Managing Clinical Supervision: Ethical Practice and Legal Risk Management

Managing Clinical Supervision: Ethical Practice and Legal Risk Management Janet Elizabeth Falvey with Timothy Management Pacific Grove, CA: Brooks/Cole, 2001

BEGINNING WITH THE foundations of clinical social work in Mary Richmond's innovative clinical research contributions (Richmond, 1917), through the work of Charlotte Towle (1963) and up through the present, the supervisor-supervisee relationship has been recognized as critical to both the ongoing professional fulfillment of the clinical social worker and also to the delivery of effective services for clients. Many studies have documented that deprivation of the support of well-conducted clinical supervision contributes to the "burnout" of mental health professionals and seriously erodes the quality of care given to clients (Kahn, 1993). However, despite this scientific awareness, there exists a profound crisis facing mental health care, which Janet Falvey, in Managing Clinical Supervision: Ethical Practice and Legal Risk Management, brings to our attention in her exposition of the ethical and legal issues entailed in clinical supervision. Even though 50% of psychiatrists and psychologists and 24-30% of social workers regularly supervise other professionals (p. 26-27), and all mental health disciplines require from I to 5 years of supervised practice to attain eligibility for professional credentialing, Falvey says,

* The majority of supervisors remain unable to specify supervisory models, theories, or research that inform their practice" (p. 9).

* Supervisors are rarely trained for supervision but instead act based on their experience as counselors and supervisees.

* There are few licensing or credentialing bodies for supervisors in mental health fields.

* There are few courses available that address the topic of clinical supervision.

* Supervisory support is lacking or grossly inadequate for most practicing mental health professionals.

Falvey's book is full of evidence for her concerns. Consider for instance one study she cites in which 40% of licensed school social workers had not been evaluated by supervisors in 3 or more years, while many school-based mental health professionals received no supervision or evaluation at all. "How can their work be valued if it is never evaluated?" Falvey asks (p. 107), making it clear that the lack of supervision contributes both to a decay in the quality of service provided to clients, and also erodes the respect accorded to the mental health disciplines. Falvey emphasizes that these conditions occur in practice despite the existence of legal and ethical guidelines that make the lack of supervision unethical and put both mental health practitioners and administrative and clinical supervisors at risk of legal exposure. Falvey includes several appendices containing the ethical standards and guidelines of the major mental health professions with regard to clinical supervision. Those for social workers state explicitly, "Supervision is recommended in all settings where clinical social work is practiced ... when clinical social work supervision is not available from staff, outside supervision should be secured" (National Council on the Practice of Clinical Social Work, NASW, cited in Falvey, 2002, p. 147). In addition, Falvey includes carefully summarized cases in which supervisors and mental health practitioners were held legally liable for not following ethical and legal guidelines for clinical supervision; lack of knowledge of these guidelines was never considered by the courts to be a legitimate justification for malfeasance.

Falvey's emphasis is not on how to do clinical supervision, and she makes it clear that there is a great need for reflective theoretical developments in this area. Instead, her book is a compilation of information about the legal and ethical issues inherent in clinical supervision, regardless of the theoretical model being used by supervisor and supervisee. As she says, "this book is not about how to do supervision, but rather how to manage it effectively" (p. 3) in the context of multidisciplinary practice, diverse legal and ethical codes, and responsibilities that include administration, teaching, and clinical consultation. Falvey covers topics that include supervisor-supervise contracts and policies, evaluating supervisor competence, informed consent of client and supervisee for the supervisory process, confidentiality and its limits, and evaluation and documentation in supervision. She does not pull any punches and addresses topics that have caused every mental health practitioner and supervisor grave concern: clients expressing suicidal intentions, decisions about reporting child abuse at the risk of damaging an alliance with a client, having to counsel supervisees out in the field or document reasons why their employment should be terminated. The book has an "in the trenches" orientation that makes it all the more valuable for supervisors and practitioners facing the difficult dilemmas of contemporary mental health care. She opens every chapter with a case example that continues throughout the book. The example is complex enough to illustrate the issues Falvey addresses, although it lacks the actual interview process that would make it feel more "real" to an experienced clinician.

Falvey also documents the legal and ethical mandates that hold supervisors responsible for the supervisees' clients' wellbeing. The integrity of her commitment to clients is a laudable foundation of her work; for instance, she reiterates, "Probably the most troubling aspect of supervising comes with the recognition that we are ultimately accountable for the welfare of our supervisee's clients-even if we have no direct knowledge of them" (p. 70).

Falvey is able to pay attention to the perspectives of both supervisor and supervisee, and she is an advocate for both parties. For instance, she is frequently sensitive to emotional conflicts that can undermine supervisors' providing sound supervision, such as when supervisors hesitate to provide needed critical feedback because of their misuse of the supervisory relationship to meet personal needs for a "peace at any price" form of relating. Falvey also discusses supervisees' conflicts between wanting to improve client care, and their illusion that maintaining the supervisor's esteem means not disclosing aspects of their practice to their supervisors, even serious actions such as ethical violations. Moreover, she looks at the consequences of these problems. As an example, she cites a finding that 97% of supervisees report that they have not informed their supervisors about critical incidents in practice, thus exposing themselves, their clients, and their supervisors to considerable jeopardy (p. 83). Falvey highlights how important it is for supervisors to carefully select their supervisees because supervisors are inevitably dependent on their supervisees' accounts of their treatment processes, saying, "Given their degree of legal and ethical exposure in this role, supervisors should have the authority to accept or refuse to supervise anyone regardless of whether they are admitted to or hired by the institution" (p. 73). Moreover, given the difficulty and importance of clinical supervision, Falvey is concerned that, "Although seldom addressed in the literature, the reality for many practicing supervisors is that their employers fail to consistently provide the time or resources to conduct competent supervision" (p. 75).

Her work is short and powerful. It serves as an invaluable handbook. Its brevity, while a strength, means that some important issues were insufficiently treated. For instance, Falvey probably underestimates the profundity of the problem entailed in the diversity of theories used to practice in mental health care. The supervisor's theory invariably influences how supervision is conducted and how supervisees' practice is evaluated. Theories differ considerably in how they define the role of clinical supervision in effective treatment, how they define what the clinical supervisor should do, and how they define what the practitioner should do in order to provide competent care. The diversity and even incompatibility of theories is an important issue both for developing scientific foundations for mental health care (Tyson, 1995), including clinical supervision, and also for practitioners' everyday choices.

Consider the following three examples of the aims of clinical supervision, from three different theoretical models. A psychoanalytically-oriented supervisor in residential care emphasized that the role of supervision helps the supervisee to distinguish internal issues from the issues the client is addressing (Cohen, 1992). A recent study of a short-term, outpatient behavioral practice model notes that clients reported more satisfaction (using scales introduced into the therapy process) when supervisors simply shifted from discussing administrative concerns to asking supervisees questions about their clients (Harkness & Hensley, 1991). In a third theoretical model, intrapsychic humanism, one of the important functions of clinical supervision is to help the supervisee recognize how her/his caregiving motives (motives to genuinely nurture the client's psychological development) can be overridden by personal motives (all other motives, including motives to feel professionally confident). Because therapists can only provide care based on their experiences of having been cared for by others, which often have been suboptimal, without the help of a supervisory relationship, personal motives can preempt caregiving motives in ways that are invisible to the supervisee (Pieper & Pieper, 1990, 1999). The stable regulation of personal motives by caregiving motives is the sine qua non for effective intrapsychic treatment, and as such, clinical supervision is indispensable for the intrapsychic humanism therapist. Notice that a supervisor using any one of the theories above would evaluate a supervisee's work very differently than would a supervisor using another theory. In the context of theoretical diversity, how do we evaluate what constitutes effective supervision? Falvey recommends an explicit discussion and written contract between supervisor and supervisee about their theoretical orientations, which while practical and laudable, does not resolve the many questions raised by the diversity of clinical theories used today.

A related issue is the relationship between ethical and legal guidelines for supervision, and common, theoretically based practices. For instance, family therapy supervisors often ask supervisees to videotape their treatment sessions, and at times the supervisor even joins the treatment process. Ethical and legal guidelines state informed consent needs to be obtained both for videotaping and for supervision. In actual practice, however, things often do not seem clear. What does such informed consent consist of and who is eligible to give it? What constitutes a "no" vote? In one clinic example, a 7-year-old child, hearing that her treatment was to be taped, ran out of the treatment room, down the hall, and, despite the therapist's hot pursuit, quickly found where the videotape machine was that ran the camera, and turned it off. The therapists and supervisors proceeded with the taping, never taking the child's behavior as a communication of her protest against having her therapy session taped. In this instance, the theoretical rationale for videotaping and having the supervisor join the system is in conflict with ethical standards about informed consent and respecting the self-determination and dignity of the client (in this case, the dissenting child).

To delve more deeply into this issue, what does it mean for both the supervisee and the client when supervisors require their supervisees to tape-record client sessions for the purpose of supervision, or, when supervisor/researchers ask clients to fill out instruments about the effectiveness of service for the purpose of research about supervision, which they otherwise would not complete, as occurred in the Harkness & Hensley study above? Clearly, such efforts do not have a therapeutic purpose in themselves, but instead serve the causes of research and supervisee education, and it has been well argued that such interventions influence the treatment process and compromise the quality of service (Pieper, 1994).

Yet another example comes from an early study of psychoanalytic supervision in which a patient's treatment was being tape recorded for the purpose of group supervision. As the patient wanted to discuss very painful material and expressed difficulty exploring the issue with the tape recorder on, the therapist suggested the tape could be turned off The patient, relieved, shared more readily, then, as the patient became less distraught, the therapist asked to turn the tape back on. The author of the study did not address the ethical problem concerned with overriding the client's reservations about tape recording, and also did not report that any member of the supervisory group (which was hearing the tape) raised the possibility that the patient's treatment might have been damaged by the requirement of tape recording for so many third parties to the treatment relationship (Kubie, 1958), even though the data describe the patient's clear protests and description of heightened anguish caused by the tape recording!

Finally, disparities in power have a profound impact on supervisory and treatment relationships, and Falvey does not address these as thoroughly as they need to be in understanding the foundations of clinical supervision. For example, over a decade ago Paula Dressel noted how "patriarchy operates in the work place not only through men and women performing different jobs, but also through male supervision of female employees, male production of knowledge for women's work, and other features of the labor process" (Dressel, 1987, p. 295). Another form of discrimination invades the supervisory relationship when institutional racism puts a "glass ceiling" on the careers of people of color and holds them in subordinate positions, as supervisees, within agencies.

Also, Falvey could devote more attention to how clinical supervision can help supervisees with di versity issues in any form (sexual orientation, racial, cultural, socioeconomic status, status of disability). For instance, in addressing culturally sensitive clinical practice, Pindehughes emphasizes how important it is that clinicians develop reflectiveness about problems such as overidentification with clients from similar cultures, or negative assumptions based on prejudices about clients from other (or clinicians' own devalued) cultures (Pinderhughes, 1989). Presumably, clinical supervision is a most important way clinicians can develop their reflectiveness about their biases in practice with clients experiencing internal and external forms of oppression.

But my identification of these areas that need more attention when addressing clinical supervision is, at least in part, a sign that Managing Clinical Supervision is so good that it stimulates much thought and further questions. This is a book that agency administrators and supervisors, educators involved with clinical practice, and mental health care practitioners will find most helpful. Janet Falvey has provided us with a solid building block in the foundation for remedying the crisis in mental health care supervision that we all face today.

References

Cohen, Y., & Schneider, S. (1992). The effects of supervision on the "self" in residential treatment center counselors. Therapeutic Communities: the International Journal for Therapeutic and Supportive Organizations, 13, 107-115.

Dressel, P. (1987). Patriarchy and social welfare work. Social Problems, 34, 294-309.

Harkness, D., & Hensley, H. (1991). Changing the focus of social work supervision: Effects on client satisfaction and generalized contentment. Social Work, 36, 506-512.

Kahn, W. A. (1993). Caring for the caregivers: Patterns of organizational caregiving. Administrative Science Quarterly, 38, 539-563.

Kubie, L. S. (1958). Research into the process of supervision in psychoanalysis. Psychoanalytic Quarterly, 27, 226-236.

Pieper, M. H. (1994). Science, not scientism: The robustness of naturalistic clinical research. In E. Sherman & W. J. Reid (Eds.). Qualitative research in social work. New York: Columbia University Press.

Pieper, M. H., & Pieper, W. J. (1990). Intrapsychic humanism: An introduction to a comprehensive psychology and philosophy of mind. Chicago: Falcon II Press.

Pieper, M. H., & Pieper, W. J. (1999). The privilege of being a therapist: A new psychology, intrapsychic humanism, offers a fresh perspective on caregiving intimacy and the development of the professional self. Families in Society, 80, 479-487.

Pinderhughes, E. (1989). Understanding race, ethnicity, and power: The key to efficacy in clinical practice. New York: The Free Press.

Richmond, M. (1917). Social diagnosis. New York: Russell Sage Foundation.

Towle, C. (1963). The place of help in supervision. Social Service Review, 3, 403-415.

Tyson, K (1995). New foundations for scientific social and behavioral research: The heuristic paradigm. Needham Heights, MA: Allyn & Bacon.

Katherine Tyson

Professor

Loyola University of Chicago

School of Social Work

Chicago, Illinois

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