LPC Managing Differences and Difficult Populations

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Managing Differences and
Difficult Populations
Glenn Duncan LPC, LCADC, CCS, ACS

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.

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.

 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.

 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 client, therapist and supervisor, cultural competence,
and comfort with ambiguity.

Evaluation of Supervisees
 Formative Evaluations – the process of facilitating skill acquisition and
professional growth through direct feedback.
 Less discomfort for both supervisor and supervisee.
 Stress process and progress, not necessarily outcome.
 Summative Evaluations – using clear criteria to measure supervisee
performance.
 Can be a source of more discomfort for both supervisor and supervisee.
 Pitfalls include: lack of a clear set of standards, lack of a positive working
relationship, lack of good communication skills.
 Antidote to distress: the amount of time and care put into formative evals.

Making Evaluations a More Positive
Experience
1. Remembering the Power Differential – supervisors must be sensitive
to the position of the supervisee. This can make the supervisor a more
compassionate evaluator.
2. Clarity adds to the positive context – clarity about supervisor’s
clinical and administrative roles (e.g., who gets a copy of this evaluation,
how/will this evaluation impact the supervisees’ future role within the
organization, how/will this evaluation impact pay increases).
3. Supervisees’ defensiveness should be addressed openly –
supervision makes supervisees feel “naked”, and defensiveness should be
put into the context of being a natural phenomenon.
4. Supervisees’ individual differences should be addressed openly
– evaluation may be affected by differences (cultural, gender, sex, age,
etc.).

Experience5. Evaluations should be a mutual and continuous process – beyond
foundational competencies, the supervisee should be actively involved in
determining what is to be learned.
6. The formative evaluation process should be the most active –
the process of learning skills and facilitating professional growth should be
the most active part of supervision and involve the supervisee fully in that
process.
7. Evaluations must occur within a strong administrative structure
– supervisors must know that their evaluations will be taken seriously and
supported by the administration within the organizational structure. Nothing
is more damaging as when an evaluation is negated or overturned by the
administrative hierarchy.
8. Supervisees must be aware of, and know due process
procedures – they must know there’s a place to go to if they feel the
evaluation is unfair.

Experience9. Avoid premature evaluations – it is important to resist overreacting to
the person who either shows unusual potential or who appears to be
faltering.
10. Supervisees must witness the professional development of their
supervisors – the best way to accomplish this goal is to invite feedback
and use it. Also sharing your continuing education activities with supervisees
helps with this goal (e.g., presenting new ideas you have recently been
exposed vs. playing the “all-knowing guru”).
11. Relationship, relationship, relationship – supervisors must always
keep an eye on the relationship, which influences all aspects of supervision.
Too close or too distant can impact evaluations as can deteriorating
relationships.
12. If you do not enjoy supervising, you should not be supervising –
supervising for any reason less than the enjoyment/love of supervision,
causes the challenge of evaluation to become too great of hurtle.

The Process of Evaluation
1. Negotiating a supervision-evaluation contract.
2. Choosing evaluation methods and supervision
interventions.
3. Choosing evaluation instrument(s).
4. Communicating formative feedback.
5. Encouraging self-assessment.
6. Conducting formal summative evaluation sessions.

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.

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.

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.

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.

LPC/LAC Guidelines for Cultural
Competence
Training 13:34-15.2 Contact-hour requirements for licensed professional
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.

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.

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.

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?

Ethnicity vs. Organizational Culture
Exercise
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).

Exercise
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.”

Exercise
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.

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 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?

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 2007. 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.

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”.

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?

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/Recovery
2. Supervisee Experiential Levels
3. Education Levels of Staff
4. Transference/Countertransference Reactions of Supervisees

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.

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.

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).

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.

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.

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.

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 patient's (supervisee’s)
influence on the therapist's (supervisor’s) unconscious feelings,
causing a reaction towards the client (supervisee) by the therapist
(supervisor).

Categories of Supervisor
Countertransference
1. 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).

Categories of Supervisor
Countertransference
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.

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

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.

Exercise: Managing Difficulties in Your Staff
You’re the supervisor of a particularly fragile soul. You recently came
into the organization under a management restructure where your job
was to start an Intensive Outpatient Treatment Program and oversee and
supervise 2 clinicians within this program.
Both clinicians have been working at the organization for over 10 years
and have been doing outpatient treatment with no supervision and
oversight. Your supervisor apologizes for this state of affairs as it should
have been he who supervised these clinicians but did not. Your
supervisor has given you full reign to oversee this (dramatic) change, as
these 2 clinicians have over 18 years each of experience, but little
experience in group situations, no experience running an IOP, and very
little clinical supervision.

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.

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:

Exercise: Managing Differences in Your
Staff
1. 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?

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.

Ethical Decision Making
Decision 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.

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.

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.

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 client's confidentiality is a
decision made in relation to a third party.
 Decisions are not compelled internally; rather, they are socially
compelled.

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.

Ethical Complaints Against Counselors
1. 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.

2. 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.

3. 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.

4. 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.

5. 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.

Managing Difficult Staff
1. Don't generalize – be very clear about what the problems
and symptoms are.
- Some individuals simply aren't 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.

2. Don't 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 their reactions 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.

4. Don't 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.

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.

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.

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.

The Impaired Clinician – Substance
Use
 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?

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.)

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

Title 45 – Uniform Enforcement Act – Duty to
Report
 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 professional's 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.

Report
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.

Report
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 professional's
knowledge of the other health care professional's impairment or incompetence was
obtained as a result of rendering treatment to that health care professional.

Title 45 – Uniform Enforcement Act – Acts
which 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;

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;

I. Is incapable, for medical or any other good cause, of discharging the
functions of a licensee in a manner consistent with the public's 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

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.

Counsel for Affordable Quality
Healthcare
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 one's 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.)

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 role
1. 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.

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.

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?

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?

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?

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.

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.

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.

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.

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).

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.

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.

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.

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.

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?

Bibliography
 Bernard, J. M. & Goodyear, R. K. (2013). Fundamentals of Clinical Supervision, 5th
Ed. Pearson Educational Inc., 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.

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

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