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Exercise 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 meeting?
I would incorporate it as a clinical vignette type of training within the meeting to highlight the difference of boundary crossing as sharing the clinician’s response in the here-and-now to the client’s material. The response of the clinician could be experiencing an emotion, physical sensation or thought and sharing that in the service of the client to see if it increases resonance or awareness is a therapeutic intervention. As a Gestalt trained clinician, I am familiar with this exercise and believe it has great therapeutic value. I am also familiar with how to downgrade such an experiment if it’s too much for the client and would share that as well. I would then share more examples of boundary violations which would be unwanted by the client, not in service of the client, potentially damaging or exploitative and focus on the intent of the clinician. I would encourage group discussion, role play and case examples to help the treatment team better understand the difference. I would keep this as a learning and open environment so the team would feel safe to bring up questions or seek consultation about this in the future.
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?
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. There are times when I also shift into an advisor role, particularly when supervising conditionally licensed therapists who may need specific direction around clinical and administrative issues, or requirements of the Board.
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?
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. The chapter on countertransference/transference was especially helpful and I will continue to address this, as well as boundary violation/crossings. Reviewing codes of ethics is an important reminder as part of regular practice. I would use some of the questions we were presented with in homework as potential discussion points or queries for my supervisees as learning opportunities as well.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.
Client was a mom, highly intelligent, in unhappy marriage, pregnant with second baby, both professionals from parents who were doctors. She was depressed, in conflict with mother-in-law, friends, cried most of the entire sessions, didn’t seem to want to make any changes personally, only expected others around her to change.
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 dreaded every session with her, hoped she’d cancel, felt bored, watched the clock every 5 minutes.
Question 3
Briefly describe how your reactions facilitate or inhibit your empathy for the client.
It was hard for me to have empathy when she seemed to want help but rejected every intervention. I tried to not show my frustration or boredom, and even at times tried to use that as a way to connect more deeply with her. I tried to remember her pain and desperation and stay with that to support her.
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).
This always intrigued me as we had some family cultural similarities of cultural background and I personally have experienced depression but didn’t think to her extent. I also have a physician father as she and raised with high expectations, so I think that played a role. It was odd that we shared the same birthdate (not year) and I felt so disconnected from her. I also shared a cultural name with her sister (which I did not reveal). There were these oddities that just added to my frustration that I should feel more connected to her and be able to help her more. Also, I didn’t feel that I shared her tendency to push others away and be in conflict with them, and so that was confusing, plus I experienced her doing that with me.
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 tried to look at my response in order to quiet the countertransference and stay more connected with her pain. I tried using more motivational interviewing, both the skills and spirit of MI. Occasionally I used disclosure of frustration and not sure how to help as it seemed she wanted it but didn’t, to try to better understand and move into her pain. I also didn’t disclose often because I felt it mostly would not be helpful and would recreate her cycle of conflict with others, and didn’t sense that she was emotionally resourced enough to address this process therapeutically. I also used the strategy of exploring issues like career around which she could engage in a different way sometimes with more engagement.
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?
If I was not able to remain somewhat empathic or if my reactions got in the way of doing therapy and not being able to hold her in positive regard, then I would seek more supervision. I’m not sure that I needed therapy per se to work with her. I did not seek therapy, however perhaps because of some of the weird connections I felt that frustrated me, it would have been enlightening.
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 my countertransference reactions as a therapist were getting in the way of therapy, of continuing to serve the client well with the highest level of empathy and support and use of skills—if I felt I was giving up and just sitting there, so to speak, and not engaged, then I would recommend therapy of the therapist. If it was also bleeding over into my work with other clients, or subsequent sessions during the day, or holding boundaries or taking it home, that would be another reason to recommend therapy. Also, if I found myself engaging in poorer self-care or unable to do so, that would be a big indicator for need of therapy.Question 1
Who are the parties that will be impacted by whatever course of action is chosen?
John, Steve, clients of John, clinicians at the agency, friends and family of John and Steve
Question 2
What are the ethical issues involved in this scenario, including conflicting and competing values of the parties involved?
Dual relationship of friendship and supervisory relationship between John and Steve
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
Agency mission to promote recovery for clients and how would that also be extended to John as a provider to be aligned with agency mission but competing with counselor requirements to not be impaired on the job
Vicarious trauma impact on John affecting his work, mental health and recovery, and whether agency has an obligation given the large high trauma caseload they assigned him
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 could talk to John about developing an action plan with disciplinary results if changes don’t occur. It might involve things like leave of absence to resume recovery and self-care and obtain treatment as needed, monitoring return and work performance, staff interaction, etc. I’d assume it really would have to involve HR. Pros are that John may get help and not lose job, cons are that he may feel singled out and exposed to his peers/colleagues at the agency, may interrupt client care. Cons are that it also may be difficult to monitor this kind of plan.
2) Steve could take more severe action and report John to licensing board, terminate him. Pros may be that he follows strict agency rules, cons are that John does not get a chance to rehabilitate, loses friendship and trust with Steve.
3) I can’t really imagine Steve not doing anything as a supervisor and friend. I know that’s simply put, but it would not serve either of them well. If Steve cares about John as a friend, he would want to see him get help for burnout, relapse, etc., and come up with a plan that may allow for John to keep his job with appropriate rehab, and ultimately John would see the position in which he place Steve and make amends about that as well.
Question 5
Who should the clinical supervisor (Steve), consult regarding this scenario and why?
Steve should seek supervision of supervision with another supervisor and also consult with someone at his agency. He could consult with his professional organization as well; for instance, the ACA will offer ethical and legal consultation.
Question 6
What is the best possible course of action for a clinical supervisor (Steve) to take in this situation?
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. Another consideration would be whether Steve should continue to supervise John going forward, given their friendship and dual relationship, and to consider whether this is in the best interest of John’s mental health/recovery/work performance. That should be a conversation between John and Steve at some point, if there is even another supervisor available. The relational repair that could happen I think would be far better than transferring to a different supervisor, but it is still a course of action potentially.
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?
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.Question 1
Who are the parties that will be impacted by whatever course of action is chosen?
Parties impacted include Janet (therapist), Larry (client), supervisor, potentially AA group members, Larry’s family (if any), employees at agency dealing with his random appearances.
Question 2
What are the ethical issues involved in this clinical scenario, including conflicting and competing values of the parties involved?
In my opinion, ethical issues include client’s breech of therapist’s boundaries with harassing/stalking behaviors of her; agency duty to provide client with mental health/substance use treatment; therapist duty not to abandon client; if relevant, potential need to alert probation officer; therapist’s disclosure of AA attendance/recovery to supervisor and/or agency employees in dealing with this issue. Primary conflicting values seem to be around boundary violation/harassment and duty for provision of services to client.
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.
One viable course of action is to terminate Larry from Janet’s caseload and transfer him to another therapist. According to the ACA Code of Ethics, ethical issues should be resolved with all parties involved, but it is unclear if involving Larry in a conjoint meeting with Janet would be safe to her and if it would exacerbate his boundary infractions. Risks are that he will feel abandoned, increase his harassing/stalking behaviors of her, possibly drop out of treatment with new provider and relapse. If Janet also files for a protection from harassment order, cons are that it could escalate Larry, may be hard to enforce, may require more police interference at an agency where other clients will be triggered; pros are that it may provide more safety to Janet and reduce her fears. Cons of not filing an order to protect Janet could trigger her recovery and put her own recovery in jeopardy.
Another course of action would be to meet with all parties, Janet, Larry and supervisor to create a plan of action going forward that would involve Larry ceasing the harassing behaviors and remaining in counseling with Janet, and only terminating or transferring if he defaults on the agreement. Risks would include that it may still put Janet on edge and keeps her at risk without legal backup. Pros are that Larry may not experience abandonment by Janet and be able to work through this issue by exploring other ways to seek emotional support without resorting to harassment/boundary violations.
In either scenario, if Janet is unable to return to her regular AA meeting due to Larry’s attendance there or fear of it, she may lose her support group and the other AA attendees may also lose their fellowship with her. Similar cons may happen for Larry as well.
Question 5
Who will you, as a supervisor, consult regarding this clinical scenario and why?
I would consult with my supervisor and/or agency director, my liability insurance provider and attorney, possibly a police mental health liaison, as they can all contribute to the ethical decision-making process and it is critical to document consultation as well.
Question 6
What is the best possible course of action to take in this clinical situation?
I believe protection of Janet, the therapist, and the agency employees with do-no-harm actions to the client: file protection from harassment, transfer client to another counselor at the agency for continuity of care, allow Janet to return to her regular AA meeting comfortably with the legal order in place. It would be important for the facilitator at the AA meeting to know the potential threat of Larry appearing on premises if Janet were there to mitigate crisis.
Question 7
How will you implement the decision, document the decision making process, and monitor and evaluate the effects of the decision?
The decision would be documented in progress notes, crisis notes, supervision logs, discharge summary, new therapist re-opening documentation. Monitoring with all agency staff involved and any legal interaction as needed.Question 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? It’s a huge amount of added responsibility but also a risk that I’m aware I’m taking on, in order to best serve my supervisee and their clients. I also feel anxiety around that, but try to keep in mind that the vicarious liability responsibility comes as an expectation with the extra experience and training needed to be a clinical supervisor and it keeps me from taking the task lightly. Understanding the importance of vicarious liability is something I can model for my supervisees to help them realize the gravity of their own liability for clients.
Question 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) I currently request a supervisees who have had issues or need greater oversight to complete more thorough paperwork in terms of a supervisee agenda prior to our meeting, so that they prepare with greater care and organization and I have access to more details about their cases.
2) I encourage master’s level interns to videotape sessions when consent is given in order to provide greater in the moment supervision and assess for issues.
3) I engage in peer supervision and supervision of supervision to help me see any blind spots, process cases and issues, and consult as needed.
Question 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? I’m in private practice but my master’s level interns are from USM so there is support from the student’s advisor and internship instructor, with whom I meet once or twice during their internship. I also attend regular trainings and engage in ongoing professional development in issues of supervision. I found my prior experience in agency work to be lacking in adequate supervisory support.My name is Sindee Gozansky, LCPC, CRC. I’m in private practice in Portland, Maine. I see individuals and couples, and have taught as an adjunct instructor at USM in the past. I have been supervising conditionally licensed clinicians and student interns for a while, and am interested in clinical supervision topics, especially supporting master’s level students. I also seek support around ethical issues which arise in couple’s work.
