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Clinical Supervision > Chapter 5 - The Supervisor: Part 3
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Chapter 5: THE SUPERVISOR: PART 3Ethical Issues And Other Potential Problems Of A SupervisorIn many ways, you're the gatekeeper of your organization for legal and ethical issues. As supervisor, you must model proper ethical and legal practices in your supervisory relationships--the place where ethical procedures are developed and strengthened.
You're first accountable for maintaining the highest legal, ethical, and moral standards and for being a model of practice to other staff members. You need to be alert to ethical concerns and respond to them properly. Part of your job is to aid in merging solutions for daily ethical and legal issues into clinical practice. Some of the basic assumptions for combining ethical issues into clinical supervision are:
Ethical and legal issues most important to clinical supervisors include:
[QN.No.#19.Ethical and legal issues most important to clinical supervisors include:] CommunicationIf you google "communication skills" in regards to a clinical supervisor, you'll see a multitude of job listings for supervisors "with good communication skills." So, just what are communication skills?
According to most management gurus, a person who has good communicator skills has already won half the battle. Whether on the personal front or the frontlines at work, a person needs the sharpened tools of effective communication. If you listen and speak well, there is not much opportunity for misunderstanding. Keep that in mind: the basic reasons for misunderstandings are lack of ability to listen effectually or to speak ably. The dictionary definitions of communication skills include:
Taking all of this into consideration, one realizes that every opportunity to present ideas, thoughts, aims, or principles is a communication event. This includes formal situations--meetings, workshops, seminars, trade fairs, etc.--as well as informal conversations. It includes communication media (newspaper, TV, radio, etc.), and communication technologies (phones, pagers, Internet, and more). Communication professionals include camera crews, journalists, advertisers--and clinical supervisors (Definition of Communication Skills, 2011). Lack of Timely Supervisory Feedback The lack of timely supervisory feedback is the cause of many ethical complaints (Cole, 2001). What is meant by "timely" feedback? To have the most compelling impact, feedback should take place as close to the event to be discussed as possible. However, McConnell (1993) states, "It is important to know that supervisors don't always have to respond instantaneously. However, they do have to respond in a timely manner. The difference lies in the nature of the problem." He goes on to describe a situation where the supervisee is abusing equipment, which requires immediate feedback, vs. the supervisee needing to know the number of hours to be worked to qualify for a particular benefit, which does not require immediate feedback.
[QN.No.#20. True or False: The lack of timely supervisory feedback seldom causes ethical complaints.] Wilson (1980) stated that "the time and effort expended on process recording become virtually meaningless without appropriate and timely supervisory feedback" (pg. 33). As process recording is very important within the work of several different theories, this must be carefully noted. Other Communication IssuesPoor communication is one of the causes for conflict, including personality clashes, in the workplace. Skills that can facilitate good communication include (Mistry and Latoo, 2009):
[QN.No.#21.Skills that facilitate good communication include:] A key role of the supervisor is feedback, which--to be successful--must be:
In addition it needs to be:
If your supervisee is offended by feedback, check to be sure you don't have a hidden agenda and that you're not acting bully-ish. Giving feedback should be an ongoing process that boosts motivation and moral and leads to greater job satisfaction and effectiveness. If you're doing your job of feedback properly, the final report will never be a surprise to the supervisee because it will have been constant and always about his performance. CompetenceIn this day and age, supervisors are required to have a large group of skills and knowledge of procedures. The list of skills includes the ability to (Malone, 2009):
The goal is that the supervisee will become competent, too.
Counselor CompetenceIt's interesting that a search for the areas in which a counselor needs to develop competence turns up many thousands of results regarding the need for competence, but it seems that few of them actually discuss in which areas competence is needed. However, there are at least eight areas in which the supervisor will want to assess and foster competence in the supervisee:
Of all of these competencies, it has been found, however, that supervisees who become effective counselors are not necessarily those who can use any specific techniques (Wampold, 2001), but rather those who show tolerance, empathy, social intelligence, a sense of well-being and self-esteem (Eriksen and McAuliffe, 2006). Therefore, as a supervisor, you may want to focus on helping your supervisees to develop these personal characteristics. [QN.No.#22. True or False: Excelling in a specific technique is more important for becoming an effective counselor than having characteristics of social intelligence, empathy, tolerance, and sense of well-being.] A four-level or stage development theory of counselor competence has been given by Smith (2006). It's a simple, but useful tool for helping determine where a counselor is at in her development: Stage one is "The Unaware" counselor, one who has unconscious incompetence. A counselor in this stage will typically make statements such as: "Well, let me tell you of an even worse situation than yours…") "What you ought to do about this situation is ___." "When this happened to me, I ___." Stage two is "The Novice" counselor, one who has conscious incompetence. This counselor has at the very least realized how incompetent she is. A counselor in this stage will commonly make statements like: "Golly, can you tell me a little more how he/she feels?" "I don't know how I can be of help to you." "What can I do to make you feel better about your situation?" Stage three is called "The Technician," a counselor who has developed a level of competence of which he's aware--conscious competence. This level of counselor often makes statements such as: "You feel ___ because ___." "I hear anger/fear/joy in your voice. Can you tell me some more about those feelings?" "…and that makes you feel___." "What I hear you saying is ___." Stage four in this model is "The Artist," one who has reached a level of unconscious competence. Characteristic comments at this level may be: "I hear the hurt/anger/joy that you're experiencing now. Let's you and me focus on these present feelings." "Be aware of your eyes. I can see the tears in your eyes as you express this hurt." "I, too, have felt such hurt--yes, it is a painful feeling. Let's stay with that hurt feeling for a while." "The pressure to look 'OK' is great, and I sense that pressure right now, with me." Supervisor CompetenceThe Substance Abuse and Mental Health Services Administration, a section in the U.S. Department of Health and Human Services, has put out a number of publications for those working with clients who are substance abusers. Their Technical Assistance Publication (TAP) Series 21-A is for clinical supervisors in the field of substance abuse treatment. However, because it's 100% applicable and very important for any sort of clinical supervisor and because of its thoroughness, the areas of competencies for clinical supervisors are largely included here (Center for Substance Abuse Treatment, 2007).
Foundation AreasTheories, Modalities and Roles of Clinical Supervision
Counseling and supervising are two very different things, even though there are similarities. There is a unique knowledge base for clinical supervision, and a supervisor needs to know various theoretical views. A supervisor must also be aware of the variety of roles she must fill, as well as many different approaches to put them into effect. Competencies include:
Leadership Obviously an essential feature of clinical supervision, leadership has many definitions, such as (Leadership, 2011), "organizing a group of people to achieve a common goal," "ultimately about creating a way for people to contribute to making something extraordinary happen," and "the process of social influence in which the supervisor can enlist the aid and support of supervisees accomplishing a task" such as achieving organizational goals. Leaders coach, inspire, mentor and motivate. They build teams, create cohesion, provide structure, and resolve conflict. Additionally, leaders build the culture of an organization, assist growth and change for both individuals and the organization, and advocate for service delivery that is culturally sensitive and of high quality. Competencies include:
Supervisory Alliance The context of clinical supervision is the relationship between the supervisor and supervisee. To have a positive relationship, there must be a mutual understanding of goals and tasks, and a healthy professional bond between the two. An effective supervisor needs a thorough understanding of the dynamics and nature of this relationship. Competencies in this alliance include:
Critical Thinking Processes referred in critical thinking include analyzing, applying information, conceptualizing, evaluating, and synthesizing. In addition to using these processes to solve problems and make sound decisions, supervisors also must help supervisees to develop these skills. Competencies in critical thinking include:
Performance AreasCounselor Development Key to delivering high-quality client care is the constant development of staff clinical skills. This is an intricate process involving collaborating, facilitating, supporting and teaching counselor capabilities. In the context of the supervisor-supervisee relationship and within professional, legal, and ethical guidelines, supervisors need to facilitate this process. A consistent maintenance of a multicultural perspective is also a supervisor's responsibility. Supervisor competencies for counselor development include:
Professional and Ethical Standards In an environment of regulatory, statutory, and professional guidelines, supervisors must identify competencies that relate to protecting the public, staff members and clients. They also develop their own professional integrity and identity in the context of supervisory practice. In this context, competencies include: [QN.No.#23. Areas related to competencies of professional and ethical standards include:]
Performance Evaluation Evaluation of counselors is pivotal in the assurance of high-quality client care. Clinical supervisors have a professional and ethical responsibility to regularly monitor the quality of performance of supervisees, to assist in improving their clinical competence, and to evaluate their readiness to assume more autonomy in practice. This area is very closely related to Counselor Development; the competencies for each are very interactive and complementary, but still are distinct. Performance evaluation competencies include:
Transference and Counter-TransferenceTransferenceSigmund Freud noted that patients sometimes had fantasies about him and strong feelings that were not founded in reality. He invented the word "transference" to describe this process. He believed that these patients were transferring feelings from important people in their childhood to the therapist. Many folks believe that transference happens in everyday life, not just psychotherapy (Connor, 2006), although Freud designed psychoanalysis to encourage this transference (Reidbord, 2010).
In this context, it's assumed the client will assume things about what the therapist is fond of and what he dislikes, what her life out in the world is like, what her attitude is toward the client, and so on. These assumptions are derived from the client's experiences with and assumptions about other major relationships, such as relations with the client's parents as a child. Another way to describe transference is as taking your past psychological and emotional needs and placing them in the present--reacting to a person (client to therapist, supervisee to supervisor, and vice versa in both of these relationships) in terms of your fears, what you need to see, or what you see when you know almost nothing about that person. This occurs without you understanding why you react and feel the way you do. Causes of transference reactions are unmet emotional needs, neglect, and abuses that occurred when one was a child. The therapist may encourage transference through deliberate opacity and non-disclosure. This is to try to re-create dynamics of the client's formative years in a way that both the therapist and client may observe them. The goal is that clients will discover that they have assumptions about others and themselves that are not based on fact or are obsolete and are not helpful to them. This is an insight that can lead to long-lasting psychological change. [QN.No.#24. An insight regarding transference that can lead to long-lasting psychological change has the following characteristics:] Once a transference pattern is discovered, the client has a choice to respond in terms of what is truly going on instead of what happened years ago. If the client can't recognize the difference between the present and the past, it's likely that she will continue to repeat the same screwed up relationships over and over or have the same problem over and over. Sometimes transference is referred to as a "projection." This focuses on the person projecting his own motivations, emotions or feelings onto another person, not being aware that the response is more about him than about the other person. The therapist may remind the client of things his father did when he was growing up. This can cause the client to "fall in love" or "fall in hate" with the therapist. These very intense forms of transference can also occur when clients assume someone is a terrible person simply because that person's hairdo or favorite TV program reminds them of a mother that sexually abused them or an emotionally abusive father. That sort of transference is negative. At the other extreme, a warm, kind and supportive therapist may remind clients of what is absent in their life that they're wanting. This might then cause the client to idealize the therapist and put her on a pedestal that is totally beyond reason. They may then become excessively attached to the therapist. These intense forms of transference can become full-blown obsessions if not dealt with. These "meltdowns" can end in nightmares, dangerous choices, fantasies, accidents, stalking someone, and even violence. Signs to make one suspicious that a transference reaction is happening:
Counter-TransferenceSeveral times in the discussion of transference, the words "vice versa" have been used, indicating that the transference is not necessarily always client towards therapist or supervisee towards supervisor; it may also go the other direction. In these cases, it's called "counter-transference." The therapist or supervisor is reacting, or counter-reacting, to the client's transference. This is the reason a therapist may feel like they're falling in love with a client, or a supervisor with a supervisee.
Originally, counter-transferences were considered to always be hindrances to therapy. However, since the 1950s, they have been considered as potentially important information for the therapist to employ to aid the client (Reidbord, 2010). They can act as discriminating interpersonal indicators--finely adjusted instruments in the realm of social interactions. For instance, if a therapist is irritated by a client for no apparent reason, she may ultimately discover unconscious, difficult to perceive provocations by the supervisee that aggravate and repulse others, thus keeping the client isolated and lonely. [QN.No.#25. Counter-transference can be an issue if:] Counter-transference reactions that are based on the therapists reactions to immaterial attributes of the client (such as physical resemblances to a relative), experience with a prior client, or by circumstances unrelated to therapy (such as an argument at home, a traffic jam in coming to work, an anticipated vacation) are not useful for helping the client. They may, however, indicate that the therapist should also pursue therapy. Unrecognized or unexamined counter-transference is not only not helpful, it can be detrimental to treatment. It can happen even if the counter-transference is positive, such as enjoying the client's humor to the point that underlying bitterness or anger is either ignored or not recognized. However, counter-transference is more often a problem if it's negative. The therapist may be irked, contemptuous, bored or paralyzed when seeing a particular client. The therapist must identify these feelings and handle them. Once in a while, if the counter-transference is not manageable, the therapist may need to refer the client to a colleague. However, most of the time the therapist can recognize and understand these feelings and constructively use them in the treatment. In the above discussion, you could also substitute the word "supervisor" for "therapist," and "supervisee" for "client." Another approach to counter-transference is broader and less Freudian in its approach. It includes anything in a therapeutic alliance that distorts or hides the reality of it. This is often called a "parallel process," still based on the therapist having issues similar to those of the client, and trying to take care of her own unresolved problems (pain, anxiety, etc.) by "fixing" the client. This ignores the client's needs. Masterson (1989) stated that often clients like this approach because they don't need to do any of the work. Instead, the therapist transfers their own hurting self to the client and therefore treats the client in the way they want others to treat them. Freud called this "acting out"--what is forgotten is reborn through enactment. Even though parts of the personality may be dissociated or repressed, the feelings are close to consciousness; the consequences are both feeling and fighting anxiety. The anxiety and associated defensiveness then become apparent in therapy (or supervision). The therapist/supervisee may be attempting to express something that is happening with the client, but the supervisee may be unable to consciously describe it in supervision because of his own anxiety. Gediman and Wolkenfeld (1980) stated that the core of resistance to learning is the need to expose oneself in order to learn. Supervisees (and supervisors) often have a narcissistic need to retain his image, which causes them to both want and resist learning. For you, as the supervisor, it's important to be aware of possible counter-transference or parallel process, and be sure it's not your own. A way to do this is to ask yourself some questions, and perhaps look at a checklist. Important questions you must ask yourself any time you become aware of possible counter-transference are (Reidbord, 2010):
[QN.No.#26. Questions the supervisor or therapist must ask herself if she becomes aware of possible counter-transference include:] The comparable checklist approach is to check off which of the following are accurate statements you as a supervisor could make (Cole, 2001). As the supervisor,
Sexual Issues between You and Your SuperviseeUpfront, any sexual relationships between supervisors and supervisees are unethical. That, however, does not mean that sexual transference and counter-transference issues will not come up. Brodsky (1977) states that there are four potential causes of these issues:
[QN.No.#27. True or False: There are some circumstances where a sexual relationship between supervisors and supervisees is not unethical.]
Any or all of these may be going on at the same time, complicating the analysis of the problem(s) and what is happening. SeductionSeduction is more than seduction for sexual behavior. It can include instances of a client trying to "seduce" the therapist into liking her. Or it can be a way to try to gain power. Even these goals, however, are often demonstrated by acting seductively with the opposite sex or telling sexual jokes with one's own gender (White, 1992).
This can also be true of a therapist trying to "seduce" the client for those same reasons. Identical situations can take place between supervisors and supervisees. In all cases, the trick for the supervisor or therapist is to constantly not be themselves seduced by thoughts of power, but still be available for the supervisee or client. There are special problems when dealing with a suicidal client, especially one with a borderline personality disorder. If the client either seduces or idealizes the therapist, it can easily lead to violations of boundaries. If the client demonstrates demeaning or provocative behavior, the therapist could be rejecting of the behavior, or even cruel. The client might easily take this as personal rejection and actually commit suicide. Another possible scenario, is that this kind of a client might try to give the therapist the responsibility of keeping them alive (Slipp, 2000). The sooner it's realized what kind(s) of counter-transference are occurring, the more likely it is that these extreme situations may be avoided. Constant asking of the questions and looking at the check-lists that were given earlier are good steps to take in this direction. Family IssuesFrom the previous discussion, it can easily be seen that issues from the family of origin can be a common cause of transference issues. Because transference happens "all the time" and in all kinds of relationships, there are likely to be many transference issues with a family and based on the family.
Hayes, et al. (1998) examined data from 127 interviews with eight psychologists using brief family therapy; the therapy of eight clients was involved. This brought to light three realms relevant to counter-transference in family therapy--and likely in any kind of therapy. These realms were:
These give a framework for where to look for possible transference and counter-transference issues. Social Network and Other Technology IssuesSocial networks are a common part of an individual's life, and will affect his psychological issues. These can be a source of some transference and counter-transference issues. However, these issues will be much like those already discussed.
Nowadays, a different tack regarding social networks involves those that have arisen because of modern technology: social networks and social networking--Facebook, Twitter, Blogster, Flickr, LinkedIn, Skype--the list goes on and on. These groups can be the cause of many psychological problems, many of which involve transference and counter-transference, and many of which do not. The availability of technology and the Internet has had a huge impact on both attitude and practices concerning issues such as privacy, crossing boundaries, and self-disclosure--even the delivery of clinical supervision. Often associated legal, ethical, and practice standards for the use of technology lags behind the use of technology. As a supervisor, you have a responsibility to oversee the proper use of technology by your supervisees, and that you properly educate them. You'll likely also need to ensure that your agency offers enough safeguards and training in this area. As an example, here are a couple of situations that bring up multiple issues to be resolved (Gilbert and Maxwell, 2011). Scenario 1: Joanne was a Facebook friend of her supervisor, Moira. Moira hosted a wedding shower for another staff member, and there were Facebook postings from the shower. Joanne was astounded to see pictures of Moira obviously intoxicated and wearing a coconut bra, even though it was worn over her other clothing. After that, whenever Joanne met with Moira for supervision, she was unable to get that picture out of her mind. Issues:
Beverly's job is stressful, and she often uses Facebook to get emotional support from her friends about frustrations related to her job. One day, believing she had masked client identifications, Beverly entered a message about problems of patients and families and her reactions. A friend of one of Beverly's friends realized that Beverly had spoken about one of her relatives; she filed a complaint with the federal Office for Civil Rights. Beverly, her supervisor, and her agency faced a huge fine for breach of confidentiality, an unannounced survey by The Joint Commission, and possible employment termination for both Beverly and her supervisor. Issues:
Be sure you go over these issues with your supervisees. Otherwise, your job may be at risk. Contextual IssuesOther potential sources for transference and counter-transference issues are contextual issues. These issues include:
[QN.No.#28: Potential contextual sources for transference and counter-transference issues do NOT include:] The factor that receives the most attention is culture. The U.S. Department of Health and Human Services (2009) believes that more care should be given to:
Supervisor competencies in general have been discussed twice in great detail earlier in the course. Cultural competence is the capability to respect and honor the language, convictions, behaviors, and interpersonal styles of individuals and families that are being given services, as well as staff providing those services. Cultural competence is an ongoing, active developmental process demanding commitment. Belief systems are fabricated by culture, especially regarding mental health issues. Culture also forms symptoms, coping patterns, and relational styles. The supervisory process must consider three levels of culture:
There are also three important areas in supervision in which cultural and contextual factors are key:
As a supervisor, it's your responsibility to address the attitudes, beliefs, and biases of your supervisee regarding contextual and cultural variables in order to move their professional development forward and further quality client care. Becoming cultural competent and able to incorporate other contextual variables into supervision is an intricate, long-term procedure. Cross, et al. (1989) recognized six stages of a continuum of cultural proficiency:
One view that didn't find a place in Cross' stages is the "particularist." In this view, families are more different than alike; each family is entirely unique and there are no generalizations. This view allows culture to be spread to include each family's internal beliefs. The primary worry here is that environmental factors will be completely ignored and all issues seen only for an internal exclusive perspective (Cole, 2001). Another view stresses family differences only based on ethnicity, involving cultural generalizations. The result is a danger of stereotyping and over-systematizing shared meanings (Cole, 2001). The multidimensional perspective looks at the large number of factors that impact the clinical picture. This approach includes a large variety of sub groups and proceeds beyond generalizations. In fact, this view has so many facets that it can be overwhelming and confusing to supervisees (Cole, 2001). Regardless of the level of training you or your supervisees may or may not have had in multicultural counseling, it's your responsibility to aid them in building on the skills they have and be aware of where they fall short in cultural competence. If you've not already done it, you'll need to examine cultural influences on your own attitudes, experiences, practices, and values and assess what their effects are on your relations with supervisees and clients. Some questions to ask yourself during this examination are (U.S. Department of Health and Human Services, 2009):
Because of the nature of cultural differences, you and your supervisee will want to attend workshops and conferences and take continuing education classes that focus on cultural competence and other contextual factors. You should also participate in multicultural activities, such as discussion groups, community events, religious festivals and other ceremonies. In any instance, the supervisory relationship involves a basic difference in power. It's important to heed this difference, especially if the supervisor and supervisee come from different cultural backgrounds. The misuse of power is always a risk, but even more so when working together with clients and supervisees from differing cultural contexts. When the supervisee is from a minority group and the supervisor from a majority group, this difference can be exaggerated. You'll need to guard against supervision quality being a threat from institutional discrimination. This is also true if the supervisee is gay and the supervisor is heterosexual, or the supervisee has only a bachelor's degree and the supervisor has a master's degree or higher. Other alliances that need careful watching are a female supervisee and a male supervisor, a supervisee who is older than the supervisor, and so on. You'll also need to watch and discuss those supervision relationships that go the other direction. PowerPower has been mentioned as a potential cause for transference and counter-transference. Brodsky's (1977) statement included the idea that the supervisor is considered an authority, and the supervisee is often quite dependent and will generally not risk angering or challenging the supervisor.
At the risk of furthering an untruth and in order to help round out the discussion of power with transference and counter-transference, a theory of Abusive Multiple Transference (AMT) has been supposedly posited by David W. Bernstein. We could find no scholarly reference to it, but there are scores, if not hundreds of sites, including Wikipedia (Wikipedia, n.d.), that give this piece of wisdom as fact. Because it's so widespread, and because it seems plausible, it has been included here. In this assumed theory, it's stated that that abusers not only transfer negative feelings they hold towards their abusers to their own victims, but also transfer the dominance and power of the former abusers to themselves. The case of the serial killer Carroll Cole is given as an example of this kind of power transference. Cole's mother took part in several illicit sexual relationships when his father was gone during World War II. She forced Cole to watch these affairs, and later beat him to be sure that he would not tell his father. In school, classmates teases him because he "had a girl's name." Whether it was related to this or not, at age 10 he drowned a classmate of his own age. When he was 42, he was arrested for killing a woman and confessed to killing 14 or more women, apparently those he felt were "loose" and who reminded him of his mother. Carl Jung gave a more positive view of power and counter-transference. He speaks of counter-transference as being all of the feelings that the therapist has towards the client. He pictured the importance of those feelings by the image of the "wounded physician," stating that "it is his own hurt that gives the measure of his power to heal." Jung also said that "only what he [the therapist] can put right in himself can he hope to put right in the patient" (Stevens, 2011). NurturanceAs mentioned earlier, the question of nurturing is how much to nurture, in relation to promoting dependence, offering comfort, or giving a clear message that the supervisee is out of control--especially if the supervisee is tearful (Brodsky, 1977).
According to Adams (2010), under the appearance of kindness, too much nurturance can undermine the goal. Although the statements he makes are focused on clients, there is some application of them to supervisees also: [QN.No.#29. True or False: You can never give a supervisee or a client too much nurturance.]
objectivity, even though he may not have all the data Adams (2010) uses a situation of pain and a pain clinic to illustrate these points. A pain clinic was giving one client high amounts of OxyContin, advocating for his pain disability. However, the pain clinic had no clue about the client's past--addictive, criminal, economic and social. This past included a dishonorable discharge from the military, alcoholism, drug convictions, prison terms, an estimated eight divorces and other instances suggesting he had little or no impulse control and likely no ability to learn from his own experiences. Although it's appropriate to be supportive of a client, it's also necessary to understand what is truly motivating and/or controlling the client. If supervisees appear too much involved with a client, they must be directed as to whether they have a complete and accurate understanding of the client (Adams, 2010). In the mid-1960s, research was done to compare counselor experience, the degree to which they "liked" clients. They related these to the type of approach the counselors made to client hostility and dependency. It was found that only in the more inexperienced counselors was there a link between "liking" and nurturance. Counselor approach to client hostility correlated with counselor needs for nurturance and affiliation; the approach to dependence didn't correlate with either nurturance or affiliation (Mills and Abeles, 1965). This research gives you clues as to which of your supervisees might be inclined to give inappropriate nurture. EmpathyJust as with nurturance, there is healthy and unhealthy empathy. The supervisee's background and life experiences may enhance or hinder their ability to understand a client. Between you and the supervisee, there is the possibility of over-identification or assumption if, for example, you have similar life experiences such as parenthood (Brodsky, 1977).
Empathy may be defined as the natural human ability to be aware of the emotions and feelings of others and to try and help them. The word "empathy" comes from the German Einfhlung, literally "to feel inside something" (Wisp, 1986). Einfhlung is the result of a process when an observer would project himself inside the perceived object. Kohut (1984) believes that the therapist can only rely on two things to promote analytic cure: empathy and interpretation. He defines empathy as the "capacity to penetrate with thought and sentiment into the life of another person." Even the neurosciences have aided in explaining the phenomena that are at the root of empathy. Decety and Jackson (2004) use two perspectives: 1) a psychodynamic perspective (empathy as the art of communication), and 2) a humanistic perspective (empathy as an innate ability). They suggest that empathy in humans has three basic constituents:
These three constituents interweave. They should act together to produce empathy. [QN.No.#30. Three things work together to produce empathy. They are:] The relief in all of this is that these constituents are generally unconscious and occur naturally. As a supervisor, you only need to be certain that your supervisee is displaying empathy appropriately and is not over-identifying with the client. Therapeutic RelationshipsThe therapeutic relationship has several other names, also:
No matter the name, it may be defined as the relationship between a healthcare professional and a client. It's the means, or instrument, by which the professional hopes to connect with and influence change in a client (Therapeutic Relationship, n.d.). Ford (1978) evaluated the Client's Perception of the Therapeutic Relationship (CPTR), and learned that individual therapists had a considerable effect on CPTR ratings, while the client's significant others were correlated negatively with the outcome. Ford made several other conclusions:
Studying Ford's research alongside several others, Niolon (1999) concluded that, as everyone knows, the therapeutic relationship interacts with specific therapy strategies to either hinder or enhance reaching client goals. Perhaps more valuable, the relationship is at least as important to productive therapy as the techniques used. Although given in a context of nursing, the Registered Nurses’ Association of Ontario (2006) listed two areas required to establish a therapeutic relationship that are also apropos for therapists:
[QN.No.#31. Which statements are true about therapeutic relationships?] Many of the aspects of a therapeutic relationship have already been discussed, from theory to supervision approaches, from communication and competencies to transference and counter-transference issues. Two more need some attention.
Dual RelationshipsDual or multiple relationships in psychotherapy are situations where multiple roles exist between a therapist and a client. For example, there is a dual relationship when the client is also a business associate, employee, family member, friend or student of the therapist (Zur, 2011a).
In 1990, Kenneth Pope made a claim that became an authoritarian standard of therapeutic ethics: ". . . non-sexual dual relationships, while not unethical and harmful per se, foster sexual dual relationships.” The following year, Simon (1991) voiced his agreement, stating that "The boundary violation precursors of therapist-patient sex can be as psychologically damaging as the actual sexual involvement itself." It's no wonder that social workers and therapists came to believe that if we avoid any appearance of dual relationships, we also avoid all forms of harm and exploitation" (Zur, 2011b). However, Zur (2011b) argues that, "To assert that self-disclosure, a hug, a home visit, or accepting a gift is likely to lead to sex is like saying doctors’ visits cause death because most people see a doctor before they die." Dr. Arnold Lazarus (1994) labels Pope's kind of thinking as "an extreme form of syllogistic reasoning." Sequential statistical relationships cannot simply be translated to causal ones (Zur, 2011b). Zur goes on to state that this attempt to protect the public from therapists who might exploit them, is not only a simplistic solution to a complex problems, but it imposes isolation on the therapeutic sessions that could increase the likelihood of exploitation and decrease treatment effectiveness. He states that it allows incompetent therapist to express their power with neither witnesses nor accountability, and to go along with the isolation and disconnection so prevalent currently in our culture. He believes that, "If we dare to cultivate multiple, non-sexual and non- exploitive relationships with our clients when appropriate, we can be better, more effective therapists" (Zur, 2011b). Even though many still believe that there should be no dual relationships between therapist and client, this is not always practical. For example, in a small town there was one middle-aged therapist who had likely treated most of the adults at one time or another over the years. She was attempting to build a small addition to her home, pretty much on her own. However, she needed to hire someone to do some of the heavier jobs for her. The only person who seemed to be available was a young man who was currently a client. Her agency approved her hiring him to do the job. By this, one might assume along with Zur (2011b) that some dual and multiple relationships between therapist and client, as well as between supervisor and supervisee are ethical and some are not. Obviously, sexual relationships in these relationships are always unethical and often illegal (U.S. Department of Health and Human Services, 2009). However, other dual relationship issues may be more subtle and complex, as in the example given. In a dual or multiple relationship, the challenge is to avoid potential harm to or risk of exploitation of the individual in the subordinate position (Reamer, 2009). Another challenge is to maintain proper boundaries, which can blur. If the two individuals are working together on a community event, sitting on the same committee, or partaking in a work-sponsored activity can open doors for crossing boundaries. Some safeguards for managing dual or multiple relationships include (Malone, 2009): [QN.No.#32. Sometimes dual-relationship are unavoidable and ethical. Point out which relationships are NOT acceptable:]
Of course the simplest way to deal with dual or multiple relationships is to avoid them. If this is impossible, solutions can be found (Reamer, 2009) for even complex ethical issues if:
As a supervisor, it's your responsibility to see that solutions are found when dual and multiple relationships become an issue. Self-DisclosureAs with dual relationships, self-disclosure on the part of a therapist or supervisor has generally been frowned upon in the past. Again as with dual relationship, this has been changing since the end of the twentieth century.
Self-disclosure is an example of boundary crossing, but not a violation of boundaries or dual relationships. Zur (2011c) states that self-disclosure can be a therapeutic technique that is both ethical and highly effective when used skillfully and appropriately. In fact, he believes that non-disclosure by a therapist can be damaging to therapy when working with a populations that is stigmatized, such as gays and lesbians. Referring specifically to the supervisor-supervisee relationship, Brown and Bourne (1996) believe that the supervisor must attract the supervisee's interest by modeling and offering practice in engagement skills by using metacommunication, feedback, and self-disclosure. They believe that this improves both supervisor-supervisee relationships, and those of therapist-client. [QN.No.#33. Which statement(s) about self-disclosure is/are accurate?] The way a supervisor may use self-disclosure in clinical supervision differs with different supervision styles (Ladany and Lehrman-Waterman, 1999). The Supervisory Styles Inventory identified three kinds of supervisory styles (Friedlander and Ward, 1984):
They discovered that those using the Attractive Style were more likely to use self-disclosure both in general and when specifically relating neutral counseling experiences. Those who followed the Interpersonal Sensitive Style used fewer disclosures of neutral counseling experiences. Marketplace IssuesA primary marketplace issue for clinical social workers and other therapists is being paid by insurance companies, i.e., can you independently bill insurance companies and Medicare. Until 2002, only physicians were generally allowed direct payment by these companies. A mental health practitioner had to be under the supervision of a physician, who would bill the insurance company and pay the therapist. Community mental health centers would hire a physician to sign-off on therapist case notes so the agency could bill the insurance companies for the services rendered.
In 2002, Medicare listed some non-physician practitioners who could independently bill for psychiatric diagnostic evaluations and psychotherapy (Medicare Payment Advisory Commission, 2002). The same rules generally apply to federal CHAMPUS/TRICARE programs and the Indian Health Service. General rules require that the practitioner must have at least a master's degree from appropriate programs. The specific categories include: Marriage and Family Therapists: MFTs are trained in family systems and psychotherapy; they diagnose and treat emotional and mental disorder within the framework of couples' relationship, marriage, and family systems. They usually have at least a master's degree, and often a doctor's degree in marriage and family therapy, plus two or more years of supervised clinical experience. They can be licensed in 44 states, including California. In California, requirements for supervision and experience had a number of changes in regards to supervision hours after January 1, 1010 (California Board of Behavior Sciences, 2010). You will want to annually check for the most up-to-date requirements in your state. Licensed Mental Health Counselor and Licensed Professional Clinical Counselors: These licensed professionals have at least a master's degree and sometimes a doctoral degree in counseling, and have at least 3,000 hours of supervised clinical counseling. Historically these counselors have received their degrees via a university's education department and have worked in a number of settings, such as colleges and schools, community and government agencies, private practices and businesses. The Department of Health and Human Services reports that their counseling is differentiated by a preventive and developmental orientation, plus its focus on the environmental context of the individual (Medicare Payment Advisory Commission, 2002). A significant marketplace issue is the signing of insurance forms for reimbursement: The form required the signature of the professional who provided the service. A trainee provided the service. A supervisor signed the form. This constitutes fraud. It also constitutes a dilemma for the service-providing agency. A good solution, which has usually been accepted by the insurance company, is to have the trainee sign as the one providing the service, and the supervisor co-sign as "Supervisor." Licensed Clinical Social Workers: Although the Report to Congress: Medicare Coverage of Nonphysician Practitioners (Medicare Payment Advisory Commission, 2002) does not have a separate section for licensed clinical social workers as it does for the other categories just listed, there are references in it that show that an LCSW may also directly bill for Medicare payment. However, it stipulates that the LCSW must be legally authorized to make diagnosis and treat mental illness by the state in which they're licensed. California LCSW licenses do allow for this (California Board of Behavior Sciences, 2011a). Medicare Part B currently allows psychiatrists and certain nonphysician practitioners such as psychologists and social workers with the equivalent of a master’s degree in psychotherapy to bill independently for mental health services, and Medicare will make direct payment to them. Psychologists are paid at 100% of the physician fee schedule, but social workers only receive 75%. LiabilityAs a supervisor, you must be realistic about the fact that the minute you took on the responsibilities of a supervisor, you also took on a bigger risk for liability and potential ethical violations. The moment you became a supervisor, you amplified the risk that you could sit in a chair in the California Board of Behavior Sciences--or worse--answering questions.
By becoming a supervisor, you amplified the risk that you might need to defend the actions of yourself and/or your supervisee in a circuit court hearing. Because of the heightened statistical risks, you need to understand some fundamental legal principles and the impact they have on your practice of supervision (Haarman, 2011). Clinical supervision is administered within the structure of a legal, contractual relationship and under a few ethical and legal constraints (Munson, 2002). You, as supervisor, take official responsibility for the supervisee's work, and you therefore appropriate its legal liability; the agency that gave you authority to supervise also assumes that liability. You must constantly be vigilant in risk-assessment and risk management of matters relating to domestic violence, duty-to-report, duty-to-warn, perceived threats to the supervisee, and so on. In addition to civil law, most states regulate the practice of clinical social work to prevent abusive and fraudulent practice. In many jurisdictions, the clinical supervisor is legally accountable to the state licensing board (Munson, 2002). There are five general legal principles you must understand so you can direct your practice and so you can practice effective risk management (Falvey, 2001):
[QN.No.#34. Which legal principles must you understand in order to practice effective risk management?] From this you may surmise that there are many causes for alleged malpractice--from breach of confidentiality to financial improprieties to failure to exercise due care. Although many legal issues are specifically associated with the supervisory relationship, there are other areas of concern related to job-management activities, such as styles of record-keeping and the impact of HIPAA rules. Because these legal concerns are so complex, there needs to be a formal, written agreement between the supervisor, supervisee, and agency carefully defining the essential features and limits of the supervisor-supervisee relationship (Munson, 2002). Robb (2004) pointed out that a supervisor's legal liability includes more than her direct supervisees. It includes partners, paraprofessionals, unlicensed assistants, volunteers, other professional coworkers, and student interns. Managing risk is an open-ended undertaking. Standard of CareEven when clients consent to allow a trainee to treat them, they're not by that consenting to substandard care (Harrar, VandeCreek, and Knapp, 1990). The standard of care is a continually changing, to some degree loosely defined, and slowly emerging principle concerning the practice of a profession that the people in a society should be able to have confidence in.
Haarmon (2011) uses the dentist as a concrete example to define standard of care. If a person seeks dental services, he has a right expect certain practices. Those expectations are not the same as they were in the 1870s, and have developed over time. The public has a right to be given dental care that is consistent with current technology, current standards and current knowledge of dentistry. A person gets services from a licensed dentist, and several months later discovers that the dentist had a crazy idea that he was only going to sterilize his instruments every four or five months in order to conserve energy and water. If that person later develops a disease that is blood-borne, he will probably be able to hold the dentist liable, because he without a doubt violated the standard care of the dental profession. There is a standard of care for the mental health professions. A standard of care for supervision is emerging (Haarman, 2011). The center of the standard of care includes an essential feature of competency. Those who look for services from professionals, especially licensed professionals, have a right to expect that the professional is able to provide what they say they can provide. If someone is providing services without suitable credentials or under falsified credentials, she's violating the standard of care, and if damages occur, you could have a claim against them. Those seeking service expect confidentiality, which--with certain limitations--is part of the standard of care. If that confidentiality is violated by a professional and damages occur, a client may have a valid liability claim and an expectation of compensation for damages. Implications for some dual relationships are part of the standard of care. If you seek services from a mental health professional, it doesn't mean I am agreeing to subject yourself to a sales presentation about vitamins or real estate investments (Haarman, 2011). Saccuzzo (1997) found five major principles of standard of care that were found over and over again in case law, statutes, professional literature, and codes of ethics:
Standards of Care for Supervision were brought out of statutes, ethics, case law, and clinical practice by Falender and Shafranske (2004). Included were:
[QN.No.#35. Which of these are part of supervision's standards of care?] Statutory LiabilityThere are definite requirements for practicing your profession that are stated and explained in statutes or administrative rules. These are called the principle of statutory liability. If you overlook, ignore, or violate the requirements that are spelled out in the statutes, you'll probably be found civilly or criminally liable. For example, all states and U.S. territories have mandatory reporting laws for child abuse. If you fail to report such abuse, or choose not to, you would likely be blamed for wrongdoing and fined or possibly even imprisoned (Haarman, 2011).
California law demands that all supervisees keep weekly written logs of all supervised experience. The law also demands that the supervisee gets the supervisor's signature on each of those logs. Logs must include notation of the precise work setting in which the work took place, dates, the kind of interaction (e.g., face-to-face, phone, individual, group), and the professional services given or work performed. The supervisor's license may be revoked for inadequate supervision (California Board of Behavior Sciences, 2011). Violation of a statute in California only results in a rebuttable presumption of negligence. Therefore, if a violation of the licensing statute occurs in California, the burden is transferred to the supervisor to prove that, in fact, he was not negligent (Saccuzzo, n.d.). These statutes are just a few among many. You'll want to get the whole list from the website of the California Board of Behavior Sciences and familiarize yourself with them. Negligence/MalpracticeIt's important that you, as a supervisor, understand the legal concept of negligence when a professional does not observe the standard of care. As a supervisor, you can be negligent by not observing--whether intentionally or unintentionally--the applicable standard of care as it pertains to supervision.
There are appropriate assumptions about supervision, the chief of which is that supervision truly takes place. In a board complaint or a court setting, a supervisee might show documentation that the supervisor canceled supervision 25 times in 52 weeks of supervision. This is obvious evidence that the supervisor failed to meet the responsibilities and duties of supervision, and is potential negligence. This lack of timely and consistent supervision may have brought about injury to a client, or at the least may not have given enough quality control or allowed for the supervisee's development and growth (Haarman, 2011). Malpractice is professional negligence and is thus a tort--a wrong involving an infraction of a civil duty that is owed to another person. A person who has received a tortuous injury has the right to receive "damages," usually monetary compensation, from the person or people who are responsible--liable--for those injuries. If the person who is injured can prove that the one(s) who cause the injury acted without taking reasonable care to prevent hurting others--that is, negligently--tort law allows compensation. For a successful malpractice suit, there must be substantial evidence and must show "the four Ds"--Dereliction of a Duty Directly causing Damages (Behnke, et al., 1998). Four tests of malpractice were described by Bennett, et al. (1990) and expanded by Guest and Dooley (1999) in the framework of supervision:
[QN.No.#36. In the framework of supervision, which of these is/are accurate test(s) of malpractice?] Supervisory malpractice includes lawsuits filed by a supervisee or a client against a supervisor who has allegedly breached the practice standards of professional supervision. Because of the nature of the supervisory relationship, supervisors are at high risk of undergoing licensing board complaints (Harris, 2003). According to Reaves (1998), state psychology licensing boards reported that the fifth most common violation reported as improper or inadequate supervision. You need to take care that you're not part of that statistic. Direct LiabilityIf you do something resulting in damages to a person or thing, you can be held directly liable for the damages. Some common examples are causing automobile accidents because of what you're doing while you drive--texting, putting on makeup, reading a map, etc.
Direct liability for supervisors is founded on incorrect, improper, or unethical omissions or actions on the part of the supervisor. Direct liability takes place if a person takes some sort of action, or fails to act, causing some sort of damage to another person. Harrar, VandeCreek, and Knapp (1990) gave examples of supervisory direct liability that might be summarized as involving any action or lack of action that is a dereliction in carrying out the responsibility to adequately supervise a supervisee’s work. A list of supervisor behaviors that represent potential direct liability charges might include:
[QN.No.#37. Supervisor behaviors that represent potential direct liability charges might include:] Vicarious LiabilityNot only do you have direct liability for your actions as a supervisor, you may also be liable for the actions of your supervisees. Vicarious liability is founded on three concepts (Falvey, 2001):
[QN.No.#38. Vicarious liability is founded on which of the following concepts:] Even though you did nothing wrong as a supervisor, if your supervisee caused damages, you may hold some responsibility for her actions. Saccusso (1997) asserted that "supervisors can be liable not only for their own negligence in failing to supervise adequately, but also for the actions of their supervisees." Factors that could determine a supervisor's vicarious liability include:
In our society where folks are inclined to litigate, a supervisor must comply with accepted professional practices, as well as with regulations of state and licensing agencies. Risk Management StrategiesIt's obvious that you'll want to do all you can to minimize the likelihood of being sued because of your role of supervisor. There are steps you can take to accomplish this.
The first step may occur when you or your agency hires a new employee. It might be wise to require a formal application process with appropriate documentation. Make sure the supervisee is selected according to approved evaluation procedures concerning minimal standards for a trainee position. "Reasonable care" in hiring supervisees might involve asking the following questions about an applicant (Cole, 2001):
Other steps to take include:
Taking these steps may prevent you from agreeing to supervise "walking lawsuits," or "loose cannons." For your use once you have accepted a supervisee, Falvey (2001) set forth a list of the "Top 10 Risk Management Strategies for Supervision":
[QN.No.#39. Which of the following is/are NOT a part of good risk management strategies?] In a similar vein, Recupero & Rainey (2007) exposited a practical list of actions a supervisor could and should do to cut down the possibility of liability:
Therapy RecordsTherapy records involve a number of demands and constraints. Some of the demands are considering ethical standards, legal requirements, situational contexts and more. As a supervisor, one of your jobs is to aid your supervisees to keep proper records. You may also have some input into agency policies.
Some of the record keeping is required by state and/or federal laws. These will be addressed as you continue through this program. You'll need to combine your training and education, as well as a multitude of skills to recognize pertinent issues and to resolve problems that you run into. Ten Sixteen Recovery Network (n.d.) gives a good overall picture when it tells its clients that the clinical file serves as a:
[QN.No.#40. Clinical files serve as:] Because of the nature of the clinical file, also called the therapy records, it's very important to be sure they're used only for proper purposes and in proper situations. It's part of your job as supervisor to aid in this protection of the records. The American Psychological Association publishes guidelines for keeping records. Thirteen guidelines are given (American Psychological Association, 2007). Although they relate specifically to psychologists, they're applicable to any mental health practitioner and supervisor. The records are not necessarily the sole responsibility of these folks, but a collective responsibility of them and their agency. However, to bring home the importance for you, as a supervisor, to be aware of these guidelines, the original APA wording of "psychologist" has been changed to "supervisor" and some adaptations have been made to fit your role:
There are a number of ways the information and requirements regarding records could be presented. It was decided to use these 13 guidelines as the framework for the more details discussions of significant points.
Responsibility for RecordsBoth the supervisor and the supervisee are responsible both ethically and professionally to build and keep up the clinical records. To sound redundant, the records record and, in some way copy or reflect the supervisee's professional work. Often the records are the only way for you, the supervisee, and necessary others to know what the supervisee did and why. Consequently, the supervisee will want to keep high-quality records to reflect high-quality work. If any of it is called into question in the future, accurate records will make explanations and accountability easier.
[QN.No.#41. Keeping up clinical records is the responsibility of:] Some keys to good records are legibility and accuracy, made as soon as possible after therapy or another contact is completed. Logical organization that is replicated in every record is also essential. If there is ever a conflict between agency policies and procedure of the applicable code of ethics, you'll need to address the conflict in the manner delineated in the code of ethics. You must clarify the nature of the conflict, state your commitment both to the agency and the code of ethics, and--as much as possible--resolve the conflict in a way that follows the code of ethics (American Psychological Association, 2007). Content of RecordsSome states have a list of requirements for what is included in the mental health record of any child or young adult that is in foster care. California has no such requirement.
As a matter of course, the client's record is often quite full before much therapy has taken place. Under the guidelines of your agency, you'll need to make some decisions about the record content. You should consider the:
Some agencies have a mandated record format, a list of specific information to be collected and recorded, and a given time frame within which to create the records. Your supervisees will try to include only information pertinent to the purposes of the service given. They--and you--will need to be cognizant of the possible impact on the client of language used in the record (e.g., representing symptoms as a disease, using derogatory terms). Ethical and legal requirements must be met and risks considered. Information given in broad or vague terms may not be enough for continuity of care or building a satisfactory defense against malpractice, criminal, or state licensing board complaints. On the other hand, some clients may want you to keep a minimal record to give them maximum privacy and protection. As you struggle with some of these issues, there are several specifics that may offer some guidance (American Psychological Association, 2007): The Client's Request. For whatever reasons, a client may ask that only limited records of treatment be kept. Sometimes the client may even make that the deal breaker as to whether or not she will accept treatment. You and the supervisee may decide that treatment cannot be given under this circumstance and that serving such a client is not in the best interest of either the client or the supervisee. Emergency or Disaster Relief Settings. An emergency or disaster relief situation may not allow or require substantial records. A disaster relief agency may only want short identifying information, the date and quick summary of services rendered, and the name of the provider. Or opportunity to keep detailed records may be lacking, especially in an immediate or short-term crisis. In some settings, such as disaster relief following a hurricane, there is not likely to be intervention beyond what may occur on-site; the brevity and small number of services provided may not allow detailed records to be constructed even after the crisis. Alteration of Destruction of Records. Many regulations, statutes and rules of evidence forbid alteration or removal of information once a record has been made. In a litigation, adding or removing information from a record that has been subpoenaed could create liability for your supervisee and yourself. It's best that anything added later be documented as: "When reviewing the file on (date), I realized I had forgotten to mention…." Legal/Regulatory: Some regulations and statutes order that certain information must, or must NOT be included in the record. For example, a statute may forbid you referring the results of an HIV test or giving information about chemical dependency treatment. You and your supervisee will need to follow all such mandates. Agency/Setting: The agency for which you work may have policies and procedures about the level of detail permitted in the record. This will be discussed further in the section on Record Keeping in Organizational Settings. Third-Party Contracts: You'll need to think about whether the amount of detail in a record meets the agreements in contracts with the agency and third-party payers. A number of third-party payers' contracts call for specific information to be included in a record. Not meeting the terms of the contract could precipitate non-payment, required reimbursement of funds that were already received, or legal actions. Three kinds of information may be included in the record of psychological services (American Psychological Association, 2007):
[QN.No.#42. Which of the following does NOT belong in the client's record?] Medical and Psychiatric HistoryWhen discussing the presenting complaint, diagnosis, or basis for request for services the therapist will attempt to get a routine, but sound medical and psychiatric assessment. The client may or may not be willing and/or able to give this history. If not, then the therapist must try to get information from family and caregivers. It's possible that much will have already been given to the agency before the client ever appears, such as previous psychiatric assessments and treatments, and the extent the client conformed to past treatment. Review this information as soon as possible.
The therapist may not request information without the consent of the client. However, if that information is give without a request from the therapist, patient confidentiality is not violated (Routine Psychiatric Assessment, 2009). The interview should first investigate--through the use of open-ended questions--why the client has come. Then exploration for broad view of the client's personal history is pursued. The therapist will review significant past and present life events and the client's responses to them. Using both overt and covert means, a mental status exam (MSE) will be given to determine the cognitive functions of:
[QN.No.#43. The mental status exam (MSE) is to determine the client's cognitive functions, including: Also to be noted in this initial assessment are:]
Related to the psychiatric history are social history, family health history, responses to normal variations of life, developmental history, daily conduct, and the potential of the client harming himself or someone other person. The Merck Manual sums up the most basic things to explore in each of these areas:
(Routine Psychiatric Assessment, 2009) The most important psychological diagnostic tools are the history and the mental status examination (MSE). These tools have been standardized, but they're still primarily subjective measure. They begin the instant the client comes into the office. The therapist pays close attention to the client's presentation--personal appearance, interactions with the office staff and others in the area, and the patient is accompanied by someone (to help determine if the client has social support). Important information about the client can be obtained through these observations that might not be disclosed through an interview or a one-on-one conversation (Brannon and Bienenfeld, 2011). From this information the therapist will determine a working diagnosis, another permanent part of the record. Depending on agency guidelines, this will probably be based on the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders(DSM-IV). (The fifth edition is/was due in May, 2013.) As a rule, the initial diagnosis remains attached to the client, although other diagnoses may be added if necessary. It's therefore important to be thorough in determining the diagnosis, for it will not only be used as a therapeutic guideline, but also as a determination for payment. Required Client FormsThere are a few forms that are required in most mental health records. In some cases, the client only needs to be notified verbally or in writing only. Often these notifications are part of the intake paperwork. This is good, because it will not be easily overlooked. However, often the client will not carefully read what he's signing, so it's recommended that each of the following consents and acknowledgments be given both in writing and verbally. A copy of the signed, written form should be included in the record; in this way there will never be a doubt as to whether the client received the information or not.
Consents and Acknowledgements In these instances the client is either giving consent for something, such as treatment, or is acknowledging that she has received information, such as privacy rules. Informed Consent Informed consent, which must be in the client file, requires anyone who receives any service or intervention to be adequately aware of what will be happening, what the potential risks are, as well as alternative approaches so that the person can make an informed and intelligent decision to accept and participate in that service. This form is essential for protecting the supervisee and/or supervisor from legal concerns. As supervisor, you must inform the supervisee about what the process of supervision includes, including evaluation criteria and feedback, as well as other supervision expectations. You must be certain that the supervisee has informed the client regarding counseling and supervision parameters, such as live observation, and audio- or videotaping. The consent should include:
[QN.No.#44. Informed consent forms that the client signs should NOT include:] Although it often is treated as such, informed consent is not a single event. Rather, it's a process that changes over time. During the course of treatment, it's necessary for the therapist to periodically review the risks and benefits of the current approach to therapy, and those of alternative treatment methods, especially when the client's health seems to have changed considerably. These subsequent consent to treatment discussions should be documented just as the first one was (Weiner and Wettstein, 1993). [QN.No.#45. Which of the following is/are true of informed consent:] Consent to Be Treated by a Trainee Consent to be treated by a trainee is generally included as part of the Informed Consent. Supervisees should tell the client her:
When the therapist is a trainee, you--as the supervisor--have the legal responsibility for the treatment provided. As a part of the informed consent procedure(s), the client should be apprised that the therapist is in supervised training, and your name should be given as the supervisor. [QN.No.#46. One of the informed consent forms a client must sign is consent to be treated by a trainee. This form need NOT include which of the following about the supervisee:] Notice of Privacy Practices The Notice of Privacy Practices is about how the client's mental health information is used and disclosed. The client should get a written notice either with the intake paperwork or on the first visit with the therapist. The notice must tell the client how to exercise her rights under the Health Insurance Portability and Accountability Act (HIPAA). It must also explain how the client can file a complaint with the mental health care provider and, in California, with the Health and Human Services Office of Civil Rights (Privacy Rights Clearing House, 2011). Except in an emergency situation, the client should sign a copy of the "Notice of Privacy Practices" acknowledging its receipt. That signed copy should be a part of the client's record (University of California, 2003). Financial ArrangementsThere are a couple of potential ways for a client to pay for mental health services:
If the answers to those questions are satisfactory, then the client should ask the company representative: No matter which form of payment is agreed upon, the exact agreement must be in writing and signed. A signed copy of this agreement is part of the client's record. HIPAA and Limits of ConfidentialityIt has already been mentioned that a HIPPA "Notice of Privacy Practices" must be signed by the client, indicating their receipt of that notice. The notice likely will give a list of patients' rights under that law. As with any law, changes may be made over time, but in 2011 these rights included:
[QN.No.#47. Under HIPAA, a client does NOT have which of the following rights:] In certain times and locations, there has been or is a stigma against receiving treatment for mental health. The confidentiality laws are in place to protect individuals from discrimination coming from this stigma. HIPAA protects not only disclosures made during treatment, but also the fact that the individual is in mental health treatment. This can also be a protection for family members and the therapist from potential danger should a violent individual who has intimidated the client learn that the individual is receiving support and from whom she's receiving it. Confidentiality is generally counted on as a foundation of the therapist-client relationship. As a rule, therapy is most successful when the client trusts the therapist. The confidentiality laws help to preserve this trust. The therapist must never confirm or deny that an individual is or has been a client, unless there is a legal exception to the confidentiality. In addition, every detail of written and verbal communication in the course of assessment, treatment, testing, or any other communications are also protected as private information. But there are some legal exceptions to confidentiality: threat of harm to self or others, involuntary commitment, a court order, certain lawsuits, suspicion of abuse of a minor or dependent adult, and detention of a mentally disordered person for evaluation.
On the other hand, there are those who believe a subpoena has the same force as a court order (Your MFT Ethics, n.d.a). Your agency should have a guideline as to how you and the therapist should respond to a subpoena for client information. The agency will have conferred with their lawyers regarding their response. There are too many legal variables for you and your supervisees to attempt to respond on your own knowledge. Potential responses to protect client privacy include attempts to:
The one thing you should never do is ignore it. [QN.No.#49. Potential responses to a subpoena for client information never include:] Court-Order Disclosures: If the court orders a therapist to disclose client information when the client will not authorize a release, the therapist may cooperate with the court. Therapists are not expected to bear penalties for contempt of court; it's also assumed that the court has decided that society's needs in such a case override the values of confidentiality to either the client or society. Reasonable Suspicion of Abuse of Neglect: People in certain professions are legally mandated to report suspected or alleged abuse or neglect of children, elders, or dependent adults. Therapists are in that group. In this case, children are defined as people under age 18; elders are defined as people age 65 or older. The definition of dependent adults is people between 18 and 64 whose mental or physical limitations restrict their ability to care for themselves.
Contacting authorities such as a child welfare agency does not necessarily constitute reporting; the therapist may contact them to help determine if the situation fits the mandatory reporting law. The California Welfare and Institutions Code only requires therapists to disclose information they happen upon in the course of profession activity, and only when there is a present danger. It may be considered present danger if an adult client reports past sexual abuse by a person currently in a household with children--the children may be at risk of abuse. The therapist is not required to report a claim of neglect or abuse if the person reporting it has a mental illness or dementia, there is no corroborating information or evidence, and the therapist reasonably believes that the abuse didn't occur. CANRA: In California, the law that pertains to abuse and neglect of children is largely in The California Child Abuse and Neglect Reporting ACT (CANRS). The purpose of the Act is "to protect children from abuse and neglect." Included in its intention is protection of the child's welfare during investigation: "In any investigation of suspected child abuse or neglect, all persons participating in the investigation of the case shall consider the needs of the child victim and shall do whatever is necessary to prevent psychological harm to the child victim." (Source: Your MFT Ethics, n.d.a) Releases of InformationThe HIPAA laws protect the client's privacy. However, the client can overrule many of those laws by signing a release of information, a copy of which should remain in the client's record.
The laws allow for free use of client information for TPO, or "treatment, payment, or operations." The TPO uses of personal health information (PHI), as far as you and your supervisees are primarily concerned, might be summarized as free use within the agency that is providing the treatment, which includes:
[QN.No.#50. HIPAA allows free use of client information for which of the following:] Without a signed release of information, the therapist cannot even acknowledge whether or not an individual is or has been in therapy, let alone any particulars about treatment. The release of information is generally quite specific as to the time during which information may be released to which person or organization. HIPAA rules for release of information beyond the TPO state that the document must:
[QN.No.#51: HIPAA states that a release of information form must NOT:] Because, without a release of information, you can only advise a referring organization that you cannot release requested information, it's important that you or your agency be sure that the staff of referring organization are aware that this can happen. Employee assistance professionals can aid in such situations in several ways. They can help employers establish company policies and train staff regarding issues such as confidentiality in compulsory referrals. Employee assistance professionals who are also clinicians may also counsel with employers on interpersonal and mental health issues to improve management staff's ability to improve morale, interact with employees, and decrease legal liability. Client’s Current StatusThere are several aspects of what a client's current status can refer to. Those useful to the client's record might be summed up as the status of clinical outcome and quality status (Linkins, Brya, and Johnson, 2011). All of them should be reviewed periodically and a copy of that review placed in the client's file.
Clinical Outcome Status Clinical outcome began with a mental status examination in the first clinical session or two, which resulted in a treatment plan, both of which become part of the client's record. The client's current clinical outcome status should be reviewed in terms of the client's status within the treatment plan and the current mental status. Current Status within the Treatment Plan The treatment plan should be reviewed often, with a focus on the current status of the client in relation not only to the therapy plan, but to any other services and supports that the client is receiving (Prior Authorization Utilization Review, 2007). Report the progress that has been made towards any of the treatment plan goals. Mention whatever has motivated the progress or impeded it. Although all of these are likely in the therapy session notes, it's helpful to group them together in this review. If necessary, revise the treatment plan to fit the current status. Current Mental Status The Mental Status Examination is for the purpose of determining how the client is functioning mentally, emotionally and behaviorally at the moment of the exam. As has been mentioned, much of this is accomplished through the keen observation of the therapist. There is actually a wide variation between agencies in terms of data that is actually measured and the strategies and instruments used to collect the data. Some of the most commonly used mental status assessment measures, besides criteria in the DSM-IV, are the Duke Health Profile, the Global Assessment Scale (GAS) and the similar Global Assessment of Functioning Scale (GAF). Some agencies also use assessments of depression. Duke Health Profile (DUKE): The DUKE has been popular among health and mental health researchers since it came out in 1998. Its popularity continues to this day, probably because it's a simple to take and score self-report instrument that has a record quite good validity. There are only 17 items for the client to answer as "Yes, describes me exactly," "Somewhat describes me," or "No, doesn't describe me at all." Of the questions, seven are general attitude questions, two refer to how the client believes he can do two physical tasks, and the rest refer to how the client functioned during the past week. The assessment covers six health measures (physical health, mental health, social health, general health, and perceived health), a "stand-alone" self-esteem score, and four dysfunction measures (depression, anxiety/depression, pain, and disability). The assessment and scoring forms are freely available online (Duke University Medical Center, 2005). Global Assessment of Functioning Scale (GAF): The GAF is a revision of the Global Assessment Scale (GAS), a procedure for measuring the overall functioning capability of the client during a specified period of time. Both scales are a single-item rating scale to be filled out by the clinician. There is also a children's form of the GAF. The GAF is used by the DSM in its "multiaxial" assessment system. The system has five axes for assessment (I: Symptoms that need treatment; II: Personality and developmental disorders; III: Medical or neurological conditions that may influence a psychiatric problem; IV: Recent psychosocial stressors; V: Client's level of function). The GAF is the Axis V component (Mezzich, J. E., 2002). The GAF reflects the therapist's judgment of the client's ability to function in daily life. It looks at psychological, social, occupational functioning. The scale ranges from 1 (theoretically very ill and unable to function at all in daily life) to 100 (theoretically very healthy and totally able to function in every area of daily life). The client's 5-axes diagnosis might read as: Axis I: Adjustment Disorder with Depressed Mood, Alcohol Abuse, Cannabis Abuse Axis II: No Axis II diagnosis Axis III: Hyperthyroidism Axis IV: Divorce on (date) Axis V: GAF = 56 (on admission), GAF = 65 (on discharge) [QN.No.#52. The DSM has a 5-axes assessment system that includes:] Quality Status Quality refers more to the treatment than to the client. Every agency is pressed for quality improvement in their services by government agencies, payment sources, and clients themselves. New assessment tools frequently appear. The Center for Quality Assessment and Improvement in Mental Health (CQAIMH) has an online "finder" of mental health treatment quality assessment measures (CQAIMH, n.d.). If you find one that fits the kind of treatment you're offering a client, you can include a periodic update as to the continuing improvement of the treatment quality you're giving. Treatment Plans and GoalsA mental health treatment plan is a written document that outlines the expectations for therapy. Depending on requirements of payment providers and the agency, the therapist's preferences and the severity of the presenting problem, the plan may be quite formalized or may simply be composed of loose handwritten notes. If an electronic record system is used by the agency, this may dictate the treatment plan format.
Nowadays, formalized treatment plans are required more frequently than in the past. However, no matter how lose or how formalized the treatment plan is, it's always subject to change during the progression of therapy. The plan is based on needs identified during the initial assessment and diagnostic process. The process used to choose the level of care needed should be documented. Depending on the problem(s), treatment plans may include family information (Council of Juvenile Correctional Administrators, 2007). A formal treatment plan generally consists of four or five parts--objectives and goals sometimes being combined:
[QN.No.#53. A formal treatment plan includes:] Often achieved via informally discussion the situation, the client should always be included in developing the treatment plan and this should be recorded in the record. Some therapists give the client a written copy of the treatment plan; others believe this can cause an unnatural feeling to the therapeutic relationship. However, a copy of the plan should always be given to a client who requests it (Fritscher, 2011). In addition to the treatment plan itself, often kept in the record is a full deblockedive summary that combines biopsychosocial information and a summary of key clinical issues; it functions as a connection between the treatment plan and the assessment. The narrative summary pinpoints diagnostic signs for any existing mental health problems, and includes both the reasons for the assessed level of care and any substitution for that level of care (Utah Division of Substance Abuse and Mental Health, 2009). Progress In many ways, psychotherapy is to a certain degree an unstructured process. This causes many clients who are experiencing guided self-discovery and behavioral change to ask themselves if therapy is helping. Repeated taking of a self-report questionnaire to track progress gives both client and therapists a chance to see what is improving from the client's perspective--the most important perspective. Self-report data given via a formal assessment has often been used to:
An example of such a self-report assessment is the Patient Health Questionnaire (PHQ-9), an assessment for depression that is available online (PHQ-9, (1999). Like other most successful assessments of this sort, it's short (ten questions) with easy-to-answer questions (check the level that best suits: Not at all, Several days, More than half the days, Nearly every day). The validity of the test over time is also good. These sorts of assessments, grouped under "behavior health outcome management" (BOHM), can be used every session to track progress. With real-time scoring and report generation (which can be done in a very few moments) both clinicians and clients receive excellent evaluation about the course of treatment and whether or not adjustments to the treatment plan should be made (Lambert, 2005). Although it has not always been the case, some of the newer, more advanced assessments can reliably document improvement on a single domain more than 50% of the time and, with a multi-dimensional analysis, more than 90% of the time (Kraus, Seligman, and Jordan, 2005). With payers and purchasers alike looking for documentation of client improvement, you may want to research and evaluate applicable assessments. According to the Core Battery Conference (CBC), a core assessment battery should address three distinct areas:
Kraus, Seligman, and Jordan (2005) identified only one battery that met all of the criteria defined by CBC with a short questionnaire, the Treatment Outcome Package (TOP Toolkit). The free package includes assessments for children, adolescents, adults, and substance abuse, as well as a couple of assessments of client satisfaction and a wealth of other information (Behavioral Health Laboratories, 2011). As clients proceed through therapy, progress and treatment plans are reviewed and assessed, and needed changes in the treatment plan are made to reflect the progress or lack thereof. In addition to the continual assessment of progress, the process includes:
Treatment often ends when a frustrated client leaves prematurely. Following the procedures outlined above will hopefully reduce the number of times that happens. Problems in Not Meeting Treatment Goals Assessments aside, there will be clients who just can't seem to meet treatment goals. This seems especially true in cases involving substance abuse. The treatment plan should include reports of lack of response to treatment or meeting therapy goals, or if the client is disruptive in treatment. As you would expect, the treatment plan needs to be appropriately revised (Office of Alcoholism and Substance Abuse Services, 2010). Significant Actions Taken and Outcome The main point in again mentioning "significant actions taken and outcome" is to emphasize their importance in the psychotherapy notes. Sometimes it's helpful to gather them from the individual session notes and group them into a narrative. This can add perspective that will give good guidance as to where you should go next. Documentation for All Issues with Legal ConsequencesWhenever you document a therapy session or other communication with or about a client, always keep in mind the possibility that this documentation could very well sink or save you in an instance of litigation. Some tips to follow in making this documentation the most helpful it can be may sound mundane and unrelated, but with thought you'll likely see the sense of it.
Competent documentation (Lifson and Simon, 1998) should be unambiguous and cognizant of grammar essentials--a misplaced modifier is not your friend: "The client is a 21-year-old admitted on 7-5-11 to ___ with a history of psychotic behavior, evaluated at the ___ Center and seen by a social worker there with a chemically induced psychosis." If you didn't make progress notes, but instead kept "process" notes to remind you of your own associations and counter-transference reactions, as well as your theories about treatment, these may not be truly be private, but may be "discoverable" in the event of litigation involving your client or between your client and you. You were reviewing your progress notes and noticed that at one point you saw a problem, evaluated benefits and risks of several treatment options, talked them over with your competent client, and outlined a treatment plan to which the client agreed. But you overlooked documenting some elements of the process. How should you handle it? Make a brand new progress note, date it "today," and write, "As I reviewed my note for (date), I see that I overlooked indicating that. . ." This will give the needed information to any who may need to read the note, it makes no attempt to hide the error, and in the event of later litigation, it will be better than no note at all. This all translates to the principle that corrections should be in real time, labeled contemporaneously, and transparent. [QN.No.#54. You discover you left important information out of a progress note. You can:] If you're bent on self-destruction as a therapist, one of the easiest ways to do this is to keep no notes or poor, incomplete notes. If you noticed something in therapy, you need to respond to it and then document that response. Although preventing liability for your sake is important, the leading rationale for good documentation is that it contributes to, facilitates and enables, and is essential to client care. Documenting or charting weekly, biweekly, or monthly does you, your clients, and even your colleagues an immeasurable disservice. These tips can be summarized in three basic rules that will minimize risk to both you and your clients (Lifson and Simon, 1998):
The North Dakota Department of Health (n.d.) gives several lists of what to do when "Charting with a Jury in Mind." Some of these are repetitious, which only emphasizes their importance:
Client Fails to Follow Clinical Directives It may be that your client--or that of your supervisee--will not progress, or will progress so slowly as to make no difference unless they follow the clinical directives, which will necessarily be part of the treatment plan. But the therapist is frustrated because a particular client continually fails to follow the clinical directives. Three questions may be asked in such situations (Relaxed Therapist, 2006):
The answer to "Why should your clients do anything you say?" may be found in the relationship between you and your client and within yourself. How you see yourself and your role in the therapeutic relationship will decide to what extent you expect the client to follow your advice. If you see yourself--and perhaps more importantly, if your client sees you--as the "bus driver" to take the him to his destination, you'll be the one frustrated if the client keeps challenging the route you take because he wants you to be only the travel agent. Why should your client do what you're saying now? Because you've studied your heart out and continue to do so in order to know what direction you clients need to go in, you may have come to believe that there is only one right way to recovery. Or you may have a number of ways the client can go towards recovery, but the client believes there is likely only one way and it doesn't fit any of the ways you're suggesting. You may be the one with the therapy experience, but your client is the one with the "being me" experience. If you client says a certain way won't work for him, you'll save time, energy, and frustration if you don't try to convince him why it will work for him. Instead, find out why she thinks it won't work for her, why she or her situation are different from everyone else. There may be no different but, then again, there may be. You won't know without asking; you need to ask the client what she thinks WILL work for her. She's more likely to follow her own advice, and perhaps you can lend a helpful hand in the process--which is the way therapy works in the first place. The third question, why wouldn't your client follow your suggestion, has a number of potential answers:
[QN.No.#55. If a client won't follow your suggestions, some of the reasons may be:] Any of those feelings is likely a deal breaker. All of this is reinforcement for the need for the client to be a major part of making the treatment plan. However, there are times when the client should do what you say, and there will have to be grave consequences if they don't. Examples of these times include:
If clients of these sorts do not follow clinical directives, follow the legal protocol that you must, and document the client's failure to follow clinical directives and what you did as a result. [QN.No.#56. Which of the following statements are true regarding whether or not a client must follow the therapist's directives:] Telephone Conversations with Client and Others It may be difficult to get into the habit of writing therapy notes about telephone conversations with a client or with others, such as social workers, about them. However, it's just as important--sometimes more important--to document these calls as it is to document a therapy session. If you have a call with a social worker and that person keeps a record and you don’t, there could easily be a time when your memory does not match their notes and it could lead to problems. It's especially important to document phone calls that are related to issues with legal consequences. An example of a dilemma that could arise from not documenting a telephone call: A former client is suing you. This individual attempted to commit suicide and was hospitalized after the failed attempt. She's now claiming that you didn't sufficiently intervene when she showed symptoms of suicidal ideation. After you received the lawsuit, you looked through the clinical record and discover that you had neglected to document a call you made to a psychiatrist just before the client's suicide attempt. You consulted with the psychiatrist about the woman's suicidal ideation. It would be unethical to insert a short note about the phone call at the end of the clinical note you had written just before the woman's suicide attempt. You can only hope the psychiatrist made a note that will prove it was this woman you called about; this isn't likely, because--in the name of confidentiality--you didn't mention the client's name. E-Mails, Phone Messages, and Texts A new aspect of record keeping has arisen because of modern digital technologies. These present new clinical, ethical, and legal issues in the field of mental health. We are warned frequently of the lack of security/privacy for e-mails, text messages, and mobile phone use. How using these means of communication with or about the clients affects confidentiality is still not clear. Thus, the by-word when using these digital methods is "caution." [QN.No.#57. Modern digital technologies have added new considerations in the field of mental health. Which of the following are true when using e-mail, mobile phone messages, and text messages?] Should the actual voice-mail messages, texts, and e-mails be included in the client's clinical record? A basic and simplistic answer is that at the very least, notes on the content of these messages if they have clinical or other significance should be in the record. Messages that it may be important to archive include those during a crisis or other high-pressure situations, or if therapists are flooded with messages from clients in ways that may be or become stalking, harassment, or threatening. Phone messages from clients are not a new phenomenon. Ever since the advent of the answering machine the potential for clients leaving a message for their therapist has been a reality. There are several way to handle these messages, in addition to the aforementioned written notes about the content of the message.
E-mail is becoming a common and acceptable way to for therapists and clients to communicate. It can be a time saver for needed rescheduling of appointments, eliminating the game of phone tag, busy phone lines, being put on hold, and numerous other annoying problems of phone calls. However, all is not gold when it comes to e-mail communication with clients (Zur, 2010a). What about the suicidal client that sends an e-mail you don't see for 18 hours? Or the client who, by the nature and length of their e-mail, extends the time of their session by half an hour? Or who wants a "short" answer right away to a therapy questions? Or--the list could be quite long. Also, e-mails are fundamentally vulnerable because they can be accessed by unauthorized people fairly easily, compromising the confidentiality and privacy of the communications. Encrypting your e-mails requires the complexity of public and private encryption keys and teaching clients to use them. Or you can use an Informed Consent form that delineates privacy risks so clients can choose whether or not to use e-mails. This consent form would be included with others that clients are required to sign (Zur, 2010b). The consent form may also include charges that may be incurred when the e-mails and their responses essentially extend therapy session, and any other guidelines you have for the use of e-mail with clients. All of this information must also be stated verbally in a therapy session--probably more than once. Zur (2010a) offers some excellent guidelines for using e-mail with your clients:
E-mails should be printed out and included in the client's file. Texting is one of the newer methods of communication between clients and therapists. Some agencies may not allow therapists to give out their cell phone numbers, preferring that clients that call after hours be transferred to an answering service that will transfer the call to the therapist on-call. And many therapists may not want to offer 24/7/365 availability to their clients. Regardless, it's almost inevitable that there will be a time in the near future when, because of the health market becoming more and more consumer-driven, many administrative and simple communications between clients and therapists will be done via cell phones and texting. In fact, on-call therapists for an agency might have a company cell phone for use during their on-call time. This may be a problem for those older therapists who can't or won't learn to text. As with other electronic communications, issues of security, confidentiality, and privacy are an inherent part of texting. A signed Informed Consent form, like the ones mentioned above, or a list of Office Policies that the client receives on intake should be used. At the very least text messages should be summarized, and the summary placed in the client's file. However, you can also have an actual record of the text itself to place in the file (possibly with a "translation" into "real English" for the sake of others who must read the file and who are not savvy to all of the texting abbreviations). Here are several ways to keep that record (Zur, 2010b):
All of these methods involve online services and will therefore have potential--sometimes inherent--problems of security, confidentiality, and privacy. Some programs may have security measure in force, but you'll want to check them out before you use them, and always employ Informed Consent forms. HIPAA confidentiality rules are always to be considered. If you communicate with your clients through e-mail and if you store clinical records digitally, you must be sure that your computer has impeccable password, firewall, virus protection, logs, and backup systems, encryption if necessary, and other computer safety measures (Zur, 2010b). You also need to be aware that HIPAA has some special rules for "a health care provider that conducts certain transactions in electronic form (called here a 'covered health care provider')" (HIPAA, 2005): "In electronic form means: using electronic media, electronic storage media including memory devices in computers (hard drives) and any removable/transportable digital memory medium, such as magnetic tape or disk, optical disk, or digital memory card; or transmission media used to exchange information already in electronic storage media. Transmission media include, for example, the internet (wide-open), extranet (using internet technology to link a business with information accessible only to collaborating parties), leased lines, dial-up lines, private networks, and the physical movement of removable/transportable electronic storage media. Certain transmissions, including of paper, via facsimile, and of voice, via telephone, are not considered to be transmissions via electronic media, because the information being exchanged did not exist in electronic form before the transmission." If you're a covered entity, you must comply with HIPAA's Privacy Rule (HIPAA, 2003) and Security Rule (HIPAA, n.d.), which are different from the HIPAA rules that are discussed elsewhere in this course. Consultations Documentation about consultations with a social worker or another professional within your organization is just as important as documenting any other transaction or communication with or about the client. The only reason this topic has been given a section of its own is to emphasize that it's just as important as any other kind of documentation. Gifts from Clients and Reasons Accepted No blanket statement can be made that accepting a gift is either always acceptable or never acceptable. Accepting a gift from a client may be unethical at times, but there are times when it's the most ethical and/or helpful thing the therapist could do. Whether or not it's ethical may depend on several factors:
[QN.No.#58. Sometimes you or your supervisee must decided whether or not it is ethical to accept a gift from the supervisee/client. Factors to be considered in your decision include:] The therapist must address the issue in each individual case. The answers to a couple of questions can help find the answer:
The setting and the nature of the therapeutic relationship influence the decision as well. It may be permissible to accept certain gifts from a client that comes in once a year for a session, but accepting the same gift from a client that is currently having weekly therapy sessions may not be permissible. The primary criterion by which to judge if the action is ethical is the client's best interest (Lyckhom, 1998). All Information Related to Suicidal, Homicidal or Abuse Concerns Even though it may be another time burden to suitably document a suicide risk assessment, it's something your supervisee sometimes must do, and you must see the he does it. It's best done immediately after a clinical evaluation of the client (Ministry of Children and Family Development, n.d.). Although it's tempting to use a form with "Yes/No" check boxes (e.g., Is the client suicidal?) or a subjective rating scale from 1-5, it's better to do a thorough risk assessment and a step-by-step narrative of the clinical judgment and planning that followed. Clear documentation that records the risk assessment, estimation of risk, approach to safety planning, treatment goals, and clinical consultation is important for a number of reasons:
Documentation of suicide risk in an outpatient setting should include:
Essential principles to think of when assessing risk of suicide in a young person (Ministry of Children and Family Development, n.d.) include:
[QN.No.#59. When you need to assess suicide risk in a young person, you should:] Perhaps the most important helpful thing an agency can give its therapists to aid in dealing with suicidal, homicidal, or other serious dangers presented by a client is a clear, written policy of management of these clients. This should include policy regarding supervision when a patient presents such dangers (Cole, 2001). [QN.No.#60. What is the single, most helpful thing an agency can give its therapists and supervisors to help in dealing with suicidal or homicidal clients?] Evidence of Continuity of CareThere are basically two kinds of situations for which documentation of continuity of care is required:
If consultations take place, a copy of the consultation should be present in the record as evidence of continuity of care maintained between the two providers (VA Premier Health Plan, 2007). The non-profit National Committee for Quality Assurance is working with a number of federal and state agencies, as well as private businesses to improve healthcare quality. One of the areas in which they're striving to build this quality is in the area of continuity and coordination of care. The organization has a seal that is widely known as a symbol of quality. Medical organizations that wish to include the seal into their marketing and advertising must pass a rigorous review and report on their performance annually. One of the requirements in this review is that there is continuity and coordination between medical and mental health care (National Committee for Quality Assurance, 2011). The two questions they must positively answer (and prove) are:
Ways some of the medical providers (Excellus BlueCross BlueShield Connection, 2009) live up to these continuity and coordination of care issues are by:
Records are kept as evidence of continuity of care between the primary care physician and the behavioral health provider. Essential collaboration includes sharing or acquiring a summary of recent behavioral health clinical outpatient or inpatient care in the previous 12 months and/or relevant treatment information via written or telephone communication that is included or documented in the treatment record. Records also include written communications and/or documentation of telephone conversations that include an assessment, working DSM-IV diagnosis and a clinical plan of care. A standard electronic document, the Continuity of Care Document (CCD) is being developed jointly by ASTM International, the Massachusetts Medical Society (MMS), the Health Information Management and Systems Society (HIMSS), and the American Academy of Family Physicians (AAFP). Its purpose is to promote and improve continuity of patient care, to reduce medical errors, and to make certain of at least a minimum standard of the transportability of health information when a patient or client is transferred or referred to, or is otherwise seen by another provider (Continuity of Care Record, 2003). Confidentiality of RecordsQuestions sometimes come up in regards to access to records because of differences between state and federal laws. The Health Insurance Portability and Accountability Act of 1966 (HIPAA) laws are the primary federal laws in these differences. In California there are three main sources of law that may be involved:
Patient Access to RecordsAn individual has a right to the confidentiality of her own mental health records. In most cases, this right of confidentiality stipulates that only the individual, her guardian, and her treatment providers may know the content of the record. However, whether or not an individual has the right to access her own records depends on what laws are applicable (M-POWER, n.d.).
HIPAA allows for psychotherapy notes to be withheld, although they encourage providers to give the information to the individual if they believe that is appropriate. HIPAA denies access to records when there is danger to either the individual directly involved or to another person (HIPAA, 2011c), whereas California law only looks at significant risk of "substantial detrimental or adverse consequences"to the individual (California Health and Safety Code, 2010). [QN.No.#61. True or False: HIPAA allows psychotherapy notes to be withheld from the clients under certain circumstances.] If this access to mental health records is denied, the client must be informed of the denial. Also, written records of both the request and the reasons for denial must be put in the client's file (California Health and Safety Code, 2010). If the individual affected directly by that disputes the decision, California's IPA law requires a state agency to re-examine its determination that that particular information is exempt from access (California Department of Health Care Services, 2007). When there are differences between state and federal laws, the state laws preempt the federal laws. This statement is based on the Federal Register (Standards for Privacy….) statement, "…A state law may also not be preempted because it comes within section 1178(a)(2)(B), section 1178(b), or section 1178(c); in this situation, a contrary federal law would give way." Inspection by Parents of Child’s Mental Health RecordsDiscretion to Refuse Access to Parents: In most cases, parents and guardians are allowed access to the health and mental health records of the child or youth. However, in California at least, in the instance of minors aged 12 and older, if the health care provider determines that such access would have a damaging effect on his professional relationship with the minor client or on the minor's psychological well-being or physical safety. Under Section 123115(a)(2), this decision of the availability of the minor's records for inspection shall not attach any liability to the provider, unless the decision is established to be in bad faith (California Health and Safety Code, 2010).
[QN.No.#62. Health providers may refuse to give parents access to their child's health and mental health records. Which of the following is NOT an acceptable requirement?] Discretion to Not Inform Parents without a Minor's Consent: The California Family Code (2010) requires the health care provider to involve a parent or guardian in a minor's treatment unless the provider determines that this involvement would not be appropriate. This decision and any attempts to contact parents must be documented in the minor's record. There will be some necessary sharing of certain confidential information if parents are involved in treatment. Nonetheless, participation in treatment does not mean parents necessarily have a right to access the confidential records. To whatever extent possible, providers should try to regard the minor's right to confidentiality while still involving parents in treatment (California Family Code, 2010). Discretion to Inform Providers without Authorization: Records kept in connection with treatment or prevention of drug abuse that is regulated, conducted, or assisted--whether directly or indirectly--by the California Department of Alcohol and Drug Programs cannot be shared with providers who are not working for the same treatment or prevention program except in an emergency (California Health and Safety Code, 2010). Health care providers working for programs that are not state assisted may share information for treatment or referral services with other providers. However, without written client authorization, they may not share psychotherapy notes (California Civil Code Section 56-56.07, 2010 and National Center for Youth Law, 2010). Disclosure of Record Keeping ProceduresDisclosure of record keeping procedures is potentially a part of informed consent (American Psychological Association, 2007). As you recall, an Informed Consent document is a statement of what will be happening in therapy, its risks, benefits, and alternatives, and signed by the client before beginning therapy and giving consent for therapy. A notice of HIPAA privacy laws that has been signed as having been explained to the client is also a part of the informed consent process. Also discussed were informed consent forms for using e-mail, texting and other electronic communications between client and therapist.
Sometimes, the client might want to know how the records will be maintained, and this may include disclosure of record keeping procedures. This may be particularly important if the procedures will probably affect confidentiality or if the client articulates expectations about record keeping that are different from required procedures. It's possible that the way in which records are maintained could potentially affect the client in ways that she might not anticipate. It's encouraged that you and your supervisees inform clients about such situations. For example, more and more often certain client records may become part of an electronic file that can be accessed by a wide range of institutional staff. In some educational settings, federal, state, and institutional regulations require record keeping procedures that could enlarge the range of people who have access to the records of a school psychologist. When mental health client records are released with appropriate permission to do so, from that point it's possible that they might be distributed further without the therapist's or client's knowledge or consent. The client should be alerted of this possibility before the consent for release of information is signed. An example of this, records released in a context of litigation may be placed in the public domain and be accessible to anyone. [QN.No.#63. Disclosure of record keeping procedures is potentially a part of informed consent. What information might be needed for a client to decided whether or not to sign the consent form?] Maintenance of RecordsTo be clinically useful and legally safe, clinical records must be kept up-to-date and be well organized.
Records are only useful if efficient retrieval is possible. Records that are organized logically and updated systematically, and that are thorough and accurate accomplish this. The therapist and supervisor can more easily monitor ongoing care and interventions. If the client's care needs to be transferred elsewhere, for whatever reason, this sort of records allow for continuity and coordination of care. Organizational MethodsThere are a variety of methods for organizing the records to aid in storage and retrieval. Logical and consistent methods will generally be most useful. For example, a logical file labeling system will assist in recovering records (American Psychological Association, 2007).
Dividing the files into several sections may be helpful:
Because psychological test data may require especially careful consideration before being released, and therefore may best be clustered within the file to make that perusal easier. A specific, often overlooked, area of concern is the re-release of data from previous therapist's records as a part of the record that should be released. Should the therapist decided not to release that information, having that in a separate part of the file will make it easier to carry out that decision. When asked for legitimate release of information for which a release form has been signed, the therapist must still consider several items:
For example, the therapist has received a court order of "any and all records" that were used when the therapist formed certain opinions. It would likely be necessary to re-release some third-party information that is in the record. However, the therapist can give advance notification to the client, allowing enough time for an objection to be raised before responding to such requests for records. Psychotherapy NotesFor privacy reasons, HIPAA has given its own definition of psychotherapy notes. A discussion of progress notes follows the outline of the applicable HIPAA definition and rules.
HIPAA Definition of Psychotherapy NotesSome items that have traditionally been included as parts of the psychotherapy notes have been defined by HIPAA as something separate. HIPAA's definition of psychotherapy notes is:
"Psychotherapy notes means notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual’s medical record. Psychotherapy notes excludes medication preblockedion and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date" (HIPAA, 2003). Note that items that this definition pretty much limits psychotherapy notes to anything relating to the contents of therapy session conversations and does NOT include:
[QN.No.#64. According to the HIPAA definition of psychotherapy notes. Items NOT mentioned that these notes don't include are:] HIPAA states that psychotherapy notes are to be kept separate from the rest of the record. Only the provider who took the notes (or others within the provider's agency) can access them, unless there is a HIPAA complaint authorization from the client (American Psychological Association, 2007). Providers are exempt from forwarding or otherwise sharing psychotherapy notes with other entities without client authorization, except for legally defined exceptions. Physically integrating information included in the above list into the psychotherapy notes does not automatically mutate it into protected information. If a provider has integrated information excluded from the definition of psychotherapy notes with a psychotherapy note (e.g., results of clinical tests, symptoms), the provider is responsible for extracting information that is required to reinforce the reasonableness and necessity of a Medicare claim, or other legal request for information (Provider Inquiry Assistance, 2005). The Department of Health and Human Services (HHS) Office for Civil Rights (OCR) is responsible for enforcing the privacy protections and access rights for consumers. The HIPAA privacy rule does not require or allow any new government access to medical information, with one exception: the rule does give OCR the authority to investigate complaints and to otherwise ensure that covered entities comply with the rule. In order to ensure covered entities protect patients' privacy as required, the rule provides that health plans, hospitals, and other covered entities cooperate with the Department's efforts to investigate complaints or otherwise ensure compliance (U.S. Department of Health and Human Services, 2001). Progress NotesPsychotherapy notes are sometimes called progress notes. Some of the information that HIPAA excludes in its definition of psychotherapy notes are summaries. However, the specifics that formed the basis for the summaries are included in the psychotherapy, or progress notes. The progress notes:
Face-to-Face Therapy Anyone acquainted with the field of therapy is familiar with face-to face therapy. The client and therapist meet and have a session. This most often takes place in the therapist's office, but can also occur in hospitals, jails, or similar settings. But because of the experience of the years for this kind of therapy, record keeping and process notes easily fall into the deblockedions above. Electronic Therapy Before the advent of the Internet, face-to-face therapy was the only type of therapy, except for crisis telephone services. In recent years, therapists have taken advantage of the Internet and the telephone to offer almost the whole gamut of therapeutic services. This kind of therapy not only has a number of names (e.g., TeleMental Health, Telehealth, E-Therapy, E-Counseling), it's also provided by a variety of means:
A variety of client populations have eagerly sought these sorts of therapy, including those who:
However, clinical, ethical, and legal facets of electronic therapy are in many respects still under construction. There is an ongoing discussion, for example, as to whether most of these formats conform to HIPAA privacy and confidentiality laws. Whole courses are available to train the "electronic therapist" in the ethical and legal considerations (including conducting therapy across state lines, HIPAA, reimbursement, etc.), as well as the delivery of electronic therapy with its practice, logistic, and technologic aspects (Zur, Ofur, 2011d). Nonetheless, if your supervisees provide any kind of electronic therapy, records must be kept. The rules and regulations and other discussions above all apply. SecurityIn light of confidentiality and privacy for every individual, there must be suitable protection against unauthorized access to or loss of the records. As a safeguard against electronic and physical breaches of confidential information, there needs to be limited access to the records. New challenges to preservation of security have appeared because of advances in technology. However, there must be a plan in place to protect the records (American Psychological Association, 2007).
Two basics to consider are:
Paper records must be kept in safe location where they may be protected not only from unauthorized access, but also from damage or destruction (water, mold, fire, insects). Condensed records, or a full copy of them, may be kept in separate locations to better protect them from disasters--natural or unnatural. [QN.No.#65. Client records that are on paper, must be protected from:] Electronic records may need protection from different kinds of damage--mechanical insult or electric fields; power outages or surges; attacks from viruses, worms, and other destructive programs. A plan for archiving files may include off-site storage of data or file and system backups. [QN.No.#66. Client records that are in electronic form must be protected from:] Access to paper records may be controlled by storing files in locked cabinets or other such containers that are housed in locked offices or storage rooms. Access to electronic records may be controlled via security procedures such as firewalls, passwords, authentication, and data encryption. Retention of RecordsThere are numerous potential circumstances that might require a release of client records after termination of client contact (e.g., legal proceedings, requests from treatment providers or the clients themselves). They may also be needed at some time for the social worker or therapist to show the nature, quality, and rationale for services provided. It's also a possibility that the records might be requested to give light in resolving a legal dispute and administering justice when the nature of the treatment provided or the psychological condition of the client at the time of services would be needed (American Psychological Association, 2007).
This gives rise to the question of just how long you should keep the records. Perhaps the most practical answer is, "As long as necessary for the future care of the client, and as long as the record may be used in the defense of the therapist" (Cole, 2001). The APA states that, unless there is an overriding requirement, it would be good to keep records for seven years after the last service delivery date for adults or until three years after a minor reaches the age of majority, whichever is later. However, they also state that you may want to keep them longer. These suggestions are the law in California; each state has its own laws. In deciding whether to keep the records for a longer period of time, you would want to weigh the potential benefits associated with keeping the records versus risks associated with potential privacy loss or having information that is outdated/obsolete. Possibilities that you may want to consider when making the decision to continue to keep or to eradicate files include:
One other item to consider: The client has the right to amend his medical records as long as you have the record (Pritts, 2005). Preserving the Context of RecordsThere are times for which the information in a client's record is specific to a given time frame or a particular situational context during which the services were delivered. Over time, as the context changes, the meaning and relevance of the information may also change. The information in the record should be recorded in such as way as to preserve the context.
For example, if you or your supervisee assess or treat an individual who is under extreme external stress or who is in crisis, those stresses may affect the client's functioning in that setting, but the client's behavior in that situation may not be at all representative of the client's normal functional characteristics. Or--a child who is being severely physically abused may show low scores in a cognitive assessment that may not be close to accurately predicting future functioning of the child. Or if you need to write a case summary of a client who had been violent, but only in the midst of one psychotic episode, you would want to carefully record the context in which the behavior took place. Always try to create and maintain a client's records in such as way as to show related information about the context in which the record is created (American Psychological Association, 2007). [QN.No.#67. Preservation of the context of client records includes:] Electronic RecordsIssues pertinent to electronic records have already been discussed. But, because of the extreme importance and uniqueness of electronic records, it will be tied together here with some addition information.
Aspects of electronic record keeping that need to be kept in mind are:
In many cases, those in the social work and mental health fields will be subject to the HIPAA Privacy Rules and Security Standards. This requires a detailed analysis of the risks associated with your electronic records. It would likely be helpful to conduct that risk analysis even if you're not technically subject to the HIPAA rule. These HIPPA requirements are also a means to help you to closely examine certain office practices:
Whether the Security Regulations apply or not, the swift changes in the technologies for service delivery, media storage, and billing necessitate frequent consideration of how to use these methods and media in terms of record keeping standards (American Psychological Association, 2007). The ease of creating, transmitting, and sharing electronic records can expose you to risks of unintentional disclosure of confidential information. Some precautionary actions include:
[QN.No.#68. Precautionary actions that can be taken to protect unintentional electronic disclosure of confidential information include:] Record Keeping in Organizational SettingsOrganizational settings, often present unique record keeping challenges. Record keeping requirements for organizations may be substantially different from requirements in other settings. You may run into conflicts between the organizations' practices and establish professional guidelines, legal and regulatory requirements, or ethical standards. In addition, ownership of and responsibility for a record is not always clearly defined. A number of service providers may access and contribute to the record, potentially affecting the degree to which you may execute control of the record and its confidentiality.
This may be summarized as potential:
You, your colleagues, and your agency's management may need to consult with one another to define record keeping procedures that serve the needs of different disciplines, while at the same time meeting acceptable record keeping guidelines and requirements. In this consultation, you'll need to review local, state, and federal regulations and laws that pertain to the organization. If there is a conflict between an ethics code and the organization's policies, you'll need to clarify the nature of the conflict, make your (and others involved) ethical commitments known, and resolve the conflict in a way that is compatible with those ethical commitments. The nature of your legal relationship with the organization may dictate record keeping practices. The physical record of your services may be owned by the organization and you may not take it with you. However, if the relationship is one of consultation, you may be the one who owns and is responsible for the record. It will be helpful to clarify these issues when you begin your relationship with an organization, minimizing the possibility of misunderstandings. If a team of people from different disciplines is involved in service delivery, there may need to be wider access to records than usual. Because others (e.g., nurses, physicians, paraprofessionals, etc.) may have access to and may make entries into the client's record, you may have much less direct control over it. This is another call for you to help in developing and refining organizational record keeping policies. Note that because multidisciplinary records may not have the highest level of confidentiality, you and your supervisees will want to record only information that matches organizational requirements and that is necessary to correctly picture the service provided. Other information may then be kept in a separate and confidential file (American Psychological Association, 2007). Multiple Client RecordsRecord keeping issues may be more complex when you provide services to multiple clients, such as in a group therapy session. If the records include information about more than one specific client, legitimate disclosure of information regarding that client may put another client's confidentiality in jeopardy.
It's the responsibility of you and your supervisees to keep records in a fashion that assists authorized disclosures but at the same time protects privacy of other clients. When you provide services to several people who have a relationship (e.g., spouses or parents and children), you must define at the beginning:
If it looks like you may be asked to play potentially conflicting roles (e.g., family therapist and then witness for one part in divorce proceedings), you must take judicious steps to appropriately clarify, modify, or withdraw from a specific role or roles. In a group therapy setting, you must describe at the beginning each party's role and responsibility, and the limits of confidentiality. If you're asked to provide services to someone who is already receiving similar services elsewhere, you must consider carefully any treatment issues and potential welfare of the client(s). Discuss these issues with the client (or the client's guardian or other legal representative) to diminish risks of conflict and confusion. Also, when appropriate, consult with the other service providers, always being cautious and sensitive to therapeutic issues (American Psychological Association, 2010). Other precautionary steps you can take include:
To successfully "pull all of this off," you'll need to be familiar with regulatory and legal requirements concerning the release of a record that contains information about more than one client (American Psychological Association, 2007). Financial RecordsFinancial records are considered by HIPAA to be part of the protected psychotherapy notes; at least they're not on the list of unprotected information. As a rule, a fee agreement or policy will be part of the record, and is the foundation for documenting reimbursement for services. Precise financial records aid payers to evaluate the nature of the payment obligation, and also aid in knowing which services have been billed and paid. Records that are up-to-date can forewarn both the provider and the client of accruing balances that, if not addressed, could adversely affect the professional relationship.
Financial records include (American Psychological Association, 2007), as appropriate:
Disposition of RecordsCertain events require collection, storage, transfer, or disposal of client records. These events are:
Disposition of client records must be handled in such a way that confidentiality is maintained and client welfare safeguarded (American Psychological Association, 2007). This refers to all private information--written or unwritten--such as communications during the time of providing service, computer files, e-mail or fax communications, written records, and video-tapes. This means that the therapist needs to have suitable plans in place from the beginning of her job. Also to be planned for, in case of unexpected changes, are contingencies for continuation of services (Barnett and Zur, 2011). In the circumstance of unexpected events, the plans might include control and management of closed records by an agency or trained individual. In the circumstance of planned events, depending on who the employer is, the provider may wish to retain custody and control of the closed records. It may be helpful to have a method for notifying clients regarding any changes in the custody of their records, especially recently terminated services or open cases. You'll want to check legal and regulatory requirements to see if you should post a public notice about changes in this custody, such as a notice in the newspaper. If records are to be disposed of permanently, they must be disposed of in such a way that they cannot be recovered, such as shredding. You must to provide for confidentiality in transportation to the shredding facility, as well as in that facility. This might require accompanying the records through the disposal process or having a confidentiality agreement with those responsible for the disposal. Disposal of electronic records have unique challenges, because you may not have the technical expertise to fully erase or otherwise delete records before, as an example, disposing of an external back-up storage device or a computer hard drive or other electronic record repository. Even though efforts may be made to erase or delete records, they may still be accessible for some "geeks" with specialized knowledge. You'll possibly need to work with a technical consultant to find a satisfactory method for destruction of electronic records. These could include physical destruction of the entire medium or demagnetizing the storage device. Evaluation of the SuperviseeIn spite of the awareness that a big part of supervision is the supervisor's evaluation of the supervisee, it's apparently something that is often far from the favorite task of a supervisor. Some of the reasons for this include (Lichtenberg et al., 2007):
However, no matter what problems are related to it, supervisor evaluation of the supervisee is an established fact and must be faced. Interestingly, unless things have dramatically changed in the 21st century, supervisees frequently receive no evaluation until the last day of the required training, and then receive some negative feedback about which they had heard nary a word in the course of training. You can see why the lack of performance evaluation has been the most commone ethical violation reported by supervisees in supervision (Ladany and Lehrman-Waterman, 1999). For contrast with the above list from Lichtenberg et al. (2007), the primary reasons given in 1993 of why supervisors often don't give negative feedback were (Robiner, Fuhrman, and Ristvedt, 1993):
It's ironic that supervisees report that supervisors who give abundant constructive feedback and evaluation are their best supervisors (Falender, 2010). The Association of State and Provincial Psychology Boards (2003) suggested that summative evaluation be given to supervisees in written form four times during each training year. Summative evaluations of supervisees would examine the outcome of their clinical work.It would include:
A related type of evaluation is formative evaluation, which tries to improve or strengthen the person being evaluated. As it relates to supervisees, it examines their delivery of therapy or a social work program, the quality of this delivery, and assessment of the context. A formative evaluation includes:
Current thinking is moving towards a 2-way feedback, where supervisees also evaluate supervisors. Supervisees might fear that summative feedback could influence their own evaluations negatively, and thus be cautious in giving summative feedback to supervisors. However if you, the supervisor, are truly open to feedback and accepting of it, it can be very helpful to both you and the supervisee. If, however, you respond with dismissive behaviors, resistance, or even anger, it will obviously not be a helpful process (Falender, 2010). Options to aid effective competency-based evaluations:
If the supervisee does not meet performance standards, she can be given an action plan for improvement, or in most drastic situations, a longer period of time of required supervision. Supervisees who don't meet standards after the action plan approach are rare (Falender, 2010). Red flags for performance problems include:
[QN.No.#69. Red flags for performance problems to pay attention to when evaluating supervisees do NOT include:] Not meeting performance standards are reflected in professional functions in one or more of the following (Lamb, Anderson, Rapp, Rathnow, qne Sesan, 1986):
After you've determined that the supervisee is not meeting performance criteria, and you've given feedback directly to him, work with the supervisee to develop a plan (based on data you can find in regard to successful completion of the behaviors in the past and factors that facilitated those) for change or completion. Construct a time-line with intermediate check-in points that are fairly close together, and document the meeting in which all of this took place (Falender, 2010). The initial check-in should be within a few days of the meeting; be sure to follow up to see if appropriate progress is being made. Even with appropriate progress, continue monitoring even past indications that the behavior has changed. If the problem behaviors don't decrease, take appropriate steps that might include:
Continue with these steps until the problem is solved or until you determine that the supervisee's position must be terminated (Falender, 2010). All steps must be carefully documented. ------------------------------------------------------------------------------------------------------------------- Objective 5: List at least five ethical or other problematic issues that can arise during supervision. Question 19. Ethical and legal issues most important to clinical supervisors include: a) Vicarious liability b) Confidentiality c) Informed consent d) Boundary concerns e) All of the above f) None of the above Question 20. True or False: The lack of timely supervisory feedback seldom causes ethical complaints. Question 21: Skills that facilitate good communication include: a) Revealing feelings b) Stating opinions c) Warning of consequences d) Offering incentives e) All of the above f) None of the above Question 22. True or False: Excelling in a specific technique is more important for becoming an effective counselor than having characteristics of social intelligence, empathy, tolerance, and sense of well-being. Objective 6: Name and explain three areas that relate to competencies of professional and ethical standards. (See #s 4 & 18) Qestion 23. Areas related to competencies of professional and ethical standards include: a) Being sure that supervisees know what the clients' rights are. b) Aiding supervisees to recognize, comprehend, and cope with specific transference and counter-transference problems when working with clients. c) Practicing only in one's areas of supervisory and clinical competence. d) a and b e) a and c f) b and c Qestion 24. An insight regarding transference that can lead to long-lasting psychological change has the following characteristics: a) The therapist should encourage transference. b) The therapist should use non-disclosure and deliberate opacity. c) Recognize that they are based on reality. d) a and b e) a and c f) b and c Objective 7: Name at least four areas where counter-transference could be an issue. Qestion 25. Counter-transference can be an issue if: a) The client terminates therapy prematurely. b) The therapist is irritated by a client for no apparent reason. c) The supervisor feels like he is falling in love with a supervisee. d) a and b e) a and c f) b and c Qestion 26. Questions the supervisor or therapist must ask herself if she becomes aware of possible counter-transference include: a) Is the feeling characteristic of you? b) Is this feeling obviously related to the supervisee or client? c) Is the feeling uncharacteristic for you (or the therapist), a reaction to one specific supervisee (or client), but the precise trigger is not obvious at once? d) Is this feeling triggered by something not related to the supervisee or client? e) All of the above f) None of the above Qestion 27. True or False: There are some circumstances where a sexual relationship between supervisors and supervisees is not unethical. Question 28: Potential contextual sources for transference and counter-transference issues do NOT include: a) Age b) Disability c) Recovery vs. non-recovery status d) School grades e) All of the above f) None of the above Qestion 29. True or False: You can never give a supervisee or a client too much nurturance. Question 30. Three things work together to produce empathy. They are: a) Unemotional sharing b) Infringement of the ego c) Mental inflexibility d) All of the above e) None of the above Qestion 31. Which statements are true about therapeutic relationships? a) They interact with specific therapy strategies. b) They are based on knowledge. c) They are as important to productive productive therapy and supervision as the techniques used. d) The therapist's capacity for self-awareness and empathy are basic for development of a therapeutic relationship. e) All of the above f) None of the above Objective 8a. Name some types of dual-relationships that are not unethical Qestion 32. Sometimes dual-relationship are unavoidable and ethical. Point out which relationships are NOT acceptable: a) Living in a small community, the therapist may at times hire a client (carpenter, electrician, etc.) b) Working together on a community event c) Having a sexual relationship. d) Taking part in a work-sponsored activity e) All of the above f) None of the above Objective 8. Give at least one pro and one con for self-disclosure. Question 33. Which statement(s) about self-disclosure is/are accurate? a) Self-disclosure is usually a violation of boundaries. b) Self-disclosure can be damaging to therapy when working with a stigmatized population. c) Supervisor modeling can be more successful if it includes self-disclosure. d) Self-disclosure will likely harm a good supervisory relationship. e) All of the above f) None of the above Question 34. Which legal principles must you understand in order to practice effective risk management? a) Vicarious Liability b) Statutory Liability c) Limited Liability d) a and b e) a and c f) b and c Question 35. Which of these are part of supervision's standards of care? a) Periodically monitoring and controlling supervisee's activities b) Providing appropriate feedback and evaluation c) Supervising only within your area of competence d) a and b e) a and c f) b and c Question 36. In the framework of supervision, which of these is/are accurate test(s) of malpractice? a) The supervisee suffered demonstrable injury or harm. b) There was a professional relationship between the supervisor and supervisee. c) The supervisor's breach of duty to practice within the standard of care was the proximate cause (reasonably foreseeable) of the supervisee’s or client’s injury. d) There is a demonstrable standard of care, and the supervisor breached that standard. e) All of the above f) None of the above Question 37: Supervisor behaviors that represent potential direct liability charges might include: a) Having a supervisory contract b) The supervisee was assigned very few clients c) A biased evaluation d) Providing clear crisis procedures e) All of the above f) None of the above Question 38. Vicarious liability is founded on which of the following concepts: a) The supervisor is in a position of authority and responsibility. b) The supervisor or the supervisor's agency does not profit from the actions of their supervisees. c) The supervisee is under the direct control of the supervisor. d) a and b e) a and c f) b and c Question 39. Which of the following is/are NOT a part of good risk management strategies? a) Document Everything b) Supervision Contract c) Maintaining Written Polities d) Liability Insurance e) All of the above f) None of the above Question 40. Clinical files serve as: a) Tools for education b) Basis for planning the client's care and treatment c) Legal document describing the care the client received d) Means by which the client or a third party payer can verify that she actually received the services billed for. e) All of the above f) None of the above Question 41. Keeping up clinical records is the responsibility of: a) The supervisor b) The supervisee c) The agency's office staff d) The supervisor and the supervisee e) All of the above f) None of the above Objective 10. List at least eight areas that belong in the therapy record. Question 42. Which of the following does NOT belong in the client's record? a) Identifying data (e.g., name, client id number) and contact information b) Assessment of client status c) Relevant cultural and sociopolitical factors d) All of the above e) None of the above Question 43. The mental status exam (MSE) is to determine the client's cognitive functions, including: a) Orientation to person, time, place, and space b) Concentration c) Judgment d) Short- and long-term memory e) All of the above f) None of the above Question 44. Informed consent forms that the client signs should NOT include: a) Information about the supervisor that includes credentials, qualifications and approach to supervision b) Due process c) Number of supervisees for which the supervisor will be responsible d) Ethical codes of conduct e) All of the above f) None of the above Question 45. Which of the following is/are true of informed consent: a) It is a single event. b) It is a process that changes over time. c) Subsequent consent to treatment discussion should all be documented. d) a and b e) a and c f) b and c Question 46. One of the informed consent forms a client must sign is consent to be treated by a trainee. This form need NOT include which of the following about the supervisee: a) Professional discipline (i.e., social work, counseling, psychology, nursing) b) Specialty (i.e., counseling, clinical, school) d) Treatment philosophy or orientation e) When the supervisee received his degree f) All of the above g) None of the above Objective 9a: What rights clients have under HIPPA. Question 47. Under HIPAA, a client does NOT have which of the following rights: a) The right to request restriction on the uses and disclosures of protected health information (PHI) b) The right to request amendments of her designated record set (DRS) c) The right to request confidential communications d) The right to request an accounting of disclosures e) All of the above f) None of the above Objective 9b. Define HIPAA's exceptions to confidentiality. Question 48. HIPAA makes some exceptions to confidentiality that include: a) Threat of harm to self or others b) Any criminal activity disclosed c) Involuntary commitment d) a and b e) a and c f) b and c Question 49. Potential responses to a subpoena for client information never include: a) Stating that you can neither deny nor confirm that any specific individual is a client and cannot release information from any client record without a court order or client consent. b) Negotiate with the issuer of the subpoena c) Ignore the subpoena d) Modify the subpoena e) All of the above f) None of the above Question 50. HIPAA allows free use of client information for which of the following: a) Use by the therapist that originated treatment notes for further treatment. b) Use or disclosure by the therapists for training programs under supervision to practice and improve their abilities in individual, family, joint, or group counseling. c) Use or disclosure by the therapist as defense in legal or other proceedings brought by the clients. d) All of the above e) None of the above Question 51: HIPAA states that a release of information form must NOT: a) Advise patient of his right to receive a copy of the authorization b) Be separate from all other documents in the client's file c) State specific uses and limitations of the use of the information by the persons authorized to receive it d) State the date after which the provider can no longer disclose information e) All of the above f) None of the above Question 52. The DSM has a 5-axes assessment system that includes: a) Symptoms that need treatment b) Recent psychosocial stressors c) Score from the Duke Health Profile d) a and b e) a and c f) b and c Question 53. A formal treatment plan includes: a) Presenting Problem b) Goals of Therapy c) Time Estimate d) Interventions and methods e) All of the above f) None of the above Question 54. You discover you left important information out of a progress note. You can: a) Add the information to the note b) Ignore it and hope it won't be a problem c) Make a new note, date it "today," and state that you realize you forgot to include. . . . d) None of the above Question 55. If a client won't follow your suggestions, some of the reasons may be: a) They don't understand it. b) They tried it but got a negative reaction. c) They tried it but couldn't do it on one attempt. d) They don't believe it will work. e) All of the above f) None of the above Question 56. Which of the following statements are true regarding whether or not a client must follow the therapist's directives: a) The client never has to follow your directives. b) The client should always follow your directives. c) The client must follow your directives when their problem has legal consequences. d) a and b e) a and c f) b and c Question 57. Modern digital technologies have added new considerations in the field of mental health. Which of the following are true when using e-mail, mobile phone messages, and text messages? a) Lack of privacy is of no concern. b) There is no potential problem of security. c) "Caution" is the by-word when using these methods. d) All of the above e) None of the above Question 58. Sometimes you or your supervisee must decided whether or not it is ethical to accept a gift from the supervisee/client. Factors to be considered in your decision include: a) The nature of the gift b) The cost of the gift c) The therapeutic/supervisory relationship between the one giving the gift and the one receiving it d) The transference or other issues that led to giving the gift e) All of the above f) None of the above Question 59. When you need to assess suicide risk in a young person, you should: a) Ask the client directly b) Estimate the risk level based on a thorough assessment c) Ask parents, caregivers and other sources of collateral information for their perspectives d) Re-evaluate the risk status periodically e) All of the above f) None of the above Objective 11. Name the single, most helpful thing an agency can give its therapists to aid in dealing with suicidal or homicidal clients. Question 60. What is the single, most helpful thing an agency can give its therapists and supervisors to help in dealing with suicidal or homicidal clients? a) A good armamentarium of assessment tests b) Regular CEU classes on the topic c) Clear, written policy of management of these clients d) Support and encouragement e) All of the above f) None of the above Question 61. True or False: HIPAA allows psychotherapy notes to be withheld from the clients under certain circumstances. Question 62. Health providers may refuse to give parents access to their child's health and mental health records. Which of the following is NOT an acceptable requirement? a) The child is age 16 or older b) The provider believes this access would have a negative effect on his professional relationship with the child c) The provider believes this access would damage the child's physical safety d) The provider believes this access would damage the child's psychological well-being e) All of the above f) None of the above Question 63. Disclosure of record keeping procedures is potentially a part of informed consent. What information might be needed for a client to decided whether or not to sign the consent form? a) Client records may become part of an electronic file that can be accessed by a wide range of institutional staff. b) When mental health client records are released with appropriate permission to do so, from that point it's possible that they might be distributed further without the therapist's or client's knowledge or consent. c) Records released in a context of litigation may be placed in the public domain and be accessible to anyone. d) In some educational settings, federal, state, and institutional regulations require record keeping procedures that could enlarge the range of people who have access to the records of a school psychologist. e) All of the above f) None of the above Question 64. According to the HIPAA definition of psychotherapy notes. Items NOT mentioned that these notes don't include are: a) Modalities and frequencies of treatment furnished b) Medication preblockedion and monitoring c) Summaries of the diagnosis, symptoms, prognosis, and progress d) The complete treatment plan e) All of the above f) None of the above Question 65. Client records that are on paper, must be protected from: a) Unauthorized access b) Water damage c) Fire d) Insect damage e) All of the above f) None of the above Question 66. Client records that are in electronic form must be protected from: a) Unauthorized access b) Power outages or surges c) Insects d) a and b e) a and c f) b and c Question 67. Preservation of the context of client records includes: a) The location in which the records are kept b) A given time frame during which services were delivered c) A specific situational context during which services were delivered d) a and b e) a and c f) b and c Question 68. Precautionary actions that can be taken to protect unintentional electronic disclosure of confidential information include: a) Use passwords and/or encryption to protect confidential materials b) Use case identification numbers, not clients' Social Security numbers to identify records c) Get training in special issues when using electronic media or consult with a specialist when necessary d) Become aware of special issues raised when using electronic methods and media e) All of the above f) None of the above Question 69. Red flags for performance problems to pay attention to when evaluating supervisees do NOT include: a) Chronic lateness b) Delinquent paperwork c) No alterations in interaction style or behavior d) Client cancellations (by client or supervisee) e) All of the above f) None of the above |
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Clinical Supervision > Chapter 5 - The Supervisor: Part 3
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