Instructor Responses to Week 3 Homework

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    Patricia Burke
    Keymaster

    Supervision and Ethics

    Instructor Response to Homework 3

    Hello everyone,

    Once again, I appreciate your thoughtful responses to the homework questions for class 3. Here are some of my thoughts and reflections on your responses to the supervision scenario involving Steve and John.

    1) Who are the parties that will be impacted by whatever course of action is chosen?

    You all point out that it is clear that the two parties that will be most impacted by whatever course of action is chosen are Steve (as the clinical supervisor) and John (as the clinician.) Steve’s primary ethical responsibility is to make sure that John’s clients are receiving good quality care, so his clients will definitely be affected by whatever action Steve takes. What if John continues to work with clients, while he is impaired? How will clients who have worked with John for a long time be impacted if John refuses to get treatment or help to resolve the impairment issue?  In addition, other parties you mentioned who would be affected include John’s clients, other clients, other staff members at the agency, co-workers, satellite agency peer team, Steve and John’s families, agency administrative staff.

    2) What are the ethical issues involved in this scenario, including conflicting and competing values of the parties involved?

    Most of you suggested that the two primary and immediate ethical concerns that need to be addressed in this scenario are 1) John’s impairment and 2) the dual relationship between Steve and John. These potential conflicts and the competing values involved are multi-layered. Not only had John come to work, impaired, but he is attempting to use his friendship with Steve to his advantage.

    Some of the other ethical issues you mentioned include:

    * There are multiple boundary issues that Steve and John are dealing with in this situation. Steve worked to minimize these possible pitfalls in discussing their dual relationship up front within their new relationship. It may have also been helpful to advocate for supervising in another office to minimize dual relationships.

    * Doing no harm to the client is another important ethical consideration. John’s heavy caseload seems to be increasing his stress responses to his clients and others around him.

    * Self-care is another ethical consideration when looking at John’s high risk of vicarious traumatization leading to relapse. All parties may be impacted by his unhealthy self-care choices. Steve may also be struggling with self-care due to his dual relationship.

    * 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.

    * John attempted to use their friendship to manipulate Steve into ignoring his relapse, as well as his other unprofessional behavior.

    * John is vicariously traumatized and burning out.

    * Steve’s supervisory competence.

    * Agency/Mainecare requirements with large volume of documentation for John’s caseload versus ability to focus on client clinical care and potential competing interests of agency requiring completion of documentation with delivery of client care

    * Competency of John as counselor due to potential impairment from drinking

    Most of you suggested that the two primary and immediate ethical concerns that need to be addressed in this scenario are 1) John’s impairment and 2) the dual relationship between Steve and John. These potential conflicts and the competing values involved are multi-layered. Not only had John come to work, impaired, but he is attempting to use his friendship with Steve to his advantage. Please Note:

    It would be important for Steve to consult both the Maine standards for Certified Clinical Supervisors and the NASW code of ethics.

    Since Steve and John are both Social Workers and Steve is a CCS, the NASW code of ethics and the Maine State Code of Ethics for Certified Clinical Supervisors should be consulted with regard to the issue of clinician impairment. Here are some sections of both that pertain to this scenario.

    NASW Code of Ethics

    2.09 Impairment of Colleagues

    (a) Social workers who have direct knowledge of a social work colleague’s impairment that is due to personal problems, psychosocial distress, substance abuse, or mental health difficulties and that interferes with practice effectiveness should consult with that colleague when feasible and assist the colleague in taking remedial action.

    (b) Social workers who believe that a social work colleague’s impairment interferes with practice effectiveness and that the colleague has not taken adequate steps to address the impairment should take action through appropriate channels established by employers, agencies, NASW, licensing and regulatory bodies, and other professional organizations.

    Other sections of the NASW code of ethics that might pertain to this situation include “Social Workers’ Ethical Responsibilities to Clients, Social Worker’s Ethical Responsibilities as Professionals, Private Conduct, and Social Worker’s Ethical Responsibilities to the Social Work Profession.”

    Maine Board of Alcohol and Drug Counselor Code of Ethics (pertains to Certified Clinical Supervisors)

    IV.     Professional Behavior – Due to the unique scope of practice substance abuse counselors provide, certified clinical supervisors must monitor the following behaviors of their staff and themselves. . . B.         The use of intoxicants and/or non-physician prescribed and monitored mood altering substance when engaged in professional pursuits.

    10.  Report to the board an alcohol and drug counselor, alcohol and drug counseling aide or certified clinical supervisor whose judgment or competency while treating clients is impaired by chemical dependency or physical or mental incapacity;

     

    There are additional ethical concerns that need to be addressed but might not have the same urgency. For example, (as dsinski mentioned) there is the competency issue with regard to Steve’s advancement to the position of supervisor. Did he get enough training before being promoted? What additional training and supervision does he need in order to support him to identify these potential conflicts in the future and perhaps prevent them with other supervisees? Again, this is not necessarily an immediate issue to be addressed but has systemic implications that should be addressed in order to prevent future ethical dilemmas.

    There is another competing value that should be taken into consideration when assessing this scenario, which is (as Chelsea mentioned) John’s right to privacy and treatment for his relapse and acute stress reactions, secondary trauma, and potential vicarious traumatization. While the care of clients is the highest priority, it is also important to remember that John was at high risk for impairment because of the increase in his caseload of people with trauma. How much responsibility did Steve (and the agency itself) have to limit the number of potentially high stress clients a clinician takes on and how much responsibility did John have to engage in more self-care practices in order to prevent impairment, if possible? So I would see this scenario as having immediate ethical implications which need to be addressed, but also long-term issues that need to be addressed on an agency wide level and administrative level.

    In addition, there is the larger agency issue of limited resources and the possibility that the first slip down the slippery slope in this scenario was the fact that the agency assigned Steve to supervise John in the first place and left it up to him to assess the potential conflict regarding the dual relationship with John. While Steve and John had good intentions with regard to trying to keep their friendship separate from work, it is clear from this scenario, that this is easier said than done. If I were a colleague of Steve’s I would want to advocate with the agency administration to develop a cogent policy regarding promotion of supervisors from within the agency to address this potential ethical conflict.

    3&4) What are all the viable courses of actions and the possible benefits and risks for each?

    As you pointed out in your comments, there are any number of viable courses of actions that could have both benefits and risks for the parties that might be impacted. Some of them are immediate and some of them are long-term.

    Some of the viable immediate courses of action include:

    A) Steve could take John at his word and do nothing, promising to keep his relapse a secret. Benefits: Steve and John could remain friends. Risks: client treatment would be compromised, both Steve (through vicarious liability) and John due to violation of ethical and licensing board standards on impairment would both be vulnerable to ethics complaints, agency disciplinary actions, and licensing board sanctions. As Chelsea wrote: “ Steve could do as John asked and say nothing. Pros- It might preserve friendship Cons- high risk of leading to further impairment and clients being harmed John not getting the help he needs.” Beth commented on this possibility: “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.”

    B) Fire or suspend John immediately. Pros: clients and co-workers are protected from John’s harmful behavior. Cons: It may not be a legal employment practice. Other cons might include that if John has otherwise been an effective counselor and has developed strong working relationships with his clients, that a precipitous firing could have a serious negative impact on his clients. And, if Steve has to suspend John or fire him, John might file a law suit against Steve and the agency and/or file an ethics complaint with the licensing board. Gretchen commented about this option: “Fire John directly. Multiple Risks for all parties including client and co-worker loss of a clinician/team member, loss of friendship, unethical treatment of an employee, agency not supporting John in his recovery, as is their mission as a co-occurring treatment center, etc.” Melissa remarked, “Steve could fire John for showing up at work intoxicated. This will damage the friendship and impact client/counselor relationship because the relationship would end abruptly. The agency would be protected.”

    C) Steve could consult with you (consulting supervisor), his own supervisor, the clinical director, and/or the agency executive director before addressing the issue of impairment with John. Benefits: Steve could potentially get support and a larger perspective on potential ethical dilemmas he needs to address with John, consultation is a cornerstone of the ethical decision making process and Steve can document that he considered his decisions thoughtfully. Risks: John might continue to act in unprofessional and potentially harmful ways (e.g. drinking on the job) if this issue is not addressed immediately by Steve and open himself, Steve, and the agency to further liability issues.

    D) Steve could ask a peer supervisor at the agency, the consulting supervisor, or his own supervisor to sit in on a meeting with John to address the impairment issue and dual relationship concerns. Benefits: Steve would have support for addressing these complex issues with John. Risks: Steve might feel like his authority as a clinical supervisor is being undermined, John might feel embarrassed, ashamed, or angry at Steve and end their friendship.

    E) Steve could address John’s use of alcohol immediately. This might include telling John that he has to leave the premises immediately for being intoxicated at work. Benefits: John’s impairment will not harm other staff or clients for the rest of the day and Steve would have a chance to consult with others to gain perspective. Risks: clients who were scheduled to see John that day would not receive treatment, John might end his friendship with Steve. If John is intoxicated and drives away without Steve addressing how he will get home and John gets in an accident, Steve and the agency might be liable. Alternative means of transportation should be made available. Gretchen wrote about this option: “Meet with John to address his relapse at work, including creating a restorative, corrective plan including being transparent about agency rules. Plan includes consequences of continuing behavior. Benefits to John: clarity about agency regulations, supportive plan. Risks to John: no focus on the increased stressors or other personal self-care, may feel friendship is compromised. Benefits to Steve: clarity about agency regulations

    F) Steve could sit down with John immediately, address his behavior, and make it clear that John must get treatment immediately to address his relapse and acute stress reactions due to secondary trauma and vicarious traumatization. Steve could try to work collaboratively with John to see if John can recognize his own impairment and develop an immediate plan for addressing his impairment including leaving the premises, taking a leave of absence/going on sick leave, going to an AA meeting, and calling the EAP for an assessment and referral for treatment. As Chelsea commented: “ Steve could have a direct conversation with John about his concerns and urge him to get help Pros- might lower John’s defensiveness and increase likelihood to get the help he needs Cons- This could be seen as Steve not handling the situation seriously enough and violating NASW code of ethics.”

    If John is not able to work collaboratively and take responsibility for his own self-care, Steve could make it clear that if John doesn’t get help right away that there will be consequences based on agency policy, including suspension and/or termination and the possibility of a complaint to the state licensing board. Benefits: Steve addresses John’s impairment immediately and prevents further harm to clients and staff, Steve works collaboratively with John to recognize and take responsibility for his own impairment. Risks: If John agrees to treatment this might jeopardize his privacy and right to confidentiality when he becomes a client. John might not be able to work collaboratively because he is so impaired and might force Steve to take unilateral action, thus causing a rift in their friendship. Beth added these remarks about this possibility: “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.”

    H) One additional viable course of action would be for Steve to report John to John’s licensing board. What would be the benefits and risks of reporting Steve immediately to the licensing board? When and how should this be done?

    All of these are possible courses of action. There is no “right” or “wrong” course of action. I want to re-emphasize that the ethical decision-making process is about carefully weighing the pros and cons of each course of action (including doing nothing), then deciding on the best possible action in that particular circumstance. As you can see from the variety of possible actions, that there are many variables to consider, all of them have pros and cons.

    5) Who should the clinical supervisor (Steve), consult regarding this scenario and why?

    Here are some of the resources you would suggest that Steve consult regarding this ethical dilemma and why:

    * His own supervisor. Human resources. Licensing board.

    * Consultation can help Steve determine his professional plan of action to support John’s clients AND John, but also to help himself balance his own self-care and recovery progress.

    * If there is a legal department, they should probably be involved as well. This is to protect the agency.

    * I would get peer consultation as Steve did in this situation. I would also consult.

    * Steve should consult another (or more than one) supervisor with more experience than he has.

    * He could consult with his professional organization as well; for instance, the ACA will offer ethical and legal consultation.

    In addition, Steve could consult with the legal department at his own liability insurance company. Since he is an LCSW, if he is a member of the National Association of Social Workers he could also consult with the NASW’s Office of Ethics and Professional Review. https://www.socialworkers.org/About/Ethics/Ethics-Education-and-Resources/Ethics-Consultations.aspx He could also consult with a peer supervision group if he belongs to such a group.

    I want to make note that the state licensing board’s mission is to protect clients. So they would not generally offer advice to a clinician or a clinical supervisor about how to handle an ethical dilemma and any information you share with the board could be used if there was ever a complaint filed against you or if Steve decides to file a complaint against John. Consult with the licensing board regulations and professional ethics codes and legal and HR resources before contacting the licensing board.

    6) What is the best possible course of action for the clinical supervisor (Steve) to take in this situation?

    Here are some of the “best” possible courses of action you mentioned for Steve to take in this scenario:

    * Sit down with John and HR. John didn’t respond well to Steve’s first attempts to handle the situation and it is clear in order to do ethical duty of assessing clinician impairment, a higher level of intervention is needed.

    * Steve can meet with the client to address all issues: compromised clinical care, supervisee’s compromised self-care and relapse, a plan of corrective action and clear consequences if these are not addressed. Steve would continue supervision of supervision (or consultation) to manage his own professional ethical work with this supervisee as well as his own self-care.

    * 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.

    * I would send John home for the day and ask to meet with him the following day when he was not intoxicated. I would discuss my worry for him, the value he brings to the agency and talk about what he might need in the way of self-care and work modifications in order to feel healthy again.

    * Steve would be wise to refer John to another supervisor. He is too close to the situation and friends with John. Also his lack of experience may be a contributing factor. Steve doesn’t know what he doesn’t know.

    * My opinion is Steve should meet with John again when he is not impaired, come up with a probationary plan that would include some time off, reduced PTSD caseload, and some form of monitoring or check in to ensure he is performing unimpaired

    Gretchen made a comment about an additional action Steve can take to support his ethical decision-making process: “Steve may decide to increase his own supervision of supervision for his own self-care, as well as his own outside supports.”

    Thanks for your thoughtful analysis of this ethical dilemma. You have touched on many of the possible courses of action and offered a comprehensive list of best possible action plans.

    Here are my reflections. As with most client/clinician ethical dilemmas, if at all possible, it is important to try and work within the respectful, collaborative nature of the relationship. In this case we are talking about the clinician supervisor relationship. I would suggest that there is the immediate issue of John’s drinking before work and some longer term ethical considerations. While technically, John might not have been drinking on the job, his recent behavior and the smell of alcohol on his breath suggests strongly that he was intoxicated and impaired while on the job. If I was Steve’s colleague I would advise him to take John out of the workflow immediately, sit down with him and try to work collaboratively with John to see if John can recognize his own impairment and develop an immediate plan for addressing his impairment including leaving the premises, taking a leave of absence, going to an AA meeting, and calling the EAP for an assessment and referral for treatment. A report about John to his licensing board should be carefully considered only after consulting with risk management advisors (like HR and legal), clinical administrators, agency policies, and relevant codes of ethics and would also depend on whether or not John complied with requirements to seek treatment.

    If Steve can quickly contact his supervisor or the clinical director of the agency before speaking to John without compromising client care or the well-being of the staff, I would recommend consultation before sitting down with John (especially since Steve and John are engaged in a dual relationship and Steve will feel very ambivalent about confronting John) and having a third party present in the interview. If Steve does not have that opportunity to consult, I think the best immediate course of action is to address John immediately. The primary ethical responsibility of the clinical supervisor is the welfare of clients. The second responsibility is the training and professional development of clinical staff. I would also advise Steve to get extended consultation with his supervisor and clinical director to develop a further plan of action including providing for continuation of client care in John’s absence, a plan for further action if John refuses treatment, a clearly articulated set of requirements for John’s return to work, and a review of Steve’s supervision of John, including his decision to load John up with trauma clients and how he addressed the dual relationship with him.

    Because of the inherent conflict of interest due to their friendship, Steve should not be making long term decisions about sanctions for John if he refuses to address his impairment or the requirements for his return to work. In addition, if John does return to work he needs to have a new supervisor. That might mean transferring him or Steve to another unit of the larger agency. I don’t believe it would be useful to try and force Steve and John to end their personal relationship. I believe that would be stepping over the agency’s legal authority, so if both Steve and John remain at the agency, their relationship as clinician and supervisor needs to end.  I think it could be useful for Steve to also look at his dual relationship with John and to help him explore, in a non-judgmental way, his own burnout potential and self-care needs.

    7) How should the clinical supervisor (Steve) implement the decision, document the decision-making process, and monitor and evaluate the effects of the decision?

    Here are some of your ideas about how to implement, document, and monitor the effects of the action plan you would encourage Steve to take:

    * He should document all noted concerns from staff and himself, document the incident where Steve was drinking on the job and his subsequent reaction, and document all supervision he receives on the matter.

    * Steve should have a witness to the conversation he has with Steve and should have follow up meetings to ensure needed plan is in being followed.

    * Implementation of the meeting is done with immediacy. Steve will communicate his concern for John professionally and personally. Focus of the supervision will be on John’s self-care, management of his caseload and restorative planning for ethical, clinical client care. Steve will be upfront with John about documenting this supervision as well as having John sign any restorative plan created in the meeting.

    * 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.

    * I would keep a written log of who I talked to, what the direction was and a timeline for implementation. When I met with John I would also document our conversation and have him sign the notes at the end so we are both in agreement of the plan moving forward.

    * Steve should document all meetings he has with John, other supervisors, agency staff around this issue. If they make a plan of rehab or treatment, documentation may be required from John to Steve of attendance or completion. More frequent check-ins if Steve continues to supervise John would be important as part of monitoring/evaluation.

    Whatever plan of action is decided upon it should be written and include expected outcomes (for both John and Steve) and reasonable time frames for completion of those outcomes. Outcomes could include John’s success in his own treatment and/or self-care strategies and Steve’s completion of additional training in supervision and ethics. While most of you commented on the need to document all conversations and action plans, it is crucial to not only document actions and outcomes but your rationale for why you took those actions. This is particularly important risk management tool in the event of any law suit or licensing board actions.

    Finally, given the broad range of knowledge that a supervisor must have to be effective, especially in working with clinicians who are treating people with co-occurring conditions (which is about 80% of the people in substance abuse treatment) a clinical supervisor should have advanced education in addition to years of clinical experience before becoming a supervisor. I think the pressure to move clinicians into supervisory roles is strong and it could easily come back to bite the agency and compromise the quality of care provided. The CCS is intended as a supervisor credential for substance abuse treatment professionals but doesn’t really address the additional training and educational needs of people supervising in mental health and co-occurring settings. In this scenario, Steve may have been promoted to supervisor too quickly and the agency administration has an ethical responsibility to him to provide more training and the remedial help and support he needs now to deal most effectively with this complex ethical dilemma.

    Thank you all again for your in-depth analysis of this ethical dilemma using Reamer’s method of ethical decision making. As you have experienced over the last two lessons, this process is lengthy and requires a willingness to engage in critical thinking and deep reflection. I think the process is well worth the effort. I hope you have found it helpful.

    In our next class we will examine the issue of countertransference in the therapeutic relationship and a respectful way for clinical supervisors to explore this topic with supervisees without slipping into doing therapy.

    ~Patricia

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