Supervision Ceus, Supervision continuing education, Supervision Course

Confidentiality of supervisees. Material obtained in supervision is confidential unless specifically stated in the supervisory contract or by exceptions recognized by the profession and law. Supervisees must keep confidential all client information except for purposes of supervision.

When a patient enters our office and psychotherapy begins, everything which is said or done by that patient, with few exceptions, are confidential. The patient holds the privilege to release the confidential information in legal proceedings. While you may object to the patient using these records, you must have solid grounds for your objection. While these are quite variable, generally patients can request and use their records in any way they please. In some instances, a legal guardian or conservator may hold the privilege if the patient is unable to do so. If the patient dies, their privilege passes to the patient's personal representative who handles legal affairs.

The holder of the privilege also has the right to read all information in his or her file with the exception of your personal notes which belong solely to you. Some therapists find this requires them to keep separate files so their personal notes do not become part of the patient's legal record. Your patient can read all notes which have their identifying information, diagnosis, treatment plan, prognosis, and other information including billing and information from other sources which you have included in the file such as notes from other physicians and hospitals. Any spare notes in the patient's file also have information which must be passed to the patient. All information in HIPAA notes are the patient's property and must be released. The file is the property of the clinician so copies must be made if the patient requests a copy of their file.

It is your responsibility to maintain the confidentiality of the records. Patient records should be kept in locked containers except when in use. They should be shredded when they are discarded to avoid the potential of having the notes fall into the hands of others. Office staff and others who handle the files should be made aware of the importance of confidentiality. Handle these records as if they were notes made by your own therapist about you. Your patient feels the same need to have the notes be private. Office staff, filing clerks, billing agencies, and others do not have the same burden of confidentiality as does the therapist. However, it is the responsibility of the therapist to inform the staff about the importance of confidentiality and to take reasonable action to be certain that staff does not violate the patient's confidentiality. While this is a solid part of HIPAA, it seems to be regularly violated by clerks and other office staff. Often my patients who work for or with counselors in the community or in government report cases which are confidential which they have read with avid interest. Try to keep this sort of clerk off your staff.

Duty to Warn - Tarasoff is directly relevant to supervisors. Tarasoff implicated the supervisor also. The Supervisor is also responsible for advising the supervisee about conditions in which it is appropriate to warn an intended victim.

In 1976, important case law was made in California which is now followed throughout the United States. A romantic young man, Prosinjit Podder, from India, fell madly in love with Tatiana Tarasoff who did not reciprocate his desire. He confessed his intention to cause her bodily harm to his psychologist at a clinic at UC Berkeley. He subsequently murdered her. The unfortunate psychologist had followed the law which until then required psychologists to keep all information from patients confidential and to disclose threats only to the intended victim. Luckily, the case came to be known by the name of the murdered young woman and the defendant was the Regents of U of C so he is never named. The California Supreme Court determined that confidentiality laws did not apply when the following rules are met.

1. The threat must be communicated to the psychotherapist directly by the patient.
2. Serious threat of physical harm is imminent.
3. The potential victim must be reasonably identifiable.

In this case, the psychotherapist must:

1. Warn any and all potential victims.
2. Notify authorities including the police, sheriff, or call 911.
3. Take steps of some sort to prevent the threatened danger.

Case law has continued to add to the confusion about when Tarasoff applies. One case found it applied when property was threatened, another found it applied when there was no overt threat but a history of violence, in another case Tarasoff was found to apply to communicating threat of suicide to subsequent caretakers.

Under Tarasoff, the psychotherapist has the duty to both warn and protect potential victims.

A therapist is also required to breach confidentiality when a patient threatens to harm another person but there is no imminent danger or the victim's identity is unknown. In this case, however, the therapist is to take steps to prevent danger but is not to notify authorities or the potential victim.

Therapist are also required to breach confidentiality if the patient is in danger of committing suicide and is to take steps to prevent the danger from occurring. In most cases, this requires the therapist to hospitalize the patient.
The courts have required that therapists be able to predict when a patient will act on their impulses and cause bodily harm to themselves or others. Therapists, regardless of their experience are unable to predict when or if someone will be dangerous. Research has consistently borne out that therapists cannot predict violence above the level of chance (Stromberg et al., 1988; Bednar et al., 1991; Otto, 1992; Simon, 2001).

Some traits are more likely than others to predict violence, with the most robust being a history of violence (Simon, 2001), male gender (Simon, 2001), substance abuse (Stromberg et al., 1988). Peterson et al., 1983 has shown some positive results in identifying people who are likely to commit suicide. The scaling is simple and quick on the SAD PERSONS test and the results have been replicated (Campbell, 2003; Juhnke, 1994,1996).

Supervisors must make sure that the supervisee has informed the client of the parameters of informed consent. This must include, but is not limited to, disclosure that the supervisee is an intern and what exactly that means. They must inform the client of the supervisory relationship. They must disclose the laws surrounding confidentiality and exceptions to confidentiality. Supervisor can verify this information by using a disclosure statement that contain all of the information necessary. Have the supervisee and client sign the disclosure statement.

The supervisor should inform the supervisee of the evaluation process they will use to determine the supervisors progress. The evaluation criteria and standards that need to meet should be discussed.

It is important to note that regardless of your behavior a patient may decide to sue you for malpractice. This could include you as well as the supervisee. This is a frightening prospect, since the grounds for filing a lawsuit are so vague that even the finest, most ethical clinicians find themselves involved in litigation which threatens to take away their license, their means of livelihood, and substantial sums of money.

The development of an ethical practice, however, may help you to avoid some of the more important pitfalls. Regardless of how many times you read through the law, regardless of how many classes you take in ethics, regardless of how well you follow the rules of the profession, make no mistake, this is a path you will need to pursue consistently throughout your career.

To be sued successfully for malpractice in a civil court, the client must prove that you have breached the standard of care (Black, 1996). There are four parts which must be seen by the court to have been met for the malpractice suit to proceed.

(1) In some way as a supervisor you have established an agreement between yourself, your supervisee and the client that you will work together in a therapeutic relationship. The law does not define this in terms of the length of time the patient has been seen or whether or not the patient has paid you. It is entirely the responsibility of the court to determine whether you have established a Duty of Care with the patient.

(2) The work done with this patient will be compared to the Standard of Care. This is also defined by the court based on what the court finds is the typical level of proficiency which would be shown by a supervisee under similar circumstances. It may be defined or suggested by an ethics code, a state standard, or case law. There is no clearly defined standard of care since both you and the circumstances in which the act occurred are unique.

(3) The client must show that there has been some Demonstrable Harm. Although some texts may imply that it is difficult to show demonstrable harm if it is psychological in nature since the client began treatment presumably due to harmful or painful problems which they hoped to cure, again, it is entirely the duty of the court to determine if you caused harm and, if so, how much harm was caused. The amount of harm caused whether psychological, physical, or financial can only be remedied in a civil suit by money. The court also decides how much money should be given the client (now plaintiff) for the harm caused.

(4)The client must also prove the supervisor and supervisee was directly responsible or the Proximate Cause for the harm which was done. So, the client must prove that the supervisee had an established relationship with the patient which would prove there was a duty to care, was working below the standard of care, which caused demonstrable harm to the client which could only have been a direct result of the supervisees actions.

Despite these levels of proof which sound difficult to attain, many therapist are sued successfully or have out-of-court settlements against them each year. Following a successful suit or settlement, one should expect an investigator from the licensing board to determine whether or not the actions taken by the counselor were egregious enough to sanction them by loss or suspension of their license, additional classes to educate the counselor and attempt to prevent further problems, or other measures.

First, it is important to take care of yourself. Supervisors who are having problems within their own families, use alcohol or drugs inappropriately, are having emotional problems, or simply need a vacation are the most likely people to make minor and major errors in judgment. This may occur from the distraction caused by the supervisor's own problems or from unconscious motives which are more likely to be enacted when one is not at one's best and inhibitions are lowered.

Second, stay in touch with changes in laws through professional organizations. Maintain your memberships and attend meetings on a regular basis. This will also help you make and maintain friendships with other practicing clinicians. You are likely to find it is helpful to know someone you trust for a consultation if you do find yourself feeling that a patient may cause problems for you. Your friends may also tell you in a much nicer way than the licensing board that you need to take a break from work.

Third, take frequent breaks from work. You will have a better chance of staying on top of your cases and come to work with a smile.

Fourth, look at your mail at a time when you can do some reading. Instead of stacking the journal you just got, scan through the articles and read the ones that interest you. You could impress your colleagues at professional meetings by dropping names and you could even try out some of the new techniques you read about and develop some skill with timing.

Fifth, if you or the person you are supervising has a patient walk in who describes a history of lawsuits, suicide attempts, and has a gambling problem which might cost him/her more than one can afford and you feel the acid turn in your stomach and your headache begin, check on the client's current level of suicide risk then on your the level of expertise needed to manage this difficult client. Do not agree to let the supervisee see anyone who walks in the door. Do not let the supervisee take on more clients than they and you can reasonably manage. We all learn from the work we do with our clients and our toughest clients teach us the most, however, to provide the client with the best care and to take care of yourself, seek information from those around you, especially experts. Reading journals and books on the topic is also very useful but it can lead to a false sense that you understand the problems you face with that particular client when you only understand the issue in a broad sense. All clinicians are much better in some areas than others and it is incumbent on the practitioner to know where they stand in their ability to treat different sorts of difficult clients.

Sixth, and most importantly, do your paperwork. It gives you time to reflect on what you are doing with the supervisee. It is also illegal to fail to do it. Some people find they do this best when they complete a formal note in the 10 to 15 minutes between sessions while others find they need to lay out an hour several times weekly or a long afternoon to get it done. Do not underestimate how much time this takes. Completing HIPAA notes can become very quick and efficient if you have a system and do them regularly. On the other hand, trying to recreate the important points of a session from hastily sketched notes during an intense session at the end of the week is nearly impossible. You remember that it was an important session but often lose the crucial meaning which was derived from the work done that day. The main idea to remember is not to fail to do notes until you find yourself served a subpoena by a court or a disability claimant. The notes you create at those times are not beneficial to you or your supervisee because they lack credibility which comes from a case note which is written soon after the session. While all this seems self-evident, it is important to recognize that keeping notes for anything other than an aid to treatment in most cases was rare until HIPAA was imposed only a few years ago. Many of us had become quite comfortable with brief, non-HIPAA compliant notes and, although we plan to change that habit, have not yet done so. Do it now. You will sleep better.

Last, know your limitations. Refer the client when you have no experience or training in treating the presenting problem. Refer them if they scare you and you feel you will not be able to find a colleague or supervisor who can help you sort out whether or not your supervisee should give this patient a try and if you have someone to help if you find you have trouble. Refer the client to a physician when you have an odd feeling that the problem does not sound solely psychological. Always refer them if there is any question about whether medication would be helpful. If they refuse, note they refused and why. Refer patients who abuse other substances if that is not an area of expertise or one in which you want to develop expertise. Having a drug or alcohol problem may seem minor and secondary to the primary diagnosis but it is amazing how frequently a drug or alcohol problem becomes the main problem very quickly or the main reason why no progress is occurring in therapy. Many of us had the fortune to be trained by masters of the craft of psychotherapy either during or after graduate school. Many of us have become the new masters of the craft. Still, for each and every one of us there are people who walk through our doors as clients and walk out as potential plaintiffs. Even the grand old masters have this happen so it can certainly happen to you.

Try to avoid doing anything which will cause you to have problems with the Licensing Board. Keep up on your paperwork. The State Board can require you to produce case notes in a very short time. If the Licensing Board sends you any sort of inquiry, do not take it lightly. Make sure they have experience. Do not just dash off a letter which answers the questions asked by the board. If they have written you and asked for a response, it is a serious inquiry about your treatment practices. The Licensing Board takes your responses seriously and what may appear to be a simple misunderstanding between yourself and your client could result in having to defend yourself and your license before a member of the Licensing Board. Make sure you have Malpractice insurance to cover the fee for an attorney to defend you. Being sanctioned by the Licensing Board is a public process and even if you do not lose your license temporarily and have to take additional classes or other tasks to bring your standard of practice up to that of other clinicians, you may lose your referral base. You will also be likely to find yourself the subject of gossip. The Licensing Board also may determine that you should lose your license to practice psychology permanently. This does not preclude having criminal or civil charges brought against you or your supervisee by your client(s). All of this is quite public also.

Try to avoid actions by ethics committees by following the rules and guidelines for practice. Make it a habit to check in on the state web site and the Licensing Board Web site on a regular basis so you know when laws are changing. Unfortunately, some therapists were convicted of violating ethics of their profession when they were following what had been a typical pattern but was in the process of changing. When you are uncertain about the rules, ask. Get answers in writing if possible. Know the name of the person with whom you spoke regarding how to most appropriately do tasks or render treatment. Consult with other supervisors and inform them of the difficulties you face. Seek legal consultation. The fee you spend may save your livelihood. Be wary of dual relationships. Be wary of any sort of variation in billing and collecting fees. Be aware of what you put in writing and that the information can be passed on to others even without your knowledge or consent, leaving you in a legal limbo which will certainly require an attorney.

The Attorney General is involved in these proceedings. They are the most serious offenses, usually involving fraud, collusion in criminal activities, and a variety of criminal offenses. In your practice, you do many things totally on your own and you are aware that within your office what occurs is privileged information. This requires that you set the standard higher for yourself and supervisee because a small bit of cheating quickly spirals into greater corruption. Do not lie, cheat, steal or engage in any behavior which could appear to have involved illicit activities. Do not enter into relationships with your supervisee which involves felonious behavior. Make it clear to supervisees who wish to have you collude with them in illegal activities that you will not do that and you must report behavior which would cause harm to others. Although therapist are rarely involved in these activities, conviction results not only in the loss of your license, it also results in criminal prosecution and incarceration. Some of the most frequent offenses involve defrauding Medicare by claiming to have performed services which were either not performed or were not reasonable treatment for the patients involved. These have usually involved large numbers of patients.

Heading Off Boundary Problems: Clinical Supervision as Risk Management

The effective management of risk in clinical practice includes steps to limit harm to clients resulting from ethical violations or professional misconduct. Boundary problems constitute some of the most damaging ethical violations. The authors propose an active use of clinical supervision to anticipate and head off possible ethical violations by intervening when signs of boundary problems appear. The authors encourage a facilitative, Socratic method, rather than directive approaches, to help supervisees maximize their learning about ethical complexities. Building on the idea of a slippery slope, in which seemingly insignificant acts can lead to unethical patterns of behavior, the authors discuss ten cues to potential boundary problems, including strong feelings about a client; extended sessions with clients; gift giving between clinician and client; loans, barter, and sale of goods; clinician self-disclosures; and touching and sex. The authors outline supervisory interventions to be made when the cues are detected.

Today the law recognizes this special role by defining a fiduciary relationship between the expert professional and the vulnerable client (3,4). The fiduciary responsibility puts the relationship in an ethical framework that bars the professional from self-dealing and from situations in which his or her personal interest conflicts with the client's (3,5). The professional is prohibited from exploiting a client and must refrain from actions that might be harmful to the client (6). This prohibition implies that minor harm can lead to serious harm (7).

Gutheil and Gabbard (8) have warned of the existence of a "slippery slope," on which unchecked seemingly insignificant acts can catalyze the development of unethical patterns of behavior. More recently, these authors have cautioned against simplistic, literal applications of their ethical warnings about boundary crossings and their relationship to violations (9). Noting the pendulum swing of policy and opinion, they call for a moderated application of boundary concepts to ethical practice, an idea that is consistent with earlier representations of ethical standards (10).

The complexities and varieties of contemporary mental health practice settings make a literal application of ethical standards impractical. Mental health professionals now work in settings ranging from formal institutions, such as psychiatric and general hospitals, outpatient clinics, nonprofit agencies, schools, private- and public-sector workplaces, and prisons, to clients' homes, which may include arrangements for assessment and treatment, intensive case management, family preservation, home health care, employee assistance programming, and hospice care. Because of the complexity of these settings and the nontraditional roles of service providers, the boundary rules governing traditional assessment and treatment are not easily applicable. Unfortunately, this situation results in the absence of clear rules or guidelines.

More important, many clients involved in these less structured treatment modalities are disenfranchised individuals who are at greatest risk for exploitation. Many are low-income minority clients with serious mental and physical disabilities that include deficits in cognition, judgment, self-care, and self-protection.

The promotion of cultural diversity in treatment environments often encourages expansion of traditional professional roles (11). The literature in this area calls for more flexible roles and more out-of-office services carried directly to the client in the client's own environment (12). However, these situations can create even greater power differentials between provider and client than are generally found in office-based psychotherapy practices. It can be argued that a higher fiduciary duty exists for mental health professionals who serve clients in less structured settings and that the relaxation of traditional roles carries with it an increased responsibility to define practice-specific ethical guidelines to protect the vulnerable client.

In this paper, we propose that agencies or practice directors and clinicians articulate practice-specific guidelines for ethical boundaries and establish supervisory processes to inhibit misconduct through careful scrutiny of early warning signs of boundary problems. We identify ten cues to possible boundary problems and suggest supervisory responses.

Clinical supervision to support ethical practice

Fundamental ethical principles can inform practice, but the complexities of the practice environment suggest that program directors might need to develop ethical guidelines adjusted to local culture, program aims, and the capabilities of providers (13). A clear and reasonably specific set of principles or ethical standards is recommended to guide local practice. The standards should be promulgated to all staff and should be signed by each provider, documenting proof of being informed.

However, developing and distributing ethical guidelines or standards does not go far enough. Clinical supervision can be used to apply general ethical guidelines to the complexities of practice settings and the uniqueness of a particular case (14,15).

Clinical supervision can support practice within ethical boundaries by following four major principles. First, the supervision should be proactive rather than reactive. The supervisor should not wait for calamity to review the supervisee's work. Supervision should be continuous and of varying intensity, based on the clinician's caseload and other characteristics of the practice setting, such as changes in funding, management, or contractual obligations.

Second, the supervision should be sensitive to the supervisee's personal situation. A supervisor should be aware of significant changes in the supervisee's life that might indicate increased vulnerabilities. Recent divorce, severe relationship problems, serious illness, or death of a loved one can leave a clinician emotionally vulnerable. A clinician who has previously practiced without distress can unexpectedly change the manner of relating with clients and create boundary concerns.

Third, the supervisor must pay attention to the details of the supervisee's cases and the interactions between clinician and client. For example, it is not helpful to simply rely on diagnostic labels to explain clinician-client problems. Instead, the supervisor should ask the supervisee to relate the full narrative sequences of clinical encounters. The patterns or themes found in the clinician-client interactions can capture meaningful content for further analysis and examination.

Fourth, the supervisory interaction should incorporate guided exploration rather than cross-examination (16). Although focused investigation can play a role during a crisis, the routine supervisory process will generally discover more useful content through less directive means. We recommend the use of the Socratic method, in which the supervisor asks a series of questions that guide the supervisee to reveal and understand his or her clinical judgments and behaviors and, optimally, develop more appropriate views (17).

Using these four principles, clinical supervision can be an effective process for detecting cues of potential boundary problems and exploring them. Based on the literature and practice, we identify ten cues that suggest possible boundary problems. Each is paired with a recommended supervisory response. Whether a boundary problem is serious or not depends less on what the clinician believes than on the regressive response or other harmful response it evokes from a client. It is also important to note that what might be helpful for one client can prove harmful for another; supervisory responses must be tailored to the specific clinician-client situation.

The cues and responses described below generally proceed from less serious to more serious. However, the order in which they are listed does not reflect an absolute ranking.

Clinicians may confuse personal caring with professional caring (18). Although such confusion generally occurs with novice clinicians, experienced clinicians are not immune to it. Strong personal feelings about a client can indicate a developing personal relationship. Contemporary community-based programs sometimes encourage a more personal interest in the client as an alternative to institutional, regimented services. The supervisor can guide the clinician to develop warm but professional relationships.

Because strong feelings are not always a problem in themselves, the supervisor should first elicit the source and quality of the clinician's feelings about the client, with the goal of promoting greater insight. Second, the supervisor should survey the intensity of the feelings and contrast the case to others in the clinician's caseload. The supervisor should then ask the clinician to examine these feelings to encourage self-observation and professional discipline.

The practice of extended sessions often develops from strong feelings about a client. An occasional episode should be little cause for concern. A pattern, especially with particular clients, is a cue to potential boundary problems. Many community-based programs place a high premium on flexible care that prioritizes the client's needs. Supervisors can help determine whether it is the client's or clinician's needs that drive the clinician's actions. Supervisors should also monitor the equity of clinical services to avoid favoritism or neglect.

The supervisor can explore the clinician's reasons for longer sessions with a client as a way of discovering subtle favoritism or other personal bias toward the client. Simply exploring these issues may curb the practice. Explicit instruction to shorten sessions or reassignment of the case may become necessary when this approach fails.

Contemporary case management programs often expect certain providers to transport clients to programs and services. In such cases, the case manager should be guided to avoid expressive psychotherapy that might explore deeply personal issues. Case managers bear considerable responsibility for drawing clients into services and for facilitating the client's access to care. When a case manager is spending considerable time with a client in the car, in the home, and in nonoffice settings, it is possible for the client and case manager to blur professional and personal roles.

A client who is enrolled in a welfare-to-work program and who has emotional problems might have difficulty understanding the professional limitations on companion-like case management services if the case manager, acting like a clinician, also delves into the client's emotional problems. The suggested intimacy arising from deeply personal conversation in the privacy of an automobile may tax the boundaries of both client and case manager. Vulnerable clients may be unable to adjust psychologically from the intensity of in-depth counseling sessions to more casual contact in the automobile. Emotionally vulnerable clinicians may experience the same problem when they step into a case manager role and have less structured engagements with clients. This practice is more worrisome when the clinician independently decides to transport a client without program approval.

When such a situation is noted, the supervisor should draw a clear line between case management and intensive psychotherapy practices. Performing both roles with the same client is a risk factor for boundary problems. The supervisor should help the case manager or clinician understand and avoid role confusion.

Current clinical practices sometimes demand the clinician's ready availability to the client. Some new therapy approaches recommend the clinician's availability for even minor "emergencies," such as in treating patients with borderline personality disorder (19). However, four practices can indicate potential boundary problems in these cases: clinicians' giving clients their personal telephone numbers (rather than the number of an answering service or crisis line), a pattern of initiating calls to clients rather than receiving them (except in serious emergencies or to monitor client safety), frequent or lengthy calls, and a pattern of late-night or weekend calls. These practices involve the clinician's personal space and privacy. Unchecked, such access invites the possibility of increasing levels of intimacy.

When off-hours calls are an issue, the supervisor should explore the clinician's goals for such contacts. Likely areas for inquiry include the clinician's need to be needed or to be considered special by the client. The supervisor should help the clinician achieve more realistic expectations about the clinician's role and appropriate services (20).

Token gifts of appreciation from clients are not of great concern, and within certain cultures, gift giving is often expected. Supervisors need to be sensitive to the cultural dimensions of gift giving, but they should also pay attention to possible boundary problems.

Three concerns arise with client gift giving—the timing of the gift, such as a birthday or Valentine's Day gift; the gift's monetary value; and its personal specificity. Highly personal gifts, even of modest dollar value, should be cause for supervisory concern. A clinician's acceptance of gifts suggests that the clinician-client relationship has changed. Likewise, gifts from the clinician to the client, except when sanctioned by program guidelines, should prompt a supervisory response.

The supervisor should help the clinician explore the possible meanings of the client's gifts. The supervisor should explore how the clinician's and client's perceptions of their relationship might be changed by the gift, either positively or negatively. When gifts are very personal or expensive, the supervisor should help the clinician understand why accepting them could be harmful to the client. They should also explore ways to return items with minimal disturbance to the clinical relationship. In such situations agency rules should be helpful. The clinician can thank the client for being thoughtful but disclose that ethical codes prohibit accepting gifts. This response helps prevent the client from feeling a personal rejection.

Many community-based programs, particularly for persons with serious mental illness and emotionally disturbed children, use in-home therapies to minimize risk of institutional care. Although many of these therapies focus on psychosocial skills training rather than expressive psychotherapy, they can create opportunities for boundary problems. Home visits that are outside sanctioned treatment should be examined very closely. Frequent visits combined with signs of personal interest in the client should prompt more focused supervisory review.

The supervisor should inquire about the clinician's feelings of special interest in the client. Inquiries may lead to exploration of the clinician's rescuer fantasies. Likewise, the clinician's anxiety or ambiguity should be examined in detail. The supervisor should take steps to reduce contact or transfer a case when there are signs of overinvolvement. The supervisor should immediately intervene if there is reason to believe that a client or a clinician is being exploited.

The clinician who overidentifies with a client might experience a need to do things for a client rather than help a client accomplish goals and learn to do things for himself or herself. At first, this behavior may appear relatively harmless or even admirable. However, such signs of enmeshment can suggest overinvolvement with a client and potential boundary problems. A clinician involved in this type of relationship might be unaware that the boundary has been crossed. For example, the clinician might believe that the actions truly benefit the client and that diminished involvement will result in the client's feeling abandoned.

In response, the supervisor should explore how this case differs from others in the clinician's caseload. The clinician's perception of unique circumstances or characteristics should provide opportunity for further discussion and, if necessary, confrontation. Uniqueness is especially troubling when it presents in two forms—the clinician's perception of a unique client circumstance or the clinician's belief that he or she has qualities that are uniquely fitted to the client's needs. In either case, the supervisor should focus on the clinician's distorted thinking and consider whether overinvolvement is the clinician's characteristic way of dealing with other people or the response to a particular type of client. If the clinician cannot adequately respond to such redirection, vigorous supervisory intervention is indicated.

Financial interaction between a clinician and client other than payment of fees is a boundary issue. Borrowing or loaning money is not always a profound ethical violation; nonetheless, it certainly warrants detailed evaluation. The use of agency funds available for client emergency needs are not a concern. The transfer of personal money or property to or from the clinician is entirely different. Bartering clinical services for goods or other services is ethically troubling and is certainly cause for supervisory exploration except in practice areas where cultural standards have made this practice more normative (21).

The supervisor should state the ethical limits regarding financial transactions with clients. Clear policies and procedures should be established to provide the clinician with unambiguous guidelines about financial issues with clients. The supervisory stance should be firm and generally inflexible. The risk of exploitation of a client in these matters is great.

Clinicians who disclose personal circumstances to clients open the door to boundary problems. Limited and clinically directed disclosures can be helpful, and in certain cultures, they are almost essential. However, disclosure of highly personal information is rarely welcome or justifiable. Clinicians who are vulnerable due to personal losses or substance use may make personal disclosures to remedy their own loneliness. Overly personal disclosures by the clinician can suggest mutuality in the relationship rather than collaboration for treatment purposes.

The supervisor should first explore the clinician's rationale for self-disclosure. Next, the supervisor should explore with the clinician the possible dynamics of such disclosures and their potential risks. The clinician should be coached on how to therapeutically redirect a client's requests for inappropriate personal information about the clinician. The supervisor should continue to monitor this issue very closely.

Some therapists use touch and hugs in their work. We consider this a high-risk practice for most mental health treatment environments. Although the occasional hug might be therapeutic, the risk of harm contradicts its use. Some children's therapists might hold a different opinion. Some young children may need physical reassurance in the course of clinical work. We recognize this need, but recommend careful monitoring of this practice with children.

In some cultures touch is an essential part of meaningful exchange, and its significance must be taken into consideration. Work with elderly persons represents another important exception—touch can be a critical part of therapeutic engagement with this population. However, as a general practice in most mental health settings, physical contact is high-risk behavior.

One might argue that seasoned clinicians could be granted greater license in this area than those less experienced. Unfortunately, experience does not immunize, and even seasoned clinicians can delude themselves into believing that sexual touching is therapeutic (22). Furthermore, despite the clinician's intentions, even "therapeutic" physical contact may be interpreted as sexual by the client (23,24).

The inequality of power and control in the clinician-client relationship also contributes to distorted perceptions of touch (25). Touch has a tendency to escalate physical response, particularly for clinicians who are as emotionally vulnerable as their clients. Sexual contact with clients is simply unethical and actionable (26,27,28,29,30,31). Psychiatry and social work have perhaps the clearest proscription against the behavior, including sexual contact with former clients. Although the major mental health professions have defined sexual behavior with current or former clients as unethical, less established professions with less clear licensure and certification standards have less clearly stated policies.

At the beginning of the relationship with a new supervisee, the supervisor should express clear rules or guidelines for physical contact with clients. The supervisor should coach the clinician on ways to show support or comfort that do not require hugging or other forms of touch. The prevalence of sexual abuse histories among mental health clients should be discussed along with the possible ramifications for clinical practice.

Conclusions

Gutheil and Gabbard (8,9) have now described a more gradual application of boundary guidelines than their earlier writings might suggest. We agree and suggest that the diversity in practice settings, cultures, and client populations calls for practice-specific ethical guidelines. Guidelines adjusted to the specific practice area can avoid both the rigid application of generic rules and purely subjective case-by-case decisions. Overly rigid rules can inhibit meaningful practice, while subjective decisions are not tested against the broader ethical consensus.

Not all clinicians are able to arrive at appropriate decisions without the benefit of dialogue with others. In fact, too much independence may be a risk factor. Strict adherence to rigid rules, on the other hand, is simply unrealistic. As an alternative to rigidity or idiosyncratic practices, we argue for the use of effective clinical supervision as a primary tool for managing the risk of boundary problems.

As administrative, educational, and monitoring resources become more scarce and as cases become more complex, the likelihood of boundary problems increases. Boundary crossings and violations may damage clients, clinicians' careers, agencies' reputations, and programs' credibility (32). Programs serving minorities, welfare recipients, persons with severe mental illness, and severely emotionally disturbed children face additional risks with already vulnerable populations. In-home services, case management, and other nontraditional services expose clients and clinicians to informal private settings. Without regular, proactive supervision, clinicians and other providers can easily lapse into boundary problems.

Clinical supervision can offer compassionate and cost-effective risk management by addressing clinical events higher up on the slippery slope. The supervisor who intervenes with a clinician's overuse of the telephone or too frequent use of home visits may prevent a lapse into sexual misconduct with a client. By using the four principles of proactivity, sensitivity, attention to narrative detail, and a commitment to Socratic methods, the supervisor is positioned to intervene successfully. The ten cues offer supervisory guideposts for discussion and inquiry.

The practice of supervision of psychoanalytic trainees has gone through a series of changes as psychoanalysis matured. Beginning with the earliest Freudians, however, an important part of learning to do psychoanalysis is to be a patient of someone who is well trained in how to do psychoanalysis appropriately.

Since the beginning, there have been as many variations of psychoanalytic thought as there have been psychoanalysts. Each analyst adopts techniques which seem to work best with their particular set of patients as well as changing in minor or major ways while seeing different patients. In general, patients lie on the couch, free-associate, discuss their dreams, and are provided with interpretations from the analyst. The emphasis is on making the unconscious conscious as the primary means to achieving an understanding of oneself and alleviating symptoms.

Thus several of Freud’s patients followed his general technique while others, most notably Jung and Adler developed techniques which are quite distinct from their analyst. Even today, many analysts can trace their “family history” through their analyst in an unbroken chain back to Freud.

In the United States, the American Psychoanalytic Association controlled who would become supervisors or “training analysts” until about 1990. Before that time, only psychiatrists were admitted to institutes certified by “the American.” A long-term lawsuit brought by psychologists on the basis of restraint of trade, eventually led to the American Institutes accepting psychologists, doctoral-level social workers, and eventual marriage and family counselors as full students who were capable of not only becoming psychoanalysts but also training analysts or supervisors.

During this lengthy and acrimonious lawsuit, psychologists and other mental health professionals set up and developed training programs of their own; many of which were certified and affiliated with the International Psychoanalytic Association. Outside of the United States, other mental health professionals were welcome, even encouraged to attend psychoanalytic institutes and become training analysts. In the United States, the earliest and longest-lasting is the William Alanson White Institute, following the techniques elaborated on by Harry Stack Sullivan. Many other institutes have emerged and have solid reputations for training psychoanalysts in the United States in variants of Freudian, Jungian, Kleinian, and other schools of thought.

Traditionally, the beginning student of psychoanalysis takes four years of formal classes. Typically students who are admitted to institutes have experience in doing psychotherapy and have had their own practices for several years. This is important because the training can be expensive. During the years of training, the student is also expected to be in analysis from three to five times weekly with a training analyst who has been certified by the institute, and until recently, the American Psychoanalytic Association, as a training analyst. The classes focus initially on theory but quickly move into a blend of theory and technique. The student is expected to pay a reasonable fee for analysis.

There is an emphasis on case presentations so students can learn from the work of others including psychoanalysts about whom they have read, their own teachers, and their peers. The learning environment is a rich one and discussion about everything, including the foundations of psychoanalysis itself is encouraged. Classes are generally small and in many cases becoming smaller because of the expense and time required for training. Freud is read extensively as are commentaries on his work.

After the first year, students are encouraged to find a patient they can see several times weekly, preferably four or five, who is also committed to the process of psychoanalysis. Prior to beginning to do analysis on a patient, students must acquire a license which legally allows them to do psychotherapy. Some psychoanalytic institutes operate a clinic to serve patients who are unable to pay much for analysis. This also helps to provide a pool of patients for students. This “first patient” is expected to lie on the couch, free-associate, and be provided with interpretations as does the student with his or her own analyst.

Additionally, the student chooses a supervisor for the case. Because the psychoanalytic institutes in America follow their own rules and guidelines rather than being governed by state or federal laws, students are free to choose a supervisor who may have substantially different training. This supervisor does not provide “hours” for obtaining a license. Supervisors, like analysts, are paid privately by each individual student. The amount which is paid varies but is generally based on the fee the patient pays rather than on the supervisor’s regular fee. Psychologists may, for instance, choose a psychiatrist, marriage and family therapist, or social worker rather than another psychologist. There is generally a trial period to ascertain whether the supervisor and student will work well together. Either may decide that the relationship between them will not promote a solid learning experience. It is important that the supervisor trust the student to bring up important issues, particularly problems, encountered in treatment. The student must also be trusted to tell the truth about what occurred in the session and work toward understanding the transference and countertransference. Some supervisors also share their personal opinions and emotions while others retain a greater distance.

The supervisor is generally seen once weekly for an hour. During that time, the supervisor may ask how the case is proceeding in a manner which is unique to the supervisor or the student may bring up issues of interest. Generally notes are not brought to supervision sessions nor are notes taken during the treatment of the patient since they are seen as interfering with the analytic process. The supervision session may focus on the therapy as a whole or on specific issues which the student is finding difficult. The student is considered to be the expert on the patient since they are in the room with them. The role of the supervisor varies but it is usually to provide insight into developing issues between the student and patient which may not be noticed by the student due to transference, countertransference, and inexperience among other reasons. Generally a bond and trust develop between the supervisor and student which may last throughout the association of each with the institute.

The patient’s symptoms and history are presented before an open committee with both the student and supervisor present along with at least one other training analyst. Primarily, the task of this committee is to help the student recognize whether or not the patient is appropriate for analysis and to determine whether the student has enough expertise to work with the patient successfully. Technique and countertransference (or feelings and thoughts of the student about the patient) are discussed as well with an emphasis of pointing out possible difficulties before they begin to occur. While many students find these meetings intimidating, they are a necessary part of integrating the student and supervisor with the ongoing work of the Institute. Despite the findings of the committee regarding the suitability of the analysis, if the student and supervisor decide to continue with the analysis, they are free to do so without criticism.

In the second, third, and even fourth years, the students choose two additional patients and two other supervisors. This is considered to give the students a broader understanding of the process of psychoanalysis as well as to clarify that different analysts work from different premises, use different techniques, and provide supervision for their students in different ways. The student must see at least three patients for at least a year with the supervisor they have chosen to work with them.

In addition, the cases, appropriately disguised, are often discussed with other committees. At least one case is written in formal psychoanalytic style which recognizes the transference or feelings of the patient toward the student-analyst, the countertransference, the main interpretations which led to change and growth, and how termination of the case and the transference was done.

Students are also given an oral exam by two examiners chosen by the institute to ascertain that they have learned the material presented in their courses. Analytic students are expected to learn not only technique but also the deeper levels of theory which underlie the techniques. The oral exam is broad, covering all types of analysis taught by the institute.

Subsequent to graduation, some students are asked to teach courses along with other faculty members. This may continue throughout the member’s life with the institute. Others prefer not to teach at the institute and may do research, develop a psychoanalytic practice, teach at a university, or a variety of other activities which use the material they have learned.

A few students become training analysts or supervisors themselves. While this step has until quite recently been a part of the American Psychoanalytic Association who determined whether or not a faculty member who had written an additional case for the American and acquired certification as an analyst, Institutes which are part of the American are currently changing this process so they can choose their own training analysts from among their members. A committee is elected to choose members who show promise of being excellent supervisors. Usually these are people who have devoted time to teaching, serving on a variety of committees which run the Institute, written and presented original papers, and are well- respected and well-liked members of the analytic community.

It should be emphasized that there is no specific manner in which supervision is done in analytic training, instead, the student and supervisor create a unique relationship in which to discuss the patient. Both the opinion of the student and the supervisor are considered to be worthwhile in treating the patient. Both can also be incorrect in their understanding and change as the analysis progresses. The student is free to use the supervisor’s suggestions or not depending on how the relationship of the student with the patient develops.

Because of the confidentiality of the relationship as well as the openness of the student, supervisor, and patient, case studies are carefully guarded. The identity of the patient is consistently disguised by giving them different ages or occupations for example. The only time the patient is discussed in detail is with the supervisor, and even then, the patient’s real name is not used unless it is relevant to the analysis.

Therefore, unlike supervision which is usually primarily didactic, this analytic supervision involves the student and supervisor as a team with the supervisor as the senior member. They attempt through their insight, experience, and understanding to help the patient be freed from the unconscious thoughts, memories, and emotions which lead to unwanted symptoms.

Student: My patient reported a dream to me yesterday. In the dream, he was dating a woman from work and had taken her to dinner. Everything was fine until he noticed that he did not have silverware. Then he tried to signal the waiter and discovered he had no arms or hands. He woke up in a panic. I waited but he didn’t say anything so I suggested that the dream created so much fear, he could not think about it long enough to have associations to it. He was still silent so I felt I had gotten it wrong.

Supervisor: Was there something about the dream which made you feel that you should say something?

Student: Well, after awhile, I started feeling like I wasn’t doing anything helpful. There was just silence and nothing was happening… I felt pretty useless…

Student: I think anybody would react to finding they had no hands…You’re right, I was feeling helpless just like he probably was and some anxiety like a milder reaction rather than panic.

Supervisor: So the content of the dream conveyed helplessness and a fear about being helpless.

Student: Now that I’m thinking about it in this way, it seems that having the dream of a date makes him feel helpless and that leads to panic. I see why he doesn’t date very often…

Discussion: This is an excellent supervisor in that it is immediately understood that there is some part of the dream which has disturbed the student. Although the student attempts to dismiss the supervisor’s interpretations, the student continues to confirm in his responses that the supervisor is correct in his or her intuition that there is a problem which may be quite serious which the student is evading. The supervisor, despite the student’s attempts to change the subject or deny the problem, continues to return to it in a manner which is gentle and allows the student to begin to explore his reaction. While further work may continue in supervision, the student has become quite aware of issues which were likely unconscious and would be wise to discuss them in more depth with his analyst.

Student: I really felt like my patient and I made progress today…She began to talk about the difficulties she has with men and then moved on to discuss her obesity and the way it protects her from sexuality with men

Supervisor: What was it about that interaction which made you feel she was making progress.

Student: Sometimes I don’t know if you are playing a game with me or if you’re just not listening.

Student: Like right now. I told you my patient made progress in understanding her obesity and its connection with her sexuality but you made me feel like nothing had happened.

Student: I don’t understand why you can’t sometimes tell me I did good work with my patient.

Supervisor: It seems important that you feel I approve of you but all you have told me is what your patient said, not about your role in her understanding.

Student: Her understanding obviously was a result of the work she and I have done.

Student: Maybe I’m falling back into needing support and praise. I sure feel like you should say something positive about my work but you’re right, I talked about work she had done as if I did not feel involved in it. I’m not sure I was involved in her being able to put the pieces together, maybe she was thinking about it on her own and they just began to make sense to her. I feel like I took her insight away from her and made it mine to impress you.

Student: No, I know I make useful interpretations but I also know that she is a good patient and continues to think about the sessions when I am not there.

Supervisor: Any thoughts about why it was so important to have my support and praise right now.

Student: …well, I feel like money is tight right now…actually, several patients have decided to quit lately and I felt it was because I was not doing a good enough job.

Supervisor: It’s painful to have that feeling.

Student: Yes. I think I had some sense that I could alleviate my concerns about making a living by being an analyst if my patients were making progress which you noticed. At the same time, I realize that my success or failure do not depend on your approval. I use to feel that so strongly as a kid with my dad.

Supervisor: Perhaps your patient has a similar need to please you by doing a good job at analysis.

Student: You may be right about that. Her parents did not give her much praise either. Maybe that’s more tied to her obesity than avoiding men.

Discussion: This supervisor is working very well with substantial difficulties which are being avoided by the student in his analysis of the patient because he has faced similar problems with his father and has not yet resolved them. The supervisor uses silence and a non-committal “Um” to allow the student to reach a deeper level of trust with the supervisor, almost as if the supervisor is temporarily in the role of the analyst. The gambit is effective in that the student becomes more ready to discuss personal problems he is having with the patient rather than glossing over the problems and pretending that the analysis is not at a turning point. Although there is some insight on the part of the student, he is expected to work out these issues in his own analysis rather than with his supervisor or his patients. It is the work of the supervisor to inform the student of problems in countertransference as they arise but the actual work of resolving the underlying problem is almost always that of the student’s own analysis.

Sample Case Discussion with a Supervisor (3)

Student: My patient has been having some problems making it in to sessions. She seems to have good reasons. Her car keeps breaking and she doesn’t have the money to fix it, her mom isn’t able to come over and watch her kids, or she’s out of money and can’t afford the gas.

Supervisor: Is it possible she is telling you that she wants to terminate analysis with you?

Student: I don’t think so. She pays me when she has the money and is concerned about paying me late. I don’t criticize her when she is unable to do that. I think she needs the help and I also think she wants to be in analysis very much.

Student: She has made some significant gains in understanding herself and her relationship to her children and their father. She sees the money problem as temporary since she is working at changing jobs so she can make more money and not have to rely permanently on the children’s father.

Supervisor: I notice you call her ex-husband “the children’s father” which implies she has no real relationship to him. Might you be attracted to her and negating his influence on her life.

Student: She and I have discussed her relationship with him extensively, as you know. She calls him “the children’s father” and I find that I think of him in that way as well.

Supervisor: Do you feel you are being pulled down into this woman’s abyss? You seem to be unconcerned when she can’t pay you, you excuse her absences as having a basis in reality, and you see her as someone who can change enough to be truly independent of her ex-husband.

Supervisor: Perhaps we see it differently because you lack experience and are far too forgiving of her lackadaisical manner rather than confronting them directly.

Discussion: It is clear that this supervisor and student do not have similar ideas about the patient. It is also clear that the supervisor has little respect for the work the student is doing. In a case such as this, if it is near the beginning of the analysis, the student may decide to seek a different supervisor who has a similar view. The supervisor also appears angry in that he consistently confronts the student in a manner which is disrespectful of the student’s relationship with the patient and the feelings and thoughts the student has about the analysis. This type of critique makes it difficult for the student to learn to do analysis because, unlike the previous two cases, he cannot openly discuss issues he actually has with the patient because the supervisor is consistently putting him in a position which is defensive. This supervisor may be seen as someone who should not be in that role since he actively attacks the student rather than promoting growth.
At times in supervision, it is necessary for the therapist to confront the student on flagrant errors and failures to deal effectively with the transference and countertransference. However, a good supervisor is likely to confront the issue early in the process and help the student work through different problems as they come along rather than having a session such as this in which the student appears barraged by criticism for many different types of issues on different levels.
The student has recourse. He can discuss the problem with his analyst to clarify his own part in the supervisory relationship. He can also change supervisors even though it would mean beginning the year of a supervised case over again. While some students feel the supervisor is always correct, because they are exposed to the work of at least three supervisors, it provides the student with the opportunity to understand how some supervisors fail to teach students, to establish trust, and to allow the student to grow into the type of analyst he will eventually become.

Student: Sorry I’m late today, the traffic was unusually bad…My patient had a dream that I would like to discuss. He is at a restaurant with his boss and other people from work. He is talking comfortably which he usually is unable to do in that sort of situation. He notices as he is talking his teeth begin to feel loose. As he is eating his teeth come out and he has to pick them from his mouth. The other people at the table notice and become silent. Then they all begin to laugh at him and make fun of him. He feels humiliated by the experience and tries to leave the table but finds he is unable to move his chair.

Student: He was very reluctant to tell me the dream or discuss it at all. When I inquired about why he was having so much trouble, he said the dream continued to make him feel humiliated and if I knew about it he was afraid I would see him as having such severe problems that I would terminate the analysis.

Supervisor: Has there been any problems between the two of you in the analysis which might make him feel that way?

Student: I feel I have not been able to make much progress, I guess. I don’t seem to have much insight into his dreams or the other information he discusses. It seems to stay at a superficial level.

Supervisor: Any ideas about why that might be happening? You had been doing very well with him prior to a few weeks ago.

Student: The only thing I can think of was that I was late several times. I seem to get on the road early enough but the traffic seems worse lately.

Supervisor: Perhaps the patient feels you are not very interested in seeing him.

Student: I can see him thinking that. He has a lot of trouble with interactions with his peers at work. He feels anxious while talking to them and then gets angry when they do not include him. He expects to be asked to go out to lunch rather than simply going when everyone else does.

Supervisor: So in his transference to you, you have become just like everyone else. You tolerate him but don’t really want him around.

Student: Yes, that feels right. He’s very servile with me but I feel he is also angry. When I interpret the anger he denies it and becomes even more servile. His history is pretty bad. He had parents who expected more from him in school and in his mind, they were constantly critical of him.

Student: I think he sees himself as an object of ridicule who no one really likes even when he is functioning well. Having the teeth come out makes me think that he feels there is nothing he can do to save himself from inevitable humiliation.

Student: Well, it seems like his teeth would be connected to biting, like anger or even rage. When they come out it seems like he becomes helpless since he cannot attack people verbally anymore without showing them he has lost his teeth…I guess I also connect the loss of teeth with poverty since people lose teeth when they can’t afford to see a dentist.

Supervisor: So the teeth seem connected to an impotent anger which he hides under his servile manner. It also sounds like he continues to feel a deep sense of shame about himself from the manner in which his parents treated him. Perhaps it would be a good idea to focus more on interpreting his anger.

Student: I think so too. I think I have been avoiding really confronting him on it because I worry he will blow up and leave.

Supervisor: Perhaps if you were to interpret that concern prior to the interpretation it would enable him to have enough understanding of himself that he would be able to stay. It would also convey to him that you are not so critical of his anger that you will want him to leave if he shows it to you.

Discussion: In this vignette, the student and supervisor are working well as a team to open up and discuss various aspects of the analysis. The supervisor gives some direct suggestions but continues to respect the student’s opinion. The supervisor also makes some comments on technique which may be useful in helping the student through what is clearly a rough time for both himself and the patient. The student is open and trusting with the supervisor including being able to admit to errors he is aware he is making. His errors are not criticized by the supervisor but instead become part of the reason why the analysis has stalled. The supervisor does not directly interpret the dream since that is the job of the student and patient but gives the student some means by which he can open up the dream and the patient’s neurosis which will hopefully lead to more trust by the patient and a deeper level of analysis.

Footnotes

Mr. Walker is assistant professor in the department of psychiatry at the University of Kentucky College of Medicine and the Center on Drug and Alcohol Research at the university, 643 Maxwelton Court, Lexington, Kentucky 40506-0350. Dr. Clark is associate professor in the College of Social Work at the university.

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