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Dennis P. Saccuzzo, PhD, J.D.

Continuing Education Information

ETHICAL BASIS FOR STANDARD OF CARE IN SUPERVISION

While licensing statutes and case law provide some guidance on how courts may define the standard of care in supervision, thus far there is neither a consensus nor an explicit statement of the standard of care in psychotherapy supervision by psychologists and other mental health professionals.1 As the authors of an extensive bibliography on clinical supervision note, “[g]uidelines and standards are lacking for interdisciplinary and postdoctoral supervision, as well as for ongoing supervision (as mandated in some states), of impaired psychological practitioners or those with subdoctoral training.”2 As these same authors also note, “no model training sequence in supervision has been developed or adopted by professional or accreditation organizations.”3 An examination of ethical and professional issues, as well as formulations concerning areas where liability may attach in the supervisory process, however, can provide some insights into the generally accepted duties of supervisors. In conjunction with statutory guidelines and case law, generally accepted principles of clinical supervision can help point the way toward a standard of care in supervision.

RELEVANT DOCUMENTS OF THE AMERICAN PSYCHOLOGICAL ASSOCIATION (APA)

Psychologists who provide supervision are guided by the Ethics Code and related standards and guidelines promulgated by APA. The latest version of the APA Ethical Principles of Psychologists and Code of Conduct was just published in 2002 and is effective June 1, 2003.4 This code represents the evolution of the APA’s efforts to formulate a formal body of ethical standards, beginning with the organization’s first statement of ethical standards in 1953.5

The 2002 code is a substantial revision of the 1992 code over five years that also represented a considerable reorganization from the earlier 1981 code.6 The significance of the various codes and revisions is that many state licensing boards have adopted, in whole or in part, the APA Ethical Standards as part of the statutory basis for regulating psychologists. Therefore, the specific APA code incorporated into these state licensing laws varies, depending on when the licensing law was adopted or revised. Thus, one is likely to find the 1981, 1989, or 1992 versions in any given state law. Fortunately, in formulating a standard of care in supervision, it is possible to draw from the wisdom and underlying principles of all versions of the code.

The APA has also published other relevant documents. The General Guidelines for Providers of Psychological Service7 provides underlying principles as well as specific guidelines pertaining to supervision, as do the Specialty Guidelines for Delivery of Services by Clinical, Counseling, and School Psychologists.8

STATEMENTS BY OTHER ORGANIZATIONS

The Association for Counselor Education and Supervision (ACES) is the only national organization to develop a specific set of ethical guidelines with relevance to supervision of students and unlicensed practitioners.9 This same association has also developed a set of standards for counseling supervisors.10

Other relevant codes from which it is possible to draw general guidelines pertaining to a standard of care in supervision include the Code of Ethics of the National Association of Social Workers 11 and the ethical guidelines developed by the American Academy of Psychiatry and Law.12 Finally, the Association of State and Provincial Psychology Boards (current name) published guidelines pertaining to supervision of unlicensed persons that were updated and expanded in 1997.13 Their recommendations go as far as stipulating the maximum number of supervisees that a psychologist should supervise at one time: 3 for predoctoral and 4 for post-doctoral students. In addition, ASPPB finds that payment for supervisory services by the predoctoral supervisee is unacceptable, whereas supervisors of postdoctoral trainees are instructed to carefully evaluate the effect of any payment on the supervisory relationship.

With all of the various guidelines, ethical codes, and position papers, it is no wonder that it is hard to find consensus guidelines on standard of care. Where inconsistency exists, it may be difficult to establish liability. For example, different supervisors might claim to be following different codes. Without some guidance as to which principles should control, it may be difficult to find liability. Similarly, supervisors may be confused as to what approach should be followed. Fortunately, there is considerable overlap and consistency.

FIVE UNDERLYING PRINCIPLES FOR ETHICAL CODES

K.S. Kitchener has described five basic underlying principles upon which she believes all ethical codes are based: (1) autonomy, (2) beneficence, (3) nonmaleficence, (4) justice, and (5) fidelity.14

Autonomy, taking responsibility for one’s own behavior, underlies a number of important ethical principles. For example, confidentiality and informed consent follow from concerns for respecting autonomy and right to privacy.15

Nonmaleficence, which is the obligation to prevent or minimize the infliction of harm, underlies competence. Competence applies in several ways to supervision. The supervisor must be aware of his or her own competency, so as not to supervise a case for which he or she is unqualified. In addition, the supervisor must be aware of the competence of the supervisee. Finally, the supervisee must be ever mindful of the limits of his or her own competence. As Melba Vasquez notes, the rule of competence “arises from the need to prevent harm; our codes similarly forbid us to violate an individual’s civil rights or to misuse assessment and diagnostic results.”16

Beneficence, a principle derived from the Hippocratic oath, refers to the goal of promoting the wellbeing and interests of patients. This principle requires practitioners to balance between competing positive goals to be achieved and competing harms to be avoided. The supervisory process involves a number of competing factors: for example, the supervisor must consider the safety of the patient as well as the personal growth of the supervisee.

Justice refers to the underlying principles of fairness and equity. The issue of justice is of particular relevance to the question of the standard of care to which students should be held. As Steven R. Smith and Robert G. Meyer have noted:

While it seems unfair to hold students to the same level of care and practice expected of a fully trained professional, it is nevertheless unfair for patients to receive a lower standard of care because they are being seen by a student. Many patients are probably unaware about the status of their therapists, who are sometimes not clearly identified. Certainly, whenever a client has reason to believe that the student is actually a fully trained professional, the student should be held to the professional level of care.17

Thus, supervision involves a number of competing goals. Students must learn, yet patients have a right to receive the best treatment possible. It is never appropriate, however, to leave the training status of a supervisee unclear or vague. For example, California law requires written informed consent of the supervisee’s training status,18 as does sound ethical practice.

Fidelity involves honesty, integrity, and fulfilling one’s commitments, promises, and obligations. In following the principle of fidelity, the supervisee is clear about his or her training status. Similarly, the supervisor has an obligation of honesty to the supervisee. This obligation entails providing timely and accurate feedback to the supervisee so that the supervisee can benefit from the supervised experience.

What is Supervision?

With the five general principles in mind, it is helpful to look more closely at the process of supervision. Gary R. Schoener and colleagues have identified six methods of monitoring the supervisory relationship: selfreport, examination of treatment record notes, audiotape, videotape, live observation, and co-therapy. 19 Each of these represents a point on the continuum of standard of care, ranging from the minimum (self-report) through the most active forms of supervision (live observation and co-therapy).20 In the self-report technique, the supervisee simply tells the supervisor about the therapy process. This technique is obviously subject to important limitations. What the supervisee reports is selective, and the supervisee may not have sufficient experience to know what relevant aspects of the treatment should be brought to the attention of the supervisor. The supervisee may also hide information that may be difficult to deal with, embarrassing, or indicative of errors.

In relying solely on self-report, the supervisor limits considerably his or her ability to monitor and control the supervisory relationship. Ralph Slovenko notes two major pitfalls that supervisors risk when relying solely on self-report: “(1) the supervisee engaging in unethical conduct with the patient which is not reported to the supervisor; (2) the supervisee not carrying out the supervisor’s recomm dations but saying that he did.”21

Slovenko then lists thirteen areas of potential liability for supervisors.22 At least four of these can be attributed to the limitations of the selfreport technique. For example, Slovenko’s ninth potential area of liability is as follows: “The trainee becomes socially involved with the client, but cleverly hides the involvement from the supervisor. The supervisor should have known by more complete supervisory sessions.”23

Although such blatantly unprofessional and unethical behaviors on the part of the supervisee probably occur rarely, Slovenko’s example does help to illustrate the inherent risks of the self-report technique. Other risks may arise due to the supervisee’s inexperience.24

These situations amply illustrate the limitations and risks of the self-report method. Surprisingly, the selfreport method is in common use. For example, state licensing laws such as California’s simply specify that the supervision is to be “face-to-face.”25 One retrospective study revealed that self-report was the exclusive method used by supervisors to monitor the supervision for 14% of the sessions, and that self-reports were the seondary source of information in 67% of all supervisory experiences.26 In legal matters, one of the first things attorneys need to ask of supervisors is how they monitored and controlled the supervision. Of particular relevance would be the methods the supervisor used to guard against sexual misconduct problems.

It is difficult to see how self-report techniques can be used to protect patients from sexual misconduct by supervisees. If the sole or major method is through self-report, the supervisor may be in a very awkward position, because there is no independent source to verify the supervisee’s reports. Supervisors who rely exclusively or heavily on self-report techniques should carefully scrutinize their practices.

Supervisors can increase their ability to monitor and control by examination of treatment records or notes in conjunction with self-report.27 These notes provide a somewhat more objective way to review patient progress as well as to ascertain whether the supervisee is following up on the supervisor’s suggestions. Again, however, such review is limited by the abilities of the supervisee to report accurately and identify the critical aspects of treatment.28

The supervisor can obtain an independent review of the therapy process through the use of audiotapes, videotapes, or live observation through a oneway screen. A retrospective survey has shown that of these techniques, audiotapes are perhaps the most frequently used (36% of sessions), followed by videotaping (14%) and live observation (13%).29 Co-therapy, in which the supervisor and supervisee act as partners in the treatment process and see the patient together during the same hour, accounted for about 10% of the sessions.30 These various practices provide a starting point for examining the ethical and professional responsibilities of supervisors and for determining a standard of care.

ETHICAL AND PROFESSIONAL STANDARDS: THE AMERICAN PSYCHOLOGICAL ASSOCIATION ETHICAL CODES

Perhaps the best starting point for understanding the ethical and professional obligations of supervisors is the APA Ethical Principles of Psychologists and Code of Conduct.31 Section 1.22 of the general standards was directly relevant, had important implications and has been modified in the 2002 code.32

2.05 DELEGATION OF WORK TO OTHERS

Psychologists who delegate work to employees, supervisees, or research or teaching assistants or who use the services of others, such as interpreters, take reasonable steps to …(2) authorize only those responsibilities that such persons can be expected to perform competently on the basis of their education, training, or experience, either independently or with the level of supervision being provi-ded; and (3) see that such persons perform these services competently.

It is the supervisor’s ethical responsibility to ensure that the individual being supervised practices within his or her competence. In order to exercise this duty, the supervisor must, of course, be aware of the supervisee’s competence, as reflected in his or her “education, training, supervised experience, consultation, study, or professional experience”.

The supervisor, by necessity, must conduct a reasonable assessment of the supervisee’s level of skill. Similarly, the supervisor must have made a sufficient assessment of the patient the supervisee is assigned to treat. Otherwise, the supervisor would have no way of knowing whether the supervisee had the competence to treat the patient.33

The supervisor must monitor the supervisory process to ensure that the supervisee’s services are being performed according to this standard of competence. Unfortunately, the APA standards give little guidance on the standard by which this monitoring should be accomplished, other than “reasonable steps.” Is accepting a supervisee’s verbal reports at face value a reasonable step? Is monitoring therapy notes along with selfreports reasonable?

A problem with a vague term like “reasonable steps” is that reasonableness is apt to be assessed after a patient is injured. Hence, the supervisor’s level of monitoring may not seem reasonable in light of the injury. While it is clear that the APA is reluctant to impose inflexible standards, it would appear that some guidance on what is reasonable is needed.

One approach is to require monitoring based on the level of education, training, and experience of the supervisee. For beginning supervisees, the monitoring should be at the high end of scrutiny, with videotapes, careful monitoring of progress notes, and continual ongoing assessment of the supervisee. As the supervisee gains in experience, the level of scrutiny and hence “reasonable steps” needed could be gradually reduced. During the end phases of training, at the postdegree level where the supervisor has a thorough knowledge of the supervisee’s strengths and limitations, self-report may be sufficient.34

A critical aspect of the APA’s Ethical Code pertaining to supervision concerns evaluation and feedback. Section 6.05(a) of the 1992 Ethical Code stated: “In academic and supervisory relationships, psychologists establish an appropriate process for providing feedback to students and supervisees.”35 This section has been strengthened in the 2002 code: …psychologists establish a timely and specific process for providing feedback to students and supervisees.

7.06 Assessing Student and Supervisee Performance

(a) In academic and supervisory relationships, psychologists establish a timely and specific process for providing feedback to students and supervisees. Information regarding the process is provided to the student at the beginning of supervision.
(b) Psychologists evaluate students and supervisees on the basis of their actual performance on relevant and established program requirements.

The requirement of feedback is critical, as has been repeatedly noted in the supervision literature.36 In the 1992 APA Ethical Code, the key words were “an appropriate process.”37 Under the new code it is the supervisor’s obligation to establish timely and specific procedures, clearly an improvement over the earlier language.

THE ASSOCIATION FOR COUNSELOR EDUCATION AND SUPERVISION ETHICAL STANDARDS

The Ethical Standards of the ACES are very extensive and well organized.38 The ACES standards emphasize three main principles: client welfare and rights, the supervisory role, and the program administration role. In explicating the meaning of client welfare and rights, the ACES guidelines specify, “supervisors should have supervisees inform their clients that they are being supervised and that the observation and/or recordings of the session may be reviewed by the supervisor.”39 Notice the clear statement of the need for informed consent for the supervisory process.40

The 2002 APA Ethics Code now has similar language:

10.01 INFORMED CONSENT TO THERAPY

(c) When the therapist is a trainee and the legal responsibility for the treatment provided resides with the supervisor, the client/patient, as part of the informed consent procedure, is informed that the therapist is in training and is being supervised and is given the name of the supervisor.

Other important features of the ACES guidelines are the explicit statements pertaining to confidentiality in the supervisory relationship.41 The ACES code expressly states that supervisors are to “make supervisees aware of clients’ rights, including protecting clients’ right to privacy and confidentiality.”42

While the importance of confidentiality cannot be overstated, Section 5.01 of the 1992 APA code may be more realistic than the ACES standards. Section 5.01 presents the duty as one of discussing the limits of confidentiality. 43 The 2002 Code has simply simplified that language.

As Steven R. Smith has noted, there are many exceptions to confidentiality.44 In the context of supervision, an important exception concerns the limits of privilege for students and assistants. For example, a psychology student in training may be covered by privileges only to the extent that the student is providing services to patients as an assistant to a covered professional.45 Thus, while a supervisee might be able to give limited assurances of confidentiality, he or she cannot guarantee that the communication will be privileged. If these limitations are not discussed, or if the patient is falsely led to believe that a communication is privileged when it is not, the patient may have a common law cause of action for failure to provide informed consent.46

Section 2 of the ACES Code, supervisory role, emphasizes monitoring. The ACES code also emphasizes the importance of evaluation and feedback. Unlike the APA code, the ACES code provides specific guidance as to what constitutes a standard of care for monitoring and evaluation. This includes the use of actual work samples via audio and/or videotape, or the use of live observation.47 The ACES code further specifies that feedback should be “ongoing,” and in a variety of forms.48 Finally, Section 2.14 expresses an important standard for ethical supervision: “[s]upervisors should incorporate the principles of informed consent and participation; clarity of requirements, expectations, roles and rules; and due process and appeal into the establishment of
policies and procedures of their institution, program, courses, and individual supervisory relationships.”49

The third major portion of the ACES code also emphasizes the supervisor’s duty to assess the supervisee. Such assessment is critical to the supervisor’s ability to restrict supervisees’ activities to “those that are commensurate with their current level of skills and experiences.” 50

Examination of the APA and ACES codes show the consistent themes of competence, confidentiality, informed consent, monitoring, and evaluation and feedback in the supervisory process. These themes are reflected in the growing literature on the supervisory process.

STANDARD OF CARE AS REFLECTED IN THE RELEVANT LITERATURE

The articles devoted to the supervision of mental health professionals number in the thousands.51 Of these, several dozen relate to legal and ethical issues. A few relatively recent articles are illustrative.

According to Melba Vasquez, supervisors have three major responsibilities in training supervisees to practice ethically: competency, personal functioning, and supervisor ethics.52 The first of these, competency, is pervasive, as seen in statutes, case law, professional ethics, and the relevant literature. Vasquez argues that competence is developed by formal training and through app-ropriately supervised experience. She provides an answer to the question of what might constitute reasonable steps to monitor and evaluate: “A responsibility of the supervisor is to assess the supervisee’s skills to ensure competence with the clientele and to follow progress through audio and videotapes, notes, discussion, co-therapy, and observations.” 53 “Promoting competency for our trainees is one of the most important ethical responsibilities.” 54

It is noteworthy that Vasquez, consistent with the ACES guidelines, points to audio and videotapes, in conjunction with more direct techniques, as the standard. It thus appears as though the time has come in which selfreport, or selfreport in conjunction with record review, will not meet the minimum standard of care in supervision.

Vasquez’s emphasis on personal functioning is also telling:

One of the most important responsibilities of a supervisor is to assess the supervisee’s limitations, blind spots, and impairments in order to protect the welfare of the supervisee’s clients. .. . As supervisors, we are responsible for monitoring trainee progress to benefit and protect the public and the profession, as well as the trainee.55

The multiple roles and responsibilities of the supervisor are evident. The supervisor must assess the supervisee and monitor the supervisory process for the protection of all the parties, and, it might be added, to avoid liability. Vasquez’s third category, supervisor ethics, includes a variety of familiar principles. First, the supervisor must be “well trained, knowledgeable, and skilled in the practice of clinical supervision,”56 that is, competent to supervise. Vasquez also emphasizes the need to obtain informed consent from the supervisee.57

A review of other leading articles in the professional literature confirms the themes emphasized by Vasquez. For example, an article by Patrick Sherry based on the 1981 APA Code is illustrative.58 Sherry examined each of the first eight principles of the 1981 code and applied them to the supervisory process.59

In analyzing the Principle of Responsibility, Sherry’s analysis points to the importance of informed consent. He urged supervisors to develop a contract specifying both the supervisee’s duties as well as the consequences of failing to fulfill these duties.

The principle of Competence naturally was prominent in Sherry’s analysis:

Several implications for the supervisory relationship follow from this standard. First, it would seem that supervisors should supervise students only over those cases for which they feel competent to provide treatment….The supervisor also has the responsibility for determining whether the student is sufficiently free from personal and emotional conflicts to be able to provide effective treatment. . . . From an ethical standpoint competence as a supervisor also implies a sensitivity to multicultural issues.60

In reviewing the principles of Confidentiality, Sherry, like others, again emphasizes the importance of informed consent: “It is also the client’s right . . . to decide how information shall be used by the therapist. In fact,APA has issued guidelines that suggest that the client be informed about the identity of the supervisor.”61

Sherry emphasizes that to protect client rights, the supervisee must not only obtain consent for any audio or video recordings, but this consent process must include a discussion of how tapes might be used, including “the identities of those in any supervision group that might hear the tape.”62 In sum, Sherry states that the principle of Confidentiality implies: “. . . [T]he supervisor has a duty to protect the client, the public, the profession, and the supervisee, in that order, by providing evaluative monitoring of the supervisee.”63

The supervisory literature pertaining to the ethical responsibilities of supervisors is surprisingly consistent.64 William R. Harrar and colleagues identify three major ethical issues they believe transcend the various theoretical orientations in psychotherapy: supervisor qualifications (competence), duties and responsibilities of supervisors, and dual relationships.65

As Harrar notes, the principle of competence is seen repeatedly in the ethical and professional literature, and is an important underlying guideline in the standard of care of supervision. For Harrar, competence encompasses the duty of the supervisor to be qualified as a supervisor by education, training, and experience. Competence also encompasses the duty of supervisors not to supervise a case they could not competently see themselves, or to assign to a supervisee a case for which he or she is not competent.66

As with other commentators, Harrar calls for timely feedback, including written goals (for informed consent) and timely written evaluations relative to those goals. In addition, these authors emphasize the importance of guarding against dual relationships. The APA ethical codes have long been concerned with the problem of dual, or as they are now called, multiple relationships.67 Multiple relationships are those in which the psychologist has more than one relationship with an individual: for example, supervisee/sex partner, student/sex partner, patient/sex partner. Although these relationships are not limited to those involving sexual relationships,68 all such relationships are suspect because of their potential to impair professional judgment and increase the risk of exploitation.

As Harrar notes, supervisors not only hold a position of power over their supervisees, they also occupy a position of trust. Present ethical practice expressly prohibits sexual and other dual relationships between supervisors and supervisees.69 Thus, in the ethical practice of supervision, supervisors have a duty to operate in the best interests of the welfare of the supervisee, and to avoid sexual relationships with supervisees and other forms of exploitation.

The 2002 APA Code addresses this issue in 3.08 which states that “Psychologists do not exploit persons over whom they have supervisory, evaluative, or other authority such as clients/patients, students, supervisees, research participants, and employees.”

TOWARD A STANDARD OF CARE IN PSYCHOTHERAPY SUPERVISION

Overview

Operating on behalf of the welfare of the patient, the supervisee, the public, and the profession creates tensions that complicate the formulation of a coherent standard of care in supervision. An articulated standard would be consistent with the often conflicting goals of protecting the patient, encouraging the growth of the supervisee, guiding the supervisor, minimizing the risks of liability, and protecting the public as well as the profession. As an analysis of liability of supervisors/employers reveals, supervisors can be found liable on the basis of statutory obligations and on a variety of theories based on vicarious and direct liability. The absence of a coherent set of standards is not a shield against liability. On the contrary, the absence of articulated standards can lead to confusion in the supervisory setting. Must every session be taped? What are reasonable efforts to monitor? How does one cope with the multiple roles and sometimes conflicting duties of a supervisor?

THE ABSENCE OF A COHERENT SET OF STANDARDS IS NOT A SHIELD AGAINST LIABILITY.

As the present analysis suggests, plaintiff’s lawyers, when pursuing a claim for damages against a psychotherapist, would be well advised to inquire into whether the therapist was under the employment or supervision of another therapist. A number of questions would arise:

  • Was the supervisor competent to supervise?
    • Was the supervisor qualified to treat this patient independently?
    • Was the supervisee competent to treat this patient, given the level of supervision?
    • What was the level of supervision?
    • How was the supervisee monitored?
    • Was the monitoring limited to selfreport? If not, what other techniques were used to insure adequate monitoring?
    • How was this monitoring process documented?
    • Did the supervisor follow accepted ethical principles, such as providing timely and periodic evaluations of the supervisee?
    • Was there a dual relationship of any kind?70
    • Was the patient fully informed as to the training status of the supervisee, the role of the supervisor, the limits of confidentiality, and other relevant factors pertinent to the relationship?

These and other issues make the supervisory role quite hazardous.

Based on statutes, case law, ethical codes, and the professional literature, it is possible to distill principles that could form the basis for a standard of care. These include the supervisor’s responsibility to be aware of relevant legal, ethical and professional practices; the ethical principles of supervision; and a specific set of responsibilities and duties of supervisors.

SUPERVISOR RESPONSIBILITIES

Supervisor responsibilities are evident in statutes,71 in ethical codes,72 and in the relevant literature.73 In short, the supervisor is responsible for the entire process, and thus must be aware of all factors involved in the practice of supervision. Awareness begins with knowledge of the relevant licensing laws of the state in which the supervisor is practicing. Such laws typically provide explicit guidelines in the conduct of supervision.74 Ignorance of the law is no excuse; and good intentions are no defense to a bad outcome. Thus, a basic building block of a standard of care in supervision would hold that supervisors accept full responsibility for the supervisory process and are aware of all relevant laws. Supervisors are also well advised to have some familiarity with case law and the various theories upon which liability may attach. Knowledge of case law is also useful for dealing with such issues as the limits of confidentiality.75 Finally, supervisors have a responsibility to be familiar with the relevant professional literature, and to maintain a current knowledge of professional developments.

THE FIVE ETHICAL PRINCIPLES OF SUPERVISION

Five major ethical principles were seen repeatedly in statutes, case law, ethical codes, and the professional literature: (1) competence; (2) confidentiality; (3) avoidance of dual relationships; (4) welfare of the consumer; and (5) informed consent. Each of these principles involves tensions and divided loyalties.

COMPETENCE

The principle of competence applies in four ways. First, the supervisor must be competent to supervise.76 This means that the supervisor is qualified to supervise by education, training, supervised experience, consultation, study or professional experience. How often do clinical training programs assign the task of supervision to junior faculty, with relatively little direct experience, let alone training in supervision? Such practices must be examined in light of the ethical and legal responsibilities of supervisors. If junior faculty are assigned the task of supervision, these faculty should be supervised themselves by a more senior faculty member. One approach might involve teams comprised of practitioners and students of differing levels of skill. Experienced supervisors
could then provide guidance to junior faculty members, who, in turn, could provide supervision for predoctoral students. Within the team, more advanced students could provide some support and guidance to less advanced students. In this way, all students can gain experience in the practice of supervision, thus ensuring that future supervisors will be competent.

Given that the supervisor is competent to supervise, he or she must also be competent to see the patient to whom the supervisee is assigned. This requirement demands that the supervisor make an assessment of patients before they are assigned to supervisees and conduct an ongoing assessment of the patient.

With knowledge of the patient, the supervisor then has a duty to assign to supervisees only those patients the supervisee is competent to treat.77 This duty requires that the supervisor conduct an assessment of the supervisee’s education, training, and experience. It also requires the supervisor to gauge the supervision to the level of the supervisee and to the needs of the patient. The less experienced or the less competent the supervisee, the greater will be the level of involvement and monitoring required of the supervisor.

Finally, the supervisee must assess his or her own competence. The supervisee must learn from the start to share in the ethical responsibilities psychologists and other mental health practitioners have to patients.

CONFIDENTIALITY

Supervision involves problems of confidentiality.78 Supervisors and supervisees need a plan in advance to deal with these issues. First, there is the issue of dealing with the limits of confidentiality. Patients must be informed in advance as to limits to confidentiality and privilege.79 It is clear that despite the common use of self-report in the supervisory process, self-report is insufficient to allow the monitoring necessary for competent supervision.80

This is true even when it is used in conjunction with record review. Thus, audio, videotapes or some form of direct observation, or facetoface interaction between the supervisor and patient will become inevitable. Supervisors need to clarify in advance what their requirements are so that supervisees can discuss with patients the process by which the supervision will be monitored.81 Moreover, given that devices as audio- or video-taping will be used, it is necessary to minimize intrusion by sharing such information with as few people as possible and by establishing and following clear rules for disposal of such media once no longer needed.

AVOIDANCE OF MULTIPLE RELATIONSHIPS

The supervisor must recognize the position of power he or she holds vis-à-vis the supervisee, and avoid any exploitation.82 Sexual relationships with supervisees are expressly unethical and clearly fall below any standard of supervision because the supervisor’s judgment and ability to protect the patient will be severely compromised. 83 Supervisors also must be alert to possible multiple relationships between the supervisee and patient.

WELFARE OF THE CONSUMER

The primary consumers of supervisory services are the supervisee and the patient.84 The supervisor is obligated to protect both. The supervisee is protected when the supervisor provides clear goals, preferably written, and timely evaluative feedback.85 Feedback is an essential aspect of the supervisory process, and failure to provide it would be less than the minimum standard of care.

At the same time, the supervisor must monitor the supervision sufficiently to protect the welfare of the patient.86 Tension arises when the supervisor must choose between closer levels of scrutiny versus giving the supervisee the opportunity to make decisions that might be mistakes. To minimize risks, the supervisor must be ever mindful of the duty to provide a continual assessment of both the supervisee and the patient. Under the minimum standard of care, the responsibility for the welfare of both patient and supervisee falls on the supervisor’s shoulders. Any mistakes that lead to patient injury are the supervisor’s responsibility as well as that of the supervisee. 87

IN SUPERVISION, RESPONSIBILITY IS MULTIPLIED, IT IS NEVER DIVIDED.

INFORMED CONSENT

Informed consent is multifaceted. Both the supervisee and the patient must be informed of any factors that might influence their willingness to enter the relationship.88 For supervisees, proper informed consent means a clear specification of the duties, training philosophy, expectations, and evaluative procedures of the supervisor. 89 For the patient, informed consent involves an explicit clarification of the relationship, status of the supervisee, and limits of confidentiality.

SPECIFIC DUTIES OF SUPERVISORS

Implicit in the responsibilities and ethical principles are a number of duties of supervisors. Several of these have appeared repeatedly through state statutes, case law, ethical codes, and the relevant literature.

  1. Duty to Monitor and Control: Supervisors have a duty to monitor and control the supervisory process as necessary to protect the welfare of both the supervisee and patient. The degree of monitoring depends on the level of development of the supervisee and the nature of the patient’s problem. For inexperienced supervisees, some form of video- or audio-taping, or perhaps even co-therapy, represents the minimum standard.
  2. Duty to Evaluate the Patient: The supervisor has a duty to assess the patient, and to continue this assessment throughout the supervisory process. Unless such an assessment is done, the supervisor cannot properly monitor the treatment process.
  3. Duty to Evaluate the Supervisee: Similarly, the supervisor has a duty to continually assess the skills and functioning of the supervisee in order to ensure that the supervisee’s level of competence comports with the supervisor’s level of competence. Again, unless the supervisor is aware of the supervisee’s level of competence, it is not possible to know if the supervisee is capable of properly caring for the patient.
  4. Duty to Provide Feedback: The supervisor has a duty to provide timely evaluations in order to facilitate the supervisee’s training and keep the supervisee informed as to his or her progress. Such feedback helps promote supervisee growth as well as keep the supervisee on track in the treatment process.
  5. Duty of Accountability: The supervisor has the duty to document the supervision through careful record keeping. Such record keeping may prove invaluable in the event of a lawsuit for negligent supervision.

PROMULGATING THE STANDARDS TO SUPERVISORS

Dissemination is an issue that is perhaps more thorny than the problem of developing a standard of care for psychotherapy supervision. Three suggestions are provided to deal with this issue.

  1. Mandatory Continuing Education For Supervisors: Given the requirement of supervised experience in all state licensing laws, it makes sense to require minimum levels of education, training, and experience for supervisors. In California, supervisors are qualified strictly by experience.90 In view of the complexities and divided loyalties inherent in the supervisory process, states that require supervision could strongly encourage a higher and uniform standard through mandatory continuing education of supervisors.
  2. Proficiency Certification: In 1995 APA began recognizing proficiencies through a rule-based procedure.91 To encourage continuing education and training of supervisors, psychological organizations could petition APA for supervision to be recognized as a proficiency and establish a certification process for supervisors. Such a process could have specific minimum levels of education, training, and experience, and the certification body could examine knowledge in the ethics, case law and procedures involved in supervision and also provide continuing education.
  3. Specialty Certification: The mechanism for recognition of specialties is either through the American Board of Professional Psychology (ABPP) or APA. The list of specialties recognized by both overlap greatly. However, ABPP’s examining boards mission is to certify licensed psychologists in any of the 11 specialty areas. These currently include behavioral psychology, clinical psychology, clinical neuropsychology, counseling psychology, forensic psychology, family psychology, group psychology, health psychology, psychoanalytic psychology, rehabilitation psychology and school psychology. At some point in its development it is possible that supervision might qualify as a specialty, rather than just a proficiency. If so, interested individuals could create a specialty certification process in supervision and petition ABPP for recognition. Such a specialization would provide a mechanism for uniform standards, peer review, and continuing education through newsletters and workshops.
  4. Fundamental Competence: Another approach is to consider supervision a basic competence that all health care psychologists would need to be trained and examined on prior to entry to independent practice. This would mean that doctoral education and training would address supervision as a competency that is needed for the granting of the degree or awarding of the internship certificate.

REFORM IN THE LEGAL PROFESSION

From the standpoint of the legal profession, attorneys need to remain cognizant of the statutes, case law, ethical standards, and professional literature discussed herein. If supervisors of mental health professionals do not police themselves, then perhaps it is up to the legal profession to protect the rights of patients receiving psychotherapy under supervision. Arguably, intervention by the legal profession in the mental health profession has had beneficial effects in areas such as the regulation of psychological testing92 and providing a check of spurious predictions of violence.93 As with reforms within the mental health professions, the major barrier to reform in the legal arena is dissemination. To make attorneys more aware of the relevant issues and potential causes of action against supervisors, courses on law and mental health could be added to the law school curricula. In addition, the gap in knowledge that attorneys have due to their relatively limited clinical experience could be bridged by targeted continuing education.

CONCLUSION

Supervision is an integral part of the practice of psychology and other mental health professions. Presently, state licensing laws, case law, a variety of legal theories, a body of ethical knowledge, and a rapidly growing body of literature regulate practitioners. Supervision is a demanding, complex endeavor with competing demands and tensions.

Patients as well as the mental health profession have much to gain from sound supervisory practices. Patients benefit when the experienced supervisor carefully guides the therapy process. A careful monitoring process might reduce the exposure risk to typical mistakes caused by inexperience. Patients are also protected when the supervisor has conducted an assessment that the patient’s problems are within the competence of both the supervisor and supervisee. Such competence is a prerequisite to effective treatment, and can only be assured by adherence to the standards of supervision as described herein. Adequate supervision will ensure that the patient’s rights are protected. Foremost among these rights are the rights to be treated with dignity and respect. It is only through a careful and fully informed consent process and frank discussion of the limits of confidentiality that such rights can be secured. In the end, sound supervisory practices must certainly increase the probability of a successful outcome for the patient, while at the same time minimizing the inherent risks of treatment from an inexperienced therapist.

The profession also has much to gain. Adequate supervision is perhaps the best guarantee that new practitioners will enter the profession with the experience and skills needed to meet the standards of patient care. Adequate supervision is also an important safeguard against the numerous sources of liability to which supervisors may be exposed. Lawsuits and bad outcomes injure the profession as well as the individual practitioner. Further, through sound supervisory practices supervisors manifest the ethical standards that are the backbone of the profession. In manifesting these standards, supervisors’ actions reflect positively on the profession as a whole.

In sum, sound supervisory practices are good for the patient, the supervisee, the supervisor, and the profession as a whole. In order to promote excellence in supervision two problems must be confronted: (1) there is a need to develop a coherent set of principles to guide the standard of care in supervision; and (2) such principles must be promulgated. This article represents one effort toward the solution of these two problems. An additional problem is the lack of information in the legal profession on the role and liability of supervisors in the mental health delivery process. To deal with this problem, course work and continuing education for attorneys are strongly recommended.

APPENDIX A
SAMPLE INFORMED CONSENT FOR SUPERVISEES

Date
Name of Student in Training
Address, city, state, zip

Dear Supervisee,

RE: Supervisory Agreement

This is to confirm that I have agreed to provide practicum supervision for you for 1-2 patients through the Clinic. I will expect you to act in accord with all Clinic policies, including videotaping your sessions.

For each new client that we accept, I expect you to provide informed consent at the outset of treatment and to explain verbally the limits of confidentially. Your discussion with the client should include your training status, the fact that I supervise you and the fact that your therapy will be videotaped and examined by me. Please provide the client with my name and clinic telephone number. In addition, I want you to personally explain the limits of confidentiality (e.g., reporting laws). While I realize that we obtain written informed consent, I want the procedure to be explained orally to each potential client. I also want your therapy notes to reflect what you told your potential clients regarding informed consent and the limits of confidentiality, as well as what the client said to communicate his or her understanding.

In obtaining informed consent, I want you to make it clear that the case may have to be transferred to another student therapist and/or supervisor over the summer. I want you to bring the case file with your therapy notes to each supervisory session so that I can examine the file and countersign your notes.

In our supervisory sessions I will concentrate on two major issues: enhancing your professional development and providing formal evaluative feedback. Regarding professional growth, I will concentrate on correct application of the APA Ethical Code. I will also concentrate on the development of your skills as a therapist, and on helping you to identify blind spots or limitations that you must confront as a professional psychologist. I also consider it to be my job to help you sort out the difference between opinion and empirically demonstrated techniques.

Regarding the evaluative feedback, it is important for you to realize that any written evaluations by me will enter into your student file and may be discussed with others involved with your training. This is usual and customary practice in clinical programs.

I want to make it clear that I cannot supervise you on any case that I could not competently handle myself. You and I will discuss each potential case and make an evaluation pertaining to the appropriateness of the case, given your level of skill and my areas of competency. In order to facilitate my assessment of your skill level, I would like you to provide me with a summary of your clinical experience, which we will review in our first supervisory session. I want you to know that in providing you with this informed consent concerning our relationship, I am trying to act as a model for you.

Ethically, I am required to inform you of factors that might influence your willingness to enter a supervisee relationship with me, just as you must similarly inform your clients in advance of the relationship.

Since responsibility in clinical work is always multiplied, and never divided, you and I both have 100% responsibility for the welfare of any client you should see under my direction. I therefore, expect you to notify me immediately, should any problem arise.

I am enclosing a copy of our agreement so that you can keep one for your files and return one signed copy to me. Please let me know if you have any questions. At our first supervising session, I will go over the provisions outlined in this letter.

I look forward to working with you beginning in the fall.

Sincerely,

Dennis P. Saccuzzo, Ph.D., J.D.

I have read and understand this supervisory agreement between myself and Dennis P. Saccuzzo, Ph.D., J.D.

_______________________________________________________________________________
(name) (date)

AUTHOR

Dennis P. Saccuzzo, Ph.D., J.D., ABPP; Professor of Psychology, San Diego State University; Founding Partner, Applications of Psychology to Law (APL); Adjunct Professor of Law, California Western School of Law; Ph.D., Kent State University; J.D., California Western School of Law.

1.See William N. Robiner & William Schofield, References on Supervision in Clinical and Counseling Psychology, 21 PROF. PSYCHOL.: RES. & PRAC. 297 (1990).

2.Id. at 298.

3.Id.

4.American Psychological Ass’n, Ethical Principles of Psychologists and Code of Conduct, 47 AM. PSYCHOL. 1597 (1992) [hereinafter APA Code]. See the December 2002 issue of the AM. PSYCHOL. for the newest version of the Ethics Code or www.apa.org/ethics.

5.AMERICAN PSYCHOLOGICAL ASS’N, ETHICAL STANDARDS OF PSYCHOLOGISTS (1953).

6 .American Psychological Ass’n, Ethical Principles of Psychologists, 36 AM. PSYCHOL. 633 (1981)[hereinafter Ethical Principles].

7.American Psychological Ass’n, General Guidelines for Providers of Psychological Services, 42 AM. PSYCHOL. 1 (1987) [hereinafter APA Guidelines].

8.American Psychological Ass’n, Specialty Guidelines for the Delivery of Services by Clinical, Counseling and School Psycholo-gists, 36 AM. PSYCHOL. 640 (1981).

9.See ACES, ETHICAL GUIDELINES FOR COUNSELING SUPERVISORS (1993) available online at http://www.acesonline.net/home.htm

10.See ACES, STANDARDS FOR COUNSELING SUPERVISORS (1989).

11 .NATIONAL ASS’N OF SOC. WORKERS, CODE OF ETHICS OF THE NATIONAL ASSOCIATION OF SOCIAL WORKERS (1990).

12.See AMERICAN ACADEMY OF PSYCHIATRY AND THE LAW, ETHICAL GUIDELINES FOR THE PRACTICE OF FORENSIC PSYCHIATRY (1989).

13.See American ASS’N OF STATE PSYCHOLOGY BOARDS (FORMER NAME), GUIDELINES FOR THE EMPLOYMENT AND SUPERVISION OF UNCREDENTIALED PERSONS PROVIDING PSYCHOLOGICAL SERVICES (1979) [hereinafter ASPPB]. For the revised version, go to www.asppb.org/pubs/Supervision.

14.See K.S. Kitchener, Intuition, Critical Evaluation and Ethical Principles: The Foundation for Ethical Decisions in Counseling Psychology, 12 COUNSELING PSYCHOL. 43 (1984).

15.See Melba J. T. Vasquez, Psychologist as Clinical Supervisor: Promoting Ethical Practice, 23 PROF. PSYCHOL.: RES. & PRAC. 196 (1992).

16.Id. at 197.

  1. See STEVEN R. SMITH & ROBERT G. MEYER, LAW, BEHAVIOR, AND MENTAL HEALTH: POLICY AND PRACTICE 3-43 (1987) at 27.

18.See CAL. CODE REGS. tit. 16, § 1391.6(b) (1997).

19.See GARY R. SCHOENER ET AL., PSYCHOTHERAPISTS SEXUAL INVOLVEMENT WITH CLIENTS: INTERVENTION & PREVENTION (1989).

20.No supervision at all, as in Steckler v. Ohio State Board of Psychology, 613 N.E.2d 1070 (Ohio Ct. App. 1992), would be below the standard.

21.Ralph Slovenko, Legal Issues in Psychotherapy Supervision, in PSYCHOTHERAPY SUPERVISION: THEORY, RESEARCH AND PRACTICE 452, 463 (Allen K. Hess ed., 1980).

22.The thirteen areas for potential liability include:
(1) The supervisor or agency promulgates an intake form to be used by the trainee, it omits relevant questions (homicidal tenden-cies, suicidal tendencies, previous therapy). The client receives improper treatment and injures himself or others.
(2) The trainee takes relevant notes during therapy, the supervisor does not study these notes and does not realize that the notes indicate a therapy method other than that offered or available.
(3) The trainee, even with the supervisor’s help, is incapable of offering proper therapy. There is a need to refer to a more competent professional.
(4) There is a need to consult a specialist, but the supervisor does not realize the need because certain facts are not discussed during the supervisory sessions.
(5) There is a medical problem which would be discovered by a person with more training, but which is not discovered by the trainee. A medical doctor is not consulted. The psychological problem is caused by a hearing loss, a vitamin deficiency, or other physical imbalance.
(6) The diagnosis is improper, the prognosis faulty, or the treatment plan ineffective. The supervisor does not discover the error in any of the three areas or the interrelationship of one to the other, and therapy continues inappropriately.
(7) Written progress notes are inadequate or do not support the treatment plan.(8) The trainee and patient (or trainee and super-visor) have a conflict of personalities, yet the treatment continues.
(9) The trainee becomes socially involved with the client, but cleverly hides the involvement from the supervisor. The supervisor should have known by more complete supervisory sessions.
(10) The trainee goes on vacation; there is no adequately prepared relief therapist.
(11) The trainee breaches confidentiality and shares a particularly intriguing story with a co-trainee or friend; word gets back to the client. The supervisor had not warned the trainee of the importance and meaning of confidentiality.
(12) The client consents to treatment but does not know it is by a trainee. He assumes it is on a regular professional level.
(13) The trainee is subpoenaed to testify in court and is improperly prepared by training or experience for courtroom testimony.
Id. at 463.

23.Id.

24.These risks are illustrated in examples (4), (5), and (6) of Slovenko’s thirteen areas for potential liability. See id.

25.CAL. CODE REGS. tit. 16, § 1387(k)(1) (1997).

26.See George J. Allen, Doctoral Students’ Comparative Evaluations of Best and Worst Psychotherapy Supervision, 17 PROF. PSYCHOL.: RES. & PRAC. 91 (1986).

27.See CAL. CODE REGS. tit. 16, § 1387(k)(1) (1997). Examination of the notes alone would be insufficient. The general standard, as exemplified in states such as California, is a minimum of one hour of “face-to-face” supervision per week. CAL. CODE REGS. tit. 16, § 1387(k)(1) (1997).

28.Slovenko’s thirteen areas of supervision liability, for example, include at least two related to record review: (1) The trainee takes relevant notes during therapy; the supervisor does not study these notes and does not realize that the notes indicate a therapy method other than that offered or available. (2) Written progress notes are inadequate or do not support the treatment plan. See Slovenko, supra note 21, at 463.

29 .See Allen, supra note 26, at 93.

30 .See id.

31APA Codes, supra note 4.

32.Part (a) of section 1.22 states: “Psychologists delegate to their employees, supervisees, and research assistants only those responsibilities that such persons can reasonably be expected to perform competently, on the basis of their education, training, or experience, either independently or with the level of supervision provided.” 1992 APA Code, supra note 4, § 1.22(a).

32.Part (a) of section 1.22 states: “Psychologists delegate to their employees, supervisees, and research assistants only those responsibilities that such persons can reasonably be expected to perform competently, on the basis of their education, training, or experience, either independently or with the level of supervision provided.” 1992 APA Code, supra note 4, § 1.22(a).

33.In 1992 Part (b) of § 1.22 stated: “Psychologists provide proper training and supervision to their employees or supervisees and take reasonable steps to see that such persons perform services responsibly, competently, and ethically.” APA Code, supra note 4, § 1.22(b).

34.See L. Dianne Borders & Claire Hamilton Usher, Post-Degree Supervision: Existing and Preferred Practices, 70 J. COUNSELING. & DEV. 594 (1992).

35.1992 APA Code, supra note 4, § 6.05(a).

36.See William Robiner et al., Evaluation Difficulties in Supervision of Psychology Interns, 46 CLINICAL PSYCHOL. 3 (1993).

37.Procedures for providing feedback should be clear and should be available to the students and supervisees. Ordinarily, these procedures are developed by programs with the input of individual psychologists. When specifications of program requirements are inadequate and not under the control of the psychologist, the psychologist should encourage and document attempts to develop new ones. See MATHILDA B. CANTER ET AL., ETHICS FOR PSYCHOLOGISTS: A COMMENTARY ON THE APA ETHICS CODE (1994) (interpreting the term “an appropriate process”).

  1. ASSOCIATION FOR COUNSELOR EDUC. AND SUPERVISION, ETHICAL GUIDELINES FOR COUNSELING SUPERVISORS (1993) [hereinafter ACES]available online at http://www.acesonline.net/home.htm.

39.Id.

40.The 1992 APA Code makes several references to informed consent. See APA Code, supra note 4, § 4.02 (discussing informed consent to therapy); Id. § 5.01 (discussing the limits of confidentiality); Id. § 6.11 (discussing informed consent to research). The duty to provide informed consent in a supervisory setting can thus be legitimately inferred. Similarly, the 2002 APA Code addresses informed consent in §3.10,§8.02, §9.03 and §10.01

41.ACES, supra note 38.

42.The ACES code further states: “Clients also should be informed that their right to privacy and confidentiality will not be violated by the supervisory relationship.” ACES, supra note 38, § 1.03

43.1992 APA Code, supra note 4, § 5.03; 2002 APA Code .§ 5.01

44.See Steven R. Smith, Medical and Psychotherapy Privileges and Confidentiality: On Giving with One Hand and Removing with the Other, 75 KY. L. REV. 473 (1986). Among the possible exceptions discussed are child abuse, adult abuse, child custody, dangerous patients, patient/litigant, criminal defense, court ordered examinations, third-party payers, and privileges after death. Id.

45.See id. at 520 (reviewing Hall v. State, 336 S.E.2d 812 (Ga. 1985)) (noting “that an appellate court had refused to apply the psychologist-patient privilege to a student in training”). See also People v. Gomez, 185 Cal. Rptr. 155, 159 (Cal. Ct. App. 1982). The court held that “[f]irst, and decisive of this case, the privilege does not extend to student interns; since the privilege does include virtually every licensed classification of ‘therapist,’ defendant is unable on this record to provide a reason that the privilege should include ‘psychology students’ or ‘student interns.’”

46.As noted by Vincent R. Johnson and Alan Gunn, “[c]onsent to medical treatment, to be effective, should stem from an understanding [of the]decision based on adequate information . . . The doctrine [of informed consent] imposes a duty . . . to inform a patient of his options and their attendant risks. If a physician breaches this duty, patient’s consent is defective, and physician is responsible for the consequences.” VINCENT R. JOHNSON & ALAN GUNN, STUDIES IN AMERICAN TORT LAW 264 (1994).

47.See ACES, supra note 38, § 2.06.

48.ACES, supra note 38, § 2.08. ACES recommends formal as well as informal evaluation throughout the supervisory process.

49.ACES, supra note 38, § 2.14.

50.ACES, supra note 38, § 3.09.

51.See William N. Robiner & William Schofield, References on Supervision in Clinical and Counseling Psychology, 221 PROF. PSYCHOL.: RES. & PRAC. 297 (1990) (reporting over thirteen hundred references on supervision between 1983 and 1989).

52.See Vasquez, supra note 15.

53.Id. at 198.

54.Id. at 199.

55.Id.

56.Id. at 200.

57.Supervisees have similar rights to privacy, respect, dignity, and due process that clients do. Because of those rights, supervisors should provide trainees with information regarding expectations, anticipated competency levels, activities, and optional experiences so that the supervisee knows ahead of time whether to agree to the particular experience and thus to participate with informed choice. . . . The failure to provide relevant and timely feedback is the problem identified in most ethical complaints from supervisor- supervisee relationships. Id. at 200 (citing PATRICIA KEITH-SPIEGEL & G. P. KOOCHER, ETHICS IN PSYCHOLOGY: PROFESSIONAL STANDARDS AND CASES (1985)).

58.Ethical Principles, supra note 6. Note that the 1981 Code was revised in 1989 with relatively minor changes. The 1992 APA Code, while containing many of the same underlying principles, represented a considerable reorganization of the 1981/1989 principles. Nevertheless, the basic ideas pertaining to supervision are remarkably similar.

59.See Patrick Sherry, Ethical Issues in the Conduct of Supervision, 19 COUNSELING PSYCHOLOGIST 566 (1991). These eight principles are (1) Responsibility; (2) Competence; (3) Moral and Legal Standards; (4) Public Statements; (5) Confidentiality; (6) Welfare of the Consumer; (7) Professional Relationships; and (8) Assessment Techniques. Principles (9) and (10), Research with Human Participants and Care and Use of Animals, were not seen as applicable. See id. at 566.

60.Id. at 573-74.

61.Id. at 577. Note that APA Code did not previously state that the supervisee’s training status must be disclosed. However, in the 2002 APA Code §10.01 with regard to Informed Consent to Therapy, section (c) does require that …when the therapist is a trainee and the legal responsibility …resides with the supervisor, the client is informed that the therapist is in training and is being supervised.

62.Id. at 578.

63.Id.

64.This consistency is probably due to the fundamental values that underlie ethical codes such as that of the American Psychological Association.

65.See William R. Harrar et al., Ethical and Legal Aspects of Clinical Supervision, 21 PROF. PSYCHOL.: RES. & PRAC. 37 (1990).

66.Harrar and colleagues point not only to the APA ethical code, but also to the APA Specialty Guidelines. See APA Guidelines, supra note 7. See also AASPB, supra note 13.

67.See 1992 APA Code, supra note 4, § 1.17; see 2002 APA Code §3.05.

68.For example, patient/business partner.

69.See 1992 APA Code, supra note 4, § 1.19(b) (“Psychologists do not engage in sexual relationships with supervisees in training over whom the psychologist has evaluative or direct authority, because such relationships are so likely to impair judgment or be exploitative.”); See 2002 APA Code §3.08.

70.See Masterson v. Board of Examiners of Psychologists, No. 95A-03-11, 1995 LEXIS 589 (Del. Super. Ct. Dec. 29, 1995) (holding that supervising psychologist’s license was revoked where the supervisee was allowed to treat a patient in the same social circle as the therapist and supervisee).

71.See N.H. REV. STAT. ANN. § 330-A:16(b)(II)(b) (“the supervisor shall assume professional responsibility for the psycho-logical assistant in a written agreement . . . .”).

72.See ACES, supra note 38 (supervisor responsible for client welfare, monitoring clinical performance, and supervisee development).

73.See Sherry, supra note 59 (supervisor has duty to protect the client).

74.See supra Part II.

75.See Smith, supra note 44 (discussing case law which indicated some limits on the privilege for students).

76.Supervisor competence was stressed in statutes. See CAL. CODE REGS. tit. 16, § 1833.1(a)(3)-(5) (1997) (explaining supervisor must affirm his or her competence to supervise).

77.See 1992 APA Code, supra note 4 (“psychologists delegate . . . only those responsibilities that such persons can reasonably be expected to perform). See also DEL. CODE ANN. tit. 24, § 3502(8) (explaining supervisor responsible for ensuring services rendered by psychological assistant are consistent with assistant’s level of education).

78.The role of confidentiality in the supervisory process was noted in several sources. See APA Codes, supra note 4 (duty to discuss limits of confidentiality); See also ACES, supra note 156 (explicit guidelines for maintaining confidentiality). See also Sherry, supra note 174 (confidentiality implies duty to protect the client by monitoring supervisee).

79.See APA Codes, supra note 4.

80.See Slovenko, supra note 21, at 462-63 (discussing inadequate monitoring as a major source of potential liability). See also Powers v. U.S., 589 F. Supp. 1084, 1101 (D. Conn. 1984) (holding supervisor liable for failure to adequately monitor).

81.See OHIO ADMIN. CODE § 4732-13-04(12)(h)(3) (1998) (statutory requirement for written treatment plan signed by supervisor).

82.See Kitchener, supra note 14 (discussing the principle of nonmaleficence, implying that the supervisor should cause no harm to the patient as well as the supervisee; discussing the principle of justice and fidelity, implying that the supervisor act fairly and honestly in dealing with the supervisee).

83.See APA Codes, supra note 4 (psychologists do not engage in sexual relationships with supervisees).

84.See OHIO ADMIN. CODE § 4732-13-04(10) (1995) (psychologist shall have full responsibility for client welfare). See also ACES, supra note 38 (supervisor responsible for monitoring client welfare).

85.See Vasquez, supra note 15 (failure to provide relevant and timely feedback frequently identified with ethical complaints).

86.See Steckler v. Ohio State Bd. of Psychology, 613 N.E.2d 1070 (Ohio Ct. App. 1992) (supervisor’s license suspended for failure to exercise full direction, control, and responsibility for client welfare).

87.In supervision, responsibility is multiplied, it is never divided.

88.See ACES, supra note 38, § 2.14 (supervisors should have supervisees inform their clients that they are being supervised and should incorporate the principles of informed consent). See also CAL. CODE REGS. tit. 16, § 1391.6(b) (statutory requirement to inform patient in writing that assistant is unlicensed and supervised as an employee of the supervisor).

89.Appendix A contains a sample of an informed consent procedure used by this author to provide informed consent to students in a doctoral training program. See infra app. A.

90.See supra text accompanying notes 17-18.

91.For example, the College of Professional Psychology of the APA Practice Organization certifies health service providers in the Treatment of Alcohol and Other Substance Abuse.

92.For a discussion of the interface between psychology and the law, see Bruce D. Sales, The Legal Regulation of Psychology: Scientific and Professional Interactions, in 2 THE MASTER LECTURE SERIES: PSYCHOLOGY AND THE LAW (C. James Scheirer & Barbara L. Hammons eds., 1980). For a discussion of the regulation of psychological tests, see Donald N. Bersoff, Regarding Psychologists Testily: The Legal Regulation of Psychological Assessment, in 2 THE MASTER LECTURE SERIES: PSYCHOLOGY AND THE LAW (C. James Scheirer & Barbara L. Hammons eds., 1980).

93.For the limits of mental health professionals’ ability to predict violence, see John Monahan, The Predication of Violent Behavior: Developments in Psychology and the Law, in 2 THE MASTER LECTURE SERIES: PSYCHOLOGY AND THE LAW (C. James Scheirer & Barbara L. Hammons eds., 1980).