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A
Supervisor's Journal Fulfills
CA BBS & BOP Supervision by Anonymous, LMFT (Note: This journal appeared anonymously in our e-mail box) |
A continuing education course for 6 ces
APA, APT, BRN, CA BBS, FL, NASW, NBCC, TXmeeting the CA BBS & BOP requirements for Supervision and Law & Ethics
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In this course, we will cover aspects of supervision, including:
Legal and ethical issues in clinical supervision
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Note: This journal appeared anonymously in our e-mail box. With it was this note:
"Please use this as a supervision course. I am staying anonymous, because it contains very raw and honest countertransference material, and I am afraid that it will ruin my reputation when therapists see how my shadow emerged when I was supervising. I am particularly embarrassed about the times when I had an urge to 'throttle my intern'. I do hope that you will publish this as a course, however. I think it will help supervisors to hear about a truthful account of supervision. I also included the law and ethics stuff, but the journal is mostly about my experience as a supervisor. Thank you."
A Supervisor's Journal
Clinical Supervision, Law and Ethics
Part I- Supervising a first year internby Anonymous, LMFT
(Choose one or both of the following statements as true:)
I sat down, eager to meet my new supervisee. I remembered, over the years, supervising many, many interns and trainees, with varying degrees of experience. I always looked forward to the first session, as everyone who I have supervised to date has brought me new awareness and insight into the art and science of psychotherapy.or
I sat down, reluctant to meet my new supervisee. I remembered, over the years, supervising many, many interns and trainees, with varying degrees of experience. I always dreaded the first session, as everyone who I have supervised to date has brought me new awareness and insight into my own shadow.(I think I would have to choose both!)
'Daniel' (all names and identifying details have been changed) followed me into the consultation room, glancing at me through wire-rimmed glasses, not really making eye contact. He immediately took out a pen, to start taking notes. He looked scared; no doubt concerned that I would judge him, finding him inexperienced, incompetent, and whatever else his self-doubt could throw at him. (Boy, was I wrong about Daniel! After our session, I ran to my well-thumbed copy of the DSM-S - The DSM-Supervisors, and realized that I had succumbed to DSM-S 378 -Engaging in an Act of Projection onto Intern by Supervisor.) He had been assigned to me by the Counseling Center, and this was our first meeting. My agenda was to begin to get to know him, to put him at ease, and to review the legal and ethical implications of being an intern.
He looks awfully serious, I think. Maybe in his early thirties. This is his first placement; I remember when I first started seeing clients, in my first internship, when I was 24. I felt so scared! I knew I didn't know anything, although I would never admit it to my supervisor. I hope Daniel's in therapy; and, unfortunately, the Counseling Center cannot require therapy for its interns. Learning to be a therapist is really painful at times. I think the closest model is that of initiation. If it feels excruciating, and that every bone is broken, and every part of your psyche activated, then you will probably end up being a good therapist. If you just cruise through, you won't ever be able to go to the depths with your clients. Poor Daniel! I bet he doesn't have a clue what he is in for!
There is a resonance in the field between supervisee and supervisor, a 'parallel process' that occurs in supervision, so I wanted to model for Daniel the feeling of an initial session, as he would soon be starting to see clients. Initial sessions can be problematic in supervision, as there is a lot of ground to cover regarding responsibilities, law and ethics, paperwork, things to review, as well as the most important part, which is beginning to get a sense of the person. In some ways this is akin to an initial therapy session, particularly in a clinic setting where there are intake forms, releases, notification of intern status, etc.Kaiser (1992), addressing the issue of supervisory relationship in family therapy supervision, highlighted the “phenomenon of isomorphism; what happens in supervision is reflected in the therapy” (p. 284). This is referred to later in this entry as the “parallel process,” in which the interaction between supervisor and supervisee directly affects the relationship between the social worker and the client. In reviewing the literature from the fields of social work, psychology, and marriage and family therapy, Kaiser identified four consistently cited issues: “the process of accountability (maintaining objectivity), the need for promoting the supervisee's personal awareness, the importance of establishing trust, and the need to attend to power and authority issues” (p. 284). (Shulman, L., “Supervision and Consultation”, From: A Social Policy Course at University of North Carolina, at Pembroke, taught by Stephen M. Marson, Ph.D., ACSW)
The concept of parallel process has its origin in the psychoanalytic concepts of transference and countertransference. The transference occurs when the counselor recreates the presenting problem and emotions of the therapeutic relationship within the supervisory relationship. Countertransference occurs when the supervisor responds to the counselor in the same manner that the counselor responds to the client. Thus, the supervisory interaction replays, or is parallel with, the counseling interaction. (Sumerel, Marie B., 1994, Parallel Process in Supervision. ERIC Digest ED372347)
I also wanted Daniel to get a sense of who I was, as we would be spending one hour a week for the next nine months together, unless something drastic happened. Whenever I consider this, my thoughts go to the other nine months in our lives, the time in the uterus. My job was perhaps like that of the mother, to create the 'free and protected place' as Dora Kalff used to say, for a therapist to develop. There are many ways in which therapists and supervisors err with regard to boundaries. One way to guard against this is to imagine that the therapeutic container is "sacred space", a temenos or 'free and protected' place. Conceptualize psychotherapy and supervision as a 'safe harbor' in which competent help is given in a clear and respectful manner, a place where the psyche of the client is honored above all. Anything that interferes with this is unethical and possibly illegal. That includes most contact outside of the therapeutic hour, including having coffee or lunch with a client or supervisee, bartering with a client for supervision or therapy in exchange for services or products, working with a client in more than one capacity, and most certainly, having a sexual relationship with a client.
My first supervisor was brutal; supervision with him was the opposite of the 'free and protected' place. When I reported to him after my first session as an intern, he told me that it was the "worst session he had ever supervised." It didn't help that all my friends had raved about him as a professor, although, years later, I realized that none had had him as a supervisor. Teaching, doing therapy and supervision are quite different at times! The person who creates the unconditional safe space of therapy may in fact be a lousy supervisor, unwilling to confront the supervisee. By the same token, the professor with many publications, who is his or her own harshest critic, may also be a poor supervisor. Such was the case with Dr. M and me. His blunt style and high expectations were a poor match for a feeling type, brand new baby therapist. I never wanted to do that to anyone I supervised.Years later I realized that those who have been initiated cruelly will tend to be cruel in their initiation of others. It is the 'wounded who wound', unless they find within themselves the archetype of the wounded healer. Having been hurt by my first supervisor, I knew to be careful, to not repeat history. In fact, I tell my students and interns "It is a 'practice' that we do, not a perfect!"
I introduced myself to Daniel, and asked him to tell me about himself. I knew that if I had been interviewing him to be my intern (rather than him being assigned to me by the counseling center) that I could not ask his age, marital status, ethnic background, whether he has children, his religion, whether he has any disabilities or health problems, etc.; basically anything that could be considered discriminatory. In fact, a supervisor cannot even ask if an intern or supervisee is in therapy!!! (source: Riemersma, Mary, The Do's and Don't of Interviewing Interns and Trainees, May/June 1992 issue of The California Therapist)
I follow these guidelines when students are assigned to me, as I think they serve three purposes: they protect the intern against feeling judged unfairly or discriminated against; they protect the psyches of both the intern and supervisor from any prejudice, conscious or unconscious that might be there, and they afford some legal protection. I always notice (much like in a therapy session) at what point the intern trusts me enough self disclose about who he or she is.
Daniel didn't tell me much about himself, other than that he felt quite ready to see clients. I asked him what part of seeing clients excited him, and he responded that actually he was not very excited about seeing children, that this placement had been his second choice. He had applied to a Psychoanalytic Center, but they turned him down, saying he needed experience before he could be accepted there.
Great! Just what I need! A person who doesn't want to be here!
But then I got a little bingo in my brain, and realized in some ways this was perfect, because many of the children and adolescents Daniel would be seeing would not want to go to therapy; but rather it was imposed on them from outside sources: school or parents.
So, I asked Daniel how it felt to be here, when he really didn't want to be here.I knew I had to be careful here, as I didn't want to cross the boundary between supervisor and therapist. I tried the old open-ended question, and Daniel stammered a bit, and was clearly uncomfortable with my question about how he felt. It seemed that, so far, in this initial session, that I was doing a lousy job of establishing rapport with Daniel. I reminded myself to trust that when and if I needed to know more, it would be revealed. But I do hope whatever ambivalence he has about being here has been worked through in therapy.
This is an issue in supervision that comes up again and again; where is the line between supervision and therapy? How much does a supervisor need to know about an intern in order to be an effective supervisor?So, I tried again. "Daniel, can you please tell me something about yourself?" I asked.
He bent down to his briefcase and pulled out his resumé. It stated that he was 33 years old, had graduated with honors, from a very prestigious school, with a major in electrical engineering. His job experience had been in the field of computers, and he had entered Psychology graduate school one year ago. There were references listed, all in his former field. He stated on the resumé that he was single, with no children. There was nothing in his resumé at all related to psychotherapy. I had no idea how he had gotten from computers to psychology. I was wary, however, in the process of what had occurred. Not red flag alarmed; more like a yellow warning sign. It seemed as if he was being very open, and self-disclosing, by offering his resumé; but in fact, it told me nothing.
The Interactive FieldHere I fell back on my trusting the process. By and large, whatever needs to be revealed, will be revealed. If Daniel's issues regarding changing fields were to become a factor in his work, I trusted that I would know about them when I needed to. I also tuned into my own process as Daniel and I were talking, and realized all my images were about my own scientific and technical ineptness. I know that I am what is considered to be a 'feeling type', and Daniel was certainly presenting like a 'thinking' type. This would explain the blank expression he had when I asked how he felt about being here.So, taking a deep breath, I tried a different tactic.
"Daniel, what do you think about being here?" Suddenly, Daniel was speaking about being at the counseling center, and all that he had done to prepare for his internship. Time and time again, when I reflexively asked him how he felt, he drew a blank. When I asked about the exact same issue, but instead remembered to ask him what he thought, then he would address the issue at hand. This is a type of diversity, I feel, that often is overlooked. "Typology Diversity" seems largely ignored, yet in some ways typology seems to be 'hardwired 'into how we process information. A smart feeling type (DSM-S 133.33, Supervisor talking about self in a way that no one is supposed to know that she is talking about herself) is often considered not bright, because abstract thinking can take a back seat to feeling in our schools and Western culture. While it is much easier to supervise someone of one's own typology, supervising those who are different stretches us. An example is with one intern I had years ago. When it came time to evaluate her, I marked her as somewhat defensive and oppositional. When she asked why, I told her it was because she seemed to fight me on everything I said. She looked puzzled, and asked for an example. I gave her one, and then she said, "That's thinking! I was thinking about it." (Thank you, Annabelle!) And she was right!
What I had felt to be oppositional, was really her thinking about what I was saying.
For an online typology test, please go to: http://www.humanmetrics.com/cgi-win/JTypes2.asp
I asked Daniel if he had any other thoughts or concerns about becoming a therapist. "No" he said. "I feel ready, I already have the first session mapped out." The little red warning light went off in my brain. I was psychically starting to hyperventilate, as can happen in the presence of the opposite type. I pulled myself back from the edge of hysteria. I cannot imagine how someone could have a treatment plan without having seen the client, nor know anything about him or her!!!
Fortunately, my training stood me in good stead, as I assumed the 'poker face' of the therapist or supervisor who has been taken off guard. "Hmmm.." I said to Daniel. No response. So I tried again. "Hmmm..can you say more about that?"
Daniel again bent down to his briefcase, pulling out a bibliography of many pages. "You see", he said, "I made a quantitative analysis of initial sessions, and have figured out exactly what has the best chance of success. You see, here it says you need a complete developmental history, and here is the diagram that you need to figure out the core issue. It is an equation with .333 weight given to the symptom, .333 to the family history or family of origin, and .333 to how the client is while in the session. Then you find out what these issues have in common, and when that is isolated, then you have the 'core' issue. From there, every thing you say or do relates to the core issue."
"Hmmm.."I said. "Daniel, have you given any THOUGHT to how this will apply with a seven year old? Or a teenager?"
"Well," he said, "that was my reason for wanting to work with adults at the psychoanalytic institute. But I have prepared this form to get an accurate history." Here he handed me a copy of his 20 page developmental history form. "I think with young children, I will send home the developmental history form for the parents to fill out. Latency age children might need some assistance, but they could do it primarily by themselves. I know I could have, when I was that age. Adolescents would certainly have the capacity to complete the questionnaire on their own."
Now, many of the children who he would be seeing in the schools had parents who had recently immigrated, and spoke little or no English. When I looked over the form, mentally filling it out regarding my 11 year old son, I realized that there was no way that my son could do it, and doubtful that I could fill it out. Maybe I have no memory left, but I cannot imagine why it would be relevant to know at what age his third tooth came in! I actually feared asking Daniel why that was on his developmental history, not wanting another bibliography to come out of his briefcase.
"Hmmm..." I said. And wondered what trickster had assigned Daniel to me!And because, quite frankly, I didn't know what to say, I brought the interview back to his tasks, and general issues about being an intern.
We spent the rest of the first hour talking, and I reviewed with Daniel the basics of being an intern. We would have at least one other session before Daniel was assigned any clients, so I hoped in the next session I could develop some rapport with Daniel and we could begin to get to know each other. I went over my expectations of him, and I made sure he knew of the legal and ethical aspects of being an intern.
Legal and ethical aspectsDaniel realized that he would be telling people that he was an intern, not a licensed therapist, and working under supervision. I stressed to him that personal relationships with patients and dual relationships would not be condoned. We talked about what would constitute a dual relationship. I also asked him, once he started seeing patients, to please let me know if he had any fantasies or dreams about a patient.
I reminded myself about the importance of therapeutic boundaries in the supervisory relationship, to avoid all dual relationships with my supervisees. I keep my own journal of feelings, fantasies and my reactions regarding about my supervisees, and discuss them in my consultation group. I had learned that the unconscious feelings stirred up in me by my supervisees and my patients can lead to the very heart of the supervisory and therapeutic process, if I have the courage to really look at them.
Therapeutic boundariesDaniel and I discussed why a sexual boundary should never be crossed. Both therapy and supervision are relationships of power. If we become unconscious of the power shadow, then it wreaks havoc upon us!According to California laws:
Any kind of sexual contact, asking for sexual contact, or sexual misconduct by a therapist with a patient is illegal, as well as unethical, as set forth in Business and Professions
Code sections 726, 729, 2960(o), 4982(k) and 4992.3(k).
“Sexual contact” means the touching of an intimate part of another person, including sexual intercourse.
“Touching” means physical contact with another person, either through the person’s clothes or directly with the person’s skin (Business and Professions Code section 728).
Sexual contact can include sexual intercourse, sodomy, oral copulation, fondling and any other kind of sexual touching. Sexual misconduct also covers a broader range of activity, including nudity, kissing, spanking, verbal suggestions, innuendoes or advances.
This kind of sexual behavior by a therapist with a patient is sexual exploitation. It is unethical, unprofessional and illegal.In California there is a pamphlet that we are required to give to our clients who have had a sexual relationship with a therapist. It is a Department of Consumer Affairs publication entitled "Professional Therapy Never Includes Sex". It is available on-line at: www.psychceu.com/proftherapy.pdf.The contents include:
Patient Bill of Rights
Definitions and warning Signs
Where to Start
What Can You Do?
Reporting Options
Administrative Action
How the Complaint Process Works
Professional Association Action
Civil Action
Finding an Attorney
Criminal Action
Where to Get Help Finding a Therapist
Self-Help Support Groups
Frequently Asked Questions
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Therapists have been disciplined by their licensing boards for not supplying this pamphlet to clients who have had a sexual relationship with a previous therapist. Single copies of the publication are available at no charge from Publications Office, California Department of Consumer Affairs, PO Box 310, Sacramento California 95802. For a copy of the Board of Behavioral Science Examiners Licensing Laws and Regulations, go to: http://www.bbs.ca.gov/law-reg.htm.
Daniel and I talked about confidentiality, and how he was going to handle questions from parents, teachers, other children (which is a very common occurrence working in a school setting), as well as outside agencies (foster homes, protective services, etc.).We talked about laws and ethics, including:5150 (involuntary psychiatric holds)informed consent,accountability,competence,
scope of practice,
client welfare,
what constituted an emergency, and
how emergencies would be handled.
(For more detail on these issues, please consider reading Safe Harbor II: Law and Ethics in Supervision)
Ethical and Legal Dimensions of Supervision. ERIC Digest.THIS DIGEST WAS CREATED BY ERIC, THE EDUCATIONAL RESOURCES INFORMATION CENTER. FOR MORE INFORMATION ABOUT ERIC, CONTACT ACCESS ERIC 1-800-LET-ERIC In recent years, it has become generally accepted that supervision draws upon knowledge and skills that are different than, and go beyond, those of psychotherapy. Similarly, the ethics and legal imperatives regarding supervision both encompass psychotherapy issues and go beyond them. Furthermore, because supervision is a triadic rather than a dyadic relationship, the supervisor must always attend to the need for balance between the counseling needs of clients and the training needs of the counselor. With the increase of litigation in American society over the past generation, ethics and law have become intermingled (Bernard & Goodyear, 1992). It is important for the supervisor to remember, however, that ethics call the supervisor to a standard of practice sanctioned by the profession while legal statutes define a point beyond which a supervisor may be liable. For our purposes here, the functional interconnectedness between ethics and the law will be accepted. COMPETENCECompetence is an increasingly complex issue as mental health and supervision have become more sophisticated enterprises. Implications of both counselor competence and supervisor competence will be described here briefly.COUNSELOR COMPETENCEBy definition, a supervisee is a person who is not yet ready to practice independently. It is for this reason that supervisors are held responsible for what happens with clients being seen by the supervisee (Harrar, VandeCreek, & Knapp, 1990). At the same time, counselors must be challenged in order to become more expert. This, then, is the supervisor's tightrope: providing experiences that will stretch the counselor's ability without putting the client in danger or offering substandard care. Whenever a close call must be made, supervisors must remember that their obligation is to the client, the public, the profession, and the supervisee -- in that order (Sherry, 1991). Therefore, the supervisor continually decides if the supervisee is good enough on a consistent basis to work with any particular client (ACES, 1993).SUPERVISOR COMPETENCEFirst, the supervisor needs to know everything, and more, than is expected of the supervisee. Secondly, the supervisor must be expert in the process of supervision. It is not enough that clients are protected as a result of supervision; the contract between supervisor and supervisee dictates that supervision must ultimately result in better counseling skills for the supervisee. In order to accomplish this, it is generally accepted that the supervisor receive training in performance of supervision as well as supervision of supervision.DUAL RELATIONSHIPSFor 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.THERAPEUTIC RELATIONSHIPSAs part of the mandate of competence, the supervisor must determine not only if the supervisee has the knowledge and skill to be a good counselor, but if he or she is personally ready to take on clinical responsibility (Kurpius, Gibson, Lewis, & Corbet, 1991). The issue of personal readiness can lead the supervisor to blur the roles of supervisor and therapist in an attempt to keep the supervisee functional as a counselor. This is problematic for two reasons: (1) it compromises the objectivity of the supervisor, especially in terms of evaluation; (2) it may allow an impaired counselor to continue to practice at the risk of present and future clients.INFORMED CONSENTInformed consent is key to protecting the counselor and/or supervisor from a malpractice lawsuit (Woody, 1984). Simply, informed consent requires that the recipient of any service or intervention is sufficiently educated about what is to transpire, the potential risks, and alternative services or interventions, so that he or she can make an intelligent decision about his or her participation. Supervisors must be diligent regarding three levels of informed consent (Bernard & Goodyear, 1992): (1) the supervisor must be confident that the counselor has informed the client regarding the parameters of counseling; (2) the supervisor must be sure that the client is aware of the parameters of supervision (e.g., that audiotapes will be heard by a supervision group); and (3) the supervisor must inform the supervisee about the process of supervision, evaluation criteria, and other expectations of supervision (e.g., that supervisees will be required to conduct all intake interviews for a counseling center in order to increase interview and writing skills).DUE PROCESSDue process is a legal term that insures one's rights and liberties. While informed consent focuses on the entry into counseling supervision, due process revolves around the idea that one's rights must be protected from start to finish. Again, supervisors must protect the rights of both clients and supervisees. An abrupt termination of a client could be a due process violation. Similarly, a negative final evaluation of a supervisee, without warning and with no opportunity to improve one's functioning, is a violation of the supervisee's due process rights.CONFIDENTIALITYConfidentiality is an often-discussed concept in supervision because of some important limits of confidentiality both within the therapeutic situation and within supervision. It is imperative that the supervisee understands both the mandate of honoring information as confidential (including records kept on the client) as well as understanding when confidentiality must be broken (including the duty to warn potential victims of violence) and how this should be done. Equally important is a frank discussion about confidentiality within supervision and its limits. The supervisee should be able to trust the supervisor with personal information, yet at the same time, be informed about exceptions to the assumption of privacy. For example, supervisees should be apprised that at some future time, their supervisors may be asked to share relevant information to State licensure boards regarding their readiness for independent practice; or supervisors may include supervision information during annual reviews of students in a graduate program.LIABILITYSupervisors should not shun opportunities to supervise because of fears of liability. Rather, the informed, conscientious supervisor is protected by knowledge of ethical standards and a process that allows standards to be met consistently. There are three safeguards for the supervisor regarding liability: (1) continuing education, especially in terms of current professional opinion regarding ethical and legal dilemmas; (2) consultation with trusted and credentialed colleagues when questions arise; and (3) documentation of both counseling and supervision, remembering that courts often follow the principle "What has not been written has not been done" (Harrar, Vandecreek, & Knapp, 1990).CONCLUSIONAs gatekeepers of the profession, supervisors must be diligent about their own and their supervisees' ethics. Ethical practice includes both knowledge of codes and legal statutes, and practice that is both respectful and competent. "In this case, perhaps more than in any other, supervisors' primary responsibility is to model what they hope to teach" (Bernard & Goodyear, 1992, p. 150).REFERENCESBernard, J.M., & Goodyear, R.K. (1992). Fundamentals of clinical supervision. Needham Heights, MA: Allyn and Bacon.Association for Counselor Education and Supervision. (Summer, 1993). Ethical guidelines for counseling supervisors. ACES Spectrum, 53 (4), 5-8. Harrar, W.R., VandeCreek, L., & Knapp, S. (1990). Ethical and legal aspects of clinical supervision. Professional Psychology: Research and Practice, 21, 37-41. Kitchener, K.K. (1988). Dual role relationships: What makes them so problematic? Journal of Counseling and Development, 67, 217-221. Kurpius, D., Gibson, G., Lewis, J., & Corbet, M. (1991). Ethical issues in supervising counseling practitioners. Counselor Education and Supervision, 31, 58-57. Ryder, R., & Hepworth, J. (1990). AAMFT ethical code: Dual relationships. Journal of Marital and Family Therapy, 16, 127-132. Sherry, P. (1991). Ethical issues in the conduct of supervision. The Counseling Psychologist, 19, 566-584. Woody, R.H. (1984). The law and the practice of human services. San Francisco: Jossey-Bass. ----- Janine M. Bernard, Ph.D. is professor and program director of the Counseling Program at Fairfield University, Fairfield, CT. ----- ERIC Digests are in the public domain and may be freely reproduced and disseminated. This publication was funded by the Office of Educational Research and Improvement. Opinions expressed in this report do not necessarily reflect the positions of OERI or ERIC/CASS. Title: Ethical and Legal Dimensions of Supervision. ERIC Digest. Document Type: Information Analyses---ERIC Information Analysis Products (IAPs) (071); Information Analyses---ERIC Digests (Selected) in Full Text (073); Descriptors: Competence, Counselor Training, Counselors, Ethics, Legal Responsibility, Supervision, Supervisors Identifiers: ERIC Digests |
We reviewed child abuse reporting, and that reports must be made immediately by telephone and in writing, within 36 hours of receiving the information concerning the incident. I started to give Daniel the California form for reporting child abuse so he could become familiar with it, but he pulled one out of his briefcase. I also told him, that in addition to the legal requirements that suspected abuse must be reported, that he must also notify me, as his supervisor.
| Child Abuse is a Serious Problem
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the victim reports that abuse has occurred or if you observe the incident when an injury or condition reasonably leads one to suspect that abuse has occurred.
Elder AbuseElder Abuse is under a provision of mandatory reporting. The following is from http://www.oaktrees.org/elder/recog.shtml"The following indicators, by themselves, do not necessarily signify abuse or neglect. They may be clues, however, and thus helpful in assessment of abuse.* Possible indicators of Physical Abuse
o Cuts, lacerations, puncture wounds
o Bruises, welts, discoloration
o Any injury incompatible with history
o Any injury which has not been properly cared for (injuries are sometimes hidden on areas of the body normally covered by clothing)
o Poor skin condition or poor skin hygiene
o Absence of hair and/or hemorrhaging below scalp
o Dehydration and/or malnourished without illness-related cause
o Loss of weight
o Burns: may be caused by cigarettes, caustics, acids, friction from ropes or chains, or contact with other objects o Soiled clothing or bed* Possible indicators of Psychological/Emotional Abuse
Helplessness
Fear
Hesitation to talk openly
Withdrawal
Implausible stories
Depression
Confusion or disorientation
Denial Anger Agitation* Possible indicators of Financial Abuse
o Unusual or inappropriate activity in bank accounts
o Signatures on checks, etc., that do not resemble the older person's signature, or signed when older person cannot write
o Power of attorney given, or recent changes or creation of will, when the person is incapable of making such decisions
o Unusual concern by caregiver that an excessive amount of money is being expended on the care of the older person
o Numerous unpaid bills, overdue rent, when someone is supposed to be paying the bills for a dependent elder
o Placement in nursing home or residential care facility which is not commensurate with alleged size of estate
o Lack of amenities, such as TV, personal grooming items, appropriate clothing, that the estate can well afford
o Missing personal belongings such as art, silverware, or jewelry
o Deliberate isolation, by a housekeeper, of an older adult from friends and family, resulting in the caregiver alone having total control* Possible indicators of Neglect by Caregiver
o Dirt, fecal/urine smell, or other health and safety hazards in elder's living environment.
o Rashes, sores, lice on elder o Elder is inadequately clothed
o Elder is malnourished or dehydrated
o Elder has an untreated medical condition* Possible indicators of Self-Neglect
o Inability to manage personal finances, e.g. hoarding, squandering, giving money away or failure to pay bills
o Inability to manage activities of daily living, including personal care, shopping, meal preparation, housework, etc.
o Suicidal acts, wanderings, refusing medical attention, isolation, substance abuse
o Lack of toilet facilities, utilities or animal infested living quarters (dangerous conditions)
o Rashes, sores, fecal/urine smell, inadequate clothing, malnourished, dehydration, etc.
o Changes in intellectual functioning, e.g. confusion, inappropriate or no response, disorientation to time and place, memory failure, incoherence, etc.
o Not keeping medical appoints for serious illness* Possible indicators of Abuse from the Caregiver
o The elder may not be given the opportunity to speak for him or herself, or see others, without the presence of the caregiver (suspected abuser)
o Attitudes of indifference or anger toward the dependent person, or the obvious absence of assistance
o Family member or caregiver blames the elder (e.g. accusation that incontinence is a deliberate act)
o Aggressive behavior (threats, insults, harassment) by caregiver toward the elder
o Previous history of abuse of others
o Problems with alcohol or drugs
o Inappropriate display of affection by the caregiver
o Flirtations, coyness, etc. as possible indicators of inappropriate sexual relationship
o Social isolation of family, or isolation or restriction of activity of the older adult within the family unit by he caregiver
o Conflicting accounts of incidents by family, supporters, or victim
o Unwillingness or reluctance by he caregiver to comply with service providers in planning for care an implementation
o Inappropriate or unwarranted defensiveness by caregiverCalifornia Laws Chapter 769, Statutes of 1986, Chapter 637, Statutes of 1987, and Chapter 1396, Statutes of 1987 provides for mandatory reporting of physical abuse when: the victim reports that abuse has occurred or if you observe the incident when an injury or condition reasonably leads one to suspect that abuse has occurred. The law requires mandated reporters to make a verbal report immediately, or as soon as possible, followed by a written report within two (2) working days. For a listing of phone numbers to report for each state, please go to: http://www.elderabusecenter.org/report/index.html(excerpted from TLC: Tender Loving Care for our Elders )
I asked Daniel about how we (notice the 'we', not 'he') could protect a client's confidentiality. It is a paradox of supervision that we are training our interns to uphold the confidentiality of their clients as we ask them to break it in supervision. We talked about how to inform clients about confidentiality, and what would be grounds for breaking it. We discussed Tarasoff (which in 25 years of practice, I have never had to use); child abuse; elder abuse; suicide; and 5150, in which a client needs to be involuntarily hospitalized for their own protection.
I told Daniel a bit about my experiences breaking confidentiality, and how kind and supportive both child protective services and the local police (when I had to 5150 someone) have been. I wanted him to realize that therapists only break confidentiality for very good reasons: abuse, and life or death issues. When we do break the container, it is our task, as much as possible, to ensure that the people who are called to intervene are compassionate and truly protective.
There is however another paradox of supervision, which is something I wrestle with every semester. How confidential is supervision? How can I create a safe and protected place for my interns when I have to evaluate them, and report on our work in the supervisors' meetings?
We discussed the agency policy that patient files are not to be removed from the office, under any circumstances, nor did the agency permit photocopies of records, due to the possible breach of confidentiality and the difficulty safeguarding these records.
We went over how clients were to pay, that any checks received would not be made out to him, but to the Counseling Center. (If he had been a private practice intern, the client checks would be made out to me, as the supervisor, not to the intern.)I had to be very conscious not to get into "robot" mode as we went over laws, rules, regulations, paperwork, etc. (While these are my least favorite parts of supervision, I know the importance of establishing an intern's knowledge of the laws and ethics regarding psychotherapy. Ultimately, our laws and ethics are there for the protection of the client, the therapist, the supervisor, and the therapeutic process. Clear boundaries make possible the creation of the 'free and protected' space.)
In a study of supervision, Kadushin (1974) conducted a national survey of 750 supervisors and an equal number of supervisees. The purpose was to identify the sources of satisfaction for both supervisors and supervisees. Supervisors in the study took great satisfaction in helping supervisees grow and develop professionally; their greatest source of dissatisfaction related to dealing with administrative red tape. Supervisees identified being able to share responsibility with supervisors and being able to obtain support for difficult cases as their greatest source of satisfaction. A majority of both the supervisors and supervisees in Kadushin's study believed that as the supervisee gained experience, the relationship became one of consultant–consultee, a form of supervision preferred by many social workers. Strong dissatisfaction with supervision was reported by many social workers, who believed the authority of the supervisor was exercised in a negative manner. (Shulman, L., “Supervision and Consultation”, From: A Social Policy Course at University of North Carolina, at Pembroke, taught by Stephen M. Marson, Ph.D., ACSW)
I reviewed with him the Counseling Center's grievance policy if either of us found it impossible to work with each other. If Daniel had been a private practice intern, I would have made it clear (both in writing and verbally) that he was hired "at will." (At this point, though, I thought that Daniel would be the least likely person who I would hire in my practice! - See the DSM-S 899.99 Negative Countertransference from Feeling type Supervisor to Thinking Type Student in the Initial Session.) "At will," means that I could "fire" him, "at will", or for any reason whatsoever, with or without cause. I have had to do this once, for severe ethical lapses on the part of a private practice supervisee, who simply would not respect therapeutic boundaries with her clients. I never want to go through that again!
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ED372354 Publication Date: 1994-04-00 Author: Cryder, Annette Petro - And Others Source: ERIC Clearinghouse on Counseling and Student Services Greensboro NC. Supervision of Marriage and Family Counselors. ERIC Digest.THIS DIGEST WAS CREATED BY ERIC, THE EDUCATIONAL RESOURCES INFORMATION CENTER. FOR MORE INFORMATION ABOUT ERIC, CONTACT ACCESS ERIC 1-800-LET-ERIC OVERVIEW: DISTINCTIVENESS AND COMPLEXITY The adage "training shapes practice" describes the work of most marriage and family supervisors. Taking this metaphor one step backward, most marriage and family supervisors also believe that "theory shapes training." In terms of theory, the defining hallmark of marriage and family supervision during its brief history has been a systemic orientation (Smith, 1993). Other distinguishing features include a reliance on live forms of supervision, and the viewing of ethical issues within larger familial, cultural, and societal contexts (Smith, 1993). THE COMPLEX FAMILY SYSTEM AND ITS INFLUENCE ON SUPERVISIONA family system is often described as constantly evolving and self-regulating. During counseling, systemic change occurs via interactions among family members and via interactions with other systems (e.g., the supervisor, the counseling team, social service agencies, legal systems, and others) (Pirrotta & Cecchin, 1988). Furthermore, each client family can be understood as a special group of people sharing a unique history, and featuring unique operating rules and social behaviors.For these reasons, marriage and family supervisees face a particularly complex and powerfully dynamic counseling situation in which they may experience a high level of anxiety (Pirrotta & Cecchin, 1988). Commonly used supervisory approaches, described below, may be thought of as avenues to effectively manage both the complexity and power of the family system, and any resulting supervisee anxiety (Pirrotta & Cecchin, 1988). Anxiety also may occur when supervisees face counseling situations that parallel their own family backgrounds. Typically, rather than helping supervisees resolve family of origin concerns, marriage and family supervisors focus on helping supervisees develop clinical skills (AAMFT, 1993). Accepted practice among marriage and family supervisors is to provide competency-based supervision that is "clearly distinguishable from personal psychotherapy" (AAMFT, 1993, p. 17). This practice speaks to the general belief that with a solid repertoire of clinical goals and skills, supervisees can manage both their own emotions and issues and those of the families they counsel. MARRIAGE AND FAMILY SUPERVISORY MODALITIES AND THEIRBENEFITS Marriage and family supervisors regard live supervision as particularly effective, because the supervisor can assist both the supervisee and the family by altering the course of counseling as it occurs. Modalities include telephone interventions, consultation breaks with trainees, and supervisor-as-co-counselor. Other conventional supervisory methods include delayed video or audiotape review, and verbal reports.One goal of videotape review is to help trainees improve what Tomm and Wright (1979) described as perceptual and conceptual skills. After watching part of a videotaped session, supervisees might be asked, for example, to describe family members' common themes or behavioral interactions, to reflect on interventions that might work in similar future situations with client families, or to describe what they have learned about marriage and family counseling from the session. Using the supervisee's verbal reports also encourages clinical growth. Verbal reporting allows a mutual questioning process between supervisor and supervisee that helps the supervisee organize information about client families into useful frameworks for consideration (West, Bubenzer, Pinsoneault, & Holeman, 1993). CONTEMPORARY FORCES SHAPING MARRIAGE AND FAMILY SUPERVISIONAs societal perspectives change, so do marriage and family counseling and supervision. Because marriage and family supervisors view families within the larger social context, the field of marriage and family supervision may be more immediately influenced by changes in the social fabric than other related disciplines. Emerging forces affecting marriage and family counseling and supervision include the evolution of social constructionist ideas, the challenge of the feminist critique, a growing awareness and recognition of cultural diversity, and the assimilation of current research into training (Smith, 1993).SOCIAL CONSTRUCTIONISM: IMPACT ON MARRIAGE AND FAMILYSUPERVISION Many ideas changing marriage and family supervision arose from a social constructionist perspective. This is the perspective that "realities are created and formed by our views of the world" (West et al., 1993, p. 136). Imbedded in this view is the assumption that there is no one "correct" reality; that there may exist a multiplicity of useful opinions concerning how to live life, and how to view the world. Counseling interventions informed by social constructionism often involve questioning sequences that illuminate new perspectives on life and new possibilities for living. Still, despite these more collaborative supervisory approaches, it continues to be true that supervisors oversee the work of supervisees, and "should recognize their legal responsibilities for cases seen by their supervisees" (AAMFT, 1993, p. 12).REFLECTING TEAM SUPERVISIONOne constructionist supervision method uses a reflecting team of peers. The process often begins with an interview in which one person questions a supervisee about a counseling-related case or dilemma while the team silently observes. Afterwards, team members share a variety of observations and thoughts they believe may help the supervisee in working with families. Some purposes of reflecting teams include a) having supervisees actively engage in co-constructing realities through the isomorphic form-follows-function reflecting process, b) creating a collaborative and supportive training atmosphere, and c) encouraging the sharing of alternative perspectives that may help supervisees solve counseling impasses or dilemmas (Davidson & Lussardi, 1991). Team members' thoughts are shared with the supervisee in a speculative manner, and are often posed using question stems such as "I wonder what would happen if..." "Could it be that..." or "How would things be different if...."NARRATIVE-INFORMED SUPERVISIONAnother constructionist perspective increasingly used in marriage and family supervision emphasizes the self-defining nature of narratives. This perspective has been most fully developed by White (1992), who believes that the narratives we construct reflect and shape our reality and the way we live our lives. During supervision, White highlights supervisees' useful narratives about their "life as a therapist" (White, 1992, p. 86). The supervisor (or a reflecting team) helps the trainee in identifying and expanding "unique outcomes" (White, 1992) in counseling sessions, those breakthrough times when the trainee did something pivotal that helped the client family. The supervisor helps the supervisee weave these unique outcomes into an evolving narrative about the trainee's "preferred way of being a counselor." Examples of possible questions are "What does this [unique outcome] say about you as a counselor?" "What do you think the family members might tell me about how you helped them?" "What does this suggest about the future direction of your work?" (White, 1992).SUMMARYThroughout its history, the field of marriage and family supervision has been shaped by the systemic orientation of its practitioners. Some prominent features of this orientation are a reliance on live forms of supervision, a contextual view of client families, and an educational supervisory role that emphasizes supervisee skill-building. Promising additions to the field of marriage and family supervision involve questioning and collaborative team approaches that aid trainees in exploring and living out their ideal ways of being counselors.REFERENCESAmerican Association for Marriage and Family Therapy. (1993). Approved supervisor designation: Standards and responsibilities. Washington, D.C.: Author.Davidson, J., & Lussardi, D. J. (1991). Reflecting dialogues in supervision and training. In T. Andersen (Ed.), The reflecting team: Dialogues and dialogues about the dialogues (pp. 143-154). New York: Norton. Pirrotta, S., & Cecchin, G. (1988). The Milan training program. In H.A. Liddle, D.C. Breunlin, & R.C. Schwartz (Eds.), Handbook of family therapy, training & supervision (pp. 78-92). New York: Guilford. Smith, R. L. (1993). Training in marriage and family counseling and therapy: Current status and challenges. Counselor Education and Supervision, 33, 89-101. Tomm, K. M., & Wright, L. M. (1979). Training in family therapy: Perceptual, conceptual and executive skill. Family Process, 18, 227-250. West, J. D., Bubenzer, D. L., Pinsoneault, T., & Holeman, V. (1993). Three supervision modalities for training marital and family counselors. Counselor Education and Supervision, 33, 127-138. White, M. A. (1992). Family therapy training and supervision in a world of experience and narrative. In D. Epston & M. A. White (Eds.), Experience, contradiction, narrative & imagination. South Australia: Dulwich Centre Publications. ----- Donald L. Bubenzer, Ph.D., is coordinator, John D. West Ed.D., is a professor, and Annette P. Cryder, M.Ed., is a doctoral student in the Counseling and Human Development Services Program at Kent State University in Kent, Ohio. ----- ERIC Digests are in the public domain and may be freely reproduced and disseminated. This publication was funded by the Office of Educational Research and Improvement. Opinions expressed in this report do not necessarily reflect the positions of OERI or ERIC/CASS. Title: Supervision of Marriage and Family Counselors. ERIC Digest. Document Type: Information Analyses---ERIC Information Analysis Products (IAPs) (071); Information Analyses---ERIC Digests (Selected) in Full Text (073); Descriptors: Counselor Training, Counselors, Family Counseling, Marriage Counseling, Supervision, Supervisors, Supervisory Methods Identifiers: ERIC Digests
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I gave Daniel the website address of the Frequently Asked Questions for MFT Interns and Trainees at the California Board of Behavioral Science at http://www.bbs.ca.gov/lic-req8.htm (Which, of course, he already had...)
The LCSW Associate Frequently Asked Questions is at: http://www.bbs.ca.gov/lic-req9.htmIf you are not a California therapist, please go to your Licensing Board for relevant information. We have some links listed in our website at http://www.psychceu.com/statece1regs.html.
Please e-mail us your state information, so that we may include it in future versions of this course! Thank you!Note for California Therapists:
Although the information regarding BBS and BOP supervisor requirements are current at the time of this writing, it is your responsibility to stay current with the regulations. We recommend that you periodically check with your professional organization and licensing board for updates.
The California BBS has a page on their website of "Forms and Publications at: http://www.bbs.ca.gov/pdf/mfrespon.pdf which includes the following:
(C) Supervisors who are licensed by the board who commence supervision on and after January 1, 2000, and have not met requirements of subsection (A), shall complete a minimum of six (6) hours of supervision training or coursework within sixty (60) days of commencement of supervision.
The Responsibility Statement for Supervisors (Section 1833.1 of the California Code of Regulations)
§ 1833.1. REQUIREMENTS FOR SUPERVISORS
(a) Any person supervising an intern or trainee (hereinafter "supervisor") within California shall comply with the requirements set forth below and shall, prior to the commencement of such supervision, sign under penalty of perjury the “Responsibility Statement for Supervisors of a Marriage, Family, and Child Counselor Trainee or Intern” (see below) revised 1-00 requiring that:
(1) The supervisor possess and maintains a current valid California license as either a marriage, family, and child counselor, licensed clinical social worker, licensed psychologist, or physician who is certified in psychiatry as specified in Section 4980.40 (f) of the Code and has been so licensed in California for at least two years prior to commencing any supervision; or
(A) Provides supervision only to trainees at an academic institution that offers a qualifying degree program as specified in Section 4980.40 (a) of the Code; and
(B) Has been licensed in California as specified in Section 4980.40 (f) of the Code, and in any other state, for a total of at least two years prior to commencing any supervision.
(2) If such supervisor is not licensed as a marriage, family, and child counselor, he or she shall have sufficient experience, training, and education in marriage, family, and child counseling to competently practice marriage, family, and c)child counseling in California.
(3 The supervisor keeps himself or herself informed of developments in marriage, family, and child counseling and in California law governing the practice of marriage, family, and child counseling.
(4) The supervisor has and maintains a current license in good standing and will immediately notify the intern or trainee of any disciplinary action, including revocation or suspension, even if stayed, probation terms, inactive license status, or lapse in licensure, that affects the supervisor's ability or right to supervise.
(5) The supervisor has practiced psychotherapy for at least two (2) years within the five (5) year period immediately preceding any supervision and has averaged at least five (5) patient/client contact hours per week.
(6) The supervisor has had sufficient experience, training, and education in the area of clinical supervision to competently supervise trainees or interns.
(A) Effective January 1, 2000, supervisors who are licensed by the board shall complete a minimum of six (6) hours of supervision training or coursework every two years. This training or coursework may apply towards the continuing education requirements set forth in Sections 4980.54 and 4996.22 of the Code. (B) Supervisors who are licensed by the board who have completed a minimum of six (6) hours of supervision training or coursework between January 1, 1997, and December 31, 1999, may apply that training towards the requirement described in subsection (A).
(C) Supervisors who are licensed by the board who commence supervision on and after January 1, 2000, and have not met requirements of subsection (A), shall complete a minimum of six (6) hours of supervision training or coursework within sixty (60) days of commencement of supervision.
(7) The supervisor knows and understands the laws and regulations pertaining to both the supervision of trainees and interns and the experience required for licensure as a marriage, family, and child counselor.
(8) The supervisor shall ensure that the extent, kind, and quality of counseling performed is consistent with the education, training, and experience of the intern or trainee.
(9) The supervisor shall monitor and evaluate the extent, kind, and quality of counseling performed by the intern or trainee by direct observation, review of audio or video tapes of therapy, review of progress and process notes and other treatment records, or by any other means deemed appropriate by the supervisor.
(10) The supervisor shall address with the intern or trainee the manner in which emergencies will be handled.
(11) The supervisor agrees not to provide supervision to a trainee unless the trainee is a volunteer or employed in one
