Course:PSYC537/2010WT1/Vignette10

VIGNETTE 10

You are a psychologist supervising a psychology graduate student. The student has been very open in supervision and has shared with you that she is going through a rough time in her personal life. Lately you’ve become concerned that her personal crisis is becoming worse and may be impairing her clinical work. She has been late for a few sessions, poorly prepared for supervision, and snapped at one of her clients in the previous session. You’ve discussed the issue with her, but she disagrees that it’s a problem and assures you that she can handle it. You raise the possibility of involving her training program to ensure that she has the support that she needs and she responds with anger, saying that she thought that the personal struggles she told you about were confidential. What would you do?

STEP 1: Who are the people potentially affected by decision?
Me, the psychologist (the supervisor)
The graduate student (the supervisee)
the clients that the student is currently seeing who might be affected by her unprofessional behaviour
Student's graduate program (Your decision could affect the program evaluations of her clinical work.)
Your decision could also affect other students in her program who might be going through personal issues that cause impairment in their clinical work. (CC)

STEP 2: What are the relevant ethical issues/laws? Which ethical values/laws are in conflict?

In this situation, for the supervisor, Principle 1: Respect for the Dignity of Persons appears to conflict with Principle 2: Responsible Caring and Principle 4: Responsibility to Society in the CPA Code of Ethics.

The relevant articles under Principle 1 are: I.1 Demonstrate appropriate respect for the knowledge, insight, experience, and areas of expertise of others. I.8 Respect the right of research participants, clients, employees, supervisees, students, trainees, and others to safeguard their own dignity. I.38 Take care not to infringe, in research, teaching, or service activities, on the personally, developmentally, or culturally defined private space of individuals or groups, unless clear permission is granted to do so. I.40 Respect the right of research participants, employees, supervisees, students, and trainees to reasonable personal privacy. I.45 Share confidential information with others only with the informed consent of those involved, or in a manner that the persons involved cannot be identified, except as required or justified by law, or in circumstances of actual or possible serious physical harm or death. (Also see Standards II.39, IV.17, and IV.18.)

The relevant articles under Principle 2 are: II.1 Protect and promote the welfare of clients, research participants, employees, supervisees, students, trainees, colleagues, and others. II.2 Avoid doing harm to clients, research participants, employees, supervisees, students, trainees, colleagues, and others. II.50 Assume overall responsibility for the scientific and professional activities of their assistants, employees, supervisees, students, and trainees with regard to the Principle of Responsible Caring, all of whom, however, incur similar obligations.

The relevant articles under Principle 4 are: IV.10 Uphold the discipline’s responsibility to society by promoting and maintaining the highest standards of the discipline. IV.13 Uphold the discipline’s responsibility to society by bringing incompetent or unethical behaviour, including misuses of psychological knowledge and techniques, to the attention of appropriate authorities, committees, or regulatory bodies, in a manner consistent with the ethical principles of this Code, if informal resolution or correction of the situation is not appropriate or possible.

According to Principle 1, the supervisor should do his/her best to maintain confidentiality of the student’s personal issues (articles I.38, I.45 and I.40) and thus refrain from disclosing her crisis to the training program without her permission. Furthermore, Principle I also recommends the supervisor to respect the student and her decision to not yet seek support for her personal problems (articles I.1 and I.8).

However, according to Principle 2, the supervisor also has the ethical responsibility to ensure that the clients under his/her students’ care are receiving competent, responsible caring and are not being harmed (articles II.1, II.2 and II.50). It seems that the student described in the vignette is currently unable to provide responsible care. In line with Principle 2, the supervisor has an ethical responsibility to prevent the student from dispensing further care, which can/should include reporting her potential impairment to her training program.

Principle 4 also suggests that the action of reporting the student’s possible impairment to her training program should be taken. According to Principle 4 (articles IV.10 and IV.13), the supervisor has the ethical responsibility to act as a ‘gate-keeper’ and ensure that students-in-training who are performing at an unsatisfactory level will not be granted their qualifications to practice. This measure ensures that future psychologists are of satisfactory competence and thus will unlikely to harm their patients or provide inadequate care. (SC)

STEP 3: How do personal biases, stresses or self-interest affect my choice of action?

One potential source of bias is whether you (the psychologist) have experienced similar personal troubles, especially if it was during your training experiences. If this were the case, you might be more prone to understanding where your supervisee is coming from. Alternatively, if you have not experienced these troubles, you might have a harder time understanding why your supervisee might not be as inclined to try and resolve these issues. Another potential source of bias is if you have been implicated in any legal proceedings in the past due to the actions of a previous supervisee. If this has previously occured, you would likely be more cautious in ensuring that your supervisees only get training experience with clients when they are not experiencing personal troubles. A third potential source of bias might be how you respond to defensive people. If you have friends or family in your life that get defensive when you try and tell them that what they are doing has negative consequences, you might either have very sensitive techniques to deal with this or have no patience. Finally, one source of personal biases depends on the type of relationship you have with your supervisee and how much you like them. If you have had a tumultuous relationship with your supervisee, you may have less sympathy for their disreguard of the ethical protocols that you are following. (AA)

I think the amount of time since I had been a grad student would influence how I handled the situation. As a current student I probably feel more empathy for the student than someone who hasn't been in this role for many years, and therefore may approach the situation more gently. This may mean I would give her more chances before involving her training program, as I understand her anxiety about this affecting her evaluation. At the same time however I would be very concerned by the fact that she does not seem worried about how this is affecting the client. This makes me question her ethical judgment and motivation for being in the program and may make me more likely to want to exercise my gate keeping responsibilities and inform the training program about my concerns. My raction to this situation may also depend on the personal issues that she is dealing with, if it something that I or someone close to me has experienced in the past I may lean towards protecting her privacy and putting off informing the training program (HM).

STEP 4: Consult with colleagues.

STEP 5: Develop alternative courses of action.

1. Continue to discuss how the student's personal struggles are affecting her clinical work, perhaps by discussing her ethical obligations, showing her videos of her interactions with clients and pointing out how they may be negatively affected, and citing specific examples (dates, meetings, etc.) where you feel she has been unprepared for supervision, in the hopes that she will see that she may be impaired and seek support herself.

2. If you think it is warranted, discuss therapy with the student, and refer her to someone outside of her training program, with whom she is not likely to come into contact with in a training setting.

3. Explain that you are very concerned for her at this point in time, go over the supervision contract and explain and that it is your duty as supervisor and a gatekeeper to involve the training program - then involve the training program.

4. Explain that it is your legal obligation to protect the clients' well-being, and start to decrease her caseload - which may mean initiating termination on her part in the clients who are least vulnerable/most appropriate, and setting up referrals or taking the clients on yourself until the student is able to resume her clinical work.

5. Wait and see if things get better. (AH)

STEP 6: Analyze likely short-term, ongoing and long term risks and benefits of each.

1 - Pros: Her crisis is kept confidential. The supervisee may gain better insight into her behaviour and how the crisis is affecting her, her work and her clients. Gaining this insight, she may later be more open to suggestions / interventions, both in terms of her own well-being, and in terms of her progression in the program. Or may even take steps of her own to separate her personal crisis from affecting her work. Cons: Even if she gains insight, this process may take time, and clients are put at risk during this time. She may continue to be resistant to the awareness of the dynamics/situations/behaviours incurred by her crisis and how it not only affects her but others as well. There may be no change in dealing with this ethical problem and her clinical work may continue to suffer. You are on a slippery slope in terms of keeping the supervision boundaries separate from a therapeutic relationship.

2 - Similar to 1, except the last point, that of the risk of supervision turning into therapy. In addition, she can more properly work through her crisis (pro).

3 - Pros: You are acting in your role as gatekeeper, holding to the discipline’s standards. Clients are better protected, and actions may be taken by the program to better ensure her progress or safeguard against her unsatisfactory work. You are protected legally, as you took steps as recommended ethically. Cons: The supervisee’s confidence is broken, and others (the program) are made aware of her personal business which she wanted to keep private. The supervisee is likely to be quite upset with you, and may stop being open with you about personal crises or anything that she believes you could use against her in the program. She may not feel cared for by you any longer. The student may be held back in the program, if not worse. Harm may be done to her professional career.

4 - Pros: Clients are better protected, and are better ensured to receive appropriate care and therapy. This option would give the supervisee more time to sort through her personal crisis and pick up the pieces. You are preventing her from dispensing further unsatisfactory care. The program is not informed, that is, her crisis remains confidential. You are protected legally, as you took steps as recommended ethically. Cons: The supervisee may be upset, as she believes she can handle the work and this would demonstrate a lack of trust in her. The program is still not informed and cannot take steps to provide her with support.

5 - Pros: Her confidence is kept. Cons: Similar as 1 / 2. You are at high legal responsibility for the care of her clients. (JK)

STEP 7: Choose course of action after conscientious application of principles.

I think the best possible option is a combination of the above steps, in a sequence to ensure provision of care but also protection of confidentiality, if at all possible. First, I would recommend outside therapy to her, as per solution 2 - this may allow her to work through some of the issues that are impairing her ability to perform her work, as well as give her an outlet where she may feel more comfortable (since she appears to be defensive with the supervisor). This also helps keep the supervisory relationship from becoming too similar to therapy. At the same time, I would also undertake the steps in solution 4, that is, reducing her caseload and ensuring proper termination or transfer of clients with whom she is unable (at this time) to adequately treat. I believe providing referrals for treatment for the student while also making sure that the clients receive competent care ensures protection of the most vulnerable parties in this situation. While I do not think notifying the training program immediately is a great idea (because of the confidentiality issues), it should be made clear to the student that, if the situation does not improve, such steps may need to be taken. This allows the supervisor to keep open the possibility of performing gate-keeping duties if the situation is not ameliorated by outside therapy for the student. Having this option discussed openly may also help the student realize how significant of an issue her conduct has become. (SV)

STEP 8: Act with commitment to assume responsibility for consequences.

STEP 9: Evaluate results of course of action.

STEP 10: Assume responsibility for consequences, including corrections or re-entry into decision making process if still unresolved.

STEP 11: Take action, as warranted, to prevent future occurrences. It appears as though while your supervisee was open to supervision at first, that she might not completely understand what exactly your role is. She may have thought you were there to provide some guidance, but also as someone she could confide in. It is important to make clear from the beginning what your role is as well as what you would expect of her, including what you would intend to do if you think that she is struggling or is having difficulties that are negatively influencing clients. You have to ensure that although you are definitely advocating for her well-being, that you also have gate-keeping responsibilities and responsibilities to the client.

Another issue here is that it sounds like she might have misinterpreted your intention to enroll her in a training program to help support her as resolving yourself of responsibility for her problems, despite the fact that she had confided in you. This could either be because you didn't approach what kind of actions you might take if you thought your supervisee was having a difficult time with her caseload in the beginning, or because you might not have properly address the supervisee's admission of difficulty (did you offer help then when she first confided in you?). It would be important to stress what the training program would mean in terms of her improvement and not necessarily because of her personal problems and that these types of decisions are based off her behaviours in session rather than what the two of you had discussed. (KA)