Ethics Column

Carolyn Tubbs

Let me begin by stating that when others share their thoughts with me about Narrative Therapy, I like to be careful to deconstruct or understand what they mean. Oftentimes, the term narrative is used synonymously with postmodern. However, for me, postmodern is a larger umbrella under which narrative models fit. In other words, postmodern philosophy informs the clinical practices of narrative models, as well as the reflexive models. The degree to which therapy is viewed as socially constructed and intentional would be considered a mark of distinction between the models. For a genre of therapy that is informed by postmodern ideas, I will be first to admit that postmodernist therapists do very little to clarify, deconstruct or contextualize what we mean by narrative. In order to keep myself accountable, I would like to contextualize my comments by saying that my comments will be referring primarily to the postmodern clinical models labeled as "reflexive," the work of Tom Andersen, Harlene Anderson, and Lynn Hoffman because they are those with which I am most familiar; however, I think that my comments are applicable to the work of the more narrative models, such as the work of White and Epston, Combs and Freedman. Therefore, my comments will focus on issues affecting supervision within clinical models informed by postmodern ideas.

In addition, I would also like to contextualize my remarks by being very explicit that my comments are in no way exhaustive in terms of the multiple ethical dilemmas encountered by supervisors working within a postmodern framework. The dilemmas I will be sharing seem salient and recurring themes in the conversations in which I partake; however, others may highlight other ethical concerns and quandaries that are much more a part of their practices. As the reader will notice, my comments will serve the purpose of identifying the issues rather than attempting to resolve them.

Now, I do not want to pretend that clinicians and supervisors using postmodern models live outside relationships with the rest of the world or even with the rest of the mental health community. They don't. But from a postmodern viewpoint, the issue of ethics is not a static concern which transcends the moral and legal mandates that are observed and enforced, but rather it is an ongoing conversation among those who define mental health practices/services, those who pay for mental health services, those who provide mental health services, and the relevant others who have a vested interest in overseeing/enforcing the process (i.e., ethics boards, attorneys, accrediting organizations). As I think about it, the field of professional ethics is based on conversations, or narratives, if you will, about people who have imputed and actual power using it inappropriately against those who do not have equal power, using power for unacceptable personal gain, or using power to decrease the fiduciary aspects of their position. In essence, conversations about ethics give voice to those who might otherwise remain voiceless or speak with muted voices. It is not the protective and accountability functions of professional ethics that seem troublesome. Instead, it is the privileging of some conversations about ethics above others that causes concern. Should the legal profession's conversation about ethics be more privileged than that of the mental health practitioners who practice in their specific discipline? Should HMOs have more to say about what are ethical or appropriate measures in clinical practice than practitioners or clients? As the various conversations about ethical standards continue, and depending on who identifies itself as the group that has ethical decision-making power, the shape, size and color of ethical dilemmas will continue to change.

In my opinion, there are four ethical issues with which most postmodern supervisors must deal. First, and probably the most troublesome, is the dilemma of hierarchy. If this issue seems difficult for clinicians to resolve, the matter becomes even more complicated when seen through the eyes of a supervisor who not only feels ultimately responsible for the well-being of the client, but also for the ultimate behaviors of the clinician who is dealing with clients. For many of the postmodern therapies, the orientation in supervision, as in therapy is toward collaboration, or a flattened hierarchy. Tom Andersen calls it "heterarchy." It is the idea that the supervisor is not there to impose some expert knowledge on the clinician, but to converse with the supervisee in such a way that the process and the content of therapy can be examined for the unspoken sociocultural influences that are affecting the client's behavior in therapy, as well as the clinician's conceptualizations about behaviors in therapy. Many times, the term "co-vision" rather than "super-vision" will be used to describe this process.

The balance between collaboration and hierarchy in the supervision process can best be summed in the following questions. Are supervisors really doing their jobs if they are not being more directive with their supervisees, especially if they "do not take the lead" or if they maintain a "not knowing" position? Are not supervisees paying supervisors for an expertise or for a clinical template which co-vision may not be providing? Is it appropriate to take the time to deconstruct or question "taken for granted practices in psychotherapy" rather than solve the imminent needs of the case, or make corrective actions to the client's cognitions and behaviors?

The second dilemma is an offshoot of the first. Is it ethical to give greater focus to the supervisee's assumptive views about the client and the supervisee's clinical model, rather than his or her technical efficiency? Again, if supervisees are paying money either directly (as in an Institute format) or indirectly (as in an academic institution format), is the supervisor not obliged to give them a certain set of skills that fall under the rubrics of skills needed by family therapists and skills needed by a mental health professional? Is it appropriate to NOT give most of the supervision time to teaching clinicians to become more efficient diagnosticians and technicians? This is especially problematic in these days of HMO and treatment efficiency. Shouldn't more emphasis be placed on the DSM-IV rather than on cultural practices or locating behaviors? In this dilemma, the spotlight is on what the supervisor should be transmitting to a technically uninformed supervisee.

The third dilemma links to the first and the second. The third ethical dilemma frequently encountered within postmodern clinical models deals with ambiguity in the process. Because the modernist ideas of rationality and logic are or have been so pervasive in our society, or at least in the groups of people who hold power in our society, our standards for "appropriate", "good", or "adequate" supervision are based on these notions. When these notions of rational and logic get operationalized, they usually mean "recipe-ed" and systematic. In accordance with this mindset, when a "super" visor gives systematic ideas to the supervisee, then they should be directive, objective, and corrective. The question then posed becomes whether an agency supervisor is acting unethically if his or her style of clinical supervision focuses more on deconstructing problems rather than case management and auditing?"

The fourth dilemma, and final dilemma that I will highlight, is that of innovative methods of supervision. For many of the postmodern forms of therapy the use of reflecting teams in various forms may pose ethical dilemmas (especially for those who do not practice in the postmodern models and use more traditional one-on-one or non-reflective team format) because of concerns about client fragility and confidentiality, as well as supervisee fragility and confidentiality. Is the reflecting team format a good way for clinicians to learn necessary conceptual and clinical competencies especially when this format seems to address their technical proficiency indirectly or not at all? In a co-therapy or two-person therapy format, is it ethical for the supervisor not to take the lead especially when a clinician, whether novice or experienced, does not know the postmodern paradigm well? Are ethical boundaries being violated if clients are privy to supervisory consultations that either occur live or are presented to them on tape? The larger question for these questions being: is it appropriate to make therapeutic use of the "secret" aspects of supervision readily available to clients?

In closing, I would say that the ethical dilemmas encountered most by those using postmodern clinical models deal mostly with hierarchy or power - who has the power to decide what behaviors are or are not ethical with which persons?

Dr. Tubbs is currently a postdoctoral fellow with the Family Research Consortium III and conducting ethnographic research in Chicago. She earned her doctorate at Purdue University with a specialty in marriage and family therapy. Her research interests include the application of postmodern concepts to family therapy practice and supervision, as well as the analysis of narratives in the qualitative research process.