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Unread August 3rd, 2008, 11:15 AM
sk8rgrl23 sk8rgrl23 is offline
Join Date: Dec 2005
Posts: 53
Default clinical autonomy in an agency

I have been bestowed upon by a new clinical supervisor and I am already having some heated disagreements with her on several points.

Despite her being young enough to be my child and I have been in social services on some level since before she was even born, she seems to have gotten her head full of authority and I've noticed a tendency for her to disagree on me about just about anything, seemingly just for her own need to be right, as she tends to state her point in globalized statements as if they were commonly understood facts when in fact she has no clue.

some issues that have been disputed:

I am a clinical supervisor and have taken on two interns so far. we as an agency are discussing the idea of establishing ourselves as a teaching facility and deciding on some basic issues to consider, one being competence of interns coming in and how to evaluate that. I am realy having my eyes opened about how unprepared and at times unsuitable some people are to be functioning in this profession. I've seen interns not seem to have a clue about what confidentiality means, be able to describe basic theoretical approaches, not seem to even know how to show up for work. The dispute with this young full-of-herself supervisor came up when I was discussing a concern I was having about my current intern with her, and we ended up arguing about some hypothetical situation of how to deal with an intern who comes in without the most basic of skills. Her spirited "can do it all" attitude is that we should never assume that an intern has basic competencies and that as a supervisor it is in fact part of our role to teach these things.

I say not. I went online and discussed this matter over the phone with two professors in the field who both said that interns are required to have certain core classes completed and not just to have been a warm body in the classroom either, but to be able to function iwth the information they were expected to learn.

Then I thought about the Egg Who Wants to Teach the Chicken here and thought abott her expecting me to assume that kind of liability and expect me to take someone on my license that isn't prepared to treat clients and I thought "wow."

There have been other instances similar to this where I feel her judgment is superceded by her need to be in authority,her new thing is that we clinicians are going to be required to take whatever clients she refers to us regardless of the appropriateness of the referral and that she is considering not letting clients switch therapists if they don't feel the one they got assigned to isnt' working, because, as she states, "sometimes that can be a learning experience for a client to have to work through how to get along with someone they don't like." sometimes that is true, and I agree with putting a limit on therapist-hopping, but to have this as a general policy seems unethical to me.

the agency power people seem to have given her a green light to do as she sees fit, and she's done a lot for this financially strapped agency in terms of bumping up productivity and tightening up paperwork quality. but it's only a matter of time till I have enough money saved up to open my parachute and jump out of the plane and into private practice.

My former supervisor was always good at listening to my point of view and respecting my clinical judgment on things. but now she's in "senior management" and slowly delegating her supervisory responsibilities to The Egg. I've thought of talking to her about my concerns but I don't want to come off as trying to put her in the middle or just being a complainer, and some of these issues are just so fundamental in terms of working styles and communication styles and philosophy that I don't ever see us working well long term, not as long as she has authority over me. when we were in parallel positions we were great and played off each other's strengths, but now it's all her way or no way.

so bottom line, I'd like to hear people's thoughts on clinical autonomy in a financially strapped public mental health agency, this supervisor's expectations and how would you deal with the situation, short of leaving which is not an option until I am ready to get into private practice.
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Unread August 10th, 2008, 03:22 PM
Da Friendly Puter Tech Da Friendly Puter Tech is offline
Join Date: Jul 2004
Posts: 60
Default Re: clinical autonomy in an agency

Not being a therapist it seems to me that some of the general work place rules of engagement would work in this situation.

All of it of course focused on the CYA and document, document, document rule of thumb.

First whenever you see your supervisor do something or make a judgment call that you believe jeopardizes the clients - document it. Might not ever use it, but it might come in handy. Should things get really tense this could mean the difference as to who keeps their job. I would go so far as to also assume that she is already doing this.

Then if your supervisor ask you to do something that either jeopardize your license or the clients it seems obvious to me that you cant do it. Ethically and morally I cant see how you can do something you consider jeopardizing to your clients.

So - time to document. Document why you consider this request to be a danger to the clients. IE if an intern is not ready to do the work, document in what ways that intern is not ready to do the work, document the instances that give you this understanding. Write them down. Keep an official "work diary" with daily notes.

Then write a note to your supervisor and to sr. management with your documentation, stating your point of view that you cannot ethically do this task - and this is why.

For instance if you are asked to jeopardize your license with an unqualified intern you need notes that shows this intern is unqualified to begin with. Then you write an official letter to management. That consists of this intern is unqualified for this and this and this reason. I am not able or willing to jeopardize my license until the intern has been brought up to a certain industry wide standard. I find it outside of the scope of my job to bring this intern up to that standard while on my license. If I am requested to bring the intern up to that certain standard, then I will not allow the intern to be on my license while he or she does remedial work.

Make sure that you hold on to documentation about the other professors and professionals you have consulted in this case. Keep the date and time of your conversations. Keep notes about the content of the conversation, and keep a receipt of any payments you made for the advice.

Please remember that no matter who is your boss your license is the rest of your life's livelihood, and there is only one person who is responsible if you do take on someone who is not qualified and that person screws up. Its not your manager.

Come up with some other ideas on how to approach the different challenges, and be willing to work with management on alternative solutions.

Yes - this will make things tense, time to develop a thick skin. "The Egg" will definitely be ticked off, and quite possibly the people above her are going to recent the waves you create.

Other options are to either leave a little faster, or to do what she says. If what she says jeopardize your license and even worse your clients well being then I am not sure how you can even consider it.

Last option, I dont know if might work in this specific case. It is the teenagers shining it on option. "Sure I will do that right now" ("Yeahh right you bonehead - in your dreams!")

Do you work, do it well, and excellent documentation will make it at the very least hard to fire you until you are ready to go.

Dont ya LOVE the CYA dance? (The only dance I do is the one of joy for being out of a corporate environment)

Da Friendly Puter Tech
(who really has changed careers a few times while using this moniker)
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Unread September 17th, 2008, 05:58 PM
William Reid William Reid is offline
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Join Date: Jul 2004
Location: Texas
Posts: 105
Default Re: clinical autonomy in an agency

". . . Then I thought about the Egg Who Wants to Teach the Chicken here . . ." Very effective mental image, Sk8rgrl.

As usual, don't consider this to be legal advice, but it's how I'd think about the issue:

Supervisory situations are different from place to place, but if you are saying that supervisors in psychotherapy/counseling clinics and teaching settings should only accept such duties when they are confident that the (usually unlicensed) supervisee has the requisite basic skills and attitudes, then I agree with you. If I understand you correctly, your supervisee is allowed (or expected) to see patients/clients by herself/himself, then you review/discuss/critique the work in some way. That means the patient/client is alone with the supervisee, and both the patient and the agency are relying on the supervisee to do a reasonable job, not do any harm, etc.

From the patient's viewpoint, the supervisee is a professional clinician (even if the supervisee has notified the patient that he/she is still in training, is required to have a supervisor, etc., notification which should occur in such settings). The patient has a right to expect reasonable care from the supervisee, who is an agent of the agency, and the agency (in part through the supervisor and in part through other vetting) should do a reasonable job of making sure the supervisee is capable of providing that care.

Assuming that the supervisor is not in the room when counseling is being done (true in most such situations), the supervisor has an obligation to be reasonably sure the supervisee is qualified to do the above. That may mean interviewing the supervisee before starting the work, reviewing his/her background & training, observing a few sessions, etc. If the supervisor believes at some point that the supervisee is not qualified to act alone, or is not performing reasonably and safely, the supervisor has a duty to both the patient and the agency to intervene in some way (which may or may not entail stopping the supervisee from doing counseling).

In such a situation, the agency is generally responsible for the acts of both the supervisor and the supervisee, and may be criticized about either (e.g., in a complaint or lawsuit). The agency relies on the supervisor to notify it if the supervisee is unqualified or doing something wrong (assuming the supervisor reasonably should be aware of same). Thus the supervisor has a duty to keep the agency informed. By the same token, the agency has a duty to take appropriate action to protect patients if the supervisor puts it on notice that a supervisee's ability or behavior is problematic. It is dangerous and improper to accept supervision of a counselor or other supervisee who you believe may be unqualified, unless appropriate safeguards for the patient are in place.

Lots of us are too cavalier about what it means to be a supervisor of this sort, and are quick to agree to take on the role. In my view, one should carefully clarify the supervisor's substantial duties, which includes your duties to patients, to the supervisee, and to the agency, and undertstand what it will take to fulfill those duties. Do not be misled by a superior who says something like "don't worry, all you have to do is review the case and sign off on the notes." That doesn't erase the professional, ethical, and legal duties I just discussed. And in many cases, the supervisor is actually the person who is responsible for the patient's care. That's often what it REALLY means when you "sign off" on a supervisee's notes or reports.

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Unread December 2nd, 2008, 11:42 PM
sk8rgrl23 sk8rgrl23 is offline
Join Date: Dec 2005
Posts: 53
Default Re: clinical autonomy in an agency

thanks for the reply. fortunately, I have "outlived" her. I think things weren't going well from more people's viewpoints than just mine.

Reading these threads was an eye opener. I hadn't been thinking along the lines of being sued, or being sanctioned by the licensure board, and if I ever come across this type of situation again, I will be sure to document them.
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