LPC Managing Differences and Difficult Populations


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This is part 4 of 5 in a 30 hour lecture series on Clinical Supervision for Mental Health Professionals. This was made for the Approved Clinical Supervisor Certificate through the NBCC. This interactive workshop focuses on the major elements of managing differences between supervisors and supervisees and issues surrounding working with difficult supervisees. In this workshop, participants will learn about the influence of individual, cultural and developmental differences between supervisors and supervisees. Different aspects of individual differences are covered (e.g., differences in belief systems and theoretical orientation between supervisor and supervisee). Different aspects of cultural differences are covered as are different aspects of developmental differences (e.g., supervisee and supervisor experiential levels). Participants will discuss areas of difficulties with supervisees, including an introduction to progressive discipline policies and due process, transference and countertransference, and other generic problems with supervisees. Teaching methods include lecture, interactive exercises and group participation/discussion.

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LPC Managing Differences and Difficult Populations

  1. 1. Managing Differences and Difficult Populations Glenn Duncan LPC, LCADC, CCS, ACSCopyright © 2012, Advanced Counselor Training Do not reproduce any workshop materials without express written consent.
  2. 2. From Differences to Similarities Exercise There are certain core tasks that each therapist must learn to master in order to be effective with clients. Supervisors must help each supervisee progress towards mastery of these tasks. What similar tasks must therapists master in order to a level of expertise when working with their clients? In a small group, brainstorm and come up with as many core tasks (e.g., the ability to establish a therapeutic relationship with a client) that you feel are needed for therapists to master, in order to be the most effective when working with clients.
  3. 3. From Differences to Similarities Develop a Therapeutic Alliance Nurture Hope Understand & Implement Best Practices in Theory and Application – knowledge of the best, evidence based therapeutic paradigms when working with clients individually, in group settings and with their families. Be able to properly assess individual client problems and needs and tailor theory and techniques that best suite individual client needs. Pharmacological interventions/interactions should also be known and taught to supervisees and known by supervisors, without prejudice (e.g., methadone prejudice). Teach Skills – emotional regulation, relaxation, problem-solving, cognitive restructuring skills, interpersonal skills, tolerance and acceptance skills.
  4. 4. From Differences to Similarities Provide Ongoing Education to the Client – the ability to conduct accurate assessments, working with the client towards individualized, behavioral treatment planning, having the client engaged in self-monitoring of thoughts, feelings and behaviors, enhance client awareness of the addition process. Build in Generalization and Maintenance Procedures – understand the concept of skill generalization to the target problem, involve significant others as allies in obtaining generalization of targeted positive behaviors, feelings and thoughts, and helping with the maintenance of them.
  5. 5. From Differences to Similarities Assess/Treat/Refer Co-occurring Problems – be able to accurately identify possible Co-occurring problems and treat (if education and training ethically provides the ability to do so), or refer client to have Co-occurring problems addressed with specialist. Assess For & Conduct Relapse Prevention – assess and work with relapse triggers and high risk situations that will occur for the client. Ensure Clients “Take Credit” and “Ownership” for Their Changes – foster independence and client ownership of the changes made. Other important clinician factors include: experience, personal characteristics of the counselor and therapist, cultural competence, and comfort with ambiguity.
  6. 6. Uniqueness of Individuals Client uniqueness can include, but is not limited to, race, ethnicity, culture, subculture, age, sexual orientation, gender, physical and psychological limitations, and geographic location. Uniqueness should be assessed: 1. In the context of identifying the difference(s); 2. Developing an understanding of the interactional nature of many differences that exist within one client. 3. Once identified, these differences should be interpreted in the context of their contribution to current functioning of the client. 4. In the case of more than one unique quality, supervisors must continue to assess and make sure supervisees are not focusing on uniqueness at the expense of another.
  7. 7. ACA Guidelines for Cultural Competence A.2.c. Developmental and Cultural Sensitivity Counselors communicate information in ways that are both developmentally and culturally appropriate. Counselors use clear and understandable language when discussing issues related to informed consent. When clients have difficulty understanding the language used by counselors, they provide necessary services (e.g., arranging for a qualified interpreter or translator) to ensure comprehension by clients. In collaboration with clients, counselors consider cultural implications of informed consent procedures and, where possible, counselors adjust their practices accordingly.
  8. 8. ACA Guidelines for Cultural Competence B.1.a. Multicultural/Diversity Considerations Counselors maintain awareness and sensitivity regarding cultural meanings of confidentiality and privacy. Counselors respect differing views toward disclosure of information. Counselors hold ongoing discussions with clients as to how, when, and with whom information is to be shared.
  9. 9. NBCC Guidelines for Cultural Competence The NBCC has no guidelines regarding cultural competence in their code of ethics. They speak to stereotyping and discrimination, but they do not speak to need for the NBCC certified counselor to be culturally competant.12.Through an awareness of the impact of stereotyping and unwarranted discrimination (e.g., biases based on age, disability, ethnicity, gender, race, religion, or sexual orientation), certified counselors guard the individual rights and personal dignity of the client in the counseling relationship.
  10. 10. LPC/LAC Guidelines for CulturalCompetenceTraining Contact-hour requirements for licensed professional 13:34-15.2 counselors. (c) A licensee shall complete at least three (3) of the 40 contact hours in the area of social and cultural competence. Social and cultural competence includes, but is not limited to, an understanding of the cultural context of relationships; issues and trends in a diverse society related to such factors as culture, ethnicity, nationality, age, gender, sexual orientation, mental and physical characteristics, education, family values, religious and spiritual values, socioeconomic status; and unique characteristics of individuals, couples, families, ethnic groups and communities. Beginning December 1, 2008, the three (3) contact hours of continuing education in the subject area of social and cultural competence shall be completed every biennial period and shall be in addition to the required five (5) contact hours of continuing education in ethics and legal standards.
  11. 11. Cultural Issues in Supervision Supervisors increasingly will have to monitor practitioners’ sensitivity to the beliefs, attitudes, behaviors, and needs of clients who are different from the practitioners. Key factors supervisors need to monitor: 1. Differing perceptions of the meaning of functions, expectations, explanations, and the behaviors of the client, practitioner, and supervisor whenever such differences are part of the client/supervisee/supervisor interactions. 2. Ensuring that respect and acceptance are shown for religious, spiritual, political, age, gender, and lifestyle differences.
  12. 12. Cultural Issues in Supervision Key factors supervisors need to monitor (continued): 3. Cultural explanations of illness. Supervisor must be able to help a practitioner accurately identify the meaning and severity of symptoms in relation to the cultural group, or individual members within that cultural group. 4. Overall cultural assessment related to diagnosis and care. Supervisee assessment of client perceptions may be impeded by differing views of language, styles of communication, valuing of socioeconomic and other statuses, acceptance of direct questioning, use of storytelling, role of privacy, boundary regulations, role of authority, and the importance of age. Any generalizations about the clients in regards to culture have the potential to produce bias in the clinician and resistance in the client.
  13. 13. Organizational Culture The clinical supervisor cannot manage without some rudimentary understanding of the organizational context, or culture, within which the supervisor must function. The following are questions you can ask in order to ascertain the nature of the organizational culture:1. Does the staff have a set of common goals, and are those goals appropriate to the setting?2. What does the administration model to the rest of the staff, what message does the administration send about itself?3. Does the organization promote professional development?4. Are, and if so, how are progress towards organizational goals monitored?5. Is there support for clinical supervision?6. What is management style within the organization?7. How does change and decision making occur within the organization?8. How political is the organization and its players, who are the key players that make policy change decisions?
  14. 14. Ethnicity vs. Organizational CultureExercise You have entered into an mental health/substance abuse outpatient treatment organization as the new director of outpatient/intensive outpatient substance abuse treatment services. This is a mid sized organization that specializes in 3 distinct departments: mental health services, substance abuse services, and a specialized case management department for working with HIV+ clients. This outpatient facility states that it does short-medium term outpatient care for clients. During your second week in the organization, you attend your first bi-weekly, interdepartmental group supervision meeting. In this meeting the head of the outpatient mental health department presents a case. This is a case of a Colombian female in her 40’s who was referred for treatment due to depression. She had been in treatment for approximately 9 months, and shared some news with her therapist (the outpatient director).
  15. 15. Ethnicity vs. Organizational CultureExercise The news the client presented was the happy news (according to the client) that her daughter was pregnant. The client was ecstatic over the news and delighted in sharing with her therapist. The therapist asked pointed questions, such as asking what the daughter will do about her college career (she is a Sophomore). The client stated that the daughter would drop out and return “eventually”, but the important thing would be focusing on her child, not her own education. The therapist then asked if the daughter would need help in rearing the child, the client responded “oh it will be great, I’ll mother her, her mother will mother her, her aunt will mother her, the baby will be well taken care of.” One last question the therapist put forth was a question concerning the father of the child. The client stated the father was not involved, nor was it necessary to have a male in the picture. “The baby will be more than cared for by us all, and my oldest son (14) will be a male role model for the baby.”
  16. 16. Ethnicity vs. Organizational CultureExercise The therapist then described how upset she was about this, and was at a loss as to how to convey to the client that while this is a blessed event, it is also a bit of a crisis given the fact that the daughter will drop out of school and no man is involved in the picture. This therapist (the mental health outpatient director) is a white woman in her mid 50’s, and in the past 5 years made a career change from working in New York City in the fashion industry (making well into the 6 figures per year), to becoming a therapist. This fact alone makes you question her sanity, which you do so quietly to yourself, not daring to state it in the meeting. However, the thought did cross your mind to just skip this woman’s treatment “crisis” and make the meeting interesting by asking her the reason for making the switch. The therapist then asked the team for guidance on how to best handle the situation. Thinking to yourself that this therapist was biased in her view of the client and not taking her culture into account when viewing the problem, you were sure others would give her this feedback. What ensued became a bizarre interaction of suggestions for the therapist to help “the client realize the crisis she was in” by other staff members. Not one other member suggested that this is not a crisis at all.
  17. 17. Ethnicity vs. Organization Culture Exercise You begin thinking to yourself how bizarre this set of transactions just was, though thinking to yourself how useful this could be in some future workshop exercise. Since nobody in the room seemed to be responding to reality, you decide to dissociate and let your mind continue to wander away from the content of the meeting and drift towards thoughts of the group makeup. Thinking first about the fact that you’re the only male member, to how one therapist’s hair has surely taken on the unintended tint of blue, and then finally drifting to remind yourself to again search the employment section of Star Ledger this Sunday. Suddenly, and quite rudely, you’re awakened from what appeared to you as a more useful pursuit of your mental energies, as the focus of the group has turned to you. The director has asked you specifically to give some feedback on this issue to the group.1. What feedback do you give to the director? Give reasons why you decided to say what you said.2. What organization cultural issues exist in this program (that we know of)? How do these issues impact our decision making for question 1?
  18. 18. Treatment vs. Organization Culture Exercise Two weeks pass, and you’re back in the room that you’ve dubbed “the outer limits” and set yourself mentally to prepare for another case presentation. This case is presented of elderly woman with no real social supports, depressed, whose case has been transferred 5 months ago from another therapist who left the agency. The woman has been in outpatient treatment during her entire stay at the agency. This therapist is asking the group for help with treatment goals for this client, and concern over a direction to go with when working with the client for the next upcoming months. You’re handed the genogram, which has been passed to each member of the supervision meeting. As you’re perusing the genogram, you come to see the date this genogram was done and it says 2002. You do a double take, out of shock, look on the back to make sure this isn’t some kind of joke shop gag gift. But, alas, it isn’t and this woman has been coming weekly to outpatient for the past 9 years.
  19. 19. Treatment vs. Organization Culture Exercise What you’ve come to learn about the organizational milieu in the now month that you’ve been working there is that E.D. is a micro-manager, but with no real clinical background, at least not enough to question the need for 9 years of supportive counseling which appears to have been downgraded to social hour for this woman (as she is stabilized on her medication, has been so for years, refuses to engage in activities to help with support networks in the community, has never been in any real crisis in the entire 9 years she’s been coming, and appears her only need to continue in “treatment” is that of her need to have an hour where she can talk to an adult who will listen). The organizational style of this meeting is one in which a person does not question the technique or decision making of another, but only provides (psychotic) advice for the continuation of something you’re sure everyone else in the room feels are salient “treatment recommendations”.
  20. 20. Treatment vs. Organization Culture Exercise But being the eternal optimist that you are, and filling in the textbook definition of insanity (i.e., expecting different results when using the same ingredients in exactly the same way), you hope beyond hope that somebody will question why this woman has been in treatment for 9 years, or at least what the need is for continued treatment when the therapist herself can’t even come up with a goal. With toes and fingers crossed, you are of course let down by the koolaid drinking mantra of each participant as they help try to brainstorm some new treatment goal for this therapist. Shaking your head and cursing yourself internally for forgetting to pick up the Star Ledger last week, the therapist notices your visible “slip” and questions the “negative vibe” she is receiving from you.1. What feedback do you give to this therapist? Do you question the group in their apparent inability to question the current effectiveness of treatment at this point? Give reasons why you decided to say what you said.2. Given that we know more about the organizational culture, does this affect our decision making for question 1?
  21. 21. Managing Difficult Staff Populations The most difficult issue you may face as supervisor is not the pathology of your clients, as that is expected; in fact it will be the undiagnosed psychiatric conditions that exist within your staff. - Glenn Duncan, 2006 Some issues that could lead to difficulties with staff:1. Therapists in Treatment/Recovery2. Supervisee Experiential Levels3. Education Levels of Staff4. Transference/Countertransference Reactions of Supervisees
  22. 22. Practitioners In Therapy/Recovery Practitioners in Therapy represent a dual edged sword. 1. They are seen by many in our field as having an edge, being a better therapist. It is the expectation of many in the field that to be a therapist one has to have gone through therapy. (e.g., addictions pecking order). 2. Practitioners tend to imitate their therapists style in their own therapy with clients. Imitation of Therapy. 1. When a practitioner’s own therapy is based on a theoretical orientation similar to the one the practitioner uses in his/her practice, the natural tendency is to imitate the therapist. 2. Practitioners do not discriminate how they use styles and techniques learned from their own therapists. 3. This imitation can produce negative results:  This can lead the practitioner to think that if it worked with them, the same technique will work with their client, which is not always the case. Supervisors can address this issue by focusing on the stylistic elements that carry over from one’s own therapy to practice, WITHOUT involving the content of the practitioners personal therapy.
  23. 23. Self Disclosure Therapists should generally disclose infrequently. The most appropriate topic for therapist self-disclosure involves professional background, whereas the least appropriate topics include sexual practices and beliefs. Therapists generally use disclosures to validate reality, normalize client experiences, model appropriate behavior, strengthen the therapeutic alliance, or offer alternative ways to think or act. Therapists should generally avoid using disclosures that are chiefly for their own needs (e.g., of this can occur with strengthening the therapeutic alliance), disclosures that remove the focus from the client, that interfere with the flow of the session, that burden or confuse the client, that are intrusive, that blur the boundaries, or that over-stimulate the client.
  24. 24. Self Disclosure Therapist self-disclosure in response to client self-disclosure seems to be particularly effective in eliciting client disclosure. Therapists should observe carefully how clients respond to therapist disclosures, ask about client reactions, and use the information to conceptualize the clients and decide how to intervene next. It may be especially important to therapists to disclose with clients who have difficulty forming relationships in the therapeutic setting. The clinical use of intentional self-disclosure requires thoughtful and judicious application. The use of self-disclosure can also vary depending on the treatment setting (e.g., outpatient vs. milieu based treatment settings).
  25. 25. Supervisee Experiential Level With experience, the supervisee should develop more: 1. Self-awareness of behavior and motivation within counseling sessions. 2. Consistency in the execution of counseling interventions. 3. Autonomy (in decision making without need of immediate supervisory feedback). 4. Sophisticated ways to conceptualize the counseling process and the issues their clients present.  Novice supervisees should have supervision focus on conceptualization issues with clients. Focusing on personal issues may be inappropriate unless these issues are blocking the supervisee from grasping conceptual information.
  26. 26. Supervisee Experiential Level Novice supervisees will be more rigid and less discriminating in their delivery of therapeutic interventions. More advanced supervisees are more flexible and less dominant when delivering interventions such as confrontation. - A lack of flexibility or introduction of dominance may indicate that a particular case is either personally threatening for the supervisee, or they experience the case as beyond his/her level of competence.
  27. 27. Staff Education Levels Staff education level differences are not as pronounced as they were in the 1980’s and 1990’s, however a rift still exists. This rift is caused in part by the addictions field. The addictions field classically has allowed people with less than a master’s degree to perform direct counseling on a client, whereas the mental health field has classically not allowed anyone with less than a master’s degree to conduct counseling on a client. This rift can also be viewed in terms of theoretical orientation of one therapeutic construct – confrontation.  Addictions Professionals = classically viewed as overly confrontational.  Mental Health Professionals = classically viewed as under confrontational.  Your Job as Supervisor if you have both of these schools of thought in your organization, is classically viewed as a royal pain in your buttocks.
  28. 28. Transference & Countertransference Transference is defined as an irrational attitude manifested by a client toward the clinician or others in a way that is not evoked by the realities of the present, but instead is derived from the client’s relationship with someone else … either past or present (Powell, 1993). Countertransference arises as a result of the patients (supervisee’s) influence on the therapists (supervisor’s) unconscious feelings, causing a reaction towards the client (supervisee) by the therapist (supervisor).
  29. 29. Categories of SupervisorCountertransference1. General Personality Characteristics – this type of countertransference stems from the supervisor’s own defenses, which affect the supervisory relationship. Two of the most common expressions of this occur in the supervisor’s wish to foster the supervisee’s identification of the supervisor, and with the supervisor’s tendency to overidentify with the supervisee.2. Inner Conflicts Reactivated by the Supervisory Situation – this focuses on the parental nature of the supervisory relationship. Many latent triangles among the supervisee, client, agency, colleagues can also reactivate intrapsychic issues among supervisors (i.e., piss you the “f” off). The countertransference occurs when the supervisor takes on a parental role (e.g., trying too much to overextend oneself to supervisees, or trying to squash any anticipated challenge from the supervisee).
  30. 30. Categories of SupervisorCountertransference 3. Reactions to the Individual Supervisee – there may be aspects of the individual supervisee that may stimulate supervisor transference. Some examples of this type of countertransference include sexual or romantic attraction to supervisees, cultural differences between the supervisor and supervisee, and economic differences between supervisors and supervisees. This reaction can also occur to personality conflicts between the supervisor and supervisee. 4. Countertransference to the Supervisee’s Transference – this is when the supervisor experiences countertransference reactions when the supervisee manifests transference responses to the supervisor. Some researchers cite that supervisees do not experience transference reactions (to supervisors) the same way clients do (to therapists) due to the differences in the supervisory relationship from the therapeutic relationship. However, supervisees distort their perceptions of the supervisor and they behave in accordance with those distortions. Supervisor countertransference is elicited from this experience.
  31. 31. Addressing Supervisee Countertransference • Addressing countertransference is an accepted task in many of the supervisory theories (Powell being a notable exception). • Inquiry into a supervisee’s subjective reactions is often initiated following a supervisees’ reports of being frustrated, bored, distracted, confused, or irritated. Other identifying factors that countertransference could be occurring are: • When departures from supervisee’s usual clinical conduct and disruptions of therapeutic frame have occurred. • When treatment appears to be going nowhere. • Supervisee factors essential to the successful management of countertransference: • Self insight • Self integration • Empathy • Conceptualizing abilities • The ability to manage anxiety
  32. 32. Addressing Supervisee Countertransference • Well established supervisory alliance is necessary in the exploration of countertransference. • Supervisor self-disclosure may be used to model and encourage transference reactions. • The use of video observation can be used to identify particular sequences of interaction in which unusual shifts in the supervisee’s demeanor, behavior, and affects occur. • Of utmost importance in addressing countertransference is the maintenance of the boundary between supervision and psychotherapy. Appropriate to supervision, inquiry directs attention to the interactions and processes specific to the supervised case, and, although personal issues of the supervisee may surface, such material is considered in light of the case.
  33. 33. Exercise: Managing Difficulties in Your StaffYou’re the supervisor of a particularly fragile soul. You recently cameinto the organization under a management restructure where your jobwas to start an Intensive Outpatient Treatment Program and oversee andsupervise 2 clinicians within this program.Both clinicians have been working at the organization for over 10 yearsand have been doing outpatient treatment with no supervision andoversight. Your supervisor apologizes for this state of affairs as it shouldhave been he who supervised these clinicians but did not. Yoursupervisor has given you full reign to oversee this (dramatic) change, asthese 2 clinicians have over 18 years each of experience, but littleexperience in group situations, no experience running an IOP, and verylittle clinical supervision.
  34. 34. Exercise: Managing Difficulties in Your Staff The clinical staff are showing a tremendous amount of resistance to these changes, and during a morning staff meeting, one supervisee took offense to a suggestion you gave her regarding how to work with a client. She stated in the meeting “I’ve been working in the field for over 18 years, I think I know how to handle this problem”. You decide to let the comment go for the moment, and next week she approaches you stating how offended she was at the comment you made. She was so offended that she needed to schedule a therapy session to process this issue. Not knowing what to do with this comment, you state that you are her supervisor and as part of this process she will need to be able to hear and accept feedback from you. She stated that further feedback would be offensive and starts to list her accomplishments as a professional over the past 18 years. She senses that you are annoyed, and gets tearful and returns to her office. You think to yourself, “gee I hope that doesn’t force her to enter an IOP herself” as you grin to yourself on your shockingly good humor, and remind yourself to tell your boss that joke.
  35. 35. Exercise: Managing Difficulties in Your Staff Despite your own feelings about this supervisee, life goes on, and so does the job. You’ve continued meeting twice a week as an IOP staff, and continue to get resistance with the changes from both of your staff. You’re at a loss of what you could do or what mechanisms you could put into place in order to get the program moving in the right direction and hopefully get these clinicians to be onboard with the program and with the changes that are being made. You decide to bring this issue your supervisor, and your team will act as that supervisor and answer the following:
  36. 36. Exercise: Managing Differences in YourStaff1. What type of countertransference is going on in this scenario (which category seems to fit best, and why)?2. What are some interventions that this clinical supervisor could do in order to deal with the extensive resistance she is getting from both supervisees.3. How should this supervisor handle the fragile soul who needs treatment every time she is given feedback.4. Act as if 1 month has passed and these interventions and suggestions have been tried. They have worked with one clinician, but not with the fragile soul. What should happen next with this other resistant clinician?
  37. 37. Ethical Decision Making Using Decision Analysis Decision analysis is a step-by-step procedure enabling us to break down a decision into its components, to lay them out in an orderly fashion, and to trace the sequence of events that might follow from choosing one course of action or another. This procedure offers some benefits. 1. It can help us to make the best possible decision in a given situation. 2. Moreover, it can help us to clarify our values, that is, the preferences among possible outcomes by which we judge what the best decision might be.
  38. 38. Ethical Decision MakingDecision analysis involves several steps including: 1. Acknowledging the decision. 2. Listing the pros and cons. 3. Structuring the decision (including development of a decision "tree" to graph decisional paths and subsequent decisional branches). 4. Estimating probabilities and values. 5. Calculating expected value. 6. Making the most appropriate decision based upon the above steps.
  39. 39. How Ethical Decisions are Made The intrapsychic approach to ethical decision making places the ethical decision bound predominantly to psychological theorizing about how decisions are made. The ethical choice occurs by having it go into the mind of the individual making the decision either intuitively or based on utilitarian values.
  40. 40. Ethical Principles For a principles-based educational approach. Krager (1985) suggested five principles relating to the development of ethical behavior:1. Respect autonomy by helping others make their own choices.2. Do no harm by avoiding actions that hurt others or place them at risk.3. Benefit others by acting in ways that contribute to the welfare and growth of other individuals and society.4. Support fairness and justice by serving all persons fairly and equally and by disregarding irrelevant factors when treating others.5. Maintain fidelity by keeping promises, being honest, and maintaining commitments.
  41. 41. How Ethical Decisions are Made The social constructivism approach to ethical decision making places the ethical decision out in the open-in the interaction between individuals as they operate in their environments. This theory posits that the interactional nature of decision making lies within the relational context of individuals and the social context that the decision is made within. 1. In professional ethics, a decision to enter into a dual relationship with a client is a decision made in interaction with the client. 2. Likewise, a decision to breach a clients confidentiality is a decision made in relation to a third party. Decisions are not compelled internally; rather, they are socially compelled.
  42. 42. Arguments Against Code of Ethics These arguments have included the decontextualized nature of codes and their consequent irrelevance to many problems of practice. The privileging of elites who usually hold positions of power that enable them to develop and enforce codes. The impossibility of developing a meaningful code that is broadly acceptable, relevant, and enforceable given the diversity of a given field.
  43. 43. Ethical Complaints Against Counselors1. Exploitation – whenever professional counselors take advantage of consumers by abusing their position of trust, expertise, or authority. - Sexual exploitation of clients - Charging excessive fees - Deceiving research participants in a way which may cause them harm. - Failing to credit coworkers for their contributions.
  44. 44. Ethical Complaints Against Counselors2. Insensitivity – Harm caused by a lack of regard or concern for the needs, feelings, rights, or welfare of others. - Rude or abusive behavior directed inappropriately towards clients, students, our coworkers. - Biased attitudes toward minority groups that adversely affect the quality of treatment. - Excessive focus on one’s own needs which supercedes the adequate consideration of the needs of others.
  45. 45. Ethical Complaints Against Counselors3. Incompetence – When professional counselors are not fully capable of providing the services being rendered. Reasons: 1. Inadequate training or experience. 2. Personal unfitness (character defect, active addiction, and/or emotional disturbance). - Delivering therapy without adequate background/training in the modality used. - Teaching courses in areas which one has little knowledge. - Continuing to provide services while under considerable stress, resulting in poor professional judgment.
  46. 46. Ethical Complaints Against Counselors4. Irresponsibility – Irresponsible behavior taking several forms. A. Lack of reliable or dependable execution of professional duties. B. Attempts to blame others for one’s mistakes. C. Shoddy or superficial professional work. D. Excessive delays in delivering necessary feedback, assessments, reports, or other treatment related services.
  47. 47. Ethical Complaints Against Counselors5. Abandonment – When the professional counselor fails to follow through with their duties or responsibilities, thereby causing consumers to become vulnerable or to feel discarded or rejected. - Premature termination of therapy services. - Refusal to fulfill commitments. - Deserting a position without adequate preparation time to find a replacement. What is adequate time to give an employer? - Leaving a position with clinical or administrative tasks left incomplete.
  48. 48. Managing Difficult Staff1. Dont generalize – be very clear about what the problems and symptoms are. - Some individuals simply arent up to the job, and would benefit from being helped to find a position that better suits their talents. Others may have a clash of personalities with an immediate superior. The first response to a troublemaker has to be, "I need more information". - Use cost-benefit analysis - take the time to assess just what are the costs to the organization of this individual, including the cost of any trouble caused. Weigh this up against the benefits brought to the organization by that individual. Only then can you decide on the appropriate course to take.
  49. 49. Managing Difficult Staff2. Dont try to change Inherent behavior. - Assuming that giving a difficult staff member more attention would change deeply rooted behavior. - If someone is persistently cynical, negative and disruptive in their job, it is more helpful to them, to you and to their colleagues if you help them to find a different role.3. See the problem through their eyes-people are often called troublemakers because they seem unreasonable. - Take the time to see the problem through their eyes. You might not change things, but you will often find that they are reasonable people with a real concern that needs addressing.
  50. 50. Managing Difficult Staff4. Dont confuse Input and output. - It is easy to push highly talented people into troublemaker mode by trying to control the way they do their jobs. - If you focus on micro-managing style, timekeeping, looking neat and having tidy desks rather than quality and timeliness of output, it is easy to alienate staff members who are often hugely productive. - Make it clear when you expect specific standards (being on time for meetings, need for paperwork being finished), but then give supervisees as much leeway as you can in day-to-day work practices. Focus on what they produce, not how they produce it (as long as how they produce it is ethical and legal). This approach can transform some troublemakers into top workers.
  51. 51. Managing Difficult Staff Exercise In small groups, I would like you to come up with a problem case that somebody is currently dealing with regarding a difficult staff. If no current problem exists, then make it a previous problem. I would like you to then brainstorm for this person as to the possibilities for resolving this situation. Have one person act as the secretary and write down brainstorming ideas. This person will describe the current (or recent past) problem (changing the names to protect the stupid), and this person will describe the solutions that the group came up with in the brainstorming section.
  52. 52. The Impaired Clinician Although the emotional functioning of a clinician should be a concern for all disciplines, the impaired clinician is a particular concern in all counseling related fields. The supervisor plays a critical role in the identification and referral of the impaired professional. Yet all too often the helping professions deny it when their own peers act in an impaired manner. This downward spiral can be averted if the supervisor intervenes in the early phases of the noticed impairment(s), identifying job performance impairment as it evolves. The final stage of discipline and potential termination is often used as one of the first intervention methods, this is due to poor supervision of the impaired employee and/or anxiety surrounding dealing with the issue when it first came up.
  53. 53. The Impaired Clinician Impairment may involve failure to provide competent care or violation of a licensee’s ethical standards. It also may take such forms as providing flawed or inferior services, sexual involvement with a client, or failure to carry out professional duties as a result of substance abuse or mental illness (Lamb et al., 1987). Such impairment may be the result of a wide range of factors, such as employment stress, illness or death of family members, marital or relationship problems, financial difficulties, midlife crises, personal physical or mental health problems, legal problems, and substance abuse.
  54. 54. The Impaired Clinician – SubstanceUse One of the most common impairment issues that is dealt with supervisees is impairment due to substance abuse.What should the agency and supervisor do if a clinician is thought to be abusing substances? First, the agency should have a substance abuse policy in place. This policy, developed in consultation with legal counsel, should specify what substances it covers, what the policy is on substance use, and what the progressive disciplinary response will be to substance abuse on the job. The policy must not discriminate against the practitioner in recovery by imposing a stricter standard on those who have disclosed their recovery history. If abuse is found, as soon as the problem is identified, the practitioner should be taken out of counseling functions immediately. However, how long should they stay out of counseling functions?
  55. 55. ACA Code on Impairment C.2.g. Impairment Counselors are alert to the signs of impairment from their own physical, mental, or emotional problems and refrain from offering or providing professional services when such impairment is likely to harm a client or others. They seek assistance for problems that reach the level of professional impairment, and, if necessary, they limit, suspend, or terminate their professional responsibilities until such time it is determined that they may safely resume their work. Counselors assist colleagues or supervisors in recognizing their own professional impairment and provide consultation and assistance when warranted with colleagues or supervisors showing signs of impairment and intervene as appropriate to prevent imminent harm to clients. (See Codes A.11.b., F.8.b.)
  56. 56. NBCC Code on Impairment The NBCC has no ethical code directly relating to impairment. Certified counselors who have an administrative, supervisory and/or evaluative relationship with individuals seeking counseling services must not serve as the counselor and should refer the individuals to other professionals. Exceptions are made only in instances where an individual’s situation warrants counseling intervention and another alternative is unavailable. Dual relationships that might impair the certified counselor’s objectivity and professional judgment must be avoided and/or the counseling relationship terminated through referral to a competent professional. They also speak briefly of impairment as it relates to supervision: NCC’s who offer or provide supervision must: i. Intervene in any situation where the supervisee is impaired and the client is at risk
  57. 57. Title 45 – Uniform Enforcement Act – Duty toReport 45:1-37 Notification to division of impairment of health care professional.A. A health care professional shall promptly notify the division if that health care professional is in possession of information which reasonably indicates that another health care professional has demonstrated an impairment, gross incompetence or unprofessional conduct which would present an imminent danger to an individual patient or to the public health, safety or welfare. A health care professional who fails to so notify the division is subject to disciplinary action and civil penalties pursuant to sections 8, 9 and 12 of P.L.1978, c.73 (C.45:1-21, 45:1-22 and 45:1-25).B. A health care professional shall be deemed to have satisfied the reporting requirement concerning another health care professionals impairment by promptly providing notice to the division, the board or a professional assistance or intervention program approved or designated by the division or a board to provide confidential oversight of the licensee.
  58. 58. Title 45 – Uniform Enforcement Act – Duty toReport 45:1-37 Notification to division of impairment of health care professional.C. (1) There shall be no private right of action against a health care professional for failure to comply with the notification requirements of this section. (2) There shall be no private right of action against a health care entity if a health care professional who is employed by, under contract to render professional services to, or has privileges granted by, that health care entity, or who provides such services pursuant to an agreement with a health care services firm or staffing registry, fails to comply with the notification requirements of this section.D. A health care professional who provides notification to the division, board or review panel, in good faith and without malice, about a health care professional who is impaired or grossly incompetent or who has demonstrated unprofessional conduct, pursuant to this section, is not liable for civil damages to any person in any cause of action arising out of the notification.
  59. 59. Title 45 – Uniform Enforcement Act – Duty toReport 45:1-37 Notification to division of impairment of health care professional.E. Notwithstanding the provisions of this section to the contrary, a health care professional is not required to provide notification pursuant to this section about an impaired or incompetent health care professional if the health care professionals knowledge of the other health care professionals impairment or incompetence was obtained as a result of rendering treatment to that health care professional.
  60. 60. Title 45 – Uniform Enforcement Act – Actswhich could cause Committee action 45:1-21 Refusal to license or renew, grounds. A board may refuse to admit a person to an examination or may refuse to issue or may suspend or revoke any certificate, registration or license issued by the board upon proof that the applicant or holder of such certificate, registration or license:A. Has obtained a certificate, registration, license or authorization to sit for an examination, as the case may be, through fraud, deception, or misrepresentation;B. Has engaged in the use or employment of dishonesty, fraud, deception, misrepresentation, false promise or false pretense;C. Has engaged in gross negligence, gross malpractice or gross incompetence which damaged or endangered the life, health, welfare, safety or property of any person;D. Has engaged in repeated acts of negligence, malpractice or incompetence;
  61. 61. Title 45 – Uniform Enforcement Act – Actswhich could cause Committee action 45:1-21 Refusal to license or renew, grounds.E. Has engaged in professional or occupational misconduct as may be determined by the board;F. Has been convicted of, or engaged in acts constituting, any crime or offense involving moral turpitude or relating adversely to the activity regulated by the board. For the purpose of this subsection a judgment of conviction or a plea of guilty, non vult, nolo contendere or any other such disposition of alleged criminal activity shall be deemed a conviction;G. Has had his authority to engage in the activity regulated by the board revoked or suspended by any other state, agency or authority for reasons consistent with this section;H. Has violated or failed to comply with the provisions of any act or regulation administered by the board;
  62. 62. Title 45 – Uniform Enforcement Act – Actswhich could cause Committee action 45:1-21 Refusal to license or renew, grounds.I. Is incapable, for medical or any other good cause, of discharging the functions of a licensee in a manner consistent with the publics health, safety and welfare;J. Has repeatedly failed to submit completed applications, or parts of, or documentation submitted in conjunction with, such applications, required to be filed with the Department of Environmental Protection;K. Has violated any provision of P.L.1983, c.320 (C.17:33A-1 et seq.) or any insurance fraud prevention law or act of another jurisdiction or has been adjudicated, in civil or administrative proceedings, of a violation of P.L.1983, c.320 (C.17:33A-1 et seq.) or has been subject to a final order, entered in civil or administrative
  63. 63. Title 45 – Uniform Enforcement Act – Actswhich could cause Committee action 45:1-21 Refusal to license or renew, grounds.L. Is presently engaged in drug or alcohol use that is likely to impair the ability to practice the profession or occupation with reasonable skill and safety. For purposes of this subsection, the term "presently" means at this time or any time within the previous 365 days;M. Has prescribed or dispensed controlled dangerous substances indiscriminately or without good cause, or where the applicant or holder knew or should have known that the substances were to be used for unauthorized consumption or distribution;N. Has permitted an unlicensed person or entity to perform an act for which a license or certificate of registration or certification is required by the board, or aided and abetted an unlicensed person or entity in performing such an act;O. Advertised fraudulently in any manner.
  64. 64. Counsel for Affordable QualityHealthcare Are you currently engaged in the illegal use of drugs? ("Currently" means sufficiently recent to justify a reasonable belief that the use of drug may have an ongoing impact on ones ability to practice medicine. It is not limited to the day of, or within a matter of days or weeks before the date of application, rather that it has occurred recently enough to indicate the individual is actively engaged in such conduct. "Illegal use of drugs" refers to drugs whose possession or distribution is unlawful under the Controlled Substances Act, 21 U.S.C. 812.22. It "does not include the use of a drug taken under supervision by a licensed health care professional, or other uses authorized by the controlled Substances Act or other provision of Federal law." The term does include, however, the unlawful use of prescription controlled substances.)
  65. 65. What constitutes supervisee impairment? “Impairment refers to the inability of professionals to fulfill the minimal responsibilities of their profession because of a mental or physical disability.” (Knapp & Vandecreek, 1997). 3 broad aspects of professional functioning that constitute competence as professional functioning that include: 1) competence 2) knowledge and skill 3) personal suitability to maintain a mental health role1. An inability or unwillingness to acquire and integrate professional standards into one’s repertoire of professional behavior.2. An inability to acquire professional skills and reach an accepted level of competency.3. An inability to control personal stress, psychological dysfunction, or emotional reactions that may affect professional functioning.
  66. 66. Impairment Reporting Guidelines The Division of Consumer Affairs (governing body for LAC/LPC) requires that impaired professionals need to turn themselves in. The Division of Consumer Affairs (governing body for CADC/LCADC) requires that any CADC/LCADC who knows of an impaired professionals continuing to work in the field, needs to report them to the committee. No specific guidelines were found in the LPC regulations upon repeated reads of these regulations (both the LPC/LAC and the LMFT sections). However, it would be advised to call the licensing board anonymously with any situation you feel could be a reportable event, to get the board’s interpretation as to whether or not there is a duty to report (getting the advice of a lawyer knowledgeable of these regulations wouldn’t hurt either).
  67. 67. Ethical Standards for LMFT/LPC/LAC 13:34-2.2 Professional Interactions with Clients (c) A licensee shall not provide marriage and family therapy services while under the influence of alcohol or any other drug that may impair the delivery of services. (d) A licensee shall obtain competent professional assistance in order to determine whether to voluntarily suspend, terminate, or limit the scope of the licensee’s professional practice or research activities which are foreseeably likely to lead to inadequate performance or harm to the client, colleague, student, or research participant.
  68. 68. Impaired Employee Vignette Mark is an LCSW and works for you as your per diem counselor, seeing clients individually and in group every Monday and Wednesday nights. It has been brought to your attention by other staff that Mark has been smelling of alcohol over the past week. You then check this out for yourself on Wednesday when Mark comes in and there is a distinct smell … of something. You’re unsure as to whether or not the smell is alcohol or mouthwash, or some evil concoction of both. Work performance has been relatively steady, except with paperwork being more behind than usual. Mark is about to start a group therapy session in 1 hour, but his client that was due in now has called to cancel. What do you do immediately? If you decide to take action, how do you handle Mark’s suspected drinking? What things shouldn’t you say?
  69. 69. Impaired Employee Vignette You’ve made all the right choices, Mark admits to his drinking problem, decides to go to inpatient treatment, which his insurance will allow 14 days of inpatient treatment. Those two weeks have passed, and Mark is now back at your doorstep, wanting to come back to work. He stated he is going to AA meetings, and is now re- engaged in outpatient counseling. Can Mark come back to work, and if so, in what capacity? If you determine he cannot come back and counsel right away, what do you do with Mark, and more importantly, what are your determining criteria for his being able to go back into a counseling role? What are your rights as an employer to monitor his treatment compliance?
  70. 70. Impaired Employee Vignette Mark appears to not be drinking, however his work performance is suffering in many areas. As part of your EAP monitoring of Mark, he admits to you that he also suffers from clinical depression, is under psychiatric care, and is compliant with his medication regime. His work has been sloppy in many areas, and he has caused others to do extra work because of this poor performance. What is your next step with Mark?
  71. 71. Assessment Model and Action Plan(Reamer, 1992)1. Identify and collect data on the professional’s impairment.2. Speculate about possible causes of the impairment.3. Constructively confront the professional with evidence of the impairment.4. Urge the professional to seek help and review the available options.5. Emphasize the consequences of the professional’s failure to address the problem or problems.6. If necessary, notify a regulatory body or governing committee on inquiry.7. Formulate a rehabilitation plan or impose sanctions, as appropriate, following standard due process proceedings.8. Monitor and evaluate the professional’s progress.9. Review the practitioner’s standing in the profession, such as licensure or employment status, and modify it as appropriate.
  72. 72. Three Due Process Steps (Lamb et. al.,1987) Reconnaissance and identification: period of time where supervisee strengths and weaknesses are observed and assessed. 1. The supervisee does not acknowledge, understand, or address the problematic behavior when it is identified. 2. The problematic behavior is not merely a reflection of a skill deficit that can be rectified by academic or didactic training. 3. The quality of service delivered by the supervisee is consistently negatively affected. 4. The problematic behavior is not restricted to one area of professional functioning. 5. The problematic behavior has potential for ethical or legal ramifications if not addressed.
  73. 73. Reconnaissance and identification (cont.) 6. A disproportionate amount of attention by training personnel is required. 7. The supervisee’s behavior does not change as a function of feedback, remediation efforts, or time. 8. The supervisee’s behavior negatively affects the public image of the agency. The aforementioned are listed as impairment issues with supervisee’s, as opposed to expected or remedial supervisee problems.
  74. 74. Discussion and Consultation Once a supervisee has been identified as displaying the possibility of impairment: 1. Extensive discussion of pertinent impairment issues among relevant personnel. 2. All former interventions and impressions should be reviewed. 3. Make a qualitative decision on the seriousness of the situation and review documentation of the process.
  75. 75. Implementation and Review This is the point of action taken on the supervisee due to behavior and discussion of that behavior. If termination isn’t decided and some probation is mandated, here are some guidelines for what should be included to the supervisee: 1. Identify the specific behaviors or areas of professional functioning that are of concern. 2. Directly relate these behaviors to the written evaluation or written report (e.g., not showing up for group sessions). 3. Provide several specific ways that these deficiencies can be remediated (e.g., from additional training to personal therapy).
  76. 76. Probation Guidelines (continued) 4. Identify a specific probation period after which the performance of the supervisee will be reviewed. 5. Stipulate, if appropriate, how the supervisee’s functioning in the agency will change during the probation period. 6. Reiterate the due process procedures available to challenge the decision. Anticipating and responding to organizational reaction. Checking with any licensing body as to whether or not this action is reportable.
  77. 77. Due Process – Staff Grievances Supervisors must follow due process guidelines when responding to grievances. Those guidelines are usually found in an organization’s policy and procedure (P&P) manual. Clinical supervisors should ensure the P&P manual complies with both Division of Mental Health standards of care, and licensure standards of care. Supervisors must ensure that supervisees know their rights as employees and understand the organization’s employee grievance procedures. If your organization has an employee handbook, there should be written documentation that the supervisee has received a copy. There should be written documentation that the supervisee has read and understood the organization’s employee grievance P&P.
  78. 78. Due Process Vignette Alfred is a client at your agency that has been seen by another therapist. Alfred is known to the agency as being a problematic client with a flare for legal posturing. It is determined by the treatment team that Alfred is not progressing at the organization at this point, and before recommending termination, the team agrees to have a psychiatric evaluation conducted (to see how the psychiatrist sees the case, if she recommends a medication regime, etc.). The clinician expresses her concerns with Alfred during the next session, especially her concerns for the paranoid overtones Alfred has been exhibiting. He recommends that Alfred see the psychiatrist, in order to get her assessment of Alfred and his possible need for medication. Alfred balks at the idea and refuses to see the psychiatrist. The therapist comes back to the treatment team with this information and the team decides that Alfred is not following the treatment plan laid out, and if he continues to refuse, he needs to be discharged.
  79. 79. Due Process Vignette The therapist goes back to Alfred in the next session, asking Alfred if he has given some thought to seeing the psychiatrist. Alfred stated again that he refuses to see her. The therapist states that this is clinical recommendation of the treatment team, and if he goes against that advise, he will not be able to continue services in the organization. He states that he does want to continue services but will not see the psychiatrist. He is terminated from treatment. He requests from you and the E.D. a hearing regarding his “untimely and abrupt” termination. You, the E.D. and your clinician meet with Alfred. He presents his case for staying, and the clinician presents the case for termination. The committee (you and the E.D.) determine that the termination was appropriate and stands (as Alfred continues to refuse to see the psychiatrist). Alfred is very upset with this decision and states that you will be hearing from his lawyer, and that he is lodging a complaint with your “contracting agencies” … in this case, the Division of Mental Health.
  80. 80. Due Process Vignette Questions Utilize the structure of the Lamb et. al. due process steps.1. Have Alfred’s due process rights been protected? If not, which area(s) of the due process steps were missed or not dealt with appropriately?2. How vulnerable is the treatment team, especially you, the supervisee, and the E.D. if Alfred should decide to take legal action and action against your grantee(s).3. If there is evidence that there is no malicious intent by the faculty, did the process they followed adequately protect the client and was this process legally defensible?
  81. 81. Bibliography Bernard, J. M. & Goodyear, R. K. (2009). Fundamentals of Clinical Supervision, 3rd Ed. Allyn and Bacon, Boston, MA. Falvey, J. E. (2002). Managing clinical supervision: Ethical practice and legal risk management. Pacific Groove: Wadsworth Flinders, C. A. & Shafranske, E. P. (2004). Clinical Supervision: A Competency- Based Approach. American Psychological Association, Washington, DC. Glegg, B. (2002). Diffusing the troublemakers, Director, 56(4), 38. Lamb, D., Presser, N., Pfost, K., Baum, M., Jackson, R., & Jarvis, P. (1987). Confronting Professional Impairment During the Internship: Identification, Due Process, and Remediation. Professional Psychology: Research and Practice, 18, pp. 597-603. Meichenbaum, D. (2001). Treatment of Individuals with Anger-Control Problems and Aggressive Behaviors: A Clinical Handbook. Clearwater, Fl: Institute Press. Munson, C. E. (2002). Handbook of Clinical Social Work Supervision, 3rd Ed. New York, Haworth Press, Inc.
  82. 82. Bibliography New Jersey Uniform Enforcement Act (2005) Printed on the Internet on June, 2011. http://www.nj.gov/lps/ca/laws/uniformact.pdf (Accessed on September 1, 2001). Powell, D. J. & Brodsky, A. (2004). Clinical Supervision in Alcohol and Drug Abuse Counseling. Jossey-Bass Publishers, San Francisco, CA. Reamer, F. G. (2000). The social work ethics audit: A risk-management strategy. Social Work. 45(4), 355-366. Reamer, F. G. (1992). The impaired social worker. Social Work. 37(2), 165-170. Stoltenberg, C. D., McNeil, B., & Delworth, U. (1998). IDM Supervision: An Integrated Developmental Model for Supervising Counselors and Therapists. Jossey-Bass Publishers, San Francisco, CA. (2007) The Counsel for Affordable Quality Healthcare (CAQH) information on impaired professionals can be found on their website at http://www.caqh.org Ethical Guidelines – LAC/LPC Code of Ethics: http://www.nj.gov/oag/ca/laws/pcregs.pdf Ethical Guidelines - CADC/LCADC http://www.njconsumeraffairs.gov/laws/adcregs.pdf