Instructor Responses to Week 5 Homework

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    Patricia Burke
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    Supervision and Ethics

    Instructor Responses to Week 5 Homework

     

    1) Boundary Crossings and Supervisor Roles in Co-occurring Treatment Contexts

    A) What are some of the strategies you would employ to initiate and facilitate a discussion about the distinction between self-disclosure as a boundary crossing or boundary violation in your treatment team meeting?

    As I read your responses to Question 1, I was struck by the tremendous respect you all expressed for the people you supervise in the scenario described as a multi-disciplinary team discussing the distinction between boundary crossing and boundary violation with regard to clinician self-disclosure. As Beth wrote: “I would be diligent in my efforts to create an open and safe space for conversation about difficult topics. I would work to communicate without judgment, and teach my supervisees communication skills that would allow them to do the same.”

    Creating a safe atmosphere for clinicians to be able to explore their own uncertainty with regard to self-disclosure or any potential ethical dilemma is the key to bringing the issue of ethics out of the realm of hypervigilance and rigid adherence to ethical codes of conduct into the realm of a fluid and contextual discussion regarding boundaries in the clinician/client relationship. Dsinski commented, “if team meetings are a safe place for all, then the discussion would be more open. These can be considered learning moments. I would also state that I am not an expert, that I am continuously learning as well as my team.” Gretchen offered this idea for creating safety: “Starting the discussion in a separate training could help increase the safety level on staff – for anyone struggling with the issue may not feel singled out.”

     Focusing on self-reflection and having clinicians share their own experience can be a helpful way to discuss self-disclosure and other boundary issues as long as it is done in a safe environment. Making the issue of ethics a regular conversation can also be helpful in normalizing the conversations. As Chelsea noted, “First and foremost, I would ensure that ethics and boundaries are interwoven into every team meeting (i find it helpful to put it on the weekly agenda that is always discussed) so that everyone is comfortable with discussing the concepts and there is not understandable anxiety when the topic is brought up out of the blue.”

    It is also important to anticipate the possibility of some tension among different professionals from different theoretical backgrounds and training regarding the issue of self-disclosure. A good strategy to manage this tension is to be open and regularly bring up the differences and commonalities of different professional codes of ethics. Melissa mentioned this idea: “I believe it is good practice to discuss openly the different lenses different professions use. I would bring the conversation back to the reason for a disclosure.”

    In addition, it could also be useful to have a discussion about the difference between “passive” self-disclosure, e.g. having photos of family in your office versus “active” self-disclosure, e.g. telling a client with a substance use disorder that you are in recovery.  What might be the impact on clients of these two kinds of self-disclosure.

    I appreciate these thoughtful approaches that invite self-reflection and creates a safe and non-threatening way to open up a discussion about self-disclosure and when it might be a boundary crossing or a boundary violation.

    Ethical principles are based on values, so a respectful, collaborative, fluid, and contextual conversation with the people we supervise will also be based on values, which are also contextual. In discussions regarding counselor self-disclosure we can ask questions like: Who will benefit by this disclosure? How and why will this disclosure benefit the client? These questions are values questions. They open up the possibility of a rich discussion that respects differing opinions, but also focuses on weighting the discussion toward one of the most important values of counseling– Beneficence (striving to benefit the people with whom we work).  I want to restate how important it is, when discussing ethical issues, to remember that there are very few clear-cut “right” or “wrong” answers. Allowing differing viewpoints to emerge in the discussion will enrich the conversation and give people a better appreciation for the complexity of ethical decision-making.

    It can also be helpful to remember that ethical principles evolve over time because cultural values and norms change. It is a delicate balance between ensuring that clients are protected from the abuse of power that can happen in a therapeutic relationship and not becoming so rigid in our ways of connecting with clients that the relationship loses its healing power. Much of this depends on who the client is. I have self-disclosed with clients when it was very powerful and healing for the client and I have also self-disclosed with other clients, when it was less helpful and, in the final analysis, was confusing to those clients. So, I always return to the question, “Am I sharing on a personal level with this particular client because I genuinely believe it might be helpful to this particular client?”

    B) Which of the supervisor roles (consultant, adviser, guide, mentor, professional colleague, educator) fits with your values and supervisory style? Which of these stances would you take in the conversation with the team and why?

    I was also struck by how you all described the fluidity and variability of the supervisory roles you would employ depending on the supervisee, the clinical context and the stage of development of the counselor. For example, Sindee wrote: “My supervisory style is more of a mentor/guide and also educator, and it also depends on the experience of the clinician with whom I’m working. When I’m supervising master’s level student interns, they often need more of an educator role in order to learn new skills and concepts whereas an experienced clinician is usually seeking supervision that is more collaborative as a mentor/guide.” Beth remarked, I tend to see myself as a guide. I prefer to help supervisees come to their own conclusions, as they puzzle through the situation.” Dsinskie mentioned, “I think guide and mentor are aligned with my values. . . .A guide and mentor means to me that we walk the journey together with my experience and role being able to help facilitate growth.” Gretchen wrote: “I feel comfortable in being a facilitator of their learning, being at times a consultant and in the teacher role.” Esther commented, “As a guide/educator/professional colleague I would use the code of ethics to guide and educate using the ethical standards and apply to case studies. Teach a problem solving model to utilize with ethical dilemmas.” Chelsea commented, “The roles of guide and educator most closely fit with the roles I would take in this context. Guide to help move the conversation to a robust discussion on the topic and ensure that everyone leaves with some concrete tips and ideas. I am also an educator when educating everyone on the different code of ethics and how it applies here.” And Melissa wrote: “I prefer the consultant role. I would help sort through reasons why or why not do disclose and help the clinician come to a resolution that feels comfortable and supported by best practices.”

    There is also a fluidity and contextual aspect of the roles we take on as clinical supervisors in our work with supervisees. The context needs to take into account our own personal supervisory styles, the clinical situation with the client and the supervisee, the supervisee’s stage of professional development and whether we are doing individual or group supervision.

    I think it is important to acknowledge the multiplicity of roles to ourselves and with our supervisees. This is part of informed consent, but from a broader perspective, this acknowledgment serves to increase the supervisor’s transparency. As I mentioned in the lesson, transparency is different than self-disclosure of personal information. Transparency in the here-and-now relational experience between supervisor and supervisee can enhance a sense of mutuality (i.e. we are both effected and transported by this relationship to new awareness) in the supervisor/clinician relationship, just as it does in the clinician/client relationship.

    2) Describe 2 -3 useful ideas and/or strategies about supervision and ethics that you have learned or been reminded of over the course of the past 5 weeks that you would like to bring back to your colleagues, supervisees, supervisor, administrators, etc. How do you envision integrating these ideas into your work?

    Here are some of the useful ideas and strategies you mentioned that you would like to take back to your work from this course:

    * This course was a great reminder about the complexity of the supervisor/supervisee relationship, and the parallels it holds to the clinician/client relationship.

    * I was reminded of the importance of healthy vs. unhealthy personal disclosure in treatment and in supervision. The question “who is this for?” is so important, and really such a simple guideline.

    * I’ve been reminded of the importance of discussing ethics and boundaries on a routine basis. I have already implemented a supervision note with topics as the header!!

    * I think being reminded about the difference of transparency and self-disclosure has been very helpful to me.

    * Having a decision-making model is sooooo helpful for me – another great reminder in this world where we are making quick decisions with back to back clients dealing with complex issues.

    * Reviewing beneficence/malfeasance/justice regularly in resolving ethical dilemmas. Using the example of the social work board finding of the very vulnerable adult and the 4 indicators of potential boundary issues.

    * Probably the biggest reminder/ take away I am taking from this training has to do with the effects of counter transference not only for the clinicians I supervise but also for myself.

    * Another strategy that I have learned from this training is the importance of educating the other managers that I work with on the concept of vicarious responsibility and this is why clinical supervision needs to be honored as highly as client appointments.

    * I enjoyed the framework that we used in the earlier lessons of how to weigh out risks and benefits for different options.

    * I also appreciated the conversations about transference and counter transference. It is helpful for newer clinicians to be reminded that this occurs and how to notice when this is happening.

    * The last lesson on boundaries is also a good reminder that different professions have different norms and values.

    * I found this course very useful given that I’m currently supervising two student interns and other conditionally licensed therapists at this time. I will definitely continue to bring forth more of the strategies.

    * Reviewing codes of ethics is an important reminder as part of regular practice. I

     Some Final Thoughts

    We have covered a lot of territory over the past 5 weeks. As I reflect on this journey, I am stuck by both the tremendous responsibility we are willing to assume both as clinicians and clinical supervisors working with people with co-occurring conditions and the tremendous sense of fulfillment that brings us to this work and keeps us doing this work. While laws, licensing regulations, and codes of ethics might bring up feelings of anxiety for us all with regard to learning to “follow the rules,” I have also come to appreciate that those ethical standards of practice are based on values such as client self-determination, dignity, compassion, justice, beneficence, and service that are very much in alignment with my own personal values and the values I heard you all express in your comments.

    In spite of the constraints and pressures of managed care, high caseloads, negotiating the intricacies of relationships and boundaries in relationships with clients with complex needs and concerns, and clinicians with a diversity of perspectives, theoretical orientations, licensing requirements, and codes of ethics, I think that, personally, what keeps me going is to remember and trust that my self-reflection on these values will help me navigate the complexities of this ethical terrain. I hope that as clinical supervisors (current and future) that you remember and reflect on your own values and make this conversation an integral part of your supervisory relationships.

    I want to thank you all again for your thoughtful reflections and the depth of your comments and analysis of the scenarios presented in this course. Your comments enriched the discussion tremendously and made, what could be a very dry exploration of ethics, a vibrant and thought-provoking conversation. Thanks!

    ~Patricia

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