Instructor Responses to Week 1 Homework

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    Patricia Burke
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    Supervision and Ethics  

    Instructor Response to Homework 1

    Hello everyone,

    I appreciate your thoughtful responses to the homework questions for class 1. Here are some of my thoughts and reflections on your responses to the questions.

    1) What  is it like for you to know that you have taken or might take on the duty and responsibility of vicarious liability as a clinical supervisor?

    Many of you expressed a sense of concern and even anxiety about the vicarious liability of the clinical supervisor. As Chelsea remarked, “To be honest, it is something that creates anxiety for me. I pride myself on adhering highly to ethical standards and though I also strive to be the best clinical supervisor I can be, at the end of the day I do not have control over another’s behavior.” My first reaction to learning of this responsibility was, “No way. How can I possibly be responsible for someone else’s actions!” As Esther commented, “The idea of taking on vicarious liability is very frightening to me. I can guide supervisee’s but have no control over whether the individual will follow through with recommendations or behave ethically towards clients.”  And Nichole commented, “ . . .while I may advise a supervisee to take certain action, there is no guarantee at the end of the day they are going to follow said advice (i.e., inaction); that is kind of a scary thought.”

    Just being a clinician and trying to do the best we can to help the people we serve is an enormous responsibility and has gotten even more so as professional ethical guidelines, Tarasoff-like case law, managed care, etc. have forced clinicians to assume an even greater mantle of responsibility. Vicarious liability transfers this added sense of responsibility to the clinical supervisor.

    In addition, you may have other responsibilities and roles at your organization that constrain you or even muddy the waters with regard to potentially competing values. This sense of anxiety or overwhelm can be more intense for new supervisors. As dsinskie commented, “This is truly a scary concept. I started out as a crisis supervisor and at least then, I participated in their training, I was with my team daily, I read their documentation, and we had routine case reviews and education. I was much less experienced myself, so I don’t think I was as aware of the liability as I am now.”

    As we get more comfortable in the role of supervisor and understand what our responsibilities and the boundaries of those responsibilities are, this anxiety often lessens, and we can begin to see that this added responsibility of a supervisor can push us to be better informed about ethics and how they shape clinical practice. As Melissa noted, “When I was a new supervisor, this was terrifying. As I became more comfortable with both my clinical skills and as a supervisor, my ability to seek out others advice grew.”  And Sindee remarked, “It’s a huge amount of added responsibility but also a risk that I’m aware I’m taking on, in order to best serve my supervisee and their clients. I also feel anxiety around that, but try to keep in mind that the vicarious liability responsibility comes as an expectation with the extra experience and training needed to be a clinical supervisor and it keeps me from taking the task lightly.”

    Beth commented on a “pay it forward” value that keeps vicarious liability in perspective: “While it is uncomfortable to know that I could have liability for the actions of others, I feel that entering this field required an acceptance of that inevitability. Other fields may not carry as much risk, but this is what I chose, and what I love. Someone else carried vicarious liability for me when I was beginning, and now I do that for others.”  Beth, I appreciate your commitment to mentoring others as you were mentored. I, too, find this aspect of supervision to be very satisfying and worth the additional responsibility I assume as a supervisor.

    And Gretchen mentioned here love of supervision as a value that may lead her back into supervision after a hiatus, due to the heavy responsibility she felt: “What I loved about supervision was its’ complexity and impact on others. Watching supervisees grow and change professionally was very rewarding. I know that by doing this supervisory work, I am also helping “30 – 40 – 50” clients, their families and their worlds by supporting the counselor – makes a positive dent in their world.” Remembering what we love about mentoring others can be an antidote to some of the heaviness of the responsibility of the role.

    By-the-way, as we will investigate in our next two lessons, in any ethical dilemma you don’t need to make “the right call” (there is no “right call”) you simply need to make the best ethical choice given the players and the circumstances. We will be learning a systematic way to develop and document the process for addressing ethical dilemmas in your supervisees’ clinical work.

    Not only does our anxiety level go up when ethical dilemmas show up in the work with others, it is quite likely the people you supervisor will also be feeling anxious, as well. The ways that you learn to lessen the impact of this anxiety in your own professional lives can potentially be quite helpful to your supervisees as well. So the idea is not to get rid of the anxiety, but so develop positive coping responses to lessen its impact on you and your work with clinicians.

    So developing solid, trusting relationships with your supervisees, keeping lines of communication open, and recognizing their competence and intention to follow ethical principles can be helpful to lessen anxiety for everyone.

    Some strategies to lessen everyone’s anxiety include:

    • Educate your supervisees about ethical guidelines and focus on concrete behaviors that can be changed to lessen risk and promote good boundaries in the therapeutic relationship.
    • Create a safe environment in which clinicians feel free to discuss their concerns. If clinicians are not open about their potential ethical conflicts because they are afraid of harsh judgment, then there is greater risk of harm and potential liability.
    • Extensive clinical and supervision documentation is an excellent way to lessen liability risk and ease some of the anxiety and tension that might show up around this sense of responsibility.
    • Perhaps most importantly, get support from your own supervisor or colleagues and be open and transparent with your supervisees if you are a bit anxious or need additional support for yourself to come up with the best solution to the clinician’s concern.

    I encourage you all to engage in a process of supervision of your own supervision, whether it be with other supervisors at your agency in a peer supervision format or with your clinical director or if those options are not available, seek outside consultation. The best way I know of to lessen the sense of responsibility that vicarious liability puts on us is to share that responsibility of others. A number of you mentioned how important it is for you to have your own supervision. As dsinskie remarked, “I have had the opportunity to resume peer supervision recently as well as sharing an office building with another licensed individual who is willing to engage in peer supervision on occasion. I feel this is a good strategy to determine what any reasonable prudent person would do in certain situations. Also, its beneficial for my own self-care.”

    There are two other points I would like to make regarding vicarious liability of the supervisor:

    1. a) Instead of viewing codes of ethics, laws, and regulations as something to be feared, I invite you all to think of them as guidelines that can help empower you as a professional in this challenging and rewarding field.
    2. b) Just as you, as clinicians, attempt to develop a solid and trusting relationship with clients from the start, focus on developing these kinds of relationships with your supervisees. If we have developed good working relationships with our supervisees (including having ongoing discussions about ethics and being transparent about our responsibility and liability as supervisors) perhaps we can trust in their ability to be aware of ethical dilemmas and give their best to working with their clients in a respectful and ethical way.

    The anxiety many of you expressed is real and when we come together in a forum like this we can share some of this anxiety and discuss the best ethical practices possible to lower risk, but also stay close to our common desire to help people while minimizing potential harm. I think the question “Are we helping or hurting?” is a wonderful question to reflect on as we navigate the complex terrain of ethical decision-making and our multi-layered responsibilities to clients, supervisees, self, agency, society. There is no quick or simple answer to this question. It a question that is more like a Zen koan; not something to be answered, but a question to help us enhance our awareness and ability to reflect thoughtfully on ethical dilemmas. It is so important to share our anxieties and our responsibilities as supervisors. Thank you all for being so honest and open.

    2) Describe 3 strategies you have already employed or have thought about employing to manage this sense of responsibility so it doesn’t impact your clinical and supervisory work negatively and/or does impact your work in a positive way?

    You all had some terrific strategies for managing this sense of responsibility, so it doesn’t interfere with you work. Here are some of those strategies:

    *Peer support is an extremely important strategy.

    * I would do well to attend to thorough documentation. I would like to have a supervision note that has topics on the top and can check off which ones were discussed.

    * Be sure I am keeping detailed documentation and providing the best clinical supervision possible.

    * Ensure that my staff are adequately trained.

    * I have increased direct in vivo supervision as well as regular quality assurance calls to clients.

    * Taking my time is another strategy I use frequently. . . Giving myself time to challenge my thinking, review facts, process with other clinicians, and review documentation and or other material (such as code of ethics) is now part of my clinical decision making strategy.

    * Consult with legal counsel.

    * I follow-up at the next supervision on any recommendations or actions taken as a result of the previous supervision.

    * I keep staff informed of new information and give them an opportunity to ask questions.

    *I consult with a consultant when in doubt about recommendations regarding a case.

    * “document, document, document” – this was a mantra instilled in me during my school years!

    * I currently request a supervisees who have had issues or need greater oversight to complete more thorough paperwork in terms of a supervisee agenda prior to our meeting, so that they prepare with greater care and organization and I have access to more details about their cases.

    * I engage in peer supervision and supervision of supervision to help me see any blind spots, process cases and issues, and consult as needed.

    *  I also attend regular trainings and engage in ongoing professional development in issues of supervision.

    * 1) Acceptance: If I choose to be in this field, and be a supervisor, accept the risk, and do my best to be prepared. 2) Consultation: While I do not have my own supervisor, I meet with colleagues regularly, to discuss case questions and get their perspectives, which occasionally includes risks or pitfalls I may not have thought of on my own. 3) Check, check and re-check my work and my instincts.

    * I put a lot of structure in my supervision for clarity within the supervisory relationship.

    * I would also engage in regular supervision-of-supervision on a regular basis. EXTREMELY IMPORTANT for me to reduce negative impacts of vicarious traumatization.

    I recommend that your plan to manage the responsibility of vicarious liability should balance risk management strategies (like documentation, careful case review, direct or indirect observation of clinicians’ work) with self-care strategies (know your limitations and get supervision for your supervisor) and relational strategies (develop trust with supervisees, maintain an open door policy, and engage in your own supervision). I want to encourage you to keep this balance as a way to manage the responsibility you have as a supervisor, protect yourself legally and ethically, but also to engage in satisfying and fulfilling relationships with the people you supervise.

    Please note: Liability insurance is a key strategy to protect yourself. Even if your agency provides liability insurance for its staff, I recommend that you buy your own professional liability insurance. The reason for getting your own insurance is that in the event you are named in a licensing complaint or lawsuit, your agency’s needs may conflict with your own, so it is important to have protection for yourself outside of the protection offered by your agency. Your professional organization can point you toward a reputable company that provides professional liability insurance. As Nichole commented, “I am actually in private practice and currently sub-contract with an agency to provide supervision to their case managers. As a sub-contractor, there is little to no support from the agency as far as managing legal and/or ethical responsibilities of vicarious liability, which is another reason why I emphasize documentation …. as well as possessing liability insurance coverage!”

    3) How does your agency support/not support you to manage the legal and ethical responsibility of vicarious liability and how can you advocate for more support if it is lacking?

    The clinical supervisor not only has a duty to clients and a responsibility to supervisees, but as a middle manager you also have a duty to the agency. This can be a particularly difficult tight rope to walk at times. In addition, there is the challenge of working in a multi-disciplinary team in which different professional codes of ethics and licensing regulations view potential ethical issues and conflicts differently and, as the clinical supervisor you are responsible for sorting this out.  In order for you to do your jobs effectively and to manage this multiplicity of roles it is extremely important for your agency to support your efforts.

    If you are in private practice, what other supports do you have to help you manage the ethical responsibilities you have for client care and any vicarious liability you might assume as a consulting clinical supervisor? Beth noted, “I no longer work for an agency, but when I did, I was in a situation where I felt unsupported by my boss. Initially, I felt I had nowhere to turn with my concerns, but I was able to speak to others and got the support I needed to correct the situation. I appreciated the acknowledgement of the potential risk, and the support I received to mitigate it.”

    So what are some of the ways agencies can support clinical supervisors? Some agencies have an attorney, an ethics committee, clinical policy review team, “ethics forum” and/or risk management department or group that you can go to for legal, ethical and risk management advice. If your agency does not have a such a formal group you might want to consider starting one or advocating for one with your administration. If you are in private practice one support you have that you may not be aware of is that your professional liability insurance company will have a legal department that you can call for a risk management consultation. I would not recommend relying completely on this, but it might offer some support.

    A number of you feel that your agency and its management are supportive of you and your responsibilities as a clinical supervisor and are aware of the importance of taking your ethical and legal responsibilities seriously. Some of the ways you feel your agency is supporting you as a supervisor include:

    * We have a process in place where clinicians (including myself) feel supported and clinical managers feel supported as well.

    * We offer group supervision and individual supervision.

    * We offer all clinicians training through out the year.

    * My CEO meets with me regularly and gives me an opportunity to inform her of any dilemma’s or potential dilemma’s either myself or staff may be facing.

    * I keep the CEO updated on any questions about either legal or ethical issues the agency may be subject because of staff issues with clients.

    * The agency has access to legal attorneys and they are consulted when the CEO or myself are unsure.

    * My agency is very supportive financially about trainings and when staff returns from workshops, information is shared among the staff for a positive benefit to all. They promote a culture of learning and shared common language regarding our professional work.

    These are all ways that an agency can help you, as a clinical supervisor, do your job more effectively, manage risk, engage in your own professional development, and share the burden of vicarious liability. A supportive agency culture is key to building your efficacy as a clinical supervisor to help your clinicians provide quality care in an ethical way.

    In a situation where the administration is not so supportive or aware of the need for ethical guidelines for practice it can be extremely important for you, as the clinical supervisor, to raise awareness of potential ethical liability at management meetings and suggest that clinical ethics become a management focus.  As dsinski noted: “I don’t think we have ever had a real discussion around this. We do have bi-monthly QI meetings and I complete a monthly supervision report which describes any issues or commendations for each supervisee. It’s a good topic to bring up!”

    Unfortunately, in many agencies the clinical supervisor is also the administrative supervisor, and this can create conflicts for you as a “middle manager.” Ideally these two functions should be handled by different individuals. When that is not possible, you can avoid conflicts with supervisees by being very transparent about the clinical and administrative roles you are in and be clear about when you are putting on these different hats.

    Another way that administrations are sometimes not supportive is not providing enough time for clinical supervisors to actually do clinical supervision. As Chelsea remarked, “Honestly, my agency does not do the best job of giving me space to manage the responsibility of vicarious liability. I do not let this deter me, however, and I continue to push back and link the need for me to provide increased clinical supervision as necessary for ethical client care as a whole.”  Chelsea, I support you 100% in your efforts to push back.

    Unfortunately, this is becoming a frequent problem in the era of managed care. Clinical supervisors not providing the supervision required by state licensing boards puts the clinical supervisor and the agency at risk and is detrimental to the quality of clinical care provided by clinicians.

    Whatever your role in an agency, make ethics a more central focus in your work, not simply as a risk management strategy, but as a way to grow as a clinician and mentor to your supervisees. In addition, seek outside supervision and consultation and discuss ethical dilemmas with your supervisor or peer group. Document your discussions.  Even if the agency is “resource poor” or has different priorities than we do as supervisors, at times, the effect of advocating for ourselves, our supervisees and our clients can be extremely empowering.

    In our next class we will take a closer look at the ethical decision-making process. Thanks again for your thoughtful reflections on the first lesson.

    ~Patricia

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