Family Therapy Resources

If you want resources for therapists in the form of articles, books, audios, or videos, please access FamilyTherapyResources.net. For information clinical supervision, please use the Search Directory feature at www.familytherapyresources.net/search.asp, and type "supervision" in the Keyword box.

The following is Contracting for Effective Supervision written by Dr. Layne Prest of University of Nebraska Medical Center, the author of "The Fly on the Wall Reflecting Team Supervision" which you can access at Family Therapy Resources.

Contracting for Effective Supervision

Learning about people and the process of therapy is ongoing. One should not assume this process stops at graduation, obtaining licensure, having a certain number of years in the field, or (even) becoming an approved supervisor. As therapists we need to continue to grow, both personally and professionally. Part of this growth includes ongoing reflection, gathering new information, incorporating different perspectives, and seeking feedback from others. Obviously one formalized format for this process is clinical supervision.

In my opinion the most important part of supervision is negotiating an initial contract for the structure and process involving the therapist, supervisee, clients, and others in the treatment system (agency administrators, office managers, other group supervision members, etc). It may seem strange to think about something as formal as developing a "contract" — especially if your supervisor is also a relatively close personal or professional acquaintance. "Of course we have the same ideas about therapy (supervision, life...), I’ve known her for years!" Well, maybe….

It is helpful for both parties involved to come to the initial supervision session(s) with ideas about what they want. Important topics to consider addressing include the obvious and the obscure. Some are similar to those a therapist should have in mind to discuss at a first therapy session. Others are particular to the supervision relationship. The topics include:

Time, place, fee, cancellation notice, confidentiality (with respect to the supervisee as well as the clients being discussed), managing legal and ethical aspects of cases, liability and malpractice insurance, theoretical orientation, style and technique preferences, supervisee/therapist training goals, therapists’ use of self, addressing diversity issues, hierarchy and power, handling disagreements about clinical approach, and so on.

Some supervisors and their supervisees may find using a checklist or other written document helpful in structuring the relationship and facilitating the discussion. Others may prefer a less formalized approach. Either way, a "contracting" process helps the two parties to clarify issues (even uncomfortable ones), focus your work, and provide a context for gauging progress. A number of articles and books are available to help with this process. I encourage you to check them out or talk with an AAMFT Approved Supervisor. Approved Supervisors have been through their own supervision as therapists-in-training, followed by a formalized training process (in graduate school and/or workshops), and a period of time as a supervisor-in-training under the supervision of an experienced AAMFT Approved Supervisor. Call on one or more to give you their perspective on supervision so that you can contract for a process that is effective for both you and your clients.

Shari Conner, Ph. D., licensed psychologist, was a presenter at the NAMFT Fall 2009 Conference. Her topic was "Restoring Super in Supervision, A Many Splendid Training." She is also president-elect of the Association of Private Practice Therapists (APPT):

Tips on Managing Liability as an Independent Practitioner

Shari Conner, Ph.D.

I was honored to speak at the fall conference of the Nebraska Association of Marriage and Family Therapists this year. Many good questions were asked about supervision, especially as it pertains to the Medicaid/Magellan process. However, of equal importance is the issue of managing one's liability. This applies to those who practice under the supervision of others, as well as to those who are independently-licensed. The purpose of this article is to summarize some issues to consider, particularly when one is carrying on his or her license the responsibility for the clinical work of others.

First, it is important to remember that in any supervisory arrangement, the supervisor is as responsible for the client's well-being as the therapist being supervised! In fact, it is the supervisor who is ultimately responsible should anything go wrong (though the therapist is likely to be sanctioned as well).

For this reason, a supervising practitioner should-indeed, must-be thinking systemically when doing a diagnostic interview and assisting with the creation of the initial treatment plan (fortunately, marriage and family therapists specialize in this type of conceptualization). Because the supervising practitioner is tasked with recommending referrals for potential client needs, he or she should not only address the type of therapy required (e.g., individual vs. family, frequency, theoretic orientation, etc), he/she should also consider that the client may need to be evaluated by professionals in other fields. It is appropriate for supervisors and independent practitioners to consider whether clients could benefit from Physical Therapy, Occupational Therapy, Speech/Language, or Vision evaluations.

Further, the supervising practitioner must also consider the mental health needs of the client that exceed the capacity of outpatient therapy to provide. These include referrals for services such as psychological evaluation, chemical dependency evaluation, psychiatric consultation, or CTA involvement. Group therapy is particularly important for many individuals, and referrals should be made as needed to resources such as domestic violence groups, 12-step programs, parenting courses, anger management classes, and community support resources like NAMI or Community Alliance.

The second primary liability issue worth noting involves those unfortunate clinical situations when one is supervising a therapist who has a high-risk client. Remember: You have vicarious liability for anyone you supervise. Thus, both you and your supervisees should be familiar with the "Legal Duty" to which you are held:

"It is the duty of one who undertakes to perform the service of a trained or graduate healthcare professional to have the knowledge and skill ordinarily possessed, and to exercise the care and skill ordinarily used in like cases, by trained and skilled members of the healthcare profession practicing their profession in the same or a similar locality and under similar circumstances. Failure to fulfill either of those duties is negligence."

In essence, this means that a therapist and/or supervisor must have the knowledge and skill that is ordinarily expected of a person in the profession (i.e., should hold a valid license and be current in continuing educational requirements). Moreover, they must "exercise the care and skill ordinarily used in like cases," meaning that, when in doubt, CONSULT!! A suicidal or otherwise dangerous case will be less of a liability for the therapist and the therapist's supervisor if they document that they have consulted with another professional who is in their locality and practices under similar circumstances. By doing so, the treatment providers are able to demonstrate that their decisions about the case were in line with "the care and skill ordinarily used" by like members of the profession.

In summary, I'd like to offer a few "principles to live by" when it comes to managing liability within the mental health profession. These are directly culled from the definition of legal duty that is described above. Adherence to them will hopefully reduce one's chances of being found liable for an adverse therapeutic event. These principles include:

1. Careful documentation of all the facts.

2. Documentation of client and family involvement when risk issues are escalating. It is particularly powerful to have a family member's signature on a document in cases of client noncompliance with your recommendations for safety.

3. Documentation of informed consent. Make sure the client has signed paperwork acknowledging their understanding of the potential risks of therapy and giving his/her consent to be treated by you.

4. Documentation that you have fully disclosed necessary information to the client, such as the exceptions to rules about confidentiality. Also, document that you have the client's consent to share personal information with family members or doctors if that is part of the treatment plan during times of increased risk.

5. Share the responsibility for difficult clinical decisions, such as by documenting consultation conversations.

6. Involve a risk manager, such as your malpractice insurance company or an attorney.

7. Always remember, if you say and do nothing, you retain full legal responsibility! Ignoring the problem won't make things better.

One final note of advice, especially for supervising practitioners: You never know when a critical situation will land itself on your desk. Be prepared in advance by knowing the procedures for involuntary hospitalization (those applying to minors and those applying to adults), local facilities available for placement, transportation options, confidentiality rules, and admission procedures. Supervision is a rewarding and enlightening experience, though it can be more fully enjoyed when one feels secure in knowing that supervisees understand how to protect both the client's safety and the providers' licenses.