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Managing Risk in a University Training Clinic
by Jean Spruill, Ph.D.
- Learn procedures used in the supervision of students for clinical services.
Understand the role and limitations of confidentiality in a training based clinic.
University-based training clinics provide
professional training for students, clinical services to clients, research
data or research participants for student and faculty research, and
generate income to support the clinic operations. These four functions
are not always compatible, and negotiating the demands of each sometimes
becomes a daunting task for the clinic director. Faculty focused on
research complain often about students needing too many clinical hours;
conversely, practitioner- oriented faculty retort that students do not
have sufficient clinical training. In between are the clients who are
not interested in meeting training needs or a research protocol.
Most directors say that working with
the students and having a role in their development as professional
psychologists is the most rewarding part of the job. Conversely, the
greatest headaches also derive from students. Students are bright, eager
to learn, work hard, take their responsibilities as a beginning therapist
very seriously, seek supervision and help when needed and often when
not needed. However, there are always those who do not fit the above
description and take enormous time and effort.
Establishing clear policies and procedures
governing the operation of the clinic will help to minimize the job-related
problems and facilitate the training of students. Procedures governing
informed consent and confidentiality, assignment of clients to therapists,
record keeping, handling of emergencies or crisis situations, reporting
child abuse, and use of clients for research purposes are essential
to clinic operations. Although the clinic director may not have direct
clinical responsibility for a case, the director does have the administrative
authority. Thus, if things go wrong, the director is held responsible.
This certainly gives rise to the “oh why did I ever take this job” feeling.
The following guidelines will minimize those days.
PREPARE A COMPREHENSIVE INFORMED CONSENT
Informed consent statements in training
clinics should include information about the training status of the
therapist, qualifications of the supervisor, how to contact the supervisor
or clinic director, exceptions to confidentiality, attendance policies,
payment of bills and procedures for collection of bills, and any use
of client data for research purposes. The therapist reviews the often
lengthy statement with the client and a dated and signed copy is kept
in the client’s file. That’s standard procedure.
EDUCATE ABOUT CONFIDENTIALITY
There are potential pitfalls to confidentiality
in a clinic environment. The director’s responsibility is to educate
staff, work-study students, therapists, and supervisors about confidentiality,
implementing and monitoring what is stated in the ethical standards.
For example, individuals other than the therapist need access to client
information - at a minimum the supervisor and other therapists on the
supervision team. Numerous people use the clinic computers. These situations
necessitate everyone being aware of potential breaks in confidentiality
and guarding against inappropriate access. Fax machines should be located
in secure areas; clients who request information be sent via fax need
to sign a specific release for that purpose. Electronic communications
pose another threat, as email is not secure. Students often send reports
to supervisors via attachments to email. Submission of information to
a supervisor by fax or email presents an ideal opportunity for students
to learn the necessity of redacting identifiable information.
Training clinics require that clients
give consent for audio or video tapes used in supervision. Policies
about the disposal of tapes, length of time and where they are kept,
and who can view tapes should be clearly stated in the clinic manual.
When supervisors are off site and want students to bring files with
them for supervision purposes, they should suggest that such files be
transported in a sealed envelope or locked briefcase.
SELECT APPROPRIATE CLIENTS
Since difficult clients require enormous
time from the therapist, supervisor, and director, the director should
determine the competency level of the students and screen out cases
that would likely be too difficult for them to handle. Likewise, the
director evaluates the specific competency of the supervisor in assigning
clients. Giving the supervisor the option of turning down a case is
DEVELOP PROCEDURES FOR EMERGENCIES
AND DIFFICULT CLIENTS
In spite of careful screening, inappropriate
clients do present and become the clinic’s responsibility. Examples
include a client who was seriously depressed and suicidal but this was
not detected during the intake interview; another client made statements
about killing his ex-wife, saying he was going to take care of her as
soon as he had enough money to buy a gun. In each instance, the therapist
followed the suggested procedures in the clinic manual for clients who
are potentially dangerous to themselves or others. Having these guidelines
for addressing such situations minimizes the risk to the client, the
student therapist, and the clinic.
REMEMBER THE SIGNATORIES TO THE TREATMENT
Treatment plans do not guarantee appropriate
treatment; however, if the client, therapist and supervisor sign the
treatment plan, complaints are less likely. Everyone begins with a committed
attitude. Having a treatment plan does not guarantee that it will be
followed. However, if the supervisor countersigns each progress note,
it is more likely that the treatment plan will evolve and be successful.
The actual fee charged is not nearly
as important as the manner in which the fees are set, communicated to
the client, managed and collected. Policies on fees should be written
and described clearly to the clients at the outset of treatment. Don’t
have a payment policy for missed or canceled sessions unless the clinic
PROVE IT OCCURRED
According to the old adage, “if it is
not written down, it didn’t happen.” To prove that it did, notes are
factual, written in objective language, and dated and signed by both
therapist and supervisor. Attempts to contact the client and any face-to-face
contacts are documented. Measures taken to protect the client (such
as in abuse or suicidal situations) are included. Hopefully, teaching
students the importance of good record keeping will not be left to the
Having a policies and procedures manual
that is detailed and covers every contingency is worthless without monitoring
the clinic activities to ensure that the procedures are followed. Periodic
audit of client files to check for treatment plans, supervisor signatures,
appropriate signed releases, and closing summaries is necessary to minimize
the risk to all parties. Even the best of students slip up occasionally
and the worst slip up frequently. Teach quality assurance.
In spite of it all, the job of a clinic
director is extremely rewarding. By following these suggestions, the
positive aspects can be maximized, the difficult situations less frequent,
and the “oh why” days a thing of the past…. At least until the next
Jean Spruill, Ph.D., Professor and Director,
Psychology Clinic, University of Alabama, Tuscaloosa, AL