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Tuesday, March 1

Ethics Corner: Ethical Considerations with Dual Relationship (2 of 2)

Ruth Lipschutz, LCSW, ACSW

This is the second article in a two-part series on dual relationships. Check out part one here.
 
NASW Code of Ethics
1.05 Cultural Competence and Social Diversity
b) Social workers should have a knowledge base of their clients' cultures and be able to demonstrate competence in the provision of services that are sensitive to clients' cultures and to differences among people and cultural groups.
 
Decisions around appropriate physical contact, giving and receiving gifts, or accepting food offered on a home visit are only a few examples of boundary decisions that could be effected by cultural norms and beliefs. Social workers need to understand the impact of religious and cultural factors in setting appropriate boundaries.
 
1.06 Conflicts of Interest
(a) Social workers should be alert to and avoid conflicts of interest that interfere with the exercise of professional discretion and impartial judgment. Social workers should inform clients when a real or potential conflict of interest arises and take reasonable steps to resolve the issue in a manner that makes the clients' interests primary and protects clients' interests to the greatest extent possible. In some cases, protecting clients' interests may require termination of the professional relationship with proper referral of the client.
 
(b) Social workers should not take unfair advantage of any professional relationship or exploit others to further their personal, religious, political, or business interests.
 
(c) Social workers should not engage in dual or multiple relationships with clients or former clients in which there is a risk of exploitation or potential harm to the client. In instances when dual or multiple relationships are unavoidable, social workers should take steps to protect clients and are responsible for setting clear, appropriate, and culturally sensitive boundaries.
 
Social workers are responsible to assure that boundary decisions respect clients or colleagues right to self-determination while protecting them from the risk of harm. This section makes clear that the obligation to assess risk rests fully with the social worker. As previously stated, some dual relationships are unavoidable and may even be helpful. The expectation is that the social worker demonstrates that they have applied an appropriate risk management decision-making protocol before, during and after termination of any dual relationship.
 
1.09 Sexual Relationships
(a) Social workers should under no circumstances engage in sexual activities or sexual contact with current clients, whether such contact is consensual or forced.
 
(b) Social workers should not engage in sexual activities or sexual contact with clients' relatives or other individuals with whom clients maintain a close personal relationship when there is a risk of exploitation or potential harm to the client. Sexual activity or sexual contact with clients' relatives or other individuals with whom clients maintain a personal relationship has the potential to be harmful to the client and may make it difficult for the social worker and client to maintain appropriate professional boundaries. Social workers--not their clients, their clients' relatives, or other individuals with whom the client maintains a personal relationship--assume the full burden for setting clear, appropriate, and culturally sensitive boundaries.
 
(c) Social workers should not engage in sexual activities or sexual contact with former clients because of the potential for harm to the client. If social workers engage in conduct contrary to this prohibition or claim that an exception to this prohibition is warranted because of extraordinary circumstances, it is social workers--not their clients--who assume the full burden of demonstrating that the former client has not been exploited, coerced, or manipulated, intentionally or unintentionally.
 
(d) Social workers should not provide clinical services to individuals with whom they have had a prior sexual relationship. Providing clinical services to a former sexual partner has the potential to be harmful to the individual and is likely to make it difficult for the social worker and individual to maintain appropriate professional boundaries.
 
This is one of the few sections of the code that incorporates a clear prohibition. Sexual involvement with current or former clients is one of the most frequent causes for complaints and law suits against social workers. It has proven to be devastating to many careers. Sexual involvement with clients, former clients, supervisees or students is always a boundary violation.
 
The prohibition is not as absolute with relatives or those with close relationships with clients. Nevertheless, the intent of this section is to communicate the requirement for the social worker to demonstrate how factors leading to their decision to enter a sexual relationship sufficiently mitigate the risk of potential harm. The predominance of opinion, and therefore the standard of care in the profession, would recommend avoiding sexual involvement with client’s relatives or close personal relationships.
 
1.10 Physical Contact
Social workers should not engage in physical contact with clients when there is a possibility of psychological harm to the client as a result of the contact (such as cradling or caressing clients). Social workers who engage in appropriate physical contact with clients are responsible for setting clear, appropriate, and culturally sensitive boundaries that govern such physical contact.
 
Physical contact is listed separately because it can be sexual or nonsexual in nature. Nonsexual contact may be appropriate or clinically important in a number of circumstances. Schools, hospitals and hospice settings are some examples of where norms around the acceptability of forms of touch such as holding a hand, nonsexual hugs, touching a shoulder, may be both common and even expected. “Clients could find such physical contact comforting and ‘therapeutic’. Moreover, physical contact may be culturally appropriate and encouraged in some ethnic or social communities.” (Stake & Oliver, 1991)
 
There exists a large range of opinions on the use of physical contact. It is the social workers responsibility to appropriately assess the impact, taking into account all relevant clinical data, cultural considerations, policies in the practice setting and their own personal values and comfort level.
 
1.11 Sexual Harassment
Social workers should not sexually harass clients. Sexual harassment includes sexual advances, sexual solicitation, requests for sexual favors, and other verbal or physical conduct of a sexual nature.
 
1.13 Payment for Services
(b) Social workers should avoid accepting goods or services from clients as payment for professional services. Bartering arrangements, particularly involving services, create the potential for conflicts of interest, exploitation, and inappropriate boundaries in social workers' relationships with clients. Social workers should explore and may participate in bartering only in very limited circumstances when it can be demonstrated that such arrangements are an accepted practice among professionals in the local community, considered to be essential for the provision of services, negotiated without coercion, and entered into at the client's initiative and with the client's informed consent. Social workers who accept goods or services from clients as payment for professional services assume the full burden of demonstrating that this arrangement will not be detrimental to the client or the professional relationship.
 
Bartering holds the potential for serious conflicts of interest. How is the value of the service or products provided determined? How is the value of the clinical services determined? What happens if either party is dissatisfied with the agreement? Due to the complexities and risks involved, the code limits bartering to “limited circumstances” and specifies the conditions that must be met in order to minimize the risk of harm. In addition to the conditions elucidated in the code, if bartering is entered into, it is helpful for the agreements to be specific and in writing.
 
1.16 Termination of Services
(d) Social workers should not terminate services to pursue a social, financial, or sexual relationship with a client.
 
2.07 Sexual Relationships
(a) Social workers who function as supervisors or educators should not engage in sexual activities or contact with supervisees, students, trainees, or other colleagues over whom they exercise professional authority.
 
(b) Social workers should avoid engaging in sexual relationships with colleagues when there is potential for a conflict of interest. Social workers who become involved in, or anticipate becoming involved in, a sexual relationship with a colleague have a duty to transfer professional responsibilities, when necessary, to avoid a conflict of interest.
 
This section extends the fiduciary duty inherent in relationships with a power differential to supervisors, educators, and colleagues.
 
2.08 Sexual Harassment
Social workers should not sexually harass supervisees, students, trainees, or colleagues. Sexual harassment includes sexual advances, sexual solicitation, requests for sexual favors, and other verbal or physical conduct of a sexual nature.
 
Risk Management Protocol
The literature contains examples of several risk management protocols. What is essential is that social workers establish clear "risk management" criteria and procedures, have these in writing and familiarize themselves with the steps.
 
Frederick Reamer (2001) suggests that “a sound risk management protocol to deal with boundary issues” should contain six major elements:
  1. Be alert to potential or actual conflicts of interest.
  2. Inform clients and colleagues about potential or actual conflicts of interest; explore reasonable remedies.
  3. Consult colleagues and supervisors, and relevant professional literature, regulations, policies, and ethical standards (codes of ethics) to identify pertinent boundary issues and constructive options.
  4. Design a plan of action that addresses the boundary issues and protects the parties involved to the greatest extent possible.
  5. Document all discussions, consultation, supervision, and other steps taken to address boundary issues.
  6. Develop a strategy to monitor implementation of action plan.
In her article “Respecting Boundaries: The Don’ts of Dual Relationships,” Claudia Dewane outlines the following factors to consider when deciding whether to enter into a second relationship:
  • How will this secondary relationship change the power differential or take advantage of a power differential in the therapeutic relationship?
  • How long will this relationship last? Is it a one-time occurrence or expected to last indefinitely?
  • How will ending one relationship affect the other relationship?
  • How much will objectivity be impaired?
  • What is the risk of exploitation?
  • What is the impact of each of these contextual factors:
    Type of practice: Community organizing or a private clinical counseling?
    Setting: Family-based service or outpatient psychiatric setting?
    Level of community involvement: Is community involvement needed to gain access to a population?
    Client’s sense of self: How vulnerable is the client? Is he or she likely to misinterpret behavior, or does he or she have a strong sense of self that could distinguish roles?
     Legality: Are there legal ramifications?
    Culture: Does this client’s culture require more or less friendliness?
     Social worker’s self: Is the worker trying to fulfill some personal need?
    Available supervision: Is competent consultation available and used?
Questions for social workers to ask in any decision making process include:
Why am I taking (or considering taking) this action?
Why am I doing this at this time?
Why with this client?
Would I do the same with other clients? If not, what makes this situation different?
What needs are being met and whose needs are they?
How does this impact the treatment plan?
How will the client/colleague interpret my actions?
What risks/benefits are involved?
Are there intermediate steps that can be taken (rather than an all or nothing approach)?
Am I documenting my decision making process and actions? Is there a reason I am excluding information from my documentation?
 
Conclusion
Boundary issues are inherent in the practice of social work. Careful risk management decision-making procedures allow practitioners to avoid boundary violations and make informed, ethical determinations when assessing boundary crossings. Clients and colleagues are protected from harm, while ensuring their rights to self-determination. Practitioners are protected from complaints and given the tools to make decisions that live into the mission of social work, to promote human well-being.
 
Dewane, Claudia J. (2010). Respecting Boundaries: The Don’ts of Dual Relationships.
Social Work Today Vol. 10 No. 1 P. 18
 
Gottlieb, M. C. (1993). Avoiding exploitative dual relationships: A decision-making model. Psychotherapy.
 
Gutheil, T.G. & G.O Gabbard (1993).The Concept of Boundaries in Clinical Practice: Theoretical and Risk Management Dimensions. American Journal of Psychiatry, 150 (2): 188–196.
 
Johner, R. (2006). Dual Relationship Legitimization and Client Self-Determination. Journal of Social Work Values and Ethics, Volume 3, Number 1
 
Kagel, J. & Giebelhausen, P. (1994). Dual Relationships and Professional Boundaries. Social Work. 39, 213–220.
 
Mittendorf, S. & Schroeder, J. (2004). Boundaries in Social Work: The Ethical Dilemma of Social Worker-Client Sexual Relationships. Journal of Social Work Values and Ethics. 1, 2–9.
 
National Association of Social Workers. 1996. Code of Ethics of the National Association of Social Workers. (Revised 2008).
 
Reamer, F. (2003). Boundary Issues in Social Work: Managing Dual Relationships. Social Work. 48, 121–133.
 
Reamer, F. (2001). Tangled Relationships: Managing Boundary Issues in the Human Services. New York: Columbia University Press.
 
Strom-Gottfried, K. (1999). Professional Boundaries: An Analysis of Violations by Social Workers. Families in Society. 80, 439–449.

Ruth Lipschutz, LCSW, ACSW, is a licensed clinical social worker with postgraduate certification in ethics, mediation, Transformational Imagery, hypnotherapy, and Eye Movement Desensitization and Reprocessing (EMDR). She received her MSW from the University of Illinois in 1978 and went on to complete the two-year postgraduate training program of the Institute for Family Studies at Northwestern University. She has extensive experience in the areas of ethics, mental health, addictions, traumatology, program development and implementation, supervision, consultation and Alternative Dispute Resolution. She is the chairperson of NASW’s National Ethics Committee and has served as a panelist, consultant, mediator, and trainer for the NASW Illinois Chapter Ethics Committee. She is currently in private practice.
 
Posted on 03/01/11 at 08:05 AM

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