[melissa cormier]

In substance abuse treatment contexts it has historically been reasonable and customary practice for clinicians to self-disclose their own status in recovery from addictions based on the idea that this self-disclosure might have a positive effect on the client and help him/her feel hopeful about the possibility of recovery. In mental health treatment contexts it has historically been reasonable and customary practice for clinicians to refrain from any disclosure of a personal nature with clients whether it be that the clinician is recovering from substance abuse or a mental health issue such as anxiety or depression.

In this exercise take the position of a clinical supervisor in a treatment program serving people with co-occurring substance abuse and mental health issues. Your treatment team is made up of mental health professionals and substance abuse counselors with different training and beliefs about self-disclosure. You have just taken this course on Supervision and Ethics and have a new understanding of the difference between boundary crossings and boundary violations and that in any discussion about preventing boundary violations with regard to clinician self-disclosure you need to be concerned about 1) reasonable and customary practice for your particular treatment context 2) intent of the clinician 3) harm (and potential of harm) to the client with co-occurring conditions when the clinician self-discloses or withholds self-disclosure.
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 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. Our treatment should focus on the clinical benefit for a disclosure and weigh it against any clinical harm that would occur from the disclosure.

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 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.
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.

Systematic method for working through ethical dilemmas’. 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. When you are supervising a multidisciplinary team, it is good to remember that not everyone on the team may act in the same way you would act in accordance with your license.

Thanks 🙂

[melissa cormier]

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.

This client is a married mother of three young children. Her husband is in the military and is an alcoholic. Her sister passed away at a young age due to alcoholism and her father is a recovering alcoholic. She struggles with anxiety and struggles with balancing parenting and working.

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.”

When she described her physical response when she hears her husband put ice in a glass, because she knows he is going to start drinking hard alcohol, I started to feel my heart race. I want to help her get out of her situation, and I jump to solving her problem and wanting to tell her what to do.

Question 3
Briefly describe how your reactions facilitate or inhibit your empathy for the client.

My empathy grows for her, however, I notice I become more maternalistic and what to “help her out of her situation.”
I have increased empathy for her because she is a mom and working and I am a working mom as well.

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).

My ex-husband struggled with alcohol. I am mindful of this when working with female clients who are in relationships where their partners are using substances. I have to remind myself that everyone journey is different and is different than mine. My job as a therapist is to be neutral and help my clients find the answers/skills they are looking for without judgment.

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? It increases my empathy towards the client. We have shared experiences in being mothers and working full time while raising children with a distant partner who is using substances. I can feel her challenges because I have walked in her shoes.

Would disclosure of the countertransference response be helpful to the client or the therapeutic relationship? How?
I would not disclose in this situation because of the risk of having the client wanting me to tell her what to do. I would share that I am a mother and working full time, however I would not share how similar our stories are. I would worry that the amount of information would harm the aspects of our clinical relationship that need to be neutral to help her come to her own conclusions without judgment or by me leading her to a conclusion.

Would disclosure of the countertransference response be harmful to the client or the therapeutic relationship? How? I think it could potentially harm the relationship. The risk of the client wanting me to “tell them what do to” is great with the stories as similar as they are.

Question 6
How would you know that your countertransference response needs to be addressed with your own counselor/psychotherapist? I would look for my own avoidance during sessions. Am I holding back or not asking specific questions. Or the opposite, am I noticing myself leading her to certain conclusions. Is my language changing to be more directive vs more curious and open? What might be some signs to look for? I would also pay attention to if I am thinking about the case at home or after work hours. Or if I am noticing more emotional dysregulation when I interact with my ex-husband.

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)?

If boundaries seem compromised, or if there appears to be greater emotional distress during supervision related to specific cases. If the clinician appears “stuck” with a specific case that has triggering elements to it. Or if the clinicians’ self-care routines appear to not be working. If a clinician is discussing feeling burned out or traumatized, then I would also explore the need for counseling.

[melissa cormier]

Question 1
Who are the parties that will be impacted by whatever course of action is chosen?
John, the agency that John and Steve work for, Steve, John’s direct clients, John and Steve’s families, other clients in the agency when John is working, other co-workers

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

Practicing counseling while intoxicated is at the heart of the conflict. There is also a need to help John get the support he needs from his supervisor. There may be possible burn out, and/or secondary/vicarious trauma going on for John based on his heavy caseload. John’s clients are also being impacted by his change in demeanor. It is unclear why the change has occurred, and the only clue is smelling alcohol on John’s breath.

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

Steve does not follow up with John and hopes that it doesn’t happen again. This is risky for John, the agency, and the clients. This would possibly preserve John and Steve’s friendship, however. This will but the agency at great risk if something happens to John at work due to his drinking or with one of his clients and it came out that Steve knew about the problem but did not address it. This would put Steve’s license at risk.

Steve follows up with John and asks to talk about how John is doing overall. They could discuss self-care strategies, and make a plan for what John needs to return to work. This strategy may preserve the friendship if Steve is able to approach John in a non-threatening and compassionate way. Based on their friendship, this may work if they have a solid relationship. A con is if John is unwilling to acknowledge what is going on for him, it puts John in a position where he may need to make a difficult decision that is in the best interest of the clients and the agency. The ethical standard of do no harm to clients I feel is the primary driver of this decision.

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.

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.

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

I would get peer consultation as Steve did in this situation. I would also consult with Legal to make sure we are acting in a way that is in accordance with the law. I would also consult the board if I felt I was stuck and unsure of where to go.

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

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. If John was unwilling to discuss this with me, I would consult with legal and I am guessing would be given guidance to move towards a disciplinary process with documentation of expectations for work for John.

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?

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. I would have frequent, regular, and documented check-ins with JOhn for a specific amount of time. If John decides to take time off, we would discuss his cases and appropriate coverage while he is out. We would also discuss messaging he is comfortable sharing with his co-workers and clients. This plan would be documented in writing.

[melissa cormier]

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

Janet and her client are the primary parties. Other parties could be any relationships Janet has with her regular AA meeting members. There is also an impact on the agency, her supervisor, and possibly other clients and clinicians that may be in the building when the client is there. Janet’s family could also be impacted.

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

The ethical issues involve Janet’s right to safety and the client’s right to treatment. Due to the clients presenting issues, and the fact that they were known before he started treatment, the supervisor has to help Janet sort out the harm to the client to end the therapeutic relationship against the harm to Janet currently and the potential harm to Janet if these behaviors that Larry is exhibiting continue and/or worsen. There is also the duty of the agency to provide services to clients struggling with complex substance use disorders and mental health disorders and the duty of the agency to protect its employees.

Questions 3 & 4
What are all the viable courses of action and what the possible benefits and risks for each?

Janet addresses her boundary concerns with support from her supervisor with Larry in session and sets clear expectations moving forward. If behaviors continue, lay out clear expectations of what will happen in regards to terminating services and pressing charges. Pro’s: Informs Larry of his behaviors and sets clear expectations moving forward. It can value the therapeutic relationship and use it as a teaching moment within the clinical relationship. Con: Potential for Larry to continue with these behaviors is high due to reported past behaviors. May put Janet in some risk. Based on strengths-based approach that allows for behaviors to be addressed in a supportive clinical environment.

Janet terminates the therapeutic relationship and discharges Larry from the practice. Pro: SAfety concerns of Janet have been validated. Con: Larry still may act in a way that is unsafe. The therapeutic relationship is harmed and Larry is at risk due to being in a vulnerable state in his recovery. The risk to the client must be taken into consideration based on code of ethics.

Larry is transferred to another therapist within the same agency or another agency that provides similar services.Pro: Janet is supported and Larry can continue in treatment. Con: behaviors are not addressed in a therapeutic manner, maybe missing a clinical opportunity for Larry.

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.

Question 5
Who will you, as a supervisor, consult regarding this clinical scenario and why? I would consult with our lawyer to verify that we are meeting our agency policies and procedures and acting in accordance with any legal standards. I would also consult with other supervisors within the agency to make sure we are finding the balance between the clients rights to services and the employee’s rights to work in a safe environment.

Question 6
What is the best possible course of action to take in this clinical situation?

I would choose the first option and have Larry and Janet meet together with the clinical supervisor to address the boundary concerns and come up with a behavior plan that must be followed for Larry to continue in treatment. I would also offer larry resources if he feels he is unable to continue in the therapeutic relationship with Janet. I would prior to the meeting notify others in the building to be aware of the timing of the conversation and have a safety plan worked out in advance of the meeting depending on Larry’s usual behavioral presentation in the office. If Larry had a history of violent outbursts, I may include the police and/or security if appropriate.

Question 7
How will you implement the decision, document the decision making process, and monitor and evaluate the effects of the decision

I would document my supervision with Janet, all communications with legal and other supervisors. I would document the visit with Larry and have in writing the behavioral plan and expectations moving forward. I would check in with Janet weekly or more frequently as needed to make sure she is feeling safe and the behaviors we outlined were being met.

I may feel differently depending on Larry’s presentation in the office during previous treatment. If he had angry outbursts for example, I would most likely take a different approach. It is a bit hard to judge with the limited information from the case presentation. There are many other factors that may change my thinking, such as Larry’s size, access to weapons, criminal history, previous domestic violence issues, age, for example.

[melissa cormier]

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?

My views on this have shifted throughout my career. 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. If there is a sticky case with one of the clinicians I am supervising, I often seek out peer consultation. I also take my time with decisions now and feel more comfortable slowing down the process of making decisions to make sure we are headed in the safest direction, weighting out different factors. I feel strongly that we have a responsibility to others in our field to offer support, challenge each other, and hold each other accountable for a high ethical and clinical standard. I now enjoy helping younger clinicians process challenging cases and also enjoy more peer consultation for my own clinical practice.

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?

Peer support is an extremely important strategy. I am fortunate to work with a very seasoned clinical team and trust their judgement. I often will seek out multiple clinicians if it is a particularly challenging case to make sure I am getting adequate feedback and support before I make a decision.

Taking my time is another strategy I use frequently. There are very few decisions that need a rapid response in the moment. 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.

I also will consult with legal is I am unsure. We have wonderful legal council that has been extremely helpful to consult when a decision feels a bit messy.

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?

Part of my clinical role at my agency, is to make sure 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 clinician training through out the year as well. I also meet twice a month with all my clinical managers as a group to discuss clinician issues and offer support to each other. Supervision is key in offering high quality clinical work. We could always do more and I look for opportunities to increase clinical conversations whenever possible.

[melissa cormier]

Hello all,My name is Missy Cormier and I am an LCSW and work as the chief clinical officer at Day One. In my role I supervise both masters level clinicians and am expanding to providing supervision to substance use counselors. Looking forward to the discussions in this class.

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