I would undoubtedly have a desire for my sister to know all the facts before making a commitment such as marriage. However, I have a duty to uphold the rights of my clients, including their right to confidentiality. Confidentiality can only be broken in exceptional circumstances, such as when someone is at risk of serious harm. Although I might find a history of sex offences and the presence of lying and (presumably petty) theft in my sister’s relationship concerning, without any indication that the client intends to put my sister?s safety at risk, I do not feel that breaking confidentiality is justified. As difficult as it may be, I would need to put my personal loyalties aside to uphold the professional responsibilities I have to the client.
(As an aside, I think it’s important not to make assumptions about what the outcome of my intervening might be. Maybe she has already noticed the money going missing from her wallet? Maybe she has already found out some or most of his past yet chooses to be with him anyway?)
The ethical dilemma, therefore, is not whether I should break confidentiality but rather whether I should continue to work with the client given the dual relationship that now exists. In this case, I feel that the answer would be no. Given the relationship I have with my sister, I would risk introducing personal bias into the counselling relationship. The best solution is a referral.
I would discuss the situation with the client, being sensitive to his reaction to the situation. No doubt he is as surprised as I am that his counsellor is his girlfriend’s sister! It may not have been a pleasant surprise for him, and he might be worried about the safety of the information he has disclosed to me. I would explain why I cannot continue to work with him, and assure him of the confidentiality of his information, both now and in the future. I would then begin the process of referring him on to another more suitable counsellor.
January/February 2010 Issue
Respecting Boundaries — The Don’ts of Dual Relationships
By Claudia J. Dewane, DEd, LCSW, BCD
Social Work Today
Vol. 10 No. 1 P. 18
Engaging in dual relationships is risky business for social workers. Read about the boundaries you shouldn’t cross.
Social work is a profession that prides itself on the use of self, the person in the process (Mattison, 2000). As distinctive and positive as it is, this concept lends itself to developing secondary relationships. These relationships can include nonsexual and legitimate interactions, many of which are unplanned and inadvertent, yet still have ethical ramifications.
Ethical issues related to professional boundaries are common and complex. Similar to a Rubik’s cube, the issue is multifaceted and rarely do all the sides line up correctly. We should be concerned with dual relationships primarily because they can hurt clients but also because they can hurt the profession and social workers.
Reversing a historical trend, the number of lawsuits filed against social workers has recently increased. A primary reason why clients sue is because they feel they have been exploited, and exploitation is at the core of the dual relationship issue.
A debate has emerged in the social work field about dual relationships. On one side are those who support avoiding dual relationships at all costs. On the other side are those who say these relationships are situationally and contextually determined. They argue that being too dogmatic about avoiding dual relationships diminishes the essence and authenticity of social work.
These two polarities represent deontological (categorical imperative) ethics and utilitarian (situational, or “the ends justify the means”) ethics: absolutists vs. relativists. An absolutist believes that certain actions are ethically right or wrong and that certain values should always determine the moral course of action. A relativist believes that moral standards are personal, subjective, and situational. The morality of a decision is measured by the goodness of the outcome. The deontological view focuses on process; the utilitarian view emphasizes outcome.
This is a case example from the National Association of Social Workers (NASW): An oncology client with a terminal diagnosis, widowed six months earlier, is unemployed and has a 5-year-old daughter for whom she feels incapable of providing good care. She has no next of kin, so she has decided to relinquish her daughter for adoption. The client notices that her social worker is good with her child. The client also overhears the social worker talking about her plans to try to adopt a child. The client asks the social worker if she would consider being the adoptive parent for her daughter.
An absolutist might argue that there should be no blurring of roles because there is a foreseeable risk of exploitation. A relativist might argue that it is a win-win situation. In this context, the mother would feel relief, the child would have a good home, and the social worker could adopt as desired. The decision is measured by the goodness of the outcome for the most people.
The social work Code of Ethics stipulates that if a dual relationship is exploitative, whether it begins before, during, or after a professional relationship, it should be avoided. There is room for interpretation, and many of the dual relationships social workers encounter are much more subtle than the egregious exploitation of a sexual relationship: developing a friendship with a client, participating in social activities with clients, belonging to the same social advocacy group as a client, accepting goods instead of money, sharing religious beliefs, counseling a friend.
What’s Right or Wrong With Dual Relationships?
The potential for exploitation or harm to a client is what makes dual relationships insidious. Dating, bartering, and entering into business arrangements with clients represent examples of situations that are best avoided.
But are these situations always wrong? Often they are inevitable, especially when the social worker is in private practice or practices in a rural setting or a denominational agency. In a small community, same sex social activities are limited and thus may be attended by both client and worker. The incidental occurrence of boundary crossings may be unavoidable. And there may be therapeutic reasons for crossing the professional boundaries, too, such as eating a meal in a family-based treatment visit or attending the funeral of a hospice patient.
Freud (2002a) has written about the inadequacy of the Code of Ethics in addressing dual relationships. In fact, she prefers calling them consecutive or concurrent relationships, arguing that the contexts in which dilemmas arise do not easily fit into the guidelines of the code.
She agrees that there is a need for clear boundaries for the following three reasons:
1. Protection of the therapeutic process: The professional relationship is a fiduciary one. It is not a friendship and even minor boundary transgressions can give a mixed message; a boundary symbolizes limits of a professional transaction.
2. Protection of clients from exploitation: Clients are vulnerable, and social workers are entrusted to protect them from more harm.
3. Protection of social workers from liability: The previous discussion of malpractice suits attests to this need.
However, Freud also asserts that maintaining the rigid power hierarchy of professional-client relationship adds to distancing and reduces authenticity. “There may even be instances when purposeful cultivation of dual relationships may be necessary for successful entry, professional legitimacy, and knowledgeable intervention” (p. 486). She objects to the concept of perpetuity, the belief that once someone is a client, he or she is always a client, meaning a social worker should never have any relationship with a former client.
She refers to the American Psychological Association, which provides the following specific contextual factors when deciding whether a dual relationship is appropriate:
• the amount of time that has passed since the professional relationship;
• the nature, duration, and intensity of the professional relationship;
• the circumstance of termination;
• the client’s history and vulnerability;
• the client’s current mental status; and
• the likelihood of an adverse impact on the client.
It could be argued that these criteria provide a loophole for retrospective rationalization for impaired objectivity. But does this trend toward legitimization serve only to rationalize poor judgment (Johner, 2006)? Reamer (2000) indicates that social workers’ emphasis should not necessarily be on avoiding dual relationships at all costs but instead managing risk. In some cases, risk management may call for avoidance.
Conceptual distinctions proposed in the literature may help put decision making in perspective: boundary crossings, violations, and excursions (Ringstad, 2008). A boundary crossing occurs when a professional is involved in a second relationship with a client that is not exploitative, coercive, or harmful. Boundary crossings have been defined as bending the code, whereas boundary violations are breaking the code. They are not inherently unethical, but they could be. The crossing becomes a violation when the dual relationship has negative consequences for the client.
The distinction between crossings and excursions may lie in the difference between inadvertent and deliberate. A blurring may occur unexpectedly when you see a client in the grocery store and he or she introduces you to family members. An excursion, however, may be more deliberate, as when you serve as an evaluator for an adoption to someone you know.
Rural communities often have a limited pool of healthcare and mental health providers. In rural or small towns, the possibility of simultaneous personal and professional involvement is high if not inevitable (Brownlee, 1996). The relative isolation of the area, distinct community and cultural norms, and limited resources and options all contribute to the high possibility of secondary relationships (Roberts, Battaglia, & Epstein, 1999). If there is no other referral source, is it better to leave the need unmet or provide the service?
This is a case example from the NASW: A rural social worker who provides clinical services at a nursing home has agreed to assume medical power of attorney for a number of patients who have no other appropriate resources. The social worker differentiates the roles, never providing counseling to the patients for whom he has the fiduciary role and responsibility. One effect is that clients to whom he provides counseling can never have the opportunity to select him as their legal representative, and clients for whom he has power of attorney cannot receive clinical services.
Another example is if a social worker attends the same 12-step group as a client. Should the social worker limit his or her involvement in the group? Social workers have an obligation to their clients but also to their own well-being (Rothman & Sager, 1998).
Possible courses of action in such a situation include the following:
• Assuming an absolutist stance, the social worker may decide to go to a meeting where clients are unlikely to attend.
• The social worker may make the best of an awkward situation, stay at the meeting, and be selective about what experiences to share, maintaining some boundary with the client. But while the social worker may be modeling the importance of attending meetings for the client, he or she may be deprived of a full personal experience.
• The social worker may decide to participate fully, which is a risk he or she may feel comfortable managing.
Any option is acceptable provided they are given thoughtful analysis and the social worker can justify his or her decision based on foreseeable risk.
Reamer (2001) proposes a typology of the following five categories of dual relationships in social work:
1. Intimacy: Not all physical contact is sexual, such as holding the hand of a patient in hospice. What about intimate gestures such as sending a card?
2. Personal benefit (monetary gain): Social workers should not borrow from or lend money to clients, but what about being named in a will or finding a house before it is offered on the market because a client is a realtor? How about accepting referrals from current clients? Is the counselor using the client for his or her own financial gain? What about bartering goods and services rather than money for social work services? I had a student who reported that her field instructor/supervisor was being “paid” for her social work services by receiving massages from her client who was a masseuse.
Freud contends that bartering can be an empowering equalizer, that the traditional distancing accepted in psychosocial counseling prohibits authenticity and keeps the client in a one-down position, as if they have nothing to give. Those with egalitarian practice perspectives may agree.
3. Emotional/dependency needs: Many of us are in the social work profession because we find it rewarding; it fills an emotional need. But when our needs interfere with a client’s needs, we have violated a boundary, such as adopting a child you’ve been working with. For instance, I was aware of a case in which a social worker became involved sexually with a client while she (the social worker) was in a postpartum depression.
4. Unintentional/unplanned relationships: These accidental crossings, particularly in small communities, are not inherently unethical but require skillful handling. Inadvertent situations—meeting a client in the grocery store or at the gym, attending a family gathering and realizing your cousin’s boyfriend is your client—are the ones in which we try to minimize risk to the client.
5. Altruism: The most common reason we enter into dual relationships is because we want to help: A client asks you to purchase wrapping paper for her daughter’s school fund-raiser; you give a client your old computer because she needs it for her studies; a client needs a ride home. Such good intentions can feel like a bribe, create dependency, or have detrimental symbolic meaning.
How to Decide
Factors to consider when deciding whether to enter into a second relationship include the following:
• 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?
Imagine different scenarios, hopefully with the help of a trusted colleague, and consider all the possible ramifications of changed relationships.
Cultural sensitivity may also influence the decision. Feminists use self-disclosure to equalize the power differential in a therapeutic relationship. Africentric approaches emphasize mutual aid that “it takes a village” to help. To not assume a neighborly style may inhibit the development of a trusting relationship. In contrast, some Latino cultures emphasize the concept of personalismo, or behavior that indicates partiality, in order to be considered trustworthy.
Contextual factors that have been addressed in the literature (Freud, 2002; Brownlee, 1996; Roberts, 1999) are as follows:
• 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?
Social work is a profession in which dual relationships are common because of the nature of the work and clients’ vulnerability. It is our responsibility to protect clients and demonstrate appropriate standards of care and boundaries. Handle each situation with the utmost professionalism. Seek consultation through professional organizations; support networks are even available electronically for those in remote areas.
— Claudia J. Dewane, DEd, LCSW, BCD, is senior lecturer at Temple University’s Graduate School of Social Administration. She is the founder of Clinical Support Associates, providing supervision, consultation, and training to professional social workers.
A Rural Model
Dual relationships have been found to be more prevalent in rural areas (Brownlee, 1996; Roberts, 1999). Gottlieb (as cited in Brownlee) developed a model for analyzing the appropriateness of a dual relationship in rural settings that can be applied to most social work settings. Using the critical dimensions of power, duration, and termination, the model recommends that social workers do the following:
• Assess the current and future relationship on the dimensions of power, duration, and termination.
• Determine the extent of role incompatibility.
• Seek consultation.
• Discuss the decision with clients in terms of possible ramifications.
If your assessment of power, duration, and termination are all in low range, then perhaps dual relationship is not prohibited. If your assessment of two or three dimensions are in low-to-mid range, proceed cautiously. If any of the assessed dimensions are in the high range, it is best to avoid.
Brownlee, K. (1996). Ethics in community mental health care: The ethics of non-sexual dual relationships: A dilemma for the rural mental health profession. Community Mental Health Journal, 32(5), 497-503.
Freud, S., & Krug, S. (2002). Beyond the code of ethics, part I: Complexities of ethical decision making in social work practice. Families in Society, 83(5), 474-482.
Freud, S., & Krug, S. (2002a). Beyond the code of ethics, part II: Dual relationships revisited. Families in Society, 83(5), 483-492.
Gottlieb, M. C. (1993). Avoiding exploitative dual relationships: A decision-making model. Psychotherapy, 30, 41-48.
Johner, R. (2006). Dual relationship legitimization and client self-determination. Journal of Social Work Values and Ethics, 3(1)
Mattison, M. (2000). Ethical decision-making: The person in the process. Social Work, 45(3).
Reamer, F. G. (2001). Tangled relationships: Managing boundary issues in the human services. New York: Columbia University Press.
Ringstad, R. (2008). The ethics of dual relationships: Beliefs and behaviors of clinical practitioners. Families in Society, 89(1), 69-77.
Roberts, L. W., Battaglia, J., & Epstein, R. S. (1999). Frontier ethics: Mental health care needs and ethical dilemmas in rural communities. Psychiatric Services, 50(4), 497-503.
Rothman, J., & Sager, J. (1998). From the front lines: Student cases in social work ethics. Allyn and Bacon.