2011 Student Ethics Essay Award – 3rd Place
Providing Effective Treatment in the Face of Power Differential: A Clinical Situation
By Emily Riddle
Western Carolina University
Cullowhee, North Carolina
NSSLHA Chapter Advisor: Kimberly C. Crawford
The clinical supervision process provides opportunities for graduate clinicians to hone their therapy skills under the guided watch of an experienced speech-language pathologist. The process also presents a power differential at times, particularly between supervisors who have control over their supervisees and the student clinicians who may feel intimidated by this disparity. An ethical dilemma could arise if the power differential is not handled carefully, particularly if the effectiveness of a client's speech-language intervention is at risk. There are ethical ways to handle any such instance, and ample resources are available to guide the supervisor and supervisee to an ethical solution.
One example of an instance where a client's welfare is at risk is in a first-time student clinician's struggle with finding effective therapy techniques for a challenging client. The new responsibilities of planning and carrying out treatment are daunting, and it can be difficult to find an effective treatment plan quickly when struggling with a steep learning curve. If a supervisor sees a clinician struggling for effectiveness and withholds suggestions for improvement, then she is misusing her power as the clinical supervisor at the cost of the client. Granted, these challenges also serve as learning opportunities for budding clinicians, and a supervisor's role is to guide the clinician to grow from the experience; however, both professionals are directed by ASHA's Code of Ethics to "hold paramount the welfare of the persons they serve professionally" ( 2010, p.1). If the client's intervention is sacrificed to a learning opportunity, neither supervisor nor clinician is honoring this code.
Certain pressures may influence the behavior of a supervisor or student clinician in this situation. To begin, a clinician may continue to struggle in providing effective treatment, believing that if she cannot find a solution herself, as her supervisor instructs, she is not trying hard enough. She may internalize this difficulty and begin to see herself as a poor clinician. Similarly, the supervisor may feel compelled to shape strong clinicians, and thus challenge the student to problem-solve independently. In her book, Workplace Skills and Professional Issues in Speech-Language Pathology, Vinson (2009) describes a stage in the supervisory process called the "self-supervision phase" (p. 227). In this phase a clinician can plan, carry out, observe and analyze his or her own treatment independently, and incorporate these experiences into plans for future treatment. Perhaps this supervisor feels led to push her student clinicians toward this self-supervision phase and thus withholds therapy suggestions in order to stimulate growth.
During any supervision situation, it is important to identify when and if a client's welfare is at risk, as well as when and if supervision is adequate. In this instance, the clinician should keep note of the client's progress and/or maintenance of skills taught in therapy as a means of assessing the client's welfare. The client's lack of progress despite variations in therapy technique should serve as a red flag to the clinician and supervisor that his or her wellbeing may be in jeopardy. There are also a number of options if the clinician feels that her supervisor's instruction may not be adequate. One benefit of graduate school is being in a cohort of students that share both clinical and academic experiences. The clinician could inquire about the supervision experiences of her schoolmates and gauge how they relate to her own. She could also research the ideal supervision experience for clear definitions of roles and responsibilities. Saras and Post (2004) note the six "Cooperating Teacher's I's" in their study about how supervisors handle challenging situations with graduate clinicians: ignore, intervene, interject, interact, interrupt and intercept (p. 122). The clinician could assess her supervisor's use of these tools to measure if the instruction she receives is adequate. Ultimately, if either the client's welfare is at risk or the supervision is inadequate, the clinician should address these issues with her supervisor.
The clinician may be intimidated by her supervisor's authority and hesitate to bring up these ethical concerns, but she is obligated professionally and ethically to discuss these matters with her supervisor if the client's welfare is at stake. Only then can an ethical solution come to fruition. Nevertheless, the clinician should not approach her supervisor expecting to be handed a fully formed lesson plan. Instead she should present her best possible work and ask for constructive critique. This allows the supervisor an opportunity to modify and instruct rather than provide the clinician with all of the answers. Likewise, the supervisor could then encourage the clinician to seek out answers on her own but perhaps while offering some key starting points. The clinician could also frame her questions about therapy techniques in the context of the client's lack of progress, potentially triggering the supervisor's realization of holding paramount the welfare of the client. However, if the supervisor refuses to contribute to the situation by providing thoughtful feedback or critique, the clinician should contact an authority above the supervisor for assistance since the welfare of the client is at risk. In any way that a solution is sought, communication between the supervisor and the clinician should be clear and open. If both individuals hold the client's wellbeing as the most important factor in the situation, rather than who holds the most power or authority, then each person should be able to speak and act professionally without fear of intimidation or disrespect.
Power differentials in a clinical setting can muddy the waters when it comes to ethical practice. In this situation, a supervisor chose her obligation to help train strong clinicians over her obligation to provide effective treatment to a client. Similarly, the clinician acted according to her supervisor's expectations by modifying treatment (as best she knew how) to no avail, instead of realizing the potential risks this presented to the client. Despite any difference in amount of power or authority, both clinician and supervisor are responsible for acting professionally and providing the greatest possible benefit to the client. These goals can be achieved through clear communication and mutual respect, no matter how the authority is dispersed.
American Speech-Language-Hearing Association. (2010). Code of Ethics. Available from www.asha.org/policy.
Saras, L. J., Post, D. M. (2004). Supervisory Responses to Critical Teaching Incidents During Speech-Language Therapy. (English). Clinical Supervisor, 23(1), 121-137. doi:10.1300/J001v23n01.
Vinson, B.P. (2009) Workplace Skills and Professional Issues in Speech-Language Pathology. San Diego: Plural Publishing.