New therapists often use the terms “supervision” and “consultation” interchangeably.  The problem is that they refer to very different relationships and obligations.  Do you know the difference between supervision and consultation?

Supervision is hierarchical. It often occurs

"Hierarchy" by brka / Kristijan Brkic

within the context of your schooling, employment or post-graduation when you are attempting to satisfy client contact hours for licensure in your state.  If you are under supervision, then you are required to comply with any directives given to you by your supervisor.

Consultation occurs between colleagues or peers and is often used as a way to expand a therapist’s ideas for working with a client.  Consultation is also considered a risk management tool but obligates you to take no specific action other than that based on your own professional judgment.

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Tags: Consultation, Supervision

When you decide to seek clinical consultation, there are 5 things that you should document in your clinical notes.  They are the 5 W’s:

• When you seek consultation;
• Why you are seeking consultation and why now;
• Who you are seeking consultation from;
• What opinions / information / recommendations you are receiving from that person even if they contradict your own clinical judgment;
• What your final professional opinion / plan is and why you are / are not going to go along with the recommendations received.
  

  "Questions" by Tim O'Brien / Oberazzi

In other words, your clinical rationale all along the way needs to be documented in your notes.  Why?  To protect both you and your client.

Should you end up in a malpractice suit (which is quite possible), your proper documentation will assist you in explaining your thought process concerning your work with your client.  Likewise, should anything happen to suddenly prevent you from continuing to work with your client, your general direction of treatment can more likely continue seemlessly because you have taken the time to thoroughly document your clinical rationale and intent.

Tags: Consultation, Documentation

Carla read my post here and wrote in asking:

What do you do when as a result of finding out that you are a counselor, your church now wants you to provide counseling services to members of the congregation? Or the fact that you have taught classes at ministry events, and as a result some of the participants want to come see you?”

"Nice, Small Church" by Speediakal

How flattering!  But, here are 9 things that I consider before deciding whether or not to see members of my own church . . . .

1. Size matters.  I have found that it is difficult to be active in a church whose congregation numbers only 200 and still maintain my privacy.  That, in turn, colors my professional relationship with my client.  He knows more about me (and I know more him) than is always best.  If, on the other hand, my congregation numbers 1000, then it may be relatively easy for me to maintain my privacy and to minimize personal interactions outside of the counseling office.
2. I consider how I will handle it if I discover that my client is sexually or romantically involved with one of the leaders in my church (who happens to be married).  As far fetched as that may sound to you, it is not all that uncommon and it may very well change how you feel about your church home.  It did for me.  And, that’s before my client AND my church leader both wanted to vent to me, wanted me to choose sides, and then wanted me to publicly condone their behaviors to others!
3. I also consider how my own unforeseen weaknesses / foibles in my personal or church life (challenges in relationships, lapses in judgement, my own spiritual practices, etc.) might negatively impact my relationship with my client . . . .  Unanticipated exposure of those things can actually color what happens in my church and with my client.
4. I also consider the possibility that my partner / spouse / friend / child / sibling / parent may want to befriend my client.  That’s a mess in and of itself! And, what will I do if I believe (from my  clinical work) that the relationships with my client might not be good for my loved one?
5. I’ve had clients catch me before I could dash off from church services to “catch me up” on the latest chapter of their weekend disaster.  Do I want to do therapy in the parking lot?  Do I want to act disinterested?  Or, do I want to dread seeing that client every time I enter the church door?
6. I also have to consider if / how I am going to interact with my clients when I see them.  Am I going to speak to my clients when I see them at church?  Am I going to ignore them?  What if my new client sits down beside me on the pew?  Wants to hug me?  Asks me to take communion with her — or just “conveniently” times it so that it happens that way?
7. What if I sign up for a church dinner club and get assigned to the one that my client attends?  Am I going to explain to the host why I had to leave abruptly when my client showed up?  Am I just going to let the host think I’ve lost my mind?  (Yep, that’s exactly what I did as I ran out the back door.)
8. What if I agree to host a Bible study and my client shows up . . . or his wife . . . or someone who eventually becomes his spouse?  Am I really going to ask my client to leave because there’s a dual relationship if he stays?
9. Sometimes clients can be possessive of their therapists (and you won’t always know this ahead of time).  I’ve had Client A  show up “hurt” or mad at his therapy appointment because he had seen me talking to someone else at church.

OK, so I could go on and on . . . . My point is this . . . .  While much of this can make for great grist for the clinical work that you do with a client, do you really REALLY want to contaminate your personal life (and the lives of your loved ones), your spiritual home, and your professional life with this stuff?  Just think about it and, if you do, consult, consult, consult.

Can you think of other questions / situations / concerns to consider before jumping in to provide therapy within your own religious community?

Tags: Boundaries, Consultation, Ethics, Policies and Protocols, Reputation

I feel like I’m slave labor for the agency.  No one tells me how to help my clients.  I’m just left to figure it out on my own.”

My supervisor signs off on my paperwork every week but doesn’t really do anything.  We meet. I describe each one of my cases to him.  And, then we spend the remainder of the hour talking about his family.  THIS is SUPERVISION????!!!!”

How do I get the time I need to actually work with my clients?  The paperwork here is overwhelming and my supervisor is too busy to even discuss it.”

Every year the horror stories roll in . . . .  What’s a new counselor to do?  Having a great experience with clinical supervision doesn’t just happen in a vacuum.  In case your graduate program forgot to tell you, here ARE  nine things you can do to insure that you have the best supervisory experience possible.

1. Interview several potential supervisors even if you think you already know who you want.  Good supervisors will limit the number of counselors that they supervise so that they have ample time to spend with you.
2. Once you ask someone to supervise you, ask for a written contract with that individual that specifies details of your professional relationship.
3. Remember that supervision IS a professional and hierarchical relationship.  Don’t blur those boundaries and don’t tolerate a supervisor who blurs those boundaries.
4. Schedule regular meetings with your supervisor and make them a priority.  Treat them as you would an appointment with any other professional.  Expect your supervisor to do the same.
5. Your supervisor should make arrangements to be available to you in case of client emergencies.  If s/he is unable to do so, s/he should make arrangements for some other qualified professional to be available in her place.
6. In the event that your supervision is not going as you had envisioned it would, you need to be prepared to initiate that conversation.  Go in with an open mind, state your concerns and ask for what you need.
   

   "Perseverance" by Marcus Smith

7. If you have attempted to discuss the issue with your supervisor and are not satisfied with her response, you may seek consultations with peers.  However, until the licensing board in your state or and attorney tells you otherwise, you are required to abide by the directives of your supervisor.
8. If you are unable to satisfactorily resolve your differences with your supervisor, you may have the option to seek a new supervisor.  However, note that some states limit the number of supervisors that you may use to satisfy licensing requirements.  Check with your specific state to be sure of the rules related to this.
9. Most important of all, if you should need to leave your supervisor behind due to a conflict, take the time for self-evaluation.  Learn what you can about you and about this situation.  It is not something that you want to repeat.

How is your supervision going?

Related Posts

Clinical Supervision and Money Gouging

10 Question You Must Ask Your Potential Supervisor

Tags: Boundaries, Consultation, Contract, Emergency, Relationships, Self-Evaluation, Supervision

The Basics of Clinical Supervision

Lately, I’ve found myself in a lot of conversations about clinical supervision.  If you’re getting ready to graduate from your clinical program in one of the mental health professions, it’s time to start thinking about your own clinical supervision.

Prior to obtaining your license as a professional counselor, social worker, or psychologist, you will be required to obtain 1500-4000 hours under clinical supervision.   If you are fortunate enough to work in an agency, hospital, or school, it is likely that your employer will provide clinical supervision for you on site at no expense to you.  If that’s the case, consider it a benefit of the job.

However, if following graduate school you attempt to go directly into private practice (as is the option in some states) or end up working for an employer that does not provide your clinical supervision, then you will need to find a supervisor and pay for supervision on your own.  (Look for 10 Questions You Must Ask Your Potential Supervisor next week to learn more about how to find a great supervisor.)

"Money Jar" by Automania / Mike

Supervision and Money

I’m not sure why but not one of my professors in graduate school ever thought to talk with us about those additional costs that we would incur following graduation.  So . . . let me break the news to you. . . .

One of the many reasons you may want to start out working for an agency that provides your clinical supervision is that it can be expensive if you have to pay for it on your own. If you are paying out of pocket, you should expect to pay whatever a typical clinical hour costs in your geographic area.

I charge the UCR – usual and customary rates – for those working on the Front Range in Colorado.  My fees are $100 – $125 / hour for individual counseling  and $60 / hour for group counseling.  I charge the same rates / hour for clinical supervision and you will find that most reputable supervisors charge based on their hourly clinical rate as well.

Too Expensive

If  you find those rates to be objectionable, you have a right to understand why these are actually reasonable fees and that good supervisors are not simply gouging you for “easy  money” (as one new graduate noted this week on a discussion list).  Here are some things to consider . . . .

• The professional standard for clinical supervision has shifted in recent years.  Your clinical supervisor is now expected (and in many cases, required) to obtain formal training in clinical supervision at her own expense.  In the State of Texas, that requirement is a minimum of 40 hours plus ongoing continuing education in the area of supervision.
• Your clinical supervisor is legally and ethically responsible for each and every client that you come in contact with.  S/he is also responsible for every decision that you do / do not make and every action that you do / do not take.  That’s a LOT of additional responsibility.
• Your supervisor is responsible for reading every bit of your initial client assessments, progress notes, all correspondence, and termination paperwork and providing feedback as needed.  That’s a LOT of time.
• Your clinical supervisor will typically meet with you on a weekly basis for 1-2 years.  That’s additional time out of her schedule every week s/he could be using to see a client and earn her hourly fee.
• During your weekly meeting with your clinical supervisor, s/he is required to essentially develop your abilities as a mental health professional.  Her roles will alternate between teacher, mentor, consultant and evaluator.
• For every hour that your clinical supervisor spends with you, s/he is most likely spending another hour in preparation — completing paperwork, refining a plan to help develop you as a counselor, gathering materials, reviewing literature to meet your unique needs and interests.  That’s MORE TIME.
• Your clinical supervisor remains on call for you 24 hours / day.
• And, long after you have completed your hours of clinical supervision, s/he remains liable for all those decisions you made while under supervision.  Assuming you are seeing 20-30 clients / week while your supervisor is also seeing that many clients / week, her choice to supervise you, in effect, doubles her risk of being sued.

I’m sure there are other risks / costs involved in being a clinical supervisor.  If you can think of them, please share them with us here so that new graduates will have a clearer understanding of why fees are set the way they are.

And, if you are a new or soon-to-be-new graduate who is considering clinical supervision, let me know if any of this is new information for you.

Tags: Consultation, Evaluator, Fee, License, Mentor, On Call, Paperwork, Supervision, Teacher, UCR

This is part of an episodic series, The Therapist’s Networking Guide.
To see the previous post in this series, click here.

On Monday, in the The Therapist’s Networking Guide I talked about the difference between strategic and shotgun networking.  Today, I want to stress that networking includes much more than just showing up at a monthly meeting with your business cards in one hand and your other hand outstretched (asking for business).  If that’s your idea of networking, you may want to re-think your understanding.

Real networking . . .. strategic networking is much more effective when it is about you creating and extending an ever-expanding circle of contacts that may have the ability to refer clients / referrals to you, provide resources to inform you, share ideas to inspire you and information to support you.

Here’s the beginning of a list of the many ways you can begin to build / expand your network:

• Attending meetings and workshops.
• Keep up with what is going on in your field.
• Share your services and skills by volunteering in your community.
• Join a leads or networking group.
• Mentor new professionals.
• Seek out professionals who are interested in building reciprocal referring relationships.
• Gather information about other professionals, clinics, and treatment facilities that can support you now and in the future.
• Offer classes related to your professional interests.
• Refer clients (when appropriate) to allied health professionals.
• Get involved in your civic / religious community.
• Collaborate on projects.
• Join an on line community -  a discussion list, a blog community, or other social media.
• Stay connected to former employers and college instructors.
• Create / join a consultation group.
• Exchange resources with other professionals.
• Serve on committees.
• Meet colleagues for coffee or lunch.

These are just a few of the many ways that you can start to grow your network.  Can you help me expand this list?  What is it that you are doing to create / expand your professional network?  And, what is it that you can commit to start doing today to increase your circle of contacts?

The next post in this episodic series is The Therapist’s Networking Guide:  Are You Helping Your Network Take Care Of You?

Tags: Consultation, Network