their degrees before supervision was considered a specialty. Mental health counselors promoted to supervisor roles, who are not developmentally prepared, can experience anxiety, confusion, and low self-confidence (Stoltenberg, McNeill, & Delworth, 1998). A senior counselor promoted to supervisor, with no or little supervisory training, may not adequately assess the developmental level of the supervisee and fail to implement appropriate strategies to promote growth and development (Pearson, 2001). As witnessed in this study, rural workers transition differently, or more rapidly, through developmental levels due to the nature of rural work. The findings support the need for initial and continued education and training for rural workers. However, rural counselors have low rates of professional memberships and attend few conferences (Coll et al., 2007) and finding and accessing continuing education and training opportunities is often a barrier (Morrissette, 2000).

Building Sidewalks: Supporting Rural Supervisors

The need for peer support and collaboration to reduce feelings of isolation was shared 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 can receive supervision of their own services (Stamm, 2003; Weigel & Baker, 2002) and may alleviate the stressors. The economy, failing industry, and managed care restrictions have an effect on those living in rural areas and service providers are struggling financially to survive. The comment, “Mental health gets the short end of the stick!” seemed to reverberate throughout all of the findings in this study. Systems, such as managed care companies, need to invest in supervision in order to improve rural clinical services (Stoltenberg et al., 1998). Agencies need to support regular supervision, training, and professional development opportunities through financial support and time off. A rural symposium for supervisors can be implemented that follows the general curriculum presented by Riess and Fishel (2000). Finally, technology can be used to support rural supervisors. Examples include: on-line discussion forums, videoconferencing, and web- based supervision (Sampson, Kolodinsky, & Greeno, 1997).

Limitations and Research Recommendations

Due to the philosophical underpinnings of qualitative research, one cannot guarantee that the results of this study may be transferable. The current sample lacked diversity and may not be representative of all rural supervisors. Researcher biases and presuppositions may affect the outcomes of this qualitative study (Berg, 2007). For example, the formulation of research questions and data analysis may have been influenced by the researcher’s perspective. Specifically, a few of the research questions may have been leading and needed to be more open-ended. Interviews can be a limitation in qualitative research as the researcher may influence the direction of the interview. In addition, the auditors in this study served in dual roles and were not completely unattached to the study. The present study should be replicated in other rural locations with a larger and more diverse sample. Further studies need to examine the assumptions shared by rural supervisors, examining the effect of the rural context on rural mental health counselors compared to their urban counterparts. Future research should use other qualitative methods, such as case studies or ethnography to illuminate rural supervisors’ experiences. Finally, the use of technology to enhance rural supervision should be explored.

An analysis of relevant themes that emerged from interviews with ten rural supervisors provided a rich description of the experience of rural supervisors. The results demonstrate that working in rural mental health settings provides unique challenges. Rural supervisors expressed the challenges of working in multiple roles, lack of cultural competence, and working from a generalist perspective, while lacking training and support. There is a need for counselor educators to provide specific training and field experiences to prepare supervisors for rural work and for enhanced support of rural supervisors.