Table of Contents

The Skovholt and Ronnestad Model

Informed Consent

 

 

 

 

Models of Supervision                                   

 

Course Objectives

1.  Describe the developmental stages that new clinicians go through.

2.  Describe the different theoretical models of supervision.

4.  Identify barriers that can lead to impasse and resistance.

5.  Describe transference and countertransference as they relate to parallel process.

 

Models and Theories of Supervision

Models and theories are a set of principles that help us understand and process information. Working on an assumption or within a framework allows the clinician to work with purpose and direction.

Developmental Models of Supervision

Developmental models of supervision have been around for the last thirty years. Developmental models of clinical supervision suggest that supervisees pass through a series of developmental stages. There are two basic concepts of developmental supervision:

The first describes the counselor moving through a series of stages that are quite different from one another. The counselor is striving for competence.

Second, each stage must be qualitatively different if maximum growth is to occur.

Three different models of developmental supervision are presented below.

Littrell, Lee-Borden, & Lorenz Model This model attempts to match supervisor behavior to the developmental needs of the supervisees. 

The four stages of the Littrell, Lee-Borden & Lorenz Model are summarized below:

Stage 1 : This stage involves the relationship building between the supervisor and supervisee. In this initial stage the supervisor and supervisee set goals and write a working contract.

Stage 2: The supervisor is both a teacher and plays the role of counselor. The supervisee explores the feeling that arise during the therapy sessions. The supervisee is cognizantly aware of their deficient in skills, technique and theory.

Stage 3: The supervisor moves away from damage control. The supervisee is progressing and feeling more confident.

Stage 4: The supervisor moves further away from the supervisee and takes on more of a consulting role. The supervisee becomes responsible for their own development.

The Stoltenberg and Delworth Model

Stoltenberg and Delworth described three developmental levels of the supervision process and eight dimensions. The Stoltenberg and Delworth model has three levels of development.

The first level occurs when counselors are new to the field of counseling psychology. Typically the counselor is in the process of learning the theories of psychotherapy. They are trying to account for the particular theory of psychology as it applies to their own lives as well as those of their clients. The beginning counselor is motivated to learn and improve their skill level. The experience of a low level of skills and the knowledge that their skills are being critiqued creates a high level of anxiety.

Interventions of the Supervisor

It is crucial for the supervisor to effectively evaluate the supervisee during the level one stage of development. Supervisees self reports are usually unreliable because of countertransference concerns. It is recommended that the supervisor rely on direct observation as the therapy sessions progress.

Level two counselors are typically in internships. They are post graduates and attend supervision on a regular basis. Level two counselors have moved beyond general theory and begun to explore different approaches at a deeper level. They have become more comfortable with their skill level and reporting of clinical material has taken on a more meaningful expression.

Intervention of the Supervisor

The level two counselor needs to be accountable for their interventions and the reasons for using them. It is the responsibility of the supervisor to question the supervisee about their intervention style, technique and desired outcome. The supervisor should be understanding and supportive of the supervisee and provide reliable and accurate feedback.

Level two counselors display a willingness to explore the concept of transference and countertransference. Counselors should be ready to address their own personal issues that arise during the course of treatment. It is important for the supervisor to promote counselor independence and confidence in their ability to perform psychotherapeutic techniques.

Level three counselors become self reliant. Their ability to empathize with their clients increases. Their relationship with the supervisor is more in balance.

Intervention of the Supervisor

The supervisees capacity to accept confrontation becomes more apparent. The supervisor provides support and caring when necessary.

The eight dimension are listed below:

1. intervention skills

2. assessment techniques

3. interpersonal differences

4. client conceptualization

5. individual differences

6. theoretical orientation

7. treatment goals and plans

8. professional ethics

The three structures proposed to trace the progress of trainees through the levels on each dimension are:

1. the trainee’s awareness of self and others

2. motivation toward the developmental process

3. the amount of dependency or autonomy displayed by the trainee

 The Skovholt and Ronnestad Model

The Skovholt and Ronnestad Model of Supervision uses a life span model which includes eight stages to assess the growth of the supervisee. It is believed that the supervisee should assess one’s growth to determine which stage they are in. The same could be said about the supervisor.The Skovholt and Ronnestad Model of Supervision is grounded in research.

Stage 1: Competence

This is commonly thought of as the “common sense” stage of development. At this stage the new counselor uses the knowledge and experiences they already have.

Stage 2: Transition to Professional Training

(First year of graduate school)

Stage two counselors are in their first year of graduate school. They are likely enrolled in beginning counselor courses and are learning theories of psychotherapy. This may be combined with technique training. They are being presented with new ideas and thought processes.

Stage 3: Imitation of Experts

(Middle years of graduate school)

Grad school counselors are mimicking their instructors and supervisor. They are typically open to new ideas and are beginning to become conceptual.

Stage 4: Conditional Autonomy

(Internship)

Counselors are now working as professionals. Their skill level is increasing, their techniques are becoming more refined and their conceptual world is expanding.

Stage 5: Exploration

(Graduation - lasts 2-5 years)

Counselors become analytic and think beyond traditional training. They cast aside previously introduced material.

Stage 6: Integration

(lasts 2-5 years)

During this stage, counselors work toward autonomy and independence. They develop theories and approaches that fit their personality and belief system.

Stage 7: Individuation

(lasts 10-30 years)

During stage seven the counselor refines their concept of psychotherapy. They expand upon knowledge and become more authentic.

Stage 8: Integrity

(lasts 1-10 years)

The counselor continues to expand upon their knowledge base. They integrate new interventions and develop a sense of independence. They are able to apply theory and apply principles that are effective while eliminating those that are not.

 

Integrated Models of Supervision

Integrated models of supervision are described as eclectic. This allows the clinician to integrated several models into a working paradigm. Some supervisors may choose to lecture, most typically, during group supervision. Others prefer the counselor approach, moving into areas of the supervisees psyche to uncover unconscious motives and desires. Other supervisors may find themselves in a co-therapist role with the supervisee. Regardless of the role, each integrated model serves a specific purpose. The purpose is to help identify obstacles that prevent the supervisee from learning, growing and ultimately helping the client sitting before them.

Discrimination Model of Supervision

Bernard's (Bernard & Goodyear,) The discrimination model is "a-theoretical." The discrimination model of supervision is a training model. The focus of this model rests on three principles; process, conceptualization and personalization.

Communication is viewed as a process. The question that might be asked is did the supervisee correctly reflect the affect of the client. Was the process material in anyway reframed? Was the material presented out of context? What would help the supervisee help the client to more accurately reflect their true emotion.

Conceptualization describes the supervisees ability to apply theory to the counseling session. It also describes why and how the supervisee decided to use a particular technique, the desired result of that technique and the actual outcome.

Personalization refers to the unspoken aspects of the therapy session. The main theme of personalization is body language and what this information tells the client about the counselor.

Theoretical Models of Supervision

Most supervisors adapt the same theoretical model that they use in their practice to the supervision hour.

The psychoanalytic supervisor would not only pay attention to the developmental stages of the client but also those of the supervisee. The supervisor would pay special attention to the defensive structure of the supervisee. During the middle stages of supervision you might expect the supervisee to avoid certain topics. This might have to do with the new found knowledge of working with the client or may be a result of the transferencial relationship that has developed between the supervisor and supervisee. The last and most important stage would be the working through stage. Upon successful completion of the working through stage is an independent, integrated professional counselor that is ready to venture out on their own.

Behavioral supervisors believe in problem solving. Two skills are required of the behavioral supervisor and supervisee: Identification of the problem, and selection of the appropriate learning technique (Leddick & Bernard, 1980). Role reversal is a common technique used by the behavioral supervision. The supervisor takes on the role of the supervisee while the supervisee plays the role of the client.

A Carl Rogers supervisor would place heavy emphasis on unconditional positive regard, genuineness and empathy. Carl Rogers (cited in Leddick & Bernard, 1980) outlined a program of graduated experiences for supervision in client-centered therapy. Group therapy and a practicum are the core of these experiences.

Systemic therapists (McDaniel, Weber, & McKeever, 1983) argue that supervision should be therapy-based and theoretically consistent. Systemic therapist place heavy emphasis on structure and solid boundaries between the supervisor and supervisee. The same emphasis is placed on the counseling session.

There are advantages and disadvantages to integrated psychotherapy models. When the supervisor and supervisee have different theoretical orientations transference and countertransference issues are more likely to occur. When the two share the same theoretical orientation the training is more effective and the learning curve is minimized. The supervisee is more likely to benefit from the sharing of a theoretical orientation.

Parallel Process in Supervision

Parallel process originated from psychoanalytic theory.  It’s derived from issues of transference and countertransference. When the supervisee, during a supervision session, recreates the feeling and presenting problem of their psychotherapy session with the supervisor, parallel process is active. Example: Clients presenting problem is being the victim of child abuse. The sessions are emotionally charged and often the feelings of dread, anger, fear, resentment and helplessness are directed toward the supervisee. The supervisee response back with empathy, understanding and concern. When the supervisee presents this case during supervision they recreate the feeling of dread, anger, fear, resentment and helplessness in the supervisor. This is the transference. When the supervisor responds back to the supervisee with feeling of empathy, understanding and concern the countertransference issues have taken hold. What took place in supervision is parallel with what took place in the counseling session.

Another example would be when a client shows up late for sessions and doesn't notify the supervisee.  This behavior irritates the supervisee.  The supervisee (who typically has no history of lateness) shows up late for the weekly supervision session, thus evoking the same irritation in the Supervisor.

To effectively resolve transference and countertransference issues the supervisor and supervisee need to develop a strong sense of self. They must be able to identify their strengths and weaknesses as well as develop an awareness of possible reactions to any given interaction.

Parallel process, when identified by the supervisor can be used to facilitate the understanding of the transference and countertransference issues between the supervisee and client.  Supervisors can also model new strategies for the supervisees. If the client would benefit from an interpretation instead of empathy the supervisor can respond back with an interpretation. Example: The supervisee shows up late for a session. Instead of responding with irritation, the supervisor interprets the behavior. I noticed that you are normally on time. This last meeting you were late and didn't call. This helps to model the appropriate response toward the client. It also opens up the supervisory session to explore the feelings and thoughts of the supervisee regarding lateness.

Searles (1955) made the first reference to parallel process, labeling it a reflection process. He suggested that "processes at work currently in the relationship between patient and therapist are often reflected in the relationship between therapist and supervisor.  Searles believed that the emotion or reflection experienced by the supervisor was the same emotion felt by the counselor in the therapeutic relationship. Although Searles recognized that the supervisor's reactions also might be colored by his/her past, this was not the focus of the reflection process.

As in the example above, the supervisee unconsciously recreates the feeling of irritation in the supervisor. This is the same feeling evoked in the counseling session. The supervisee may unconsciously be seeking answers to resolve the problems in the counseling session. Supervisors should be aware of this phenomenon.

Another reason for parallel process is the supervisee and the client may have similar issues. The supervisee may closely identify with the client as a way resolve their own inadequacies. Thus evoking a therapeutic response from the supervision.

Not everyone agrees with Searles reflective process theory.  Doehrman (1976) believes that parallel process can be bi-directional. The supervisor may believe that the supervision hour is not a place for the supervisee to discuss their personal problem.  They are referred to individual counseling to deal with their problems. The risk of bi-directional parallel process occurs when the supervisor responses unconsciously to the counselors feelings, the counselor in turn responses with the same feeling toward their client.

The supervisor may unconsciously display their own belief system. The supervisee in turn display and imposes the same believe system when working with the client, thereby creating parallel process.

Addressing Parallel Process

With advanced supervisees, parallel process should be address as it occurs. Addressing the parallel process will help the supervisee to improve as a clinician.  Responding to the parallel process helps the supervisee understand and respond to transference and countertransference issues. It helps the supervisee model appropriate interactions and interventions with the client. Addressing the parallel process helps to move the sessions for content oriented to process oriented.

When working with beginning counselors addressing parallel process can have a negative effect. New counselors are just beginning to understand theory, interpretation, techniques and interventions. Presenting parallel process as a concept that the counselor is currently participating in can produce unnecessary anxiety in the new counselor.

Learning Style

Supervisors should tell the supervisee what their theoretical orientation is. They should tell the supervisee what is expected of them. They should inform the supervisee regarding informed consent, standard of care, legal and ethical considerations, scope of practice, confidentiality, business practices and any other information pertinent to their work with their clients and within the supervisory relationship. Discussing the above at the beginning of supervision will help to alleviate problems in the future. It will also help to build a positive relationship between the supervisor and supervisee.

The supervisor should discuss with the supervisee their style of learning. The supervisor should make every attempt to accommodate the supervisee by providing information and instruction in a way that is conducive to the supervisees learning style. This may involve story telling, real time examples, theorizing, role playing, interpretation, conjecture, myths or inferences.

Confidentiality

Confidentiality of  supervisees.  Material obtained in supervision is confidential unless specifically stated in the supervisory contract or by exceptions recognized by the profession and law. Supervisees must keep confidential all client information except for purposes of supervision.

When a patient enters our office and psychotherapy begins, everything which is said or done by that patient, with few exceptions, are confidential. The patient holds the privilege to release the confidential information in legal proceedings. While you may object to the patient using these records, you must have solid grounds for your objection. While these are quite variable, generally patients can request and use their records in any way they please. In some instances, a legal guardian or conservator may hold the privilege if the patient is unable to do so. If the patient dies, their privilege passes to the patient's personal representative who handles legal affairs.

The holder of the privilege also has the right to read all information in his or her file with the exception of your personal notes which belong solely to you. Some therapists find this requires them to keep separate files so their personal notes do not become part of the patient's legal record. Your patient can read all notes which have their identifying information, diagnosis, treatment plan, prognosis, and other information including billing and information from other sources which you have included in the file such as notes from other physicians and hospitals. Any spare notes in the patient's file also have information which must be passed to the patient. All information in HIPAA notes are the patient's property and must be released. The file is the property of the clinician so copies must be made if the patient requests a copy of their file.

It is your responsibility to maintain the confidentiality of the records. Patient records should be kept in locked containers except when in use. They should be shredded when they are discarded to avoid the potential of having the notes fall into the hands of others. Office staff and others who handle the files should be made aware of the importance of confidentiality. Handle these records as if they were notes made by your own therapist about you. Your patient feels the same need to have the notes be private. Office staff, filing clerks, billing agencies, and others do not have the same burden of confidentiality as does the therapist. However, it is the responsibility of the therapist to inform the staff about the importance of confidentiality and to take reasonable action to be certain that staff does not violate the patient's confidentiality. While this is a solid part of HIPAA, it seems to be regularly violated by clerks and other office staff. Often my patients who work for or with counselors in the community or in government report cases which are confidential which they have read with avid interest. Try to keep this sort of clerk off your staff.

Duty to Warn - Tarasoff is directly relevant to supervisors. Tarasoff implicated the supervisor also. The Supervisor is also responsible for advising the supervisee about conditions in which it is appropriate to warn an intended victim.

Reasons for Divulging Confidential Information - Tarasoff

In 1976, important case law was made in California which is now followed throughout the United States. A romantic young man, Prosinjit Podder, from India, fell madly in love with Tatiana Tarasoff who did not reciprocate his desire. He confessed his intention to cause her bodily harm to his psychologist at a clinic at UC Berkeley. He subsequently murdered her. The unfortunate psychologist had followed the law which until then required psychologists to keep all information from patients confidential and to disclose threats only to the intended victim. Luckily, the case came to be known by the name of the murdered young woman and the defendant was the Regents of U of C so he is never named. The California Supreme Court determined that confidentiality laws did not apply when the following rules are met.

1. The threat must be communicated to the psychotherapist directly by the patient.
2. Serious threat of physical harm is imminent.
3. The potential victim must be reasonably identifiable.

In this case, the psychotherapist must:

1. Warn any and all potential victims.
2. Notify authorities including the police, sheriff, or call 911.
3. Take steps of some sort to prevent the threatened danger.

Case law has continued to add to the confusion about when Tarasoff  applies. One case found it applied when property was threatened, another found it applied when there was no overt threat but a history of violence, in another case Tarasoff was found to apply to communicating threat of suicide to subsequent caretakers.

Under Tarasoff, the psychotherapist has the duty to both warn and protect potential victims.

A therapist is also required to breach confidentiality when a patient threatens to harm another person but there is no imminent danger or the victim's identity is unknown. In this case, however, the therapist is to take steps to prevent danger but is not to notify authorities or the potential victim.

Therapist are also required to breach confidentiality if the patient is in danger of committing suicide and is to take steps to prevent the danger from occurring. In most cases, this requires the therapist to hospitalize the patient.
The courts have required that therapists be able to predict when a patient will act on their impulses and cause bodily harm to themselves or others. Therapists, regardless of their experience are unable to predict when or if someone will be dangerous. Research has consistently borne out that therapists cannot predict violence above the level of chance (Stromberg et al., 1988; Bednar et al., 1991; Otto, 1992; Simon, 2001).

Some traits are more likely than others to predict violence, with the most robust being a history of violence (Simon, 2001), male gender (Simon, 2001), substance abuse (Stromberg et al., 1988). Peterson et al., 1983 has shown some positive results in identifying people who are likely to commit suicide. The scaling is simple and quick on the SAD PERSONS test and the results have been replicated (Campbell, 2003; Juhnke, 1994,1996).

 Informed Consent

Supervisors must make sure that the supervisee has informed the client of the parameters of informed consent. This must include, but is not limited to, disclosure that the supervisee is an intern and what exactly that means. They must inform the client of the supervisory relationship. They must disclose the laws surrounding confidentiality and exceptions to confidentiality. Supervisor can verify this information by using a disclosure statement that contain all of the information necessary. Have the supervisee and client sign the disclosure statement.

The supervisor should inform the supervisee of the evaluation process they will use to determine the supervisors progress. The evaluation criteria and standards that need to meet should be discussed.

Malpractice

It is important to note that regardless of your behavior a patient may decide to sue you for malpractice. This could include you as well as the supervisee. This is a frightening prospect, since the grounds for filing a lawsuit are so vague that even the finest, most ethical clinicians find themselves involved in litigation which threatens to take away their license, their means of livelihood, and substantial sums of money.

The development of an ethical practice, however, may help you to avoid some of the more important pitfalls. Regardless of how many times you read through the law, regardless of how many classes you take in ethics, regardless of how well you follow the rules of the profession, make no mistake, this is a path you will need to pursue consistently throughout your career.

To be sued successfully for malpractice in a civil court, the client must prove that you have breached the standard of care (Black, 1996). There are four parts which must be seen by the court to have been met for the malpractice suit to proceed.

(1) In some way as a supervisor you have established an agreement between yourself, your supervisee and the client that you will work together in a therapeutic relationship. The law does not define this in terms of the length of time the patient has been seen or whether or not the patient has paid you. It is entirely the responsibility of the court to determine whether you have established a Duty of Care with the patient.

(2) The work done with this patient will be compared to the Standard of Care. This is also defined by the court based on what the court finds is the typical level of proficiency which would be shown by a supervisee under similar circumstances. It may be defined or suggested by an ethics code, a state standard, or case law. There is no clearly defined standard of care since both you and the circumstances in which the act occurred are unique.

(3) The client must show that there has been some Demonstrable Harm. Although some texts may imply that it is difficult to show demonstrable harm if it is psychological in nature since the client began treatment presumably due to harmful or painful problems which they hoped to cure, again, it is entirely the duty of the court to determine if you caused harm and, if so, how much harm was caused. The amount of harm caused whether psychological, physical, or financial can only be remedied in a civil suit by money. The court also decides how much money should be given the client (now plaintiff) for the harm caused.

(4)The client must also prove the supervisor and supervisee was directly responsible or the Proximate Cause for the harm which was done.  So, the client must prove that the supervisee had an established relationship with the patient which would prove there was a duty to care, was working below the standard of care, which caused demonstrable harm to the client which could only have been a direct result of the supervisees actions.

Despite these levels of proof which sound difficult to attain, many therapist are sued successfully or have out-of-court settlements against them each year. Following a successful suit or settlement, one should expect an investigator from the licensing board to determine whether or not the actions taken by the counselor were egregious enough to sanction them by loss or suspension of their license, additional classes to educate the counselor and attempt to prevent further problems, or other measures.

First, it is important to take care of yourself. Supervisors who are having problems within their own families, use alcohol or drugs inappropriately, are having emotional problems, or simply need a vacation are the most likely people to make minor and major errors in judgment. This may occur from the distraction caused by the supervisor's own problems or from unconscious motives which are more likely to be enacted when one is not at one's best and inhibitions are lowered.

Second, stay in touch with changes in laws through professional organizations. Maintain your memberships and attend meetings on a regular basis. This will also help you make and maintain friendships with other practicing clinicians. You are likely to find it is helpful to know someone you trust for a consultation if you do find yourself feeling that a patient may cause problems for you. Your friends may also tell you in a much nicer way than the licensing board that you need to take a break from work.

Third, take frequent breaks from work. You will have a better chance of staying on top of your cases and come to work with a smile.

Fourth, look at your mail at a time when you can do some reading. Instead of stacking the journal you just got, scan through the articles and read the ones that interest you. You could impress your colleagues at professional meetings by dropping names and you could even try out some of the new techniques you read about and develop some skill with timing.

Fifth, if you or the person you are supervising has a patient walk in who describes a history of lawsuits, suicide attempts, and has a gambling problem which might cost him/her more than one can afford and you feel the acid turn in your stomach and your headache begin, check on the client's current level of suicide risk then on your the level of expertise needed to manage this difficult client. Do not agree to let the supervisee see anyone who walks in the door. Do not let the supervisee take on more clients than they and you can reasonably manage. We all learn from the work we do with our clients and our toughest clients teach us the most, however, to provide the client with the best care and to take care of yourself, seek information from those around you, especially experts. Reading journals and books on the topic is also very useful but it can lead to a false sense that you understand the problems you face with that particular client when you only understand the issue in a broad sense. All clinicians are much better in some areas than others and it is incumbent on the practitioner to know where they stand in their ability to treat different sorts of difficult clients.

Sixth, and most importantly, do your paperwork. It gives you time to reflect on what you are doing with the supervisee. It is also illegal to fail to do it. Some people find they do this best when they complete a formal note in the 10 to 15 minutes between sessions while others find they need to lay out an hour several times weekly or a long afternoon to get it done. Do not underestimate how much time this takes. Completing HIPAA notes can become very quick and efficient if you have a system and do them regularly. On the other hand, trying to recreate the important points of a session from hastily sketched notes during an intense session at the end of the week is nearly impossible. You remember that it was an important session but often lose the crucial meaning which was derived from the work done that day. The main idea to remember is not to fail to do notes until you find yourself served a subpoena by a court or a disability claimant. The notes you create at those times are not beneficial to you or your supervisee because they lack credibility which comes from a case note which is written soon after the session. While all this seems self-evident, it is important to recognize that keeping notes for anything other than an aid to treatment in most cases was rare until HIPAA was imposed only a few years ago. Many of us had become quite comfortable with brief, non-HIPAA compliant notes and, although we plan to change that habit, have not yet done so. Do it now. You will sleep better.

Last, know your limitations. Refer the client when you have no experience or training in treating the presenting problem. Refer them if they scare you and you feel you will not be able to find a colleague or supervisor who can help you sort out whether or not your supervisee should give this patient a try and if you have someone to help if you find you have trouble. Refer the client to a physician when you have an odd feeling that the problem does not sound solely psychological. Always refer them if there is any question about whether medication would be helpful. If they refuse, note they refused and why. Refer patients who abuse other substances if that is not an area of expertise or one in which you want to develop expertise. Having a drug or alcohol problem may seem minor and secondary to the primary diagnosis but it is amazing how frequently a drug or alcohol problem becomes the main problem very quickly or the main reason why no progress is occurring in therapy. Many of us had the fortune to be trained by masters of the craft of psychotherapy either during or after graduate school. Many of us have become the new masters of the craft. Still, for each and every one of us there are people who walk through our doors as clients and walk out as potential plaintiffs. Even the grand old masters have this happen so it can certainly happen to you.

Malpractice and the Licensing Board

Try to avoid doing anything which will cause you to have problems with the Licensing Board. Keep up on your paperwork. The State Board can require you to produce case notes in a very short time. If the Licensing Board sends you any sort of inquiry, do not take it lightly. Make sure they have experience. Do not just dash off a letter which answers the questions asked by the board. If they have written you and asked for a response, it is a serious inquiry about your treatment practices. The Licensing Board takes your responses seriously and what may appear to be a simple misunderstanding between yourself and your client could result in having to defend yourself and your license before a member of the Licensing Board. Make sure you have Malpractice insurance to cover the fee for an attorney to defend you. Being sanctioned by the Licensing Board is a public process and even if you do not lose your license temporarily and have to take additional classes or other tasks to bring your standard of practice up to that of other clinicians, you may lose your referral base. You will also be likely to find yourself the subject of gossip. The Licensing Board also may determine that you should lose your license to practice psychology permanently. This does not preclude having criminal or civil charges brought against you or your supervisee by your client(s). All of this is quite public also.

Malpractice and Ethics Committees

Try to avoid actions by ethics committees by following the rules and guidelines for practice. Make it a habit to check in on the state web site and the Licensing Board Web site on a regular basis so you know when laws are changing. Unfortunately, some therapists were convicted of violating ethics of their profession when they were following what had been a typical pattern but was in the process of changing. When you are uncertain about the rules, ask. Get answers in writing if possible. Know the name of the person with whom you spoke regarding how to most appropriately do tasks or render treatment. Consult with other supervisors and inform them of the difficulties you face. Seek legal consultation. The fee you spend may save your livelihood. Be wary of dual relationships. Be wary of any sort of variation in billing and collecting fees. Be aware of what you put in writing and that the information can be passed on to others even without your knowledge or consent, leaving you in a legal limbo which will certainly require an attorney.

Malpractice due to Criminal Allegations

The Attorney General is involved in these proceedings. They are the most serious offenses, usually involving fraud, collusion in criminal activities, and a variety of criminal offenses. In your practice, you do many things totally on your own and you are aware that within your office what occurs is privileged information. This requires that you set the standard higher for yourself and supervisee because a small bit of cheating quickly spirals into greater corruption. Do not lie, cheat, steal or engage in any behavior which could appear to have involved illicit activities. Do not enter into relationships with your supervisee which involves felonious behavior. Make it clear to supervisees who wish to have you collude with them in illegal activities that you will not do that and you must report behavior which would cause harm to others. Although therapist are rarely involved in these activities, conviction results not only in the loss of your license, it also results in criminal prosecution and incarceration. Some of the most frequent offenses involve defrauding Medicare by claiming to have performed services which were either not performed or were not reasonable treatment for the patients involved. These have usually involved large numbers of patients.

Heading Off Boundary Problems: Clinical Supervision as Risk Management

Robert Walker, M.S.W., L.C.S.W. and James J. Clark, Ph.D., L.C.S.W.

Abstract

The effective management of risk in clinical practice includes steps to limit harm to clients resulting from ethical violations or professional misconduct. Boundary problems constitute some of the most damaging ethical violations. The authors propose an active use of clinical supervision to anticipate and head off possible ethical violations by intervening when signs of boundary problems appear. The authors encourage a facilitative, Socratic method, rather than directive approaches, to help supervisees maximize their learning about ethical complexities. Building on the idea of a slippery slope, in which seemingly insignificant acts can lead to unethical patterns of behavior, the authors discuss ten cues to potential boundary problems, including strong feelings about a client; extended sessions with clients; gift giving between clinician and client; loans, barter, and sale of goods; clinician self-disclosures; and touching and sex. The authors outline supervisory interventions to be made when the cues are detected.

Introduction:

Mental health professionals deal with the intimate personal matters of their clients, and they enjoy the privilege to practice because their endeavors promote the common good. The benefits of prestige and a special role in society carry a duty to safeguard the welfare of the public. The pledge to protect the public good, reflected in the Hippocratic Oath, exists from antiquity, and it binds the professional to a purpose beyond personal gratification.

Today the law recognizes this special role by defining a fiduciary relationship between the expert professional and the vulnerable client. The fiduciary responsibility puts the relationship in an ethical framework that bars the professional from self-dealing and from situations in which his or her personal interest conflicts with the client's. The professional is prohibited from exploiting a client and must refrain from actions that might be harmful to the client. This prohibition implies that minor harm can lead to serious harm.

Gutheil and Gabbard have warned of the existence of a "slippery slope," on which unchecked seemingly insignificant acts can catalyze the development of unethical patterns of behavior. More recently, these authors have cautioned against simplistic, literal applications of their ethical warnings about boundary crossings and their relationship to violations. Noting the pendulum swing of policy and opinion, they call for a moderated application of boundary concepts to ethical practice, an idea that is consistent with earlier representations of ethical standards.

The complexities and varieties of contemporary mental health practice settings make a literal application of ethical standards impractical. Mental health professionals now work in settings ranging from formal institutions, such as psychiatric and general hospitals, outpatient clinics, nonprofit agencies, schools, private- and public-sector workplaces, and prisons, to clients' homes, which may include arrangements for assessment and treatment, intensive case management, family preservation, home health care, employee assistance programming, and hospice care. Because of the complexity of these settings and the nontraditional roles of service providers, the boundary rules governing traditional assessment and treatment are not easily applicable. Unfortunately, this situation results in the absence of clear rules or guidelines.

More important, many clients involved in these less structured treatment modalities are disenfranchised individuals who are at greatest risk for exploitation. Many are low-income minority clients with serious mental and physical disabilities that include deficits in cognition, judgment, self-care, and self-protection.

The promotion of cultural diversity in treatment environments often encourages expansion of traditional professional roles. The literature in this area calls for more flexible roles and more out-of-office services carried directly to the client in the client's own environment. However, these situations can create even greater power differentials between provider and client than are generally found in office-based psychotherapy practices. It can be argued that a higher fiduciary duty exists for mental health professionals who serve clients in less structured settings and that the relaxation of traditional roles carries with it an increased responsibility to define practice-specific ethical guidelines to protect the vulnerable client.

In this paper, we propose that agencies or practice directors and clinicians articulate practice-specific guidelines for ethical boundaries and establish supervisory processes to inhibit misconduct through careful scrutiny of early warning signs of boundary problems. We identify ten cues to possible boundary problems and suggest supervisory responses.
Clinical Supervision to Support Ethical Practice

Fundamental ethical principles can inform practice, but the complexities of the practice environment suggest that program directors might need to develop ethical guidelines adjusted to local culture, program aims, and the capabilities of providers. A clear and reasonably specific set of principles or ethical standards is recommended to guide local practice. The standards should be promulgated to all staff and should be signed by each provider, documenting proof of being informed.

However, developing and distributing ethical guidelines or standards does not go far enough. Clinical supervision can be used to apply general ethical guidelines to the complexities of practice settings and the uniqueness of a particular case.

Clinical supervision can support practice within ethical boundaries by following four major principles. First, the supervision should be proactive rather than reactive. The supervisor should not wait for calamity to review the supervisee's work. Supervision should be continuous and of varying intensity, based on the clinician's caseload and other characteristics of the practice setting, such as changes in funding, management, or contractual obligations.

Second, the supervision should be sensitive to the supervisee's personal situation. A supervisor should be aware of significant changes in the supervisee's life that might indicate increased vulnerabilities. Recent divorce, severe relationship problems, serious illness, or death of a loved one can leave a clinician emotionally vulnerable. A clinician who has previously practiced without distress can unexpectedly change the manner of relating with clients and create boundary concerns.

Third, the supervisor must pay attention to the details of the supervisee's cases and the interactions between clinician and client. For example, it is not helpful to simply rely on diagnostic labels to explain clinician-client problems. Instead, the supervisor should ask the supervisee to relate the full narrative sequences of clinical encounters. The patterns or themes found in the clinician-client interactions can capture meaningful content for further analysis and examination.

Fourth, the supervisory interaction should incorporate guided exploration rather than cross-examination. Although focused investigation can play a role during a crisis, the routine supervisory process will generally discover more useful content through less directive means. We recommend the use of the Socratic method, in which the supervisor asks a series of questions that guide the supervisee to reveal and understand his or her clinical judgments and behaviors and, optimally, develop more appropriate views.

Using these four principles, clinical supervision can be an effective process for detecting cues of potential boundary problems and exploring them. Based on the literature and practice, we identify ten cues that suggest possible boundary problems. Each is paired with a recommended supervisory response. Whether a boundary problem is serious or not depends less on what the clinician believes than on the regressive response or other harmful response it evokes from a client. It is also important to note that what might be helpful for one client can prove harmful for another; supervisory responses must be tailored to the specific clinician-client situation.

The cues and responses described below generally proceed from less serious to more serious. However, the order in which they are listed does not reflect an absolute ranking.

Strong feelings about a client.

Clinicians may confuse personal caring with professional caring. Although such confusion generally occurs with novice clinicians, experienced clinicians are not immune to it. Strong personal feelings about a client can indicate a developing personal relationship. Contemporary community-based programs sometimes encourage a more personal interest in the client as an alternative to institutional, regimented services. The supervisor can guide the clinician to develop warm but professional relationships.

Because strong feelings are not always a problem in themselves, the supervisor should first elicit the source and quality of the clinician's feelings about the client, with the goal of promoting greater insight. Second, the supervisor should survey the intensity of the feelings and contrast the case to others in the clinician's caseload. The supervisor should then ask the clinician to examine these feelings to encourage self-observation and professional discipline.

Extended sessions.

The practice of extended sessions often develops from strong feelings about a client. An occasional episode should be little cause for concern. A pattern, especially with particular clients, is a cue to potential boundary problems. Many community-based programs place a high premium on flexible care that prioritizes the client's needs. Supervisors can help determine whether it is the client's or clinician's needs that drive the clinician's actions. Supervisors should also monitor the equity of clinical services to avoid favoritism or neglect.

The supervisor can explore the clinician's reasons for longer sessions with a client as a way of discovering subtle favoritism or other personal bias toward the client. Simply exploring these issues may curb the practice. Explicit instruction to shorten sessions or reassignment of the case may become necessary when this approach fails.

Inappropriate communication during transportation of clients.

Contemporary case management programs often expect certain providers to transport clients to programs and services. In such cases, the case manager should be guided to avoid expressive psychotherapy that might explore deeply personal issues. Case managers bear considerable responsibility for drawing clients into services and for facilitating the client's access to care. When a case manager is spending considerable time with a client in the car, in the home, and in nonoffice settings, it is possible for the client and case manager to blur professional and personal roles.

A client who is enrolled in a welfare-to-work program and who has emotional problems might have difficulty understanding the professional limitations on companion-like case management services if the case manager, acting like a clinician, also delves into the client's emotional problems. The suggested intimacy arising from deeply personal conversation in the privacy of an automobile may tax the boundaries of both client and case manager. Vulnerable clients may be unable to adjust psychologically from the intensity of in-depth counseling sessions to more casual contact in the automobile. Emotionally vulnerable clinicians may experience the same problem when they step into a case manager role and have less structured engagements with clients. This practice is more worrisome when the clinician independently decides to transport a client without program approval.

When such a situation is noted, the supervisor should draw a clear line between case management and intensive psychotherapy practices. Performing both roles with the same client is a risk factor for boundary problems. The supervisor should help the case manager or clinician understand and avoid role confusion.

Off-hours telephone calls to and from clients.

Current clinical practices sometimes demand the clinician's ready availability to the client. Some new therapy approaches recommend the clinician's availability for even minor "emergencies," such as in treating patients with borderline personality disorder. However, four practices can indicate potential boundary problems in these cases: clinicians' giving clients their personal telephone numbers (rather than the number of an answering service or crisis line), a pattern of initiating calls to clients rather than receiving them (except in serious emergencies or to monitor client safety), frequent or lengthy calls, and a pattern of late-night or weekend calls. These practices involve the clinician's personal space and privacy. Unchecked, such access invites the possibility of increasing levels of intimacy.

When off-hours calls are an issue, the supervisor should explore the clinician's goals for such contacts. Likely areas for inquiry include the clinician's need to be needed or to be considered special by the client. The supervisor should help the clinician achieve more realistic expectations about the clinician's role and appropriate services.

Inappropriate gift giving between clinician and client.

Token gifts of appreciation from clients are not of great concern, and within certain cultures, gift giving is often expected. Supervisors need to be sensitive to the cultural dimensions of gift giving, but they should also pay attention to possible boundary problems.

Three concerns arise with client gift giving—the timing of the gift, such as a birthday or Valentine's Day gift; the gift's monetary value; and its personal specificity. Highly personal gifts, even of modest dollar value, should be cause for supervisory concern. A clinician's acceptance of gifts suggests that the clinician-client relationship has changed. Likewise, gifts from the clinician to the client, except when sanctioned by program guidelines, should prompt a supervisory response.

The supervisor should help the clinician explore the possible meanings of the client's gifts. The supervisor should explore how the clinician's and client's perceptions of their relationship might be changed by the gift, either positively or negatively. When gifts are very personal or expensive, the supervisor should help the clinician understand why accepting them could be harmful to the client. They should also explore ways to return items with minimal disturbance to the clinical relationship. In such situations agency rules should be helpful. The clinician can thank the client for being thoughtful but disclose that ethical codes prohibit accepting gifts. This response helps prevent the client from feeling a personal rejection.

Boundary problems in in-home therapy and home visits.

Many community-based programs, particularly for persons with serious mental illness and emotionally disturbed children, use in-home therapies to minimize risk of institutional care. Although many of these therapies focus on psychosocial skills training rather than expressive psychotherapy, they can create opportunities for boundary problems. Home visits that are outside sanctioned treatment should be examined very closely. Frequent visits combined with signs of personal interest in the client should prompt more focused supervisory review.

The supervisor should inquire about the clinician's feelings of special interest in the client. Inquiries may lead to exploration of the clinician's rescuer fantasies. Likewise, the clinician's anxiety or ambiguity should be examined in detail. The supervisor should take steps to reduce contact or transfer a case when there are signs of overinvolvement. The supervisor should immediately intervene if there is reason to believe that a client or a clinician is being exploited.

Overdoing, overprotecting, and overidentifying.

The clinician who overidentifies with a client might experience a need to do things for a client rather than help a client accomplish goals and learn to do things for himself or herself. At first, this behavior may appear relatively harmless or even admirable. However, such signs of enmeshment can suggest overinvolvement with a client and potential boundary problems. A clinician involved in this type of relationship might be unaware that the boundary has been crossed. For example, the clinician might believe that the actions truly benefit the client and that diminished involvement will result in the client's feeling abandoned.

In response, the supervisor should explore how this case differs from others in the clinician's caseload. The clinician's perception of unique circumstances or characteristics should provide opportunity for further discussion and, if necessary, confrontation. Uniqueness is especially troubling when it presents in two forms—the clinician's perception of a unique client circumstance or the clinician's belief that he or she has qualities that are uniquely fitted to the client's needs. In either case, the supervisor should focus on the clinician's distorted thinking and consider whether overinvolvement is the clinician's characteristic way of dealing with other people or the response to a particular type of client. If the clinician cannot adequately respond to such redirection, vigorous supervisory intervention is indicated.

Loans, barter, and sale of goods.

Financial interaction between a clinician and client other than payment of fees is a boundary issue. Borrowing or loaning money is not always a profound ethical violation; nonetheless, it certainly warrants detailed evaluation. The use of agency funds available for client emergency needs are not a concern. The transfer of personal money or property to or from the clinician is entirely different. Bartering clinical services for goods or other services is ethically troubling and is certainly cause for supervisory exploration except in practice areas where cultural standards have made this practice more normative.

The supervisor should state the ethical limits regarding financial transactions with clients. Clear policies and procedures should be established to provide the clinician with unambiguous guidelines about financial issues with clients. The supervisory stance should be firm and generally inflexible. The risk of exploitation of a client in these matters is great.

Clinician self-disclosures.

Clinicians who disclose personal circumstances to clients open the door to boundary problems. Limited and clinically directed disclosures can be helpful, and in certain cultures, they are almost essential. However, disclosure of highly personal information is rarely welcome or justifiable. Clinicians who are vulnerable due to personal losses or substance use may make personal disclosures to remedy their own loneliness. Overly personal disclosures by the clinician can suggest mutuality in the relationship rather than collaboration for treatment purposes.

The supervisor should first explore the clinician's rationale for self-disclosure. Next, the supervisor should explore with the clinician the possible dynamics of such disclosures and their potential risks. The clinician should be coached on how to therapeutically redirect a client's requests for inappropriate personal information about the clinician. The supervisor should continue to monitor this issue very closely.

Touching, comforting the client, and sexual contact.

Some therapists use touch and hugs in their work. We consider this a high-risk practice for most mental health treatment environments. Although the occasional hug might be therapeutic, the risk of harm contradicts its use. Some children's therapists might hold a different opinion. Some young children may need physical reassurance in the course of clinical work. We recognize this need, but recommend careful monitoring of this practice with children.

In some cultures touch is an essential part of meaningful exchange, and its significance must be taken into consideration. Work with elderly persons represents another important exception—touch can be a critical part of therapeutic engagement with this population. However, as a general practice in most mental health settings, physical contact is high-risk behavior.

One might argue that seasoned clinicians could be granted greater license in this area than those less experienced. Unfortunately, experience does not immunize, and even seasoned clinicians can delude themselves into believing that sexual touching is therapeutic. Furthermore, despite the clinician's intentions, even "therapeutic" physical contact may be interpreted as sexual by the client.

The inequality of power and control in the clinician-client relationship also contributes to distorted perceptions of touch. Touch has a tendency to escalate physical response, particularly for clinicians who are as emotionally vulnerable as their clients. Sexual contact with clients is simply unethical and actionable. Psychiatry and social work have perhaps the clearest proscription against the behavior, including sexual contact with former clients. Although the major mental health professions have defined sexual behavior with current or former clients as unethical, less established professions with less clear licensure and certification standards have less clearly stated policies.

At the beginning of the relationship with a new supervisee, the supervisor should express clear rules or guidelines for physical contact with clients. The supervisor should coach the clinician on ways to show support or comfort that do not require hugging or other forms of touch. The prevalence of sexual abuse histories among mental health clients should be discussed along with the possible ramifications for clinical practice.

Conclusion

Gutheil and Gabbard have now described a more gradual application of boundary guidelines than their earlier writings might suggest. We agree and suggest that the diversity in practice settings, cultures, and client populations calls for practice-specific ethical guidelines. Guidelines adjusted to the specific practice area can avoid both the rigid application of generic rules and purely subjective case-by-case decisions. Overly rigid rules can inhibit meaningful practice, while subjective decisions are not tested against the broader ethical consensus.

Not all clinicians are able to arrive at appropriate decisions without the benefit of dialogue with others. In fact, too much independence may be a risk factor. Strict adherence to rigid rules, on the other hand, is simply unrealistic. As an alternative to rigidity or idiosyncratic practices, we argue for the use of effective clinical supervision as a primary tool for managing the risk of boundary problems.

As administrative, educational, and monitoring resources become more scarce and as cases become more complex, the likelihood of boundary problems increases. Boundary crossings and violations may damage clients, clinicians' careers, agencies' reputations, and programs' credibilit. Programs serving minorities, welfare recipients, persons with severe mental illness, and severely emotionally disturbed children face additional risks with already vulnerable populations. In-home services, case management, and other nontraditional services expose clients and clinicians to informal private settings. Without regular, proactive supervision, clinicians and other providers can easily lapse into boundary problems.

Clinical supervision can offer compassionate and cost-effective risk management by addressing clinical events higher up on the slippery slope. The supervisor who intervenes with a clinician's overuse of the telephone or too frequent use of home visits may prevent a lapse into sexual misconduct with a client. By using the four principles of proactivity, sensitivity, attention to narrative detail, and a commitment to Socratic methods, the supervisor is positioned to intervene successfully. The ten cues offer supervisory guideposts for discussion and inquiry.

Models of Supervision - Page 2

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PSYCHIATRIC SERVICES. ONLINE by Robert Walker. Copyright 1999 by American Psychiatric Association. Reproduced with permission of American Psychiatric Association in the format electronic usage via Copyright Clearance Center.