[Esther Cyr]

Week 5 Homework:
1. (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?
I would start with defining informed consent/boundary and role expectations/boundary crossing/boundary violation. Give examples of each. Give an example of a boundary violation per State Board and rational. Introduce guidelines to increase awareness of what might be a boundary crossing.
(B) Which of the supervisor roles (consultant, advisor, guide, mentor, professional colleague, and educator) fits with your values and supervisory style? Guide, educator, professional colleague
Which of these stances would you take in the conversation with the team and why? 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. As a professional colleague seek skills of each clinician participating, listen to the discussion, and work as a team in applying ethical principles to an issue. Respect of each individual and create an environment of thoughtful exploration with an end result of learning new ways to practice ethically.
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?
1. The 5 levels of informed consent (Flavy) Especially #4 that the clinician is under the supervision of named individual. In supervision clients are deidenfied, however, while clients may be informed of consulting on a matter, the name of the consultant may not be idenfied. I am looking at adding the name of the consultant on the consent for treatment form. Giving the client opportunity to question what that might mean in the therapeutic relationship.
2. 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. Reinforcing the need to bring to supervision any issue that a supervisee has doubt about regardless of how simple or unimportant it might seem. The unimportant or small can be wonderful learning opportunities and are a very important part of professional growth and risk management.

[Esther Cyr]

1. Without using any identifying information, briefly describe a few client characteristics.
History of depression, anxiety, multiple deceased family members within family of origin, liver disease, dementia, hopelessness, suicidal ideation.
2. Without disclosing personal information you are not comfortable share, briefly describe your countertransference reactions to this particular client.
I feel frustration over the client avoiding in therapy sessions, the constant derailing to avoid addressing her emotional pain. Client only attends 1 session a month, if scheduled more frequently she says it is too much and will cancel. The passive suicidal ideations scare me and that is at a baseline; the fear comes from questioning whether the client is under reporting. I see borderline characteristics and a sense she could go beyond the ideation to who the family the emotional pain she is experiencing. I dread appointments with this client as I know ahead it will take half the session to get to a point of working on an issue, then time runs out to cover what needs to be covered and I may not see this person for another month.
3. Briefly describe how your reactions facilitate or inhibit your empathy for the client.
My fear facilitates careful review of the reported suicidal ideation without a plan. The multiple loss of family of origin members is part of the hopelessness and I can empathize that she misses them and has no one outside of therapy who listens after years of mourning. The dread of the appointment results in mentally preparing for the pace, content, outcome of the session and reality that client is in the maintenance phase and my wanting the client to achieve more may not be reasonable or even the clients expectation.
4. Briefly describe the extent to which your countertransference reaction my be intensified by your own history.
I have experienced significant loss in my life. The client’s emotional pain reminds me of my own at various times of my life. Looking back I did not want to resolve my losses, but express them. My empathy and ability t stay present with this client and allow her process to be what the client needs and now what I would want for her. My history tells me it is o.k. to process and grieve in one’s own way and at one’s own pace.
5. Devise a strategy for the countertransference issue.
a. My understanding of the response has allowed me to see her need and support her growth in therapy based upon how she responds. I ask the client at the end of each session if therapy made a difference as was it helpful or not. The response she gives becomes my guide on proceeding with treatment.
b. I have disclosed to the client questioning whether therapy was helping and whether this was the right approach. The outcome was helpful and she contributed on what is helpful for her in therapy sessions.
c. Part of the disclosure was helpful, however, not all of the countertransference would be helpful and could possibly harmful. what is important is to address with client countertransference that would increase understanding in and build on the therapeutic relationship.
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?
If I experience problems with sleep, irritability, intense fear, noticing difficulty with working with client on the treatment plan, feeling stuck, physical symptoms such as sore muscles, headache, tightness in chest, starting to lose hope for the client’s treatment outcome.
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 (or other client with similar presentations)?
I would say to self, I have dealt with this countertransference in supervision. I am feeling more fear than is natural to have within a therapeutic relationship, when client feels hopeless I am starting to have feelings of helpless in helping the client, however, this may be linked to feeling helpless in areas of my life. The therapeutic relationship is starting to be impacted with my response it is time to seek counseling to address some of these responses and increase my self awareness of what is causing these and gain insight into strengths, limitations, and areas that need healing.

[Esther Cyr]

1. Who are the parties that will be impacted by whatever course of action is chosen?
Steve, John, Clients, Other clinicians at the agency

2. What are the ethical issues involved in this scenario, including conflicting and competing values of the parties involved?
Dual Relationship/Impairment of colleague/Ethical responsibility to client.

3. and 4. What are the viable courses of action and the possible benefits and risks of each?
a. Dual relationship role with Steve and John. Steve speak of John about the current issues as connected to the dual relationship role and how this has impacted current situation. Benefits: address blurred boundaries and create a corrective plan. Risks: John does not link current issues to the dual relationship roles and issues cannot be resolved between colleagues.
b. Impairment of clinician at work. Benefits: Steve could discuss John’s caseload at work, reason he assigned the co-occurring clients to him. Discuss how the number assigned to him has impacted his practice and ability to function ethically. Addressing what has prevented John from discussing issues within supervision. Develop a plan of action to address impaired behaviors. Risks: John is not responsive to address his behaviors, concerns, ethical dilemma’s with Steve. Issue/impairment plan is not developed which means Steve would have to take other steps such as reporting to the Social Work State Board. Steve would follow agency policies on reprimanding the clinician. Clients may have to be reassigned if John is unable to meet his clinical responsibilities.
5. Who should the clinical supervisor (Steve), consult regarding this scenario and why?
Steve would consult with a clinical Director or CEO of the agency he works for regarding ethical dilemma’s. Steve would have to address the clinician’s impairment and impact on clients and office staff.
6. What is the best possible course of action for a clinical supervisor (Steve) to take in this situation?
Steve would address the dual relationship role, how it has impacted the current situation, and seek to address John’s behaviors to reestablish an ethical working relationship with John. This would include the possibility that because of Steve and John’s personal relationship, it may not be possible at this point for Steve to supervise John.
7. How should the clinical supervisor (Steve) implement the decision, document the decision making process, and monitor and evaluate the effects of the decision.
Steve should implement his decision based on his consultation with a supervisor, direct supervision with John and the plan of action he has written. Documentation would have dates for each plan of action with follow-up plan to review progress. All of this should be in John’s employee record and part of his employee file. A human resource worker might be part of this implementation and follow-up depending on agency policy.

[Esther Cyr]

1. Who are the parties that will be impacted by whatever course of action is chosen?
a. Client/clinician/supervisor/agency
2. What are the ethical issues involved in this clinical scenario, including conflicting and competing values of the parties involved?
a. Dual Relationship
b. Abandonment of client
c. Client dependency
d. Clinician’s competence
e. Clinical consultation to guide decision making
3. What are all the viable courses of action and what are the benefits and risks of each?
a. Address behaviors directly with client/review boundaries and set firmly with client/address gift giving policy/in consultation address countertransference/seek continued consultation to address possible abandonment of client and personal safety within the therapeutic relationship.
4.
A. Dual Relationships/: Pro: build therapeutic relationship with client/set firm boundaries in the therapeutic relationship to include following agency policy on gift giving and spending time with clients outside of the therapy sessions/address keeping clients confidentiality when at public meetings (AA). Cons: Addressing boundaries in a negative or aggressive voice or manner/being disrespectful to the client when addressing sensitive matter such as gift giving or following clinical outside the office/not remembering it is the clinician’s responsibility to maintain boundaries and confidentiality.
B. Clinician’s competence and use of Consultation/ Countertransference: Pro’s: clinicians awareness of issues that create the countertransference/addressing countertransference in consultation/addressing fear of personal safety/seeking consultation on whether there is enough evidence of stalking behavior to require legal action or a transfer to another clinician due to countertransference issues/addressing clinicians AA meetings and how to manage own recovery in current situation. Cons: clinician may not be aware of how countertransference is connected to fears/ may not be able to make a clear, informed decision about how to proceed with the case/clinician may receive guidance in consultation and not have the emotional strength to follow through or inform the consultant due to various reasons/possible liability if a decision is made to transfer or close the case without proper rational for decision and/or appropriate documentation. Referring to code of ethics and agency policy where appropriate to support decision making.
5. Who will you, as a supervisor, consult regarding this clinical scenario and why?
I would first consult with my own clinical consultant to review the primary issues such as clinician’s countertransference/clinicians ability to manage boundary setting with this client due to not feeling safe/ abandonment issues for the client. Discuss if there is a legal and safety component that needs to be acted upon. Second, I would consult with the CEO of my agency regarding agency policy and identified issues that are a dilemma with possible legal issues and clinician’s safety. Possibly contact NASW’s Legal Assistance with questions of all precautions not to abandon the client and keep the clinician safe while complying with agency and code of ethics.

6. What is the best possible course of action to take in this clinical situation? Addressing boundary setting, preventing abandonment of client, and properly addressing clinician safety.
7. How will you implement the decision, document the decision making process, and monitor and evaluate the effects of decision? Clinical consultation notes will be detailed and complete on each meeting with the clinician to include identified issues, decision making process with pro’s and con’s and what action was taken and outcomes. Follow-up in consultation on case until all concerns are resolved. Keep my consultant and CEO updated on case throughout the decision making and action process. When case is resolved consult on resolution and if there were actions that might have been taken that would have made a positive difference in the case. Use this case as a learning tool to address future ethical dilemmas and as appropriate update agency policy as a result of this outcome.

[Esther Cyr]

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? 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.

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?
1. When supervising staff I follow-up at the next supervision on any recommendations or actions taken as a result of the previous supervision. 2. I consult with a consultant when in doubt about recommendations regarding a case. 3. I keep staff informed of new information and give them an opportunity to ask questions.

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? 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. Staff are included in the problem solving process and educated on presenting issue. The agency seeks to educate staff, there are regular and annual trainings to support staff development.

[Esther Cyr]

My name is Esther Cyr. I am an LCSW and Clinical Director for a co-occurring social service agency. I supervise case management Section 17, 92, and 13. Any information on clinical supervision for case managers that include confidentiality, dual relationships, working with guardians, and developing plans for back to work to name a few. I also provide outpatient mental health therapy to clients. I look forward to this course to enhance my clinical supervision skills.

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