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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?
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. I often enjoy hypothetical role plays, followed by open discussion of various points of view, as a way of stimulating conversations that do not feel pointed at any specific person. I would sometimes see myself proactively as a teacher, sharing information such as what this course offers, hopefully offering new ideas for supervisees to learn, such as the nuances that make a boundary crossing and a boundary violation so different from one another. I would lean towards having difficult conversations about a specific issue/problem with individuals, rather than in a team setting, in hopes of being able to have problem-solving discussion in an open and nonjudgmental fashion. I would definitely prefer a setting in which I do not have dual roles as clinical and administrative supervisor, as this does complicate the situation.
B) Which of the supervisor roles (consultant, advisor, 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 tend to see myself as a guide. I prefer to help supervisees come to their own conclusions, as they puzzle through the situation. I would feel it necessary to make sure they have the necessary tools at their disposal (i.e., codes of ethics), but I do not like to give answers to them, as I feel this does not give them the opportunity to develop their own clinical judgment. I do enjoy teaching as well, but I would probably set aside specific times for sharing that type of information, and even then, it would be made relevant to the setting, so it can be put into practice.
Exercise 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?
Because I have been in private practice, and haven’t been a supervisor in a long time, this course was a great reminder about the complexity of the supervisor/supervisee relationship, and the parallels it holds to the clinician/client relationship. It reminded me of past supervision experiences where I felt we successfully navigated difficult situations, as well as a time that I remember really feeling that I made a mistake as a supervisor, and the work I had to do to recreate an open and safe space in which we could trust our relationship again.
I was reminded about how important it is to consult the codes of ethics when making difficult decisions. There are guidelines that are helpful, and there are people in the various professional organizations who are also guides when needed.
Finally, 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. Obviously we care for our clients. If we didn’t, we shouldn’t be in this line of work. It would be easy to overstep and become too personal. This simple question should always be in the back of our brains, and used on a regular basis.Question 1
Without using any identifying information, briefly describe a few client characteristics, e.g. this person has a history of childhood sexual trauma, multiple substance abuse issues, and depression with hopelessness.
16 year old female, homeschooled. Diagnosed with Major Depressive Disorder, severe, recurrent and Generalized Anxiety. She reports emotional abuse at home, and frequently talks about feeling hopeless, that her life will never change, that she can not foresee a future in which she can have happiness. I have contact with both parents periodically, with client’s permission. Parents are extremely averse to therapy, but tolerate me because their daughter feels it is helping her. She has recently been hospitalized (and discharged) for suicidal ideation. She has no substance use issues. I have seen her fairly consistently since she was 12 and first struggled with symptoms of depression.
Question 2
Without disclosing personal information you are not comfortable sharing, briefly describe your countertransference reactions to this particular client, e.g. “I feel sick to my stomach when I know I have an appointment with this client. I feel intense guilt about the fact that the client continues to drink and hopeless about her getting better.”
I get very tired and struggle to not yawn when I am with her. I anticipate our sessions with fear that this will happen and that I will find myself watching the clock, wishing for the session to be over. I get a bit disgusted with myself that I have this anticipatory reaction.
Question 3
Briefly describe how your reactions facilitate or inhibit your empathy for the client.
This was not a reaction I initially had to this client. It took me some time to recognize that she is what was called a “help-rejecting complainer” in grad school. I spent a long time in relationship development with her, and during this time, used a great deal of motivational interviewing. I wasn’t trying to fix problems, but help her find her own motivations for starting to make change. Change did happen, and she discharged for about a year. She started up again, at about age 14. It has been since then that I have noticed my countertransference. This reaction has inhibited my ability to be empathetic toward her. I have a conversation with myself before she comes into session about how much I know she is hurting. She seems to continue to want to connect with me but not work to make any change for herself. I believe my countertransference is that I feel frustrated and helpless. I try to understand that this is probably exactly what she is feeling as well, and I try to connect with her on that level.
Question 4
Briefly describe the extent to which your countertransference reaction may be intensified by your own history (e.g. your own or family’s trauma, depression, substance abuse, etc).
I do not know where this comes from. I do not relate to her in any specific ways that I can identify (and I have talked about this in consultation). She does not remind me, in any obvious way, of significant relationships in my past. As I think about it, I believe she may remind me of people I grew up with who had potential to be more successful than they believed they could be, so they rejected the idea and never really tried. I would feel frustrated with them in similar ways.
Question 5
Devise a strategy for addressing the countertransference issue.
Some questions to explore:
• How does your understanding of your response to the client help you hear, see, understand the client more clearly?
• Would disclosure of the countertransference response be helpful to the client or the therapeutic relationship? How?
• Would disclosure of the countertransference response be harmful to the client or the therapeutic relationship? How?I have addressed this with her, without specifically naming it. My strategy was to “notice” with her that she tends to balk at anything that moves towards change talk. Actually, the first time we had that conversation is when she finally admitted to some suicidal thoughts. It was a very helpful conversation that did allow us to move forward in some ways for a short time. I did, of course, notice that during those conversations, I was not yawning or clock watching. I know that was because I knew we were making something good and therapeutic happen for her. Lately, I have noticed myself having to “prepare” for sessions with her in the same ways I used to, so I realize we are probably avoiding something very difficult that needs to be brought out into the open.
Question 6
How would you know that your countertransference response needs to be addressed with your own counselor/psychotherapist? What might be some signs to look for?
Maybe it would be helpful to explore more deeply why I am having these reactions. I have not done that. If I felt that I was not able to understand my reaction, or that I was letting my reactions become more obvious or less well-managed, I would definitely need to explore this in my own work. Another sign that it would be time to address this myself would be if I took it home with me and it affected me outside of work With this particular client, since I have had the experience before that using my countertransference to usefully inform an intervention, I obviously need to use some similar tactics again.
Question 7
As your own clinical supervisor, how would you suggest to yourself, as a clinician, that you might need to seek counseling/psychotherapy to address your own personal history as it relates to your work with this client (and other clients with a similar presentation)?
As a supervisor, if I noticed clinical skills and ability to maintain a professional and therapeutic boundary with clients was being compromised, I would hopefully recognize what might be happening for the clinician. I would schedule supervision and start by asking the clinician how she feels her work is going. I would use MI to get her reflecting on her work, and start to explore any concerns/feelings/questions coming up for her. I would ask her to wonder about why she may be reacting in certain ways, and hopefully help her get in touch with any countertransference that might be happening. Because I always emphasize that self-awareness is a large part of being an effective therapist, I do not believe any supervisee would be surprised or offended if I suggested that this was an issue that might need to be raised in their own therapy.Question 1
Who are the parties that will be impacted by whatever course of action is chosen? John, Steve, John’s clients, other clinicians
Question 2
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.
Question 5
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.
Question 6
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.
Question 7
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.Question 1
Who are the parties that will be impacted by whatever course of action is chosen?
Parties impacted include Janet, Larry, Janet’s supervisor, other agency personnel who may be experiencing or sensing Larry’s inappropriate boundaries, a potentially new counselor either within or outside the agency, potentially Larry’s family members, should he relapse.
Question 2
What are the ethical issues involved in this clinical scenario, including conflicting and competing values of the parties involved? Janet has an ethical conflict, based on Larry’s increasing boundary violations. He has a personality disorder that is manifesting in the clinical relationship. Does one “fire” a client for behaving in a manner consistent with his diagnosis? The agency has ethical decisions to make, in terms of how to handle this situation. Obviously, Janet’s safety must be ensured, and that demands some sort of action that must be determined. Larry’s behavior could get him in legal trouble; does Janet/the agency handle it with or without legal involvement? Once can assume that an ethical decision was already made and Janet had revealed to Larry that she is in recovery. Otherwise, he may not have known to look for where she attends meetings. Perhaps that is a decision the agency may revisit.
Questions 3 & 4
What are all the viable courses of action and what 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 theory and practice, and personal values including religious, cultural, ethical and political ideology.
1) Tell Janet she needs to either ignore or confront this issue on her own, despite her stated fear.
a. Pros: I fail to see any.
b. Cons: Janet is an LADC, and as such, has little to no training in working with personality disorders, so may have already missed important signs of Larry’s growing dependence, and may not be equipped to handle his potential reaction therapeutically. One could wonder if the agency made an ethically sound decision in placing Larry with Janet initially. This puts Janet in an unsafe position. She has already stated her fear, so to ignore this would be to leave the agency open to legal action should she get hurt. Janet is fearful so perhaps does not confront the issue and Larry is allowed to continue his behavior without any learning or constructive consequences, which defeats the purpose of his treatment. Janet may not feel safe going to AA meetings, which could compromise her own sobriety.
2) Supervisor meets with Larry and terminates Janet’s work with him, referring him to a new clinician within the same agency, after explaining to him why this is being done.
a. Pros: Larry is helped to understand why his actions are making Janet feel unsafe, and hopefully help him learn what appropriate boundaries are. Removes Janet from the situation. Perhaps keeps agency from any legal issues that could have arisen from leaving Janet to handle it on her own.
b. Cons: Larry will likely feel abandoned, and this could be compounded by Janet not being part of the interaction in which he learns that he is being moved to a new clinician. He shared his fears with her honestly, and he may see her as neither honest nor loyal. Despite her personal experience with the situation, she has an ethical obligation to treat him with dignity, honor and respect, which I do not feel she would be doing if she did not participate in the difficult conversation with Larry. He is at risk for relapse.
3) Supervisor and Janet determine they will meet with Larry together, respectfully share with him how his behavior is making Janet feel, and give him the choice of staying with a new clinician at the same agency or being referred to a clinician in another setting.
a. Pros: Larry’s autonomy would be respected. This could be a therapeutic intervention in which Larry receives respectful feedback about how his actions have negatively impacted Janet, and also receives feedback and suggestions for healthier ways to have a therapeutic relationship. Both the supervisor and Janet would be supporting one another, in the event Larry becomes angry or attempts to discredit the interaction at a later date. One would hope that agency policy exists to support this decision, and is in line with making sure Larry’s client rights are respected, and that his needs are a primary consideration.
b. Cons: Larry may feel abandoned and refuse to participate in a discussion about how to help himself or find solutions. He may relapse. He may decide that treatment providers are disrespectful of him, and refuse further treatment.
4) File PFA.
a. Pros: Janet would perhaps feel safe, and might feel supported by her supervisor and agency.
b. Cons: Because this appears to be a first time problem, involving the law in any way would be an overreaction, showing poor judgement and harming Larry. He has done nothing legally wrong. Larry’s rights include being allowed to participate in the decisions being made about his treatment, and filing a PFA would ignore this. While Janet may feel supported, Larry’s needs would have been completely ignored, and he would likely be further harmed by this decision.
Question 5
Who will you, as a supervisor, consult regarding this clinical scenario and why? As a supervisor, I would be consulting my clinical supervisor as well. I would do this both to double check my own lines of reasoning and decision making, and to make certain I am in line with agency policy and the decision making process of my boss. I would be asking my boss if she felt there should be legal consult before taking action.
Question 6
What is the best possible course of action to take in this clinical situation? In this situation, non-malfeasance and self-interest are not mutually exclusive, although at first glance, they may appear to be. I believe that there first needs to be constructive conversation with Janet to ascertain whether or not there were things communicated between Larry and her that may have given him an impression she was interested in some additional relationship outside of work, as well as exploration of warning signs she may have missed. Once this is done, Janet and her supervisor need to come up with how Janet will communicate her discomfort in a therapeutic and respectful way, as well as create a list of options to provide Larry. Since Janet has already stated she feels unsafe, it seems the safest and most ethical approach would then be to meet with Larry together, but let Janet take the lead in expressing her discomfort, offering options and providing Larry with insight into how his behavior has affected her. This can be turned into a learning process for Larry, if he is shown that he is not being abandoned by the agency, but that he can learn from this and make better choices in the future, and Janet can take care of herself and her safety concurrently.
Question 7
How will you implement the decision, document the decision making process, and monitor and evaluate the effects of the decision? Implementation is as stated above. All clinician contacts with client should already be documented and included as part of the ongoing process of determining next actions. I would ask Janet to document the experiences that have made her uncomfortable. I would document all conversations I have with Janet, as well as those with my supervisor and any other sources I am advised to consult (i.e., legal, other agency resources). If there is agency policy related to this situation, I would document that I consulted that as well. Finally, I would document the process in the meeting with all three parties, and the outcomes of that meeting. Any follow-up, such as the referral process that Larry chooses, would be documented as well. Ongoing supervision of Janet to process what happened, what she has learned and how she will use this knowledge moving forward to become a more informed and effective clinician will continue to be noted as well.My name is Beth Andrews. I’m a licensed clinical social worker and a licensed alcohol and drug counselor in private practice in Yarmouth. I work with both adolescents and adults, often with co-occurring disorders. I would be very interested in conversation about working with adolescents, as there often are ethical issues that arise.
