SUPERVISOR BE MINDFUL: ETHICS OF CLINICAL SUPERVISION - PART 1

All Supervision Is Rooted in Ethical Practice andRequires a High Level of Supervisor Competence

Carol Falender, Ph.D.www.cfalender.com

http://www.cfalender.com

Observe Video Clip

• Identify Ethical and Legal Infractions

• Determine how many and which ones?

• Use the Ethics Code for your profession.

How Competent Are Supervisors?

Supervisor Problems of Professional Competence

¨Over half the participants reported that their supervisors have had problems of professional competency ¤unprofessional behavior (39.9%), ¤educators being culturally insensitive or culturally incompetent (39.6%),¤ educator’s inadequate supervision skills (35.8%), ¤educators displaying inappropriate boundaries (31.6%), ¤educator’s inability to regulate emotions (30.4%),¤educators with inadequate clinical skills (27.4%)

n Furr & Brown-Rice, 2016

Potential Supervisor Ethical Infractions

• Multiple Relationships

• Informed Consent• Limits of confidentiality • Mandatory reporting• Expertise, experience, training—competence• Fees and billing

• Monitoring of supervisee’s work • Ladany et al, 1999; Wall, 2009

Supervisor Ethical InfractionsFrom the Supervisee Perspective

• 51% of the 151 beginning to intern-level supervisees sampled reported at least one ethical violation by their supervisors

• Largest categories of infractions:• Monitoring of supervisee activities and performance

evaluation• Confidentiality in supervision• Ability to work with alternative theoretical perspectives• Session boundaries and respectful behavior

• Ladany, Lehrman-Waterman, Molinaro, & Wolgast, 1999

Performance evaluation and monitoring of supervisee activities 33.1Confidentiality issues in supervision 17.9Able to work with alternative perspectives 17.9Session boundaries and respectful treatment 12.6Orientation to professional roles and monitoring of site standards 8.6Expertise/competency issues 8.6Disclosure to clients 7.9Modeling ethical behavior and responding to ethical concerns 7.9Crisis coverage and intervention 7.3Multicultural sensitivity toward clients 6.6Multicultural sensitivity toward supervisee 6.6Dual roles 6.0Termination and follow-up issues 5.3Differentiating supervision from psychotherapy/counseling 4.6Sexual issues 1.3

Complete List

Ethical Parameters

• Competence

• Informed Consent— Supervision Contract

• Attention to Multicultural Diversity

• Supervisor Responsibility/Liability

• Multiple relationships, boundaries, and objectivity

• Supervisor balancing protection of the public/client; gatekeeping for the profession; enhancing supervisee’s professionalism and competence

Ethics Codes

• American Psychological Association (2017)

• American Association for Marriage and Family Therapy (2001)

• National Association of Social Workers (2017)

• American Counseling Association (2014)

• Association for Addiction Professionals NAADAC/NCC AP Code of Ethics (2016)

• American Academy of Child and Adolescent Psychiatry (2014)

(2)

• American Nurses Association Code of Ethics (ANA)

• American Board of Pediatrics Code of Ethics (2015)

• Professional and Ethical Compliance Code for Behavioral Analysts (2016)

• American Medical Association Code of Ethics (2016)

• Code of Ethics for Certified Family Life Educators (2018)

• US Commission on Rehabilitation Counselor Certification Code of Ethics (2010)

• American Association of Pastoral Counselors

Utah Regulations

• Clarity about supervision and supervisor role/responsibility

• Consult the website for your discipline (regulations may and it is a supervisor’s and supervisee’s responsibility to keep up to date)

Examples of Ethical Challenges

• Supervisee must practice within areas of competence to perform competently “on the basis of their education, training, or experience, either independently or with the level of supervision being provided” (APA, 2.05 b): Competence is a core value in social work (NASW, 2017) and every profession• Need to attend to supervisee’s “blind spots”— attend to

metacompetence• Supervisee in a high volume behavioral therapy setting has client who

writes to him describing their special connection—supervisor monitors frequency of anxiety and she commends supervisee—he is uncomfortable with the client communication so does not mention it to supervisor and when anxiety is decreased, terminates promptly, prompting client report to board. • Falender & Shafranske, 2007; Thomas, 2010

Metacompetence of Supervisor and Supervisee

uAbility to assess what one knows and what one doesn’t knowuIntrospection about one’s personal cognitive processes and

productsuDependent on self-awareness, self-reflection, and self-

assessmentuWeinert, 2001

uSupervision guides development of metacompetence through encouraging and reinforcing the supervisee’s development of skills, knowledge, and attitudes in self-assessmentuFalender & Shafranske, 2007

• In CBT supervision, alliance is not the primary focus—rather it is on cognitions of supervisee work; also possible inattention to problematic interpersonal dynamics or emotional reactivity or emotional exhaustion of supervisee• At completion of successful CBT therapy, client no longer

qualifies for insurance, so supervisee suggests barter (having client create artwork for office and clean the office) in exchange for services. Underlying dynamic of supervisee being lower SES, Latina and supervisor is privileged, and so supervisor overlooks the potential multiple relationships, implications, and training opportunity

Use of Genograms

• Systems Therapies• Use of supervisee genograms

• Issue of mandatory self-disclosure• Consider 7.04 of APA (2017) ethics code—psychologists do not

require students or supervisees to disclose personal information in course- or program-related activities, orally or in writing, regarding sexual history, history of abuse and neglect, psychological treatment, and relationships with parents, pers, and spouses or significant others except if (1) the program or training facility has clearly identified this requirement in its admissions or program materials or (2) the information is necessary to evaluate or obtain assistance for students whose personal problems could reasonably be judged to be preventing them from performing their training or professionally-related activities in a competent manner or posing a threat to the students or others

Is there such a thing as informed consent in this instance? Consider power differential

(2)

• Potential for dual/multiple relationships between supervisors and supervisees—supervisor role transformed to therapeutic exploration—modeling unclear boundaries between supervision and therapy• Instances: supervisee in child treatment setting reveals in

genogram that his own family has a history of multiple generations of sexual abuse. Therefore he wants to work with sexual abuse survivors…he was once accused of inappropriate sexual behavior with children he was babysitting but it was an error on his part and not repeated

• What is the supervisor’s responsibility?

(3)

• Supervisee discloses a multi-generational substance abuse history in his family. Supervisor begins to wonder if supervisee has this problem, alerts other supervisors and clerical staff to be vigilant for signs of substance use/abuse in that supervisee. Supervisee goes to supervisor and asks why it feels like being under surveillance suddenly.

(4)

• Ethical issues with genogram• Purpose? Fitness for duty/practice/licensure?• Supervisee may infer confidentiality of genogram—

and of all disclosures in supervision• Does it fall within evaluative purview of supervisor?• Does it open the door to a boundary crossing for

supervisees? Expecting personal exploration beyond client focused?

• Does it open door to supervisee personal self-disclosures to clients?

Potential for Rupture

• Parallel processes• Supervisee has extremely anxious client, increasingly

contacts supervisor very frequently, to the point that the supervisor begins to be resentful

• Supervisor observes supervisee is overly controlling with client—redirects even when client is describing positive movement. Supervisor demands increasing documentation from supervisee, written transcripts, scripts to memorize

• Supervisee did not get accepted to law school so instead went into mental health; requests to receive all cases of law students so as to live vicariously through their experience and to heal

Multiple Relationships

• Small local communities of theoretically-based supervisors (e.g., psychoanalytic, humanistic, etc.), so potential for emotional intensity to intersect with multiple relationships and potential for loss of objectivity

• In communities (e.g., juvenile justice, LGBTQ, recovery) high potential for multiple relationships or networks of information, wanting supervision from someone who was a friend’s therapist/analyst, and frequency of contacts at association or affinity meetings• Falender & Shafranske, 2004; Thomas, 2010, Zur, 2017

Supervisor Errors

• Supervisor eats lunch during supervision, distracted by food, fact catsup was not included, etc.

• Supervisor expresses interest in shared interest with supervisee—music, theatre, dance, wine, etc. and spending much of supervision hour discussing, arranging to attend event or shop after work

• Supervisor always focusing on what supervisee should have done—what supervisor would have done as therapist

• Supervisor fosters supervisee dependency

• Supervisors is unable to deal with supervisee challenges to their own conceptualizations, treatment interventions—supervisors who avoid conflict with supervisees or become authoritarian, considering more advanced supervisees to be on “automatic pilot”• Falender & Shafranske, 2014; Thomas, 2010

Supervisory Contract –An Ethical Imperative

• Development of the supervision contract is an essential component of the supervisory process and serves as the basis for the supervisory alliance, enhanced articulation of expectations, for ethical informed consent, and to define parameters of the relationship and the process and content of supervision.

• Sample contract available in ASPPB Supervision Guidelines document (2015):• http://c.ymcdn.com/sites/www.asppb.net/resource/resmgr/Guidelines/Final_Supervi

sion_Guidelines.pdf

• And two sample contracts in Falender & Shafranske, 2017

http://c.ymcdn.com/sites/www.asppb.net/resource/resmgr/Guidelines/Final_Supervision_Guidelines.pdf

Supervision Contract

a. Content, method, and context of supervision—logistics, roles, and processes (APA, 2017, 7.02; 7.03)

b. Highest duties of the supervisor: protection of the client(s) and gatekeeping for the profession

c. Roles and expectations of the supervisee and the supervisor, and supervisee goals and tasks (7.02)

d. Criteria for successful completion and processes of evaluation with sample evaluation instruments and competency documents (APA, 2017, 2.06)

Supervision Contract (APA, 2017)

d. Criteria for successful completion and processes of evaluation with sample evaluation instruments and competency documents (APA, 2017, 2.06)

e. Processes and procedures when the supervisee does not meet performance criteria or reference to such if they exist in other documents (7.06)

f. Expectations for supervisee preparation for supervision sessions (e.g., video review, case notes, agenda preparation) and informing supervisor of clinical work and risk situations (4.03)

g. Limits of confidentiality of supervisee disclosures, behavior necessaryto meet ethical and legal requirements for client/patient protection, and

methods of communicating with training programs regarding supervisee performance (4.02),

h. Expectations for supervisee disclosures including personal factors and emotional reactivity (previously described, and worldviews (APA, 2017, 7.04)

i. Legal and ethical parameters and compliance, such as informed consent, multiple relationships, limits of confidentiality, duty to protect and warn, and emergent situation procedures

j. Processes for ethical problem-solving in the case of ethical dilemmas (e.g., boundaries, multiple relationships)

Supervisory Contract—Other Aspects (Falender & Shafranske, 2004; 2017)• Legal/Ethical Parameters

• Setting-specific boundary expectations• Specific reference to ethical codes, regulations, and laws• Handling electronic information—e.g., informed consent,

confidentiality• Social media guidelines

Supervisory Contract—Other Aspects (Falender & Shafranske, 2004; 2016)• Legal/Ethical Parameters (Cont.)

• Reference agency/site personnel practices• Normative management of countertransference,

reactivity, strains or ruptures to alliance• Limits of supervision

• Not personal psychotherapy

Supervisor Competence

Competence APA (2017)

• 2.01 Boundaries of Competence

(a) Psychologists provide services, teach, and conduct research with populations and in areas only within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience.

Delegation of Work to Others (APA, 2017, 2.05)

• Psychologists who delegate work to employees, supervisees,orresearch or teaching assistants or who use the services of others, such as interpreters, take reasonable steps to

(1) avoid delegating such work to persons who have a multiple relationship with those being served that would likely lead to exploitation or loss of objectivity;

(2) authorize only those responsibilities that such persons can be expected to perform competently on the basis of their education, training, or experience, either independently or with the level of supervision being provided;

(3) see that such persons perform these services competently.

Supervisor Self-Assessment

• Falender, C. A., Grus, C., McCutcheon, S., D., Goodyear, R., Ellis, M. V., Doll, B.,.,.,…Kaslow, N. (2016). Guidelines for Clinical Supervision in Health Service Psychology: Evidence and implementation strategies. Psychotherapy Bulletin(Division 29), 51(3), 6-18.

• http://societyforpsychotherapy.org/guidelines-clinical-supervision-health-service-psychology/

http://societyforpsychotherapy.org/guidelines-clinical-supervision-health-service-psychology/

Ethical Problem Solving

Ethical Problem Solving

• Koocher & Keith-Spiegel (1998) derived from Tymchuk and Haas & Malouf

• APA Model

• Additional factors to add• Personal responses to ethical issue (first step)—Barret,

Kitchener, & Burrus, 2001• Role of cultural/ diversity considerations

Ethical Decision Making Models

• Determine that the matter is an ethical one.

• Consult available ethical guidelines that might apply to provide a possible mechanism for resolution.

• Consider all sources that might influence the kind of decision you will make.

• Locate and consult with a trusted colleague

• Evaluate the rights, responsibilities, and vulnerability of all affected parties

(continued on next slide)

• (Koocher & Keith-Spiegel, 1998, 12-15)

• Generate alternative decisions

• Enumerate the consequences of making each decision.

• Make the decision.

• Implement the decision.

• (Koocher & Keith-Spiegel, 1998, 12-15)

Ethical Problem Solving Frame to Determine Boundaries of Competence

• Identify or scrutinize problem—consider relevant ethical principles, codes

• Develop Alternatives or Hypotheses—ethics and consultation

• Evaluate or analyze options—advantages/disadvantages of each; consider multicultural aspects

• Act or perform—in context of ethical principles

• Look back or evaluate—to learn from the experience• Derived by Falender from Knapp et al., 2017 model;

adapted from Pinner & Kivlighan, 2018