Clinical Supervision in the Real World

A Practical Guide to Ethics, Legal Issues, and Personal Development

Francis Martin, Janet Turner

• Publisher: Routledge
• Year: 2019
• eBook ISBN: 9781000761566
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

This practical guide provides support for mental health practitioners as they develop their approach to clinical supervision, drawing on the authors' extensive experience of counseling and psychotherapy to bring readers into the "real world" of clinical supervision.

Chapters introduce the essential responsibilities and tasks of a clinical supervisor and place emphasis on the development of a Competence-Oriented Model of Clinical Supervision, upon which a philosophical foundation for supervision can be built. Integrating up-to-date research with case vignettes and practical resources, the text discusses philosophies of clinical supervision and explores themes that often define a supervisor's contextual world, from professional ethics and legal issues to the personal development of both the supervisor and the supervisee.

Affirming and encouraging professional development as well as identifying a range of common challenges, Clinical Supervision in the Real World is a key resource for aspiring clinical supervisors looking to build their own philosophy of supervision.

SECTION III
Contextual Issues in Clinical Supervision

8
PROFESSIONAL ETHICS AND CLINICAL SUPERVISION

Clinical supervisors define much of what they want for themselves and their supervisees. However, minimally well-informed clinical supervisors know that their individual preferences may or may not be feasible ones, given their ethical and legal obligations. This is to say that ethical and legal obligations pose constraints and limits within which clinical supervisors provide their professional services. The review of these obligations in this chapter is intended to introduce several of the ethical constraints and limits about which clinical supervisors should know.

As a foundation for understanding their ethical and legal accountability, several primary obligations appear consistently in professional associations and in most state laws and regulations. One is that all major codes of ethics, including the American Counseling Association (ACA), the National Association of Social Workers (NASW), the American Psychological Association (APA), and the American Association of Marriage and Family Therapy (AAMFT), place client welfare at the top of the priorities and obligations that clinical supervisors and supervisees carry. For example, the APA ethical principles state that the ethics code “has as its goals the welfare and protection of the individuals and groups with whom psychologists work and the education of members, students and the public regarding ethical standards of discipline” (American Psychological Association, 2017, p. 3). Somewhat more explicitly, in its first standard (i.e., A.1a), the ACA Code of Ethics states, “The primary responsibility of counselors is to respect the dignity and promote the welfare of clients” (American Counseling Association, 2014, p. 4). Also, in its first ethical standard, NASW, says, “Social workers’ primary responsibility is to promote the well-being of clients” (National Association of Social Workers, 2017, p. 7). In virtually all counseling and psychotherapy codes of ethics, the fundamentally important commitment to the welfare of clients is clear and universal.

From the commitment to client welfare, many practical implications arise. This includes implications for clinical supervisors. For example, no doubt, supervisors prefer that their supervisees receive support and encouragement from their supervision. Similar to the universality of the priority placed on client welfare, this preference is virtually universal, too. However, as much as support and encouragement are needed from clinical supervisors and for supervisees, they should be provided in ways that place the welfare of the supervisee’s clients ahead of the supervisee’s welfare.

Another common commitment in all major codes of professional ethics for mental health care providers require that those who serve within the constraints of these ethics function within the boundaries of their individual competence. In the current environment in which professional competence continues to decline among mental health care providers (e.g., Goldberg et al., 2016; Spengler & Pilipis, 2015), the critical importance of competent professional functioning cannot be overestimated. Also, given the necessarily high priority placed on client welfare, virtually all codes of ethics emphasize the centrality of competence in the work of mental health care providers. For example, in its Code of Ethics, NASW includes ethical standard, 1.04, “Social workers should provide services and represent themselves as competent only within the boundaries of their education, training, license, certification, consultation received, supervised experience, or other relevant professional experience” (National Association of Social Workers, 2017, p. 9). The other major mental health care associations express their commitment to professional competence in language and emphasis that is remarkably similar. For example, APA says, “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” (American Psychological Association, 2017, p. 5).

While the major codes of ethics include other areas of agreement, the purpose of emphasizing client welfare and professional competence is to express the importance of these ethical priorities as necessary ones for clinical supervisors. Clinical supervisors place high priority on client welfare and professional competence. Thus, competence as a clinical supervisor is a requisite obligation. The need for clinical supervisors to be clear about these priorities is surely tested by their supervisees, often inadvertently. For example, when their supervisees serve a clientele that the supervisor has not served or utilize a treatment modality with which the supervisor is not familiar, clinical supervisors may need to consider their supervisory judgments with reference to client welfare and professional competence.

A clinical supervisor who provides supervision services under the aegis of one of the major codes of ethics should carefully study all of the standards in her or his respective code. The importance of this is that, quite apart from the standards that specifically refer to clinical supervision, many other standards in each of these codes add to the obligations of both supervisors and supervisees. For example, in various ways, these codes refer to client welfare, client rights, competence, avoiding harm to clients, professional boundaries, confidentiality, and much more. Mastery of these standards elevates the level of effectiveness in clinical work, but it also helps to ensure that supervisors and supervisees practice their respective roles in ethically appropriate ways.

To ensure that supervisors and supervisees practice in ethically appropriate ways, several features of initiating supervision should be carefully covered by the prospective clinical supervisor. These features begin with informed consent but include contracting and agreements about scheduling, handling emergencies, and more. For a detailed discussion of the administrative tasks of clinical supervisors, refer to the chapter on “The Administrative Tasks of Clinical Supervisors.” For now, as a statement about informed consent, Thomas (2010) recommends that the following items be included in an informed consent document: supervisory methods, confidentiality, financial issues, documentation, risks and benefits, evaluation criteria/procedures, complaint procedures, termination criteria, supervisor’s responsibilities, supervision sessions content, supervisory accessibility, supervisee responsibility, informing the supervisor, and professional development goals. To Thomas’s list, we would add supervisor qualifications, including relevant clinical experience and preparation for providing clinical supervision.

A major development in ethical and legal issues in clinical supervision has been the evolving commitment to diversity. Along with the codes of ethics from all of the major mental health care provider associations (i.e., ACA, NASW, APA, and AAMFT), all of the major models of clinical supervision include an emphasis on diversity. “In all models of supervision, it is helpful to identify culturally or contextually centered models or approaches and find ways of tailoring the models to specific cultural and diversity factors” (Center for Substance Abuse Treatment. (2009, p. 8). The Center for Substance Abuse Treatment (2009) adds that the diversity issues to consider are as follows:

• Explicitly addressing diversity of supervisees (e.g., race, ethnicity, gender, age, sexual orientation) and the specific factors associated with these types of diversity;
• Explicitly involving supervisees’ concerns related to particular client diversity (e.g., those whose culture, gender, sexual orientation, and other attributes differ from those of the supervisee) and addressing specific factors associated with these types of diversity; and
• Explicitly addressing supervisees’ issues related to effectively navigating services in intercultural communities and effectively networking with agencies and institutions.

(pp. 8–9)

Usually, a discussion of professional ethics includes giving attention to specific standards and obligations of mental health care providers. This is necessary and important. Also, knowing that ethical and unethical behavior is enacted by individuals, another necessary and important topic that compels attention is the individuals who act unethically. This is to ask, “Who are these individuals? Who is unethical?”

Who Is Unethical?

The discussion of who is unethical refers both to mental health care providers in general and to clinical supervisors in particular. To begin, who are the individuals among mental health care providers in general who violate professional ethics?

In their book, Psychology and the Mental Health Professions: Standards and Cases, Koocher and Keith-Spiegel (2008, 2016) provide a comprehensive and detailed examination of the ethical challenges with which mental health care providers are confronted and the unethical actions that they sometimes perpetrate. More than providing a careful analysis of ethical standards and the lapses in compliance with ethical standards, Koocher and Keith-Spiegel present illustrations that make their book a helpful and readable blend of academic and intellectual analysis as well as a readily recognizable story of the sometimes hazardous challenges and blunders in clinical life. Of particular importance for clinical supervisors, they provide a typology of who violates professional ethics. Koocher and Keith-Spiegel’s typology is important for clinical supervisors because it offers supervisors ways to consider some of the salient personal issues that their supervisees may exhibit when they provide clinical services to clients.

Supervisors’ consideration of Koocher and Keith-Spiegel’s typology needs to be placed in a broader range of consideration than the typology alone. Those who violate professional ethics may be snared into an ethically compromising situation that is not of their own making. For example, a counselor provided treatment for a married, heterosexual couple who came to therapy because both of them engaged in sexual intimacy with partners outside of the marriage. The counselor treated their anger, estrangement, guilt, excessive neediness, and much more, with the general result of enabling the couple to find honesty, desire, affection, and problem-solving skills, among other things. The therapeutic relationship ended. Several months later, though, the same counselor treated an adult male who had betrayed his partner with whom he was married, when he developed an intimate sexual relationship with a woman outside of the boundaries of his marriage. As the counselor treated the man, his story seemed eerily familiar. The counselor recognized the possibility that he had earlier treated the woman with whom his current client had had an illicit affair and that this same woman was a partner in the couple who had been successfully treated. This posed an ethical dilemma that could not have been predicted or reasonably expected by the counselor.

Unforeseen ethical dilemmas may be nearly inevitable for counselors and psychotherapists and their clinical supervisors. An example of an unforeseen ethical dilemma for a clinical supervisor is likely to be readily available for reporting by most experienced clinical supervisors. One such example involved a supervisor and a supervisee who provided services in a private practice that included twelve counselors and psychotherapists. The same private practice served as a training site for supervisees who sought licensing in the state. Unbeknownst to the clinical supervisor, the supervisee began psychotherapy with a young woman who suffered PTSD as a result of an automobile crash that resulted in major injuries, including the loss of one of the young woman’s arms. As the supervisee processed the case of the crash victim–young woman with the supervisor, the supervisor realized that the supervisee’s client had recently been a student in one of the clinical supervisor’s college courses and would possibly be enrolled in future courses. The inappropriate duality of the relationship between the supervisor and the supervisee’s client immediately became an ethical situation that required attention. Obviously, the situation was an unforeseen dilemma.

A truism that emerges from considering unavoidable and unforeseen ethical dilemmas is that they almost inevitably occur, although infrequently. Among other important facts about providing mental health care is the fact that neither supervisors nor supervisees can impose control over all circumstances. At times, others will act in such ways that their actions pose ethical challenges for supervisors and supervisees. Nevertheless, in such circumstances, supervisors and supervisees may be liable for the potentially adverse outcomes from the circumstances. For example, an adult individual comes to the mental health clinic for a therapy session. Before joining the counselor for a session, the client goes to the restroom. After returning to the clinic waiting room, the client reports, “I fell in the bathroom.” Clearly, the client was in physical pain as a result of the fall. While neither the counselor nor the supervisor acted in any way to create dangerous conditions for the client, they were liable for the injuries that the client suffered. In this situation, the client reasonably expected the clinic to cover medical expenses that resulted from injuries.

Allowing for unavoidable and unforeseen ethical dilemmas that may arise, who are the mental health care providers who may violate professional ethics? Generally, they are individuals who are excessively needy or who are clumsily ill-prepared. In their typology of mental health professionals who violate professional ethics, Koocher and Keith-Spiegel make this clear (2008, pp. 1–17, 2016, pp. 1–17). Their characterizations of these individuals are expressed in titles for each of the types that they discuss. For example, they identify one of the types as “The Unaware and Misinformed.” They explain that the individuals in this category lack information about their profession or the standards of ethics. Adapted from the third and fourth editions of their book, the other nine types that they discuss include the following:

• The Incompetent or Undertrained – generally, these individuals lack skill and/or preparation for the services that they are attempting to deliver. The Insensitive – these individuals fail to account for the needs, feelings, and autonomy of others, with particular reference to their clients.
• The Exploitive – these individuals take advantage of others in a planned or premeditated manner, giving deference to their needs and not the needs of their clients.
• The Irresponsible – These individuals presume to know what they need to do and to hold skills that they do not have, exhibiting unwarranted satisfaction with their clinical skill and effectiveness.
• The Vengeful – these individuals suffer disappointment in their service to clients, become angry, and seek to get even.
• The Rationalizers – these individuals possess unrecognized confusion about their role of therapist, succumbing to the temptation to believe that they are truly good and worthy of any particular reward or benefit that they can receive from their clients.
• The Therapists without Boundaries – these individuals demonstrate their neediness beyond the normative limits of the role of psychotherapists, elevating their vulnerability to making friends, lovers, or otherwise attempting to form other inappropriate connections with their clients.
• The Burned-out – these individual have attempted too much for too long and, as a result, have allowed their exhaustion to compromise their clinical judgment.
• The Therapist Who Momentarily Slips – these individuals fail to give sufficient attention to a specific set of circumstances and allow themselves to be momentarily compromised. The consequences of such compromises, though, usually extend well beyond the moment.

To Koocher and Keith-Spiegel’s list of those who violate professional ethics, we add another category. These are individuals who may be labelled as “The Ideologically-Driven and Self-Interested Therapist.” These individuals...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Dedication
• CONTENTS
• List of Charts
• Introduction
• SECTION I Orientation to a Philosophy of Clinical Supervision
• SECTION II Components of a Philosophy of Clinical Supervision
• SECTION III Contextual Issues in Clinical Supervision
• SECTION IV Creating a Philosophy of Clinical Supervision
• References
• Appendix: Assessment of Supervisee Form
• Index