Supervision for Psychologists, Psychotherapists and Counsellors

• 24/05/2024
• 14:00 SAST

Topics Discussed

1. Thabo Ndlovu
2. Lerato Mokoena
3. Annelie Van Der Merwe
4. Sipho Dlamini
5. Caseload Boundary Management

Thabo Ndlovu

32 yo male presenting with MDD and acute occupational burnout. Currently Rx escitalopram (Cipralex®) 10 mg PO OD via GP. Struggling with therapy homework compliance.

• Supervisee experiencing frustration due to client's passive resistance and intellectualisation during CBT interventions.
• Maladaptive perfectionism and core belief of inadequacy, precipitated by recent corporate restructuring and maintained by experiential avoidance.

Supervisor Input

• Shift from structured CBT worksheets to ACT defusion techniques; explore function of homework avoidance in-session.
• "I notice we often hit a wall when discussing between-session tasks, Thabo. I wonder if the pressure to do therapy 'perfectly' mirrors the pressure you feel at work?"
• Good identification of countertransference (frustration). Need to pace sessions slower and avoid colluding with the client's over-working defence.
• Abandon written thought records for 2 weeks; focus on in-session mindfulness and values clarification.

Lerato Mokoena

19 yo female university student with GAD, panic attacks, and academic adjustment difficulties.

• Mother frequently emails supervisee requesting progress updates. Client has not signed ROI for family.
• Enmeshed family system hindering age-appropriate individuation; somatic panic symptoms triggered by perceived failure to meet maternal expectations.

Supervisor Input

• Role-play boundary setting with client regarding maternal involvement; reinforce confidentiality limits under POPIA and HPCSA ethical guidelines.
• "While I appreciate your concern for Lerato, ethical guidelines strictly prohibit me from confirming attendance or sharing clinical information without her explicit written consent."
• Appropriate adherence to ethical boundaries so far; ensure client feels empowered rather than caught between therapist and mother.
• Send standard ethical boundary email to mother; review assertive communication strategies with client in next session.

Annelie Van Der Merwe

45 yo female, complex grief following spouse's sudden MVA 8 months ago. Comorbid insomnia Rx zolpidem (Stilnox®) 10 mg PO ON PRN.

• Passive SI expressed last session ("see no point in waking up"), though denies active plan or intent. Supervisee anxious about managing risk in private practice.
• Complicated bereavement compounded by lack of social support and reliance on hypnotic medication for emotional numbing.

Supervisor Input

• Formalise safety plan; increase session frequency or implement mid-week check-in; liaise with prescribing GP regarding zolpidem reliance and potential antidepressant initiation.
• "Annelie, when the pain of losing Johan feels unbearable and you don't want to wake up, we need a concrete plan to keep you safe tonight."
• Risk assessment was thorough, but documentation of protective factors needs strengthening.
• Complete Stanley-Brown Safety Plan next session; request consent to contact GP (Dr Patel).

Sipho Dlamini

28 yo male, PTSD following armed robbery 3 months ago.

• Client dissociating during initial trauma narrative exposure.
• Hyperarousal and narrow window of tolerance leading to dorsal vagal shutdown when approaching trauma memory hotspots.

Supervisor Input

• Pause prolonged exposure; return to Phase 1 stabilisation and grounding techniques (sensory orientation,TIPP skills).
• "Sipho, keep your eyes open and look at me. Feel your feet on the floor. Name three blue objects you can see in this room right now."
• Correct decision to halt exposure when dissociation occurred; monitor non-verbal cues earlier in the session.
• Spend next two sessions exclusively on affect regulation and window of tolerance psychoeducation.

Caseload Boundary Management

Supervisee consistently running 10–15 mins over time with late-afternoon clients, leading to administrative backlog and fatigue.

• Difficulty interrupting dysregulated clients at the 50-minute mark; guilt around enforcing time limits.
• Supervisee's "rescuer" schema activated by high-need clients, leading to porous structural boundaries.

Supervisor Input

• Implement a 10-minute warning cue; begin containment and grounding at minute 40 for trauma/high-distress clients.
• "We have about ten minutes left for today, so let's pause going deeper into this and focus on getting you grounded before you head back out."
• Self-awareness is high; frame time boundaries as a component of clinical safety and predictability rather than rejection.
• Track session end-times for the next fortnight and report back.

Goals

• Thabo Ndlovu: Reduce experiential avoidance; establish work-life boundaries; shift from self-criticism to values-based action.
• Lerato Mokoena: Decrease panic attack frequency; establish healthy autonomy from maternal enmeshment; improve academic coping.
• Annelie Van Der Merwe: Stabilise acute suicide risk; process acute grief via Dual Process Model; establish healthy sleep hygiene independent of sedatives.
• Sipho Dlamini: Expand window of tolerance; reduce dissociative episodes in-session prior to resuming trauma processing.

Next Steps

• Implementation: Execute safety plan with Annelie; send boundary email to Lerato's mother; shift to ACT with Thabo; revert to grounding with Sipho; enforce strict 50-minute session limits across caseload.
• Assigned Homework: Read HPCSA Booklet 10 on confidentiality; review Dual Process Model of Coping with Bereavement (Stroebe & Schut); log session durations for 2 weeks.