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Who are the parties that will be impacted by whatever course of action is chosen? John, Steve, John’s clients, other clinicians
What are the ethical issues involved in this scenario, including conflicting and competing values of the parties involved?
Potential conflict because Steve and John were already friends. It appears they were both aware of this and took steps to mitigate before any problems arose. Steve’s inexperience as a supervisor may have lent to his conviction this could be a safe scenario.
John could have felt overwhelmed by the high-needs case load he was being assigned, and if so, he had an ethical responsibility to speak up and let Steve know he was struggling with this. He may not have felt he could speak up, since he and Steve are friends, and Steve is new to the job. Perhaps John didn’t want Steve to feel badly, but in so doing, compromised his own recovery.
Steve may not have stopped to think about whether or not he was overloading John, and ethically had a responsibility to be checking in with John on a regular basis to make certain he was feeling his caseload was manageable. Again, it appears assumptions were made that the other man would have shared concerns as they arose, but neither did so, perhaps because of their friendship and not wanting to introduce conflict into it.
John did not handle his stress well when he started sharing his specific frustrations and general dissatisfaction inappropriately with other clinicians. Ethically, his first stop should have been checking in with himself and asking himself what he needed to maintain his professional stance, and take care of himself. He should also have told his supervisor that he needed more support, and perhaps ask for some client reassignments or a more balanced caseload going forward.
John attempted to use their friendship to manipulate Steve into ignoring his relapse, as well as his other unprofessional behavior.
Questions 3 & 4
What are all the viable courses of action and the possible benefits and risks for each?
Please include the pros and cons of each course of action based on relevant codes of ethics, laws, agency policies, licensing board regulations, reasonable and customary clinical supervision theory and practice, and personal values including religious, cultural, ethical and political ideology.
1) Steve does as John requests, and ignores his “slip,” based on their friendship, and tries to believe it was a one time incident. Pros: I see none. Cons: John is actively relapsing, due, at least in part, to acute work-related stress. Doing nothing would only further compromise John and his clients, put the agency and everyone involved at risk. John has an ethical responsibility to take care of himself, so as to do no harm at work. Self-care is a critical component of providing healthy care to others. Steve would not being carrying out his responsibilities as the one tasked with keeping the satellite office safe and a therapeutic environment for clients and staff. He would be role-modeling some unhealthy behaviors of his own.
2) Steve meets with John, shares his concerns and they collaborate on a course of action. Steve, having consulted with me, would already have his preferred plan of action prepared, but would be open to hearing John’s thoughts as well, as it would be best if John has some ownership and self-determination in the process. One can assume that John has been informed of his rights and responsibilities as a clinician at the agency (informed consent, agency practice regarding disciplinary issues)
a. John acknowledges his relapse and takes a leave of absence to take care of himself. He gets himself on a healthier track, and is eventually able to return to work, under closely supervised and pre-determined conditions. His clients are reassigned to other agency clinicians. Steve is able to provide continuity for John’s clients, create a safe working environment, perhaps preserve his friendship.
b. John does not acknowledge his relapse, remains defensive and does not admit to needing to focus on self-care. Steve then insists John must take time off to get sober/healthy, because ethically John is not able to work effectively at this time. John’s willingness or lack thereof may determine how or if he is able to return to work eventually. Steve’s first responsibility must be to the clients, which means John will need to demonstrate that he has found ways to better manage the vicarious trauma he was experiencing.
c. Lowest priority in the hierarchy is preserving their friendship, and ethically speaking, can not be a determining factor in the decisions made.
d. There is likely a report that must be made to the licensing body. This is another ethical dilemma and one that Steve and myself must decide how to handle. It is hoped that there is a progressive disciplinary plan of action laid out that we can follow.
Who should the clinical supervisor (Steve), consult regarding this scenario and why? Steve should be consulting his supervisor and possibly his Human Resources department. If there is a legal department, they should probably be involved as well. This is to protect the agency, Steve and John.
What is the best possible course of action for a clinical supervisor (Steve) to take in this situation? If it is possible, I believe the best course of action is to know ahead of time what the bottom-line expectations are (likely that John takes/is given time off to take care of himself and manage his own struggles), and meet with John to discuss. Best case would be that John chooses this course of action, as he then will feel like he has already started making better choices for himself, and he may face less punitive responses from the agency for taking responsibility. He could perhaps be given the chance to meet with his clients (with Steve present) to explain that he is taking time off for his own self-care (no specific personal information need be given, and the extent of this could be pre-planned), which provides healthy role-modeling for his clients. Steve can then reassign clients with sensitivity to the experience they have just been through and support both the client and the new clinician to work through how to discuss the change without violating John’s confidentiality.
How should the clinical supervisor (Steve) implement the decision, document the decision making process, and monitor and evaluate the effects of the decision? Implementations will be different depending on whether or John agrees with the decision being made. If he is on board, it could go as described above. If he is not on board, it would not be beneficial to clients to have John meet with them to transfer to new clinician. Steve would have to do this without John. Either way, if John does take the time off and take care of himself, it will be up to Steve to communicate the expectations that will be in place for John to return to work, and what could happen if these conditions are not followed. Informed consent would be important. Steve must document all conversations he has with John, concerned staff (or clients), myself (Steve’s supervisor), HR, legal. Before John goes on leave, Steve would be well-advised to let John know that the friendship must now take a backseat to the needs of the agency, and that subsequent contact will be for the business of making sure John is effectively working towards coming back to work, rather than for maintaining their friendship.