Risk Management for the Supervising Psychiatrist

Seven Steps to Avoid Common Pitfalls

By Helen Riess, MD | September 3, 2009

Dr Riess is associate clinical professor of psychiatry at the Harvard Medical School, director of education for psychotherapy supervisors and director of empathy research and training at the Massachusetts General Hospital in Boston. She reports no conflicts of interest concerning the subject matter of this article.

Fault line 3: trainee and patient

The structural framework of an alliance, a therapeutic frame (ie, place and time they meet and other logistical agreements, such as how to be reached in a crisis), and therapy goals, must also be applied between trainees and their patients. Helping trainees learn to distinguish feelings from actions is crucial in order to avoid guilt and shame that can arise from countertransference.¹⁶

The 2 most frequent causes of malpractice litigation in psychiatry are sexual boundary violations, followed by patient suicide.⁵ More than 6% of psychiatrists are sued for sexual boundary violations. Consequently, trainees must be taught to avoid dual relationships and how to recognize, formulate, and respond appropriately to sexual feelings and other intense affects.^7,16,17

Obtaining written informed consent from patients includes disclosing the training status of the clinician and notifying the patient of the existence of a supervisor. This safeguards against potential malpractice suits by disgruntled patients who claim that they were never informed about the trainee status of their clinician or the existence of the supervisor.

Fault line 4: patient and supervisor

While the supervisor is ultimately responsible for the care of the patient, the supervisor and patient do not always meet face-to-face. While many programs continue to rely on self-report by the trainee, more programs now require audio or videotapes to help uncover and monitor blind spots that may not be reported but may put patients at risk. Many programs now encourage at least 1 meeting between the patient and the supervisor as well as audiotaping and videotaping sessions. Patients have the right to meet the supervisor and must give consent before the audio or videotapes are shown.⁷

Training programs would do well to set their own guidelines to ensure that supervisors have sufficient information about the patient and his treatment.

Fault line 5: administration and trainee

Hospital administration must ensure that all trainees have dedicated time to meet with their supervisor. Many trainees do not realize that for the care they provide, their supervisor is legally responsible. This issue served as the impetus a decade ago for the Psychiatry Residency Training Program at MGH to institute an orientation lecture on supervision for all residents. Trainees are introduced to the all-important aspects of supervision. A companion continuing education seminar was offered to MGH supervisors for 5 years.¹⁸ The seminar was then translated into an 8-session course, which has been offered to new and veteran supervisors for 6 years to ensure that the current standards of supervision are disseminated (Table 2).¹

Fault line 6: administration and patient

To avoid confusion and provide the legal framework for the therapeutic relationship, it is recommended that teaching hospitals and clinics disclose on patient registration documents the teaching nature of the facility. The medical record is the bridge between the patient’s care and the treatment facility. The supervisor must ensure that all relevant medical and psychiatric care is documented and that the attending physician of record and the trainee’s status are identified in the medical record.

Conclusion

With the increased scrutiny and responsibility demanded of supervisors in mental health settings across the country, protection of all members of the psychiatric network must be given a priority. Psychiatry training programs should be required to train supervisors about the ethical, legal, and educational aspects of their role, as well as to provide forums in which excellence in supervision is taught.

Studies have demonstrated the qualities of excellent supervisors. They are active and are focused on the case; they clearly express opinions and track the main concerns of the trainee.¹⁹With the aid of videotape, peer supervision, and formal courses, supervisors have multiple resources to improve the safety of all parties involved, to refine their skills, and to make supervising more rewarding as a lifelong teaching and learning adventure.

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References
1. Riess H, Herman JB.Teaching the teachers: a model course for psychodynamic psychotherapy supervisors. Acad Psychiatry. 2008;32:259-264.
2. Smith SR, Meyer RG. Law, Behavior, and Mental Health: Policy and Practice. New York: New York University Press; 1987:3-43.
3. Kapp M. Supervising professional trainees: legal implications for mental health institutions and practitioners. Hosp Community Psychiatry. 1984;35:143-167.
4. Kapp MB. Legal implications of clinical supervision of medical students and residents. J Med Educ. 1983; 58:293-299.
5. Schulte HM, Bienenfeld D. Liability and accountability in psychotherapy supervision. Acad Psychiatry. 1997;21:133-140.
6. Masterson v Board of Examiners of Psychologists, 95A-03-011, 1995 LEXIS 589 (Del Super Ct 1995).
7. Saccuzzo DP. Liability for failure to supervise adequately mental health assistants, unlicensed practitioners and students. Cal W Law Rev. 1997;34:115-150.
8. Slovenko R. Legal issues in psychotherapy supervision. In: Hess AK, ed. Psychotherapy Supervision: Theory, Research and Practice. New York: John Wiley & Sons; 1980.
9. Harrar WR, VandeCreek L, Knapp S. Ethical and legal aspects of clinical supervision. Prof Psychol Res Pr. 1990;21:37-41.
10. Goldberg DA. Structuring training goals for psychodynamic psychotherapy. J Psychother Pract Res. 1997;7:10-22.
11. Ende J. Feedback in clinical medical education. JAMA. 1983;250:777-781.
12. Sherry P. Ethical issues in the conduct of supervision. Counsel Psychol. 1991;19:566-584.
13. Gartrell N, Herman J, Olarte S, et al. Psychiatric residents’ sexual contact with educators and patients: results of a national survey. Am J Psychiatry. 1988; 145:690-694.
14. Doe v Samaritan Counseling Center, 791 P.2d 344 (Alaska 1990).
15. Betcher RW, Zinberg NE. Supervision and privacy in psychotherapy training. Am J Psychiatry. 1988;145: 796-803.
16. Bridges N. Managing erotic and loving feelings in therapeutic relationships: a model course. J Psychother Pract Res. 1995;4:329-339.
17. Gabbard GO, ed. Sexual Exploitation in Professional Relationships. Washington, DC: American Psychiatric Press, Inc; 1989.
18. Riess H, Fishel AK. The necessity of continuing education for psychotherapy supervisors. Acad Psychiatry. 2000;24:147-155.
19. Kline F, Goin M, Zimmerman W. You can be a better supervisor! J Psychiat Ed. 1977;1:174-179.

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Risk Management for the Supervising Psychiatrist

Seven Steps to Avoid Common Pitfalls

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