As indicated in the discursive frame chapter, working directly with clients in the field of mental health is inherently one of managing risk. The impact of this history still persists in assumptions underpinning supervision in relation to managing risk.
In the transcripts, discourse associated with risk was multi-dimensional and appeared in each domain of the supervisory relationship: risk to the client, risk to the public, risk to the organisation, risk to the supervisee and risk to the supervisor.
3a. Risk to the client
Supervisees expressed needs to safeguard their clients against risks being taking in their outside lives:
525 (counselling supervisee): the client was taking risks And:
1865 (clinical psychology supervisee): I actually think he’s extremely low risk
because he only makes trips [driving] that he can make…and obviously with a risk awareness kind of hat on and thinking well that’s not good. Okay. Um but I think his risk can be managed clinically if you like, within… as part of the
assessment, and it will be a discussion I’ll be able to have with his wife as
well hopefully and so, yeah I’ve advised him as best I can.
8287: the person themselves starts engaging in behaviours that become dangerous or risky in some way, so that, you know, alcohol use increases, or
they become… they start doing things, other kind of elaborate and look kind of in the old psychiatric parlance: quite hysterical…
However, on this occasion, rather than looking at how these risks might be mitigated, the supervisor takes his own risk by suggesting that risky behaviour by the client is a way of getting attention, indeed a very efficient way of getting needs met:
8300: Efficient as well, you know….that need actually to get it met
but he does not explore with the supervisee whether there is a role in mitigating that risk for the client. Indeed, this supervisor actually says:
8327 … but in terms of what one then does about it, I think that’s a real
challenge. I don’t know that we very successfully offer very much to people in
this sort of position.
There is an issue that could be explored further about the impact of exposing and identifying the risks and the limits of the practitioner’s ability to mitigate those risks. What is the purpose of discussing the risks if not as a means to exploring possible safeguards that might be implemented? An alternative view would be that practice is complex and to try and reduce it to risk assessment and alleviation of risk reduces both the potential of the practitioner and the client themselves.
The need to safeguard the client from things going wrong within the clinical environment was also expressed:
3958: (nursing supervision session): Things going wrong is relatively, err,
uncommon. Um, and that you sort of leave…you risk…end up feeling, you know, fairly confident that we’re doing as best we can.
This particular extract emerged as the nursing supervisor and supervisee were discussing a complaint by relatives when a patient chose to spend long periods alone in their room and therefore was not perhaps as closely observed as s/he could be. The supervisor, who also works in the same ward, was familiar with the case and so was quickly able to reassure the supervisee:
3980: I think you’ll find this talk useful actually because it does deal with a lot of those issues……that you’re talking about, um, not least of which is sort of,
you know, lis…listening to people……so I…I think you can’t go far wrong…
On the face of it, this is a very reassuring statement for the supervisee. However, a supervisor who had no previous knowledge of the incident would not have been able to offer such reassurance so quickly and would, instead have needed to spend longer exploring the case and the potential implications and lessons to be learnt. It could be argued that this very foreknowledge might preclude further reflection and discussion by the supervisee, thereby, whilst possibly providing reassurance in this individual case, not providing the opportunity for the supervisee to identify and manage the risk themselves more effectively in future. In the interview following, the supervisee was very keen to ensure that I understood that the client was not at risk, and yet it could be inferred that this eagerness itself reveals a certain anxiety which is has not been entirely resolved.
5592:Yes, obviously if I felt maybe that, you know … not that the client’s at
risk, she’s not at risk, I’m not saying she’s at risk, but obviously if I felt that I
couldn’t nurse her or maybe have some knowledge how to nurse her maybe in a different … obviously we do have team talk and we obviously do openly
talk genuinely through you know sometimes how people do make you feel, but, er, I suppose that gives at that time an opportunity that you can go in there and sort of like unload a little bit of how you feel.
3b. Risk to the supervisor
2755 (Clinical psychology supervisor): I suppose that’s the risk when you’re giving away the agenda of the supervision and responding to what somebody
brings. The risk is that then something’s called from you which you don’t
necessarily choose
This supervisor is expressing the risk associated with attempting to devolve power within the supervisory relationship: that in surrendering power to the supervisee to decide what can and cannot be spoken about, consequent powerlessness leaves the supervisor vulnerable.
3c. Risk to the supervisee
7379 (counselling supervisor interview): I sometimes think of it as it’s a bit like, um, letting your friend come out of the toilets with their skirt still tucked in their pants
This delightful comment from the counselling supervisor represents very graphically the potentially conflicting responsibilities that a supervisor holds within an
organisation. Through this imagery, this supervisor draws from the discourse of supervision as safeguard in the domain safeguarding the supervisee. In order to protect her, at least from embarrassment, if not from action being taken against her within the organisation, this supervisor is expressing that she would want to negotiate with the supervisee themselves and let her know that there is something amiss before approaching the organisation. Nonetheless, in order to safeguard the client, there may have to be an occasion when this would happen. Likening your
supervisee to a friend could also reveal a level of care and protection which goes beyond the purely functional.
3d. Risk to the organisation
Confidentiality is a core principle of much practice in mental health as well as in the supervisory relationship. It was the counselling partnership that discussed this most explicitly, though not exclusively. The notion of ‘breaking’ confidentiality is seen very much as a last resort, but there was acceptance that potential needs to exist for that to happen in order to safeguard the client as well as the organisation. This is
evidenced in the section above, where the counselling supervisor appears to have some clear guidelines to her own practice in terms of behaving ‘diplomatically’:
7387: It’s one of the hardest bits to negotiate, probably, to retain the
confidence and the goodwill of the person that you feel, you know, something
needs to be said. Um, and yet, it’s holding the three corners of, you know,
the sheet of the contract, isn’t it? You want to hold onto the supervisee and
hopefully keep them onboard and enable them to learn from the experience and move on in a positive way but, at the same time, the organisation has responsibilities. I have a responsibility to the organisation to let them know if
there’s something, you know, they need to know from me and the counsellor first, rather than from somewhere else.
An illuminating extract from the nursing supervision sessions reveals a further layer of risk and raises a number of questions in respect of the place and role of
supervision in identifying and managing risks within the organisation. The example relates to concerns about a colleague’s practice and whether or not it constitutes lack of fitness to practise (though that is not a phrase used by the participants):
10757 (nursing supervision session): Um, but if I say to him [the colleague about whom the supervisee has concerns], "Oh yeah, you know, you're doing
fine."…That's not helpful and I feel that I'm sort of putting my clients at risk. Supervisor: Hmm. There's no case for saying you're doing fine, I don't think. In this example, where the supervisor is from the same organisation, he happened to know the person being discussed and also used to supervise this colleague’s
manager.
10909: Supervising somebody with a supervisory responsibility for him, I
could go into all of the things, risk, competence, and things like that. ‘We
went through a huge process of, um, myself, that person and a team leader,
kind of …. I knew the team leader as well but we didn’t ever actually get to
discuss it, just in a very brief sense. Um, but, er, in negotiating a supervisor, supporting my supervisee to try and negotiate how to deal with this kind of undertaking and how to hand it on to her manager, and, er, I was shocked
when he came back into the system, because he clearly isn’t functioning.
This raises a very important issue in terms of the conflict of interests between the discourse of supervision as safeguard (in this case safeguarding the organisation and/or the client) and the discourse of supervisionas containment and as
development. Trying to reconcile these conflicts results in some convoluted explanations, which are not entirely satisfactory.
3e. Risk to others
One of the cases discussed in a counselling supervision session related to the potential of the client to become involved in an assisted suicide. Neither the supervisor nor supervisee had come across this before. In fact, the topic was
introduced by the supervisee in the session prior to the recorded session but, as the supervisor had no experience of this, she had gone away to reflect on it and it was she who introduced the topic into the subsequent (recorded) session:
11873 (counselling supervisor): I mean, it's this assessment of risk, isn't it? And if you feel that, um, somebody is going to harm somebody else, then
you… you would have to go to the police.
Supervisee: So you would have gone to the police and not his GP?
Supervisor: No, because it's a criminal act, isn't it? So it would have been the police.
Supervisee: Yeah. But in a way, it's… it's…
Supervisor: But… but… but that's the final…You know, that's after you've explored how he feels once you've restated the confidentiality and that you
could… you have wider responsibilities and you might need to break it if you
do and how does that feel, and why is it the only option? You see, you've
got… there's a lot before you get there.
4. Safeguarding the client
13827 (counselling supervisee): I don’t see it as a get out of jail card. I don’t
… the fact that it would be G’s last resort to actually break confidentiality and maybe go elsewhere, I don’t see that as a safety net…. I see it as, um … as
kind of maybe a, um, governing body if you like. That she’s keeping check on me and if I did do something that was really unethical then she would have
every right to do that because then I shouldn’t be practising.
This is a really interesting piece of reflection by the counselling supervisee; it is not easy to unpick the distinction she makes between her supervisor acting as a safety net, which she clearly reacted quite strongly against, and her supervisor as being some kind of governing body and is a further example of the way in which these practitioners try to reconcile conflicting discourses, in this case the discourse of supervision as containment (the safety net) and the discourse of supervision as safeguard (the governing body).
This contrasts with the clinical psychology supervisor, who expressed mild concern that perhaps he was not protective enough of his supervisee concerned enough about the risks associated with his supervisees’ practice:
9298: Mm. I, I wouldn’t, I, I don’t, I don’t pretend that there aren’t times when I worry about that I don’t worry enough, if you see what I mean, uh, that I
paying more attention to issues like that? Um, the reason, the reason I think I
don’t is because again I think,I think I’ve been pretty good at, at not entering, entering into a supervisory relationship with people I don’t trust.
This supervisor has stumbled across one strategy for reducing potential anxiety about safeguarding clients and that is carefully to select supervisees that appear trustworthy.