Supervision

                                

Course Objectives

 

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

2.  Describe the different theoretical models of supervision.

3.  Recognize and describe the need for a multicultural approach to supervision.

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

5.  Describe transference and countertransference as they relate to the supervisor and trainee.

 

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.

Psychoanalytic Supervision and Case Vignettes

The practice of supervision of psychoanalytic trainees has gone through a series of changes as psychoanalysis matured. Beginning with the earliest Freudians, however, an important part of learning to do psychoanalysis is to be a patient of someone who is well trained in how to do psychoanalysis appropriately.

Since the beginning, there have been as many variations of psychoanalytic thought as there have been psychoanalysts. Each analyst adopts techniques which seem to work best with their particular set of patients as well as changing in minor or major ways while seeing different patients. In general, patients lie on the couch, free-associate, discuss their dreams, and are provided with interpretations from the analyst. The emphasis is on making the unconscious conscious as the primary means to achieving an understanding of oneself and alleviating symptoms.

Thus several of Freud’s patients followed his general technique while others, most notably Jung and Adler developed techniques which are quite distinct from their analyst. Even today, many analysts can trace their “family history” through their analyst in an unbroken chain back to Freud.

In the United States, the American Psychoanalytic Association controlled who would become supervisors or “training analysts” until about 1990. Before that time, only psychiatrists were admitted to institutes certified by “the American.” A long-term lawsuit brought by psychologists on the basis of restraint of trade, eventually led to the American Institutes accepting psychologists, doctoral-level social workers, and eventual marriage and family counselors as full students who were capable of not only becoming psychoanalysts but also training analysts or supervisors.

During this lengthy and acrimonious lawsuit, psychologists and other mental health professionals set up and developed training programs of their own; many of which were certified and affiliated with the International Psychoanalytic Association. Outside of the United States, other mental health professionals were welcome, even encouraged to attend psychoanalytic institutes and become training analysts. In the United States, the earliest and longest-lasting is the William Alanson White Institute, following the techniques elaborated on by Harry Stack Sullivan. Many other institutes have emerged and have solid reputations for training psychoanalysts in the United States in variants of Freudian, Jungian, Kleinian, and other schools of thought.

Traditionally, the beginning student of psychoanalysis takes four years of formal classes.  Typically students who are admitted to institutes have experience in doing psychotherapy and have had their own practices for several years. This is important because the training can be expensive.  During the years of training, the student is also expected to be in analysis from three to five times weekly with a training analyst who has been certified by the institute, and until recently, the American Psychoanalytic Association, as a training analyst. The classes focus initially on theory but quickly move into a blend of theory and technique. The student is expected to pay a reasonable fee for analysis.

There is an emphasis on case presentations so students can learn from the work of others including psychoanalysts about whom they have read, their own teachers, and their peers. The learning environment is a rich one and discussion about everything, including the foundations of psychoanalysis itself is encouraged. Classes are generally small and in many cases becoming smaller because of the expense and time required for training. Freud is read extensively as are commentaries on his work.

After the first year, students are encouraged to find a patient they can see several times weekly, preferably four or five, who is also committed to the process of psychoanalysis. Prior to beginning to do analysis on a patient, students must acquire a license which legally allows them to do psychotherapy. Some psychoanalytic institutes operate a clinic to serve patients who are unable to pay much for analysis. This also helps to provide a pool of patients for students. This “first patient” is expected to lie on the couch, free-associate, and be provided with interpretations as does the student with his or her own analyst.

Additionally, the student chooses a supervisor for the case. Because the psychoanalytic institutes in America follow their own rules and guidelines rather than being governed by state or federal laws, students are free to choose a supervisor who may have substantially different training. This supervisor does not provide “hours” for obtaining a license. Supervisors, like analysts, are paid privately by each individual student. The amount which is paid varies but is generally based on the fee the patient pays rather than on the supervisor’s regular fee. Psychologists may, for instance, choose a psychiatrist, marriage and family therapist, or social worker rather than another psychologist. There is generally a trial period to ascertain whether the supervisor and student will work well together. Either may decide that the relationship between them will not promote a solid learning experience. It is important that the supervisor trust the student to bring up important issues, particularly problems, encountered in treatment. The student must also be trusted to tell the truth about what occurred in the session and work toward understanding the transference and countertransference. Some supervisors also share their personal opinions and emotions while others retain a greater distance.

The supervisor is generally seen once weekly for an hour. During that time, the supervisor may ask how the case is proceeding in a manner which is unique to the supervisor or the student may bring up issues of interest. Generally notes are not brought to supervision sessions nor are notes taken during the treatment of the patient since they are seen as interfering with the analytic process. The supervision session may focus on the therapy as a whole or on specific issues which the student is finding difficult. The student is considered to be the expert on the patient since they are in the room with them. The role of the supervisor varies but it is usually to provide insight into developing issues between the student and patient which may not be noticed by the student due to transference, countertransference, and inexperience among other reasons.  Generally a bond and trust develop between the supervisor and student which may last throughout the association of each with the institute.

The patient’s symptoms and history are presented before an open committee with both the student and supervisor present along with at least one other training analyst. Primarily, the task of this committee is to help the student recognize whether or not the patient is appropriate for analysis and to determine whether the student has enough expertise to work with the patient successfully. Technique and countertransference (or feelings and thoughts of the student about the patient) are discussed as well with an emphasis of pointing out possible difficulties before they begin to occur. While many students find these meetings intimidating, they are a necessary part of integrating the student and supervisor with the ongoing work of the Institute. Despite the findings of the committee regarding the suitability of the analysis, if the student and supervisor decide to continue with the analysis, they are free to do so without criticism.

In the second, third, and even fourth years, the students choose two additional patients and two other supervisors. This is considered to give the students a broader understanding of the process of psychoanalysis as well as to clarify that different analyst’s work from different premises, use different techniques, and provide supervision for their students in different ways. The student must see at least three patients for at least a year with the supervisor they have chosen to work with them.

In addition, the cases, appropriately disguised, are often discussed with other committees. At least one case is written in formal psychoanalytic style which recognizes the transference or feelings of the patient toward the student-analyst, the countertransference, the main interpretations which led to change and growth, and how termination of the case and the transference was done.

Students are also given an oral exam by two examiners chosen by the institute to ascertain that they have learned the material presented in their courses. Analytic students are expected to learn not only technique but also the deeper levels of theory which underlie the techniques. The oral exam is broad, covering all types of analysis taught by the institute.

Subsequent to graduation, some students are asked to teach courses along with other faculty members. This may continue throughout the member’s life with the institute. Others prefer not to teach at the institute and may do research, develop a psychoanalytic practice, teach at a university, or a variety of other activities which use the material they have learned.

A few students become training analysts or supervisors themselves. While this step has until quite recently been a part of the American Psychoanalytic Association who determined whether or not a faculty member who had written an additional case for the American and acquired certification as an analyst, Institutes which are part of the American are currently changing this process so they can choose their own training analysts from among their members. A committee is elected to choose members who show promise of being excellent supervisors. Usually these are people who have devoted time to teaching, serving on a variety of committees which run the Institute, written and presented original papers, and are well- respected and well-liked members of the analytic community.

It should be emphasized that there is no specific manner in which supervision is done in analytic training; instead, the student and supervisor create a unique relationship in which to discuss the patient. Both the opinion of the student and the supervisor are considered to be worthwhile in treating the patient. Both can also be incorrect in their understanding and change as the analysis progresses. The student is free to use the supervisor’s suggestions or not depending on how the relationship of the student with the patient develops.

Because of the confidentiality of the relationship as well as the openness of the student, supervisor, and patient, case studies are carefully guarded. The identity of the patient is consistently disguised by giving them different ages or occupations for example. The only time the patient is discussed in detail is with the supervisor, and even then, the patient’s real name is not used unless it is relevant to the analysis.

Therefore, unlike supervision which is usually primarily didactic, this analytic supervision involves the student and supervisor as a team with the supervisor as the senior member. They attempt through their insight, experience, and understanding to help the patient be freed from the unconscious thoughts, memories, and emotions which lead to unwanted symptoms.

Sample Case Discussion with a Supervisor: (1)

Student: My patient reported a dream to me yesterday. In the dream, he was dating a woman from work and had taken her to dinner. Everything was fine until he noticed that he did not have silverware. Then he tried to signal the waiter and discovered he had no arms or hands. He woke up in a panic. I waited but he didn’t say anything so I suggested that the dream created so much fear, he could not think about it long enough to have associations to it. He was still silent so I felt I had gotten it wrong.

Supervisor: Was there something about the dream which made you feel that you should say something?

Student: Well, after awhile, I started feeling like I wasn’t doing anything helpful. There was just silence and nothing was happening… I felt pretty useless…

Supervisor: Perhaps the content of the dream had an influence on you as well?

Student: I think anybody would react to finding they had no hands…You’re right, I was feeling helpless just like he probably was and some anxiety like a milder reaction rather than panic.

Supervisor: So the content of the dream conveyed helplessness and a fear about being helpless.

Student: Now that I’m thinking about it in this way, it seems that having the dream of a date makes him feel helpless and that leads to panic. I see why he doesn’t date very often…

Discussion: This is an excellent supervisor in that it is immediately understood that there is some part of the dream which has disturbed the student. Although the student attempts to dismiss the supervisor’s interpretations, the student continues to confirm in his responses that the supervisor is correct in his or her intuition that there is a problem which may be quite serious which the student is evading. The supervisor, despite the student’s attempts to change the subject or deny the problem, continues to return to it in a manner which is gentle and allows the student to begin to explore his reaction. While further work may continue in supervision, the student has become quite aware of issues which were likely unconscious and would be wise to discuss them in more depth with his analyst.

Sample Case Discussion with a Supervisor: (2)

Student: I really felt like my patient and I made progress today…She began to talk about the difficulties she has with men and then moved on to discuss her obesity and the way it protects her from sexuality with men

Supervisor: What was it about that interaction which made you feel she was making progress?

Student: Sometimes I don’t know if you are playing a game with me or if you’re just not listening.

Supervisor: Um

Student: Like right now. I told you my patient made progress in understanding her obesity and its connection with her sexuality but you made me feel like nothing had happened.

Supervisor: ….

Student: I don’t understand why you can’t sometimes tell me I did good work with my patient.

Supervisor: It seems important that you feel I approve of you but all you have told me is what your patient said, not about your role in her understanding.

Student: Her understanding obviously was a result of the work she and I have done.

Supervisor: Oh?

Student: Maybe I’m falling back into needing support and praise. I sure feel like you should say something positive about my work but you’re right, I talked about work she had done as if I did not feel involved in it. I’m not sure I was involved in her being able to put the pieces together, maybe she was thinking about it on her own and they just began to make sense to her. I feel like I took her insight away from her and made it mine to impress you.

Supervisor: So she is able to do analysis on her own.

Student: No, I know I make useful interpretations but I also know that she is a good patient and continues to think about the sessions when I am not there.

Supervisor: Any thoughts about why it was so important to have my support and praise right now.

Student: …well, I feel like money is tight right now…actually, several patients have decided to quit lately and I felt it was because I was not doing a good enough job.

Supervisor: It’s painful to have that feeling.

Student: Yes. I think I had some sense that I could alleviate my concerns about making a living by being an analyst if my patients were making progress which you noticed. At the same time, I realize that my success or failure do not depend on your approval. I use to feel that so strongly as a kid with my dad.

Supervisor: Perhaps your patient has a similar need to please you by doing a good job at analysis.

Student: You may be right about that. Her parents did not give her much praise either. Maybe that’s more tied to her obesity than avoiding men.

Discussion: This supervisor is working very well with substantial difficulties which are being avoided by the student in his analysis of the patient because he has faced similar problems with his father and has not yet resolved them. The supervisor uses silence and a non-committal “Um” to allow the student to reach a deeper level of trust with the supervisor, almost as if the supervisor is temporarily in the role of the analyst. The gambit is effective in that the student becomes more ready to discuss personal problems he is having with the patient rather than glossing over the problems and pretending that the analysis is not at a turning point. Although there is some insight on the part of the student, he is expected to work out these issues in his own analysis rather than with his supervisor or his patients. It is the work of the supervisor to inform the student of problems in countertransference as they arise but the actual work of resolving the underlying problem is almost always that of the student’s own analysis.

Sample Case Discussion with a Supervisor (3)

Student: My patient has been having some problems making it in to sessions. She seems to have good reasons. Her car keeps breaking and she doesn’t have the money to fix it, her mom isn’t able to come over and watch her kids, or she’s out of money and can’t afford the gas.

Supervisor: Is it possible she is telling you that she wants to terminate analysis with you?

Student: I don’t think so. She pays me when she has the money and is concerned about paying me late. I don’t criticize her when she is unable to do that. I think she needs the help and I also think she wants to be in analysis very much.

Supervisor: Why would you think anything like that?

Student: She has made some significant gains in understanding herself and her relationship to her children and their father. She sees the money problem as temporary since she is working at changing jobs so she can make more money and not have to rely permanently on the children’s father.

Supervisor: I notice you call her ex-husband “the children’s father” which implies she has no real relationship to him. Might you be attracted to her and negating his influence on her life.

Student: She and I have discussed her relationship with him extensively, as you know. She calls him “the children’s father” and I find that I think of him in that way as well.

Supervisor: Do you feel you are being pulled down into this woman’s abyss? You seem to be unconcerned when she can’t pay you, you excuse her absences as having a basis in reality, and you see her as someone who can change enough to be truly independent of her ex-husband.

Student: Perhaps you and I see this differently because of our own experiences.

Supervisor: Perhaps we see it differently because you lack experience and are far too forgiving of her lackadaisical manner rather than confronting them directly.

Discussion: It is clear that this supervisor and student do not have similar ideas about the patient. It is also clear that the supervisor has little respect for the work the student is doing. In a case such as this, if it is near the beginning of the analysis, the student may decide to seek a different supervisor who has a similar view. The supervisor also appears angry in that he consistently confronts the student in a manner which is disrespectful of the student’s relationship with the patient and the feelings and thoughts the student has about the analysis. This type of critique makes it difficult for the student to learn to do analysis because, unlike the previous two cases, he cannot openly discuss issues he actually has with the patient because the supervisor is consistently putting him in a position which is defensive. This supervisor may be seen as someone who should not be in that role since he actively attacks the student rather than promoting growth.

At times in supervision, it is necessary for the therapist to confront the student on flagrant errors and failures to deal effectively with the transference and countertransference. However, a good supervisor is likely to confront the issue early in the process and help the student work through different problems as they come along rather than having a session such as this in which the student appears barraged by criticism for many different types of issues on different levels.
The student has recourse. He can discuss the problem with his analyst to clarify his own part in the supervisory relationship. He can also change supervisors even though it would mean beginning the year of a supervised case over again. While some students feel the supervisor is always correct, because they are exposed to the work of at least three supervisors, it provides the student with the opportunity to understand how some supervisors fail to teach students, to establish trust, and to allow the student to grow into the type of analyst he will eventually become.

Sample Case Discussion with a Supervisor (4)

Student: Sorry I’m late today, the traffic was unusually bad…My patient had a dream that I would like to discuss. He is at a restaurant with his boss and other people from work. He is talking comfortably which he usually is unable to do in that sort of situation. He notices as he is talking his teeth begin to feel loose. As he is eating his teeth come out and he has to pick them from his mouth. The other people at the table notice and become silent. Then they all begin to laugh at him and make fun of him. He feels humiliated by the experience and tries to leave the table but finds he is unable to move his chair.

Supervisor: What associations did the patient have to the dream?

Student: He was very reluctant to tell me the dream or discuss it at all. When I inquired about why he was having so much trouble, he said the dream continued to make him feel humiliated and if I knew about it he was afraid I would see him as having such severe problems that I would terminate the analysis.

Supervisor: Has there been any problems between the two of you in the analysis which might make him feel that way?

Student: I feel I have not been able to make much progress, I guess. I don’t seem to have much insight into his dreams or the other information he discusses. It seems to stay at a superficial level.

Supervisor: Any ideas about why that might be happening? You had been doing very well with him prior to a few weeks ago.

Student: The only thing I can think of was that I was late several times. I seem to get on the road early enough but the traffic seems worse lately.

Supervisor: Perhaps the patient feels you are not very interested in seeing him.

Student: I can see him thinking that. He has a lot of trouble with interactions with his peers at work. He feels anxious while talking to them and then gets angry when they do not include him. He expects to be asked to go out to lunch rather than simply going when everyone else does.

Supervisor: So in his transference to you, you have become just like everyone else. You tolerate him but don’t really want him around.

Student: Yes, that feels right. He’s very servile with me but I feel he is also angry. When I interpret the anger he denies it and becomes even more servile. His history is pretty bad. He had parents who expected more from him in school and in his mind, they were constantly critical of him.

Supervisor: So what do you think of the dream?

Student: I think he sees himself as an object of ridicule who no one really likes even when he is functioning well. Having the teeth come out makes me think that he feels there is nothing he can do to save himself from inevitable humiliation.

Supervisor: Why do you think it is his teeth which are his problem?

Student: Well, it seems like his teeth would be connected to biting, like anger or even rage. When they come out it seems like he becomes helpless since he cannot attack people verbally anymore without showing them he has lost his teeth…I guess I also connect the loss of teeth with poverty since people lose teeth when they can’t afford to see a dentist.

Supervisor: So the teeth seem connected to an impotent anger which he hides under his servile manner. It also sounds like he continues to feel a deep sense of shame about himself from the manner in which his parents treated him. Perhaps it would be a good idea to focus more on interpreting his anger.

Student: I think so too. I think I have been avoiding really confronting him on it because I worry he will blow up and leave.

Supervisor: Perhaps if you were to interpret that concern prior to the interpretation it would enable him to have enough understanding of himself that he would be able to stay. It would also convey to him that you are not so critical of his anger that you will want him to leave if he shows it to you.

Discussion: In this vignette, the student and supervisor are working well as a team to open up and discuss various aspects of the analysis. The supervisor gives some direct suggestions but continues to respect the student’s opinion. The supervisor also makes some comments on technique which may be useful in helping the student through what is clearly a rough time for both himself and the patient. The student is open and trusting with the supervisor including being able to admit to errors he is aware he is making. His errors are not criticized by the supervisor but instead become part of the reason why the analysis has stalled. The supervisor does not directly interpret the dream since that is the job of the student and patient but gives the student some means by which he can open up the dream and the patient’s neurosis which will hopefully lead to more trust by the patient and a deeper level of analysis.

Additional Required Reading:

Teaching Psychiatric Trainees to Respond to Sexual and Loving Feelings: The Supervisory Challenge

EVALUATION IN SUPERVISION

Supervisors have an ethical and legal responsibility to monitor the quality of care that is being delivered to the supervisee’s clients. In order to enhance the professional functioning of the supervisee and assure quality of care, the supervisor constantly monitors and provides feedback regarding supervisee performance. Evaluation is the “nucleus of clinical supervision”. As important as evaluation is to supervision, both supervisors and supervisees may find it stressful. Supervisors are charged to balance an understanding of individual differences in conducting counseling sessions with the notion of competent practice as ascribed by the profession. The supervisor utilizes two general methods of evaluation: formative and summative.

Formative Evaluation

 Formative evaluation is the process of facilitating professional development through direct feedback. Formative evaluation is part of the foundation of supervision. The supervisor constantly monitors and provides feedback regarding supervisee performance. Choices of supervision interventions, questions asked to facilitate discussion, comments regarding the appropriateness of a supervisee’s case conceptualization, expression of the ineffectiveness of a supervisee’s use of a skill – can all be described as formative evaluation. Because formative evaluation is consistent and tends to focus on process and progress, rather than outcome, it tends to be less stressful and threatening for both the supervisor and supervisee. Hawkins and Shohet (1989) recommend that formative evaluation be:

• Clear: Supervisor needs to be clear about the message being delivered.
• Owned: The feedback that supervisors give is their rooted in their own perceptions and is  not ultimate truth.
• Regular: Feedback should be given regularly and in a timely fashion.
• Balance: A balance of negative and positive feedback should be created over time.
• Specific: Generalized feedback is difficult to learn from. Positive and negative evaluations should be accompanied by specific examples.

Summative Evaluation

Summative evaluation is a more formal expression of the counselor’s skills and abilities. The supervisor must step back, consider all that has been seen and heard, and decide if the counselor’s work with clients and potential for working with future clients “measures up.” When supervision is linked to practicum or internship experiences, summative evaluations typically occur at the mid-point and end of the experience. The summative evaluation process tends to cause more stress for the supervisor and supervisee. By definition, summative evaluation should be the culmination of the evaluation process, if formative evaluation has occurred throughout the process, there should be no real surprises for the supervisee. Rating scales are commonly used as part of summative evaluation. In addition, more specific behavioral feedback may also be provided. Evaluation

Process Considerations

It is acknowledged that evaluations can be an anxiety provoking experience. There are steps that can be taken to facilitate a growth-producing experience.

• Supervisees (students), instructors (if part of practicum or internship), and supervisors should discuss grading and evaluation from the outset. The rationale for evaluation, criteria, and methods should be explicit.
• Evaluation should focus on the supervisees’ professional work, not personal issues.
• The supervisee and supervisor should share the responsibility for evaluation. Supervisors and supervisees could each complete evaluations separately, and then bring them together to compare impressions.
• Students in practicum and internship need to understand that clinical experience is fundamentally different from other academic work. Grades do take on a different meaning. In clinical work, a lack of knowledge or skill has consequences for clients, the supervisor, and the agency/school, as well as the student. It is important to go beyond “grade mentality” to a learning mentality and work to embrace evaluation as a process of receiving feedback about performance.
• Supervisees should communicate with their supervisors about any concerns they may have or ideas for improving supervision.

Evaluation of the Supervisor

In addition to the flow of feedback from supervisor to supervisee, part of on-going evaluation could include feedback from the supervisee to the supervisor. Attention to the process of supervision helps to facilitate a positive growth experience for all involved. In addition to regular feedback, supervisees should have an opportunity to evaluate the supervisor. Although supervisors and supervisees may have different views on what constitutes “good” supervision, feedback provided by supervisees can reveal important information.

Duty to Warn - Tarasoff

The duty to warn is as relevant for supervisors as counselors working directly with clients. In fact, in the Tarasoff case (the impetus for the duty to warn standard/law) the supervisor, in addition to the counselor, was implicated in the case. The supervisor has a responsibility to advise the supervisee of conditions under which it is appropriate to warn an intended victim.

Confidentiality

Supervision allows for third-party discussion of therapy situations. It is important to remember that the type and depth of discussion allowed in supervision, is unethical in other situations. Supervisees must keep confidential all client information except of the purposes of supervision. It is sound practice to keep explicit identifying information confidential (for instance, use only first names and reveal few specific demographics).Supervisees also have a right to privacy and it is the supervisor’s responsibility to keep information obtained in supervision confidential except for the exceptions recognized by the profession and law. end

Dual Relationships

 There are two major categories of dual relationships: sexual and non-sexual.

Sexual Dual Relationships. There are four categories of sexual relationships:

Sexual Attraction

Sexual attraction is not an uncommon occurrence in supervision relationships. Unfortunately, however, there is little attention to how to openly address and discuss the implications of the attraction – leading to successful resolve of the issue. Because acting on an attraction poses serious ethical dilemmas, addressing the attraction in supervision or through consultation with other professionals is vital.

Sexual Harassment

Unlike sexual attraction, sexual harassment is a clear abuse of power by the supervisor and is never acceptable. Sexual harassment can leave the supervisee feeling violated, vulnerable and confused.

Consensual (but Hidden) Sexual Relationships

Results of studies indicate that the majority of sexual relationships between supervisor and supervisee fall in this category. Because of the power differential inherent in supervision, it is suggested that no true “consensus” can be freely given by the supervisee. Supervisors have a responsibility to own the “power” that is automatically attributed to them by nature of their role.

Intimate Romantic Relationships. There is no distinction in the literature between relationships that occur within supervision, and those that begin there. It is understood that intimate relationship may develop when adults work together in the world of therapy. The important factor is to assure that a relationship that grew out of a supervision relationship poses no ethical compromise for the supervisor or supervisee – and that there are no consequences for the supervisee’s clients.The general consensus about sexual dual relationships is that there is much more potential for harm and negative outcomes, than the potential for good or even acceptable outcomes. Supervisees and supervisors are encouraged to  discuss these issues and/or seek consultation. The secrecy that typically occurs in the development of dual relationships is an important signal that there is a strong potential for unethical conduct and harm.

Nonsexual Dual Relationships

For both counselors and supervisors, any dual relationship is problematic if it increases the potential for exploitation or impairs professional objectivity (Kitchener, 1988). There has been greater divergence of opinion about what constitutes an inappropriate dual relationship between supervisor and counselor than between counselor and client. Ryder and Hepworth (1991), for example, stated that dual relationships between supervisors and supervisees are endemic to many educational and work contexts. Most supervisors will, in fact, have more than one relationship with their supervisees (e.g., graduate assistant, co-author, co-facilitator). The key concepts remain "exploitation" and "objectivity." Supervisors must be diligent about avoiding any situation which puts a supervisee at risk for exploitation or increases the possibility that the supervisor will be less objective. It is crucial, however, that supervisors not be intimidated into hiding dual relationships because of rigid interpretations of ethical standards. The most dangerous of scenarios is the hidden relationship. Usually, a situation can be adjusted to protect all concerned parties if consultation is sought and there is an openness to making adjustments in supervisory relationships to benefit supervisee, supervisor and, most importantly, clients.

The potential for negative outcomes, as a result of dual relationships, centers on the power differential between the two parties. Dual relationships may be problematic in that they increase the potential for exploitation and for impairment of the objectivity of both parties, and they can interfere with the professional’s primary obligation for promoting the student’s welfare. 

Informed Consent 

The concept of informed consent is being addressed last, as it has the potential for impacting the ethical/legal issues discussed to this point. Informed consent is the best defense against the difficult and confusing issues that arise in supervision. Supervisors have an obligation to determine that clients have been informed by the supervisee regarding the parameters of therapy. Clients must not only be aware of therapeutic procedures, but also of supervision procedures. The supervisor assures that clients are informed of the parameters of supervision that may affect them.In addition, supervisors have a responsibility to inform supervisees about the supervision process, potential for dual relationships, limits of confidentiality, and the conditions of their success or advancement (evaluation criteria and process). Supervisors may use a Professional Disclosure Statement as a way to facilitate the informed consent discussion.

Ethical Decision Making

Ethical dilemmas are inevitable in counseling and supervision. To increase your ability to successfully manage dilemmas, consider the following:

• Successful management relies on the ability to recognize dilemmas – attend to feelings of confusion, concern, anxiety and fear.
• Incorporate experiential learning and case analysis into your work
• Include questions regarding potential legal and ethical issues as part of case discussions
• Familiarize yourself with ethical and legal codes and cases
• Adopt and regularly implement an Ethical Decision Making Model

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 (1,2).

Today the law recognizes this special role by defining a fiduciary relationship between the expert professional and the vulnerable client (3,4). 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 (3,5). The professional is prohibited from exploiting a client and must refrain from actions that might be harmful to the client (6). This prohibition implies that minor harm can lead to serious harm (7).

Gutheil and Gabbard (8) 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 (9). 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 (10).

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 (11). 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 (12). 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 (13). 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 (14,15).

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 (16). 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 (17).

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 (18). 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 (19). 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 (20).

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 (21).

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 (22). Furthermore, despite the clinician's intentions, even "therapeutic" physical contact may be interpreted as sexual by the client (23,24).

The inequality of power and control in the clinician-client relationship also contributes to distorted perceptions of touch (25). 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 (26,27,28,29,30,31). 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.

Conclusions

Gutheil and Gabbard (8,9) 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' credibility (32). 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.

 Required Reading:

Unwitting Exposure of the Therapist-Transferential and Countertransferential Dilemmas

Supervision of Psychological Assistants

It is the responsibility of both supervisor and psychological assistant to read and understand the following important information. The laws and regulations which govern psychological assistant employment and supervision are very complex. Hours of supervised professional experience accrued by psychological assistants to apply toward meeting licensure requirements often are denied because of failure of both the supervisor and the registered psychological assistant to understand and comply with these laws and regulations. Supervisors are responsible for their psychological assistants’ compliance with the provisions of the Psychology Licensing Law (Chapter 6.6 of the Business and Professions Code) and the Board of Psychology’s regulations.

Following is a summary of important provisions governing the supervisor/psychological assistant relationship. However, both supervisors and psychological assistants should read, and are responsible for complying with, all of the provisions governing this relationship which are contained in the Board’s laws and regulations.

Notification to Patients

It is the supervisor's responsibility to inform each patient, prior to the rendering of psychological services by a psychological assistant, that the assistant is unlicensed and is allowed to provide limited psychological services only while under the direction and supervision of a licensed supervisor (Regulation section 1391.6). Supervisors also must obtain releases from the patients of their psychological assistants to enable them to access confidential patient information related to their supervision duties (Business and Professions Code section 2960(h)).

Change of Address

The supervisor must notify the Board of any change to the address of record so that renewal notices can be received in a timely manner. Such notification must specify both the supervisor’s license number and the registration number of each psychological assistant if the assistants’ addresses are to be changed as well. Note that a change of address requested by the supervisor will not automatically change the psychological assistant’s address on the registration without a specific request to also change the psychological assistant’s address.

Initial Registration and Renewal

A psychological assistant cannot begin to provide psychological services until officially notified by the Board that the registration is approved.

In order for hours of supervised professional experience to count toward licensure requirements, it is imperative that psychological assistant registrations be renewed on or before the January 31st expiration date each year. It is equally imperative that supervisors’ licenses be renewed on or before their expiration dates so that they remain qualified supervisors during the entire period that hours are accrued.

 The Board has no choice but to deny hours of supervised professional experience if there are lapses in registration or supervisors’ license renewals. While it is the supervisor’s responsibility to assure timely renewals, the psychological assistant, as the affected party, should diligently track both the registration renewal and the supervisor’s license renewal. Any psychological assistant who practices with an expired registration is practicing illegally, and the supervisor is aiding and abetting this illegal unlicensed practice.

There is a 60-day period following the January 31st expiration date during which psychological assistant registrations can be renewed. Psychological assistants cannot practice during this period until the registration has been renewed. After April 1st each year, if the registration is not renewed, it becomes canceled and no longer exists. At this point, a new application must be submitted for approval.

Note that neither psychological assistants nor their supervisors are allowed to practice (or accrue hours) while the related registrations or licenses are delinquent.

Renewal notices are sent as a courtesy by the Board. If a renewal notice is not received, the supervisor and psychological assistant remain responsible for timely renewals.

General Information

Requirements:

Every supervisor of a psychological assistant shall be responsible for ensuring that the extent, kind, and quality of the psychological services performed by the assistant are consistent with his/her training and experience and with the education, training, and experience of the supervisor (Regulation sections 1391.6).

Every psychological assistant must maintain a weekly log of all hours of supervised professional experience gained toward licensure (Regulation section 1387.5).

The supervisor and trainee must complete a supervision agreement prior to commencement of supervision (Regulation section 1387(b)(10))

Supervisors must notify the Board in writing that a psychological assistant registration has been terminated within 30 days following termination (Regulation section 1391.11)).

Supervisors must be employed in the same work setting in which the psychological assistants are employed and available to the assistant 100% of the time the assistant is rendering professional services (Regulation section 1391.5(a)).

At a minimum, supervisors must provide at least one hour of face-to-face supervision per week for their psychological assistants (Regulation section 1391.5(b)).

Supervisors of psychological assistants must report to the Board on an annual basis: 1) the nature of the limited psychological functions performed by the psychological assistant; 2) evidence of employment; 3) the location, type, extent, and amount of supervision; and 4) a certification that the limited psychological functions are within the scope of the psychological assistant’s education and training (Regulation section 1391.10)). This information is reported on the registration renewal form.

Prohibitions:

Psychological assistants must at all times be treated as employees. As such, they are prohibited from renting office space from their supervisors and must be provided with all provisions necessary to function as a psychological assistant (Regulation section 1391.8(a) & (c)).

Psychological assistants can have no proprietary interest in their supervisors’ practices, and they are not allowed to bill patients directly (Regulation section 1391.8(b)).

Supervisors are prohibited from supervising trainees who are, or have been, psychotherapy clients of the supervisors (Regulation section 1387.1(k)).

Supervisors are prohibited from supervising trainees with whom the supervisor has a familial, intimate, business, or other relationship (Regulation section 1387.1(j)).

Supervisors are prohibited from charging psychological assistants a fee for supervision (Regulation sections 1391.8(a)).

Qualified psychologists may supervise no more than three psychological assistants at any given time, and qualified board-certified psychiatrists may supervise no more than one psychological assistant at any given time (Business and Professions Code section 2913(d)).

Supervisors who are listed as both employer and supervisor on the psychological assistant registration are prohibited from delegating supervision to any other licensed professional. No credit will be granted for hours of supervised professional experience earned by a psychological assistant if that supervision was provided by anyone other than the approved supervisor (Regulation section 1391.5(c).

References

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Footnotes

Mr. Walker is assistant professor in the department of psychiatry at the University of Kentucky College of Medicine and the Center on Drug and Alcohol Research at the university, 643 Maxwelton Court, Lexington, Kentucky 40506-0350. Dr. Clark is associate professor in the College of Social Work at the university

Additional References:

Shulman Lawrence, Safyer, Andrew: The clinical supervisor, Hawthorn Press 2003

Auxier, C.R. ; Hughes, Frances R. ; Kline, William B. :Identity development in counselors-in-training, Counselor Education and Supervision, 2003

Bernard, J. M., & Goodyear, R. K. (1997). Fundamentals of clinical supervision. Boston: Allyn and Bacon.

Borders, L.D., & Leddick, G.R. (1987). Handbook of Counseling Supervision. Alexandria, VI: Association for Counselor Education and Supervision.

GR Leddick, JM Bernard - Counselor Education and Supervision, Counselor Education and Supervision 1980

Cleghorn & Levin, 1973; Liddle, 1988; McDaniel, Weber, &. McKeever, 1983; Toward a General Model of Family Therapy Supervision:New York, 1997

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.