Boundary issues in social work: managing dual relationships.
As the social work literature clearly demonstrates, ethical issues related to professional boundaries are among the most problematic and challenging (Congress, 1996; Jayaratne, Croxton, & Mattison, 1997; Kagle & Giebelhausen, 1994; Strom-Gottfried, 1999). Briefly, boundary issues involve circumstances in which social workers encounter actual or potential conflicts between their professional duties and their social, sexual, religious, or business relationships. As explored more fully later, not all boundary issues are necessarily problematic or unethical, but many are. The primary purpose of this discussion is to identify--in the form of a typology--the range of boundary issues in social work, develop criteria to help social workers distinguish between problematic and nonproblematic boundary issues, and present guidelines to help practitioners manage boundary issues and risks that arise in practice.
Boundary Issues in Social Work
Social workers--be they clinicians, community organizers, policymakers, supervisors, researchers, administrators, or educators--often encounter circumstances that pose actual or potential boundary issues. Boundary issues occur when social workers face possible conflicts of interest in the form of what have become known as dual or multiple relationships. Dual or multiple relationships occur when professionals engage with clients or colleagues in more than one relationship, whether social, sexual, religious, or business (St. Germaine, 1993, 1996). According to Kagle and Giebelhausen (1994),
a professional enters into a dual relationship whenever he or she assumes a second role with a client, becoming social worker and friend, employer, teacher, business associate, family member, or sex partner. A practitioner can engage in a dual relationship whether the second relationship begins before, during, or after the social worker relationship. (p. 213)
Dual relationships occur primarily between social workers and their current or former clients and between social workers and their colleagues (including supervisees and students).
The social work literature contains few indepth discussions of boundary issues (Jayaratne et al., 1997; Kagle & Giebeihausen, 1994; StromGottfried, 1999). Most discussions have focused on dual relationships that are exploitive in nature, such as social workers' sexual involvement with clients. Certainly these are important and compelling issues. However, many boundary and dual relationship issues in social work are subtler than these egregious forms of ethical misconduct. A recent empirical survey of a statewide sample of clinical social workers uncovered substantial disagreement concerning the appropriateness of behaviors such as developing friendships with clients, participating in social activities with clients, serving on community boards with clients, providing clients with one's home telephone number, accepting goods and services from clients instead of money, and discussing one's religious beliefs with clients (Jayaratne et al, 1997; see also Borys & Pope, 1989; Brownlee, 1996; Gutheil & Gabbard, 1993; Pope, Tabachnick, & Keith-Spiegel, 1988; Smith, 1999; Smith & Fitzpatrick, 1995; StromGottfried, 1999). As Corey and Herlihy (1997) noted:
The pendulum of controversy over dual relationships, which has produced extreme reactions on both sides, has slowed and now swings in a narrower arc. It is clear that not all dual relationships can be avoided, and it is equally clear that some types of dual relationships (such as sexual intimacies with clients) should always be avoided. In the middle range, it would be fruitful for professionals to continue to work to clarify the distinctions between dual relationships that we should try to avoid and those into which we might enter, with appropriate precautions. (p. 190)
To achieve a more fine-tuned understanding of boundary issues, social workers must broaden their analysis and examine dual relationships through several conceptual lenses. First, social workers should distinguish between boundary violations and boundary crossings (Gutheil & Gabbard, 1993; Smith & Fitzpatrick, 1995). A boundary violation occurs when a social worker engages in a dual relationship with a client or colleague that is exploitive, manipulative, deceptive, or coercive. Examples include social workers who become sexually involved with current clients, recruit and collude with clients to bill insurance companies fraudulently, or influence terminally ill clients to include social workers in clients' wills. Boundary violations are inherently unethical.
One key feature of boundary violations is a conflict of interest that harms clients or colleagues (Epstein, 1994; Kitchener, 1988; Kutchins, 1991; Pope, 1988, 1991). Conflicts of interest occur when professionals find themselves in "a situation in which regard for one duty leads to disregard of another or might reasonably be expected to do so" (Gifis, 1991, p. 88). Thus, a clinical social worker providing services to a client with whom he or she would like to develop a sexual relationship faces a potential conflict of interest; the social worker's personal interests clash with professional duty. Similarly, a community organizer who invests money in a client's business is embedded in a conflict of interest; the social worker's financial interests may clash with the social worker's professional duty to the client (for example, if the social worker's relationship with the client becomes strained because they disagree about some aspect of their shared business).
The concept of conflict of interest is addressed explicitly in the NASW Code of Ethics (2000):
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. (Standard 1.06[a])
The Code goes on to say that "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" (Standard 1.06[c]).
Some conflicts of interest involve what lawyers call undue influence. Undue influence occurs when a social worker inappropriately pressures or exercises authority over a susceptible client in a manner that benefits the social worker and may not be in the client's best interest. In legal terminology, undue influence involves the
exertion of improper influence and submission to the domination of the influencing party.... In such a case, the influencing party is said to have an unfair advantage over the other based, among other things, on real or apparent authority, knowledge of necessity or distress, or a fiduciary or confidential relationship. (Gifis, 1991, p. 508)
The NASW Code of Ethics also addresses the concept of undue influence: "Social workers should not take unfair advantage of any professional relationship or exploit others to further their personal, religious, political, or business interests" (Standard 1.06[b]).
In contrast, a boundary crossing occurs when a social worker is involved in a dual relationship with a client or colleague in a manner that is not intentionally exploitive, manipulative, deceptive, or coercive. Boundary crossings are not inherently unethical. In principle, the consequences of boundary crossings may be harmful, salutary, or neutral (Gutheil & Gabbard, 1993). Boundary crossings are harmful when the dual relationship has negative consequences for the social worker's client or colleague and, possibly, for the social worker as well. For example, a clinical social worker who discloses to a client personal, intimate details about his or her own life, ostensibly to be helpful to the client, ultimately may confuse the client and compromise the client's mental health because of complicated transference issues produced by the social worker's self-disclosure. A social work educator who accepts a student's dinner invitation may inadvertently harm the student by confusing the student about the nature of t he social work educator's relationship. A social work administrator whose family vacations with an employee and his or her family may have difficulty managing future personnel problems involving that employee.
Alternatively, some boundary crossings may be helpful to clients and colleagues. Some social workers argue that, handled judiciously, a clinical social worker's modest self-disclosure or decision to accept an invitation to attend a client's graduation ceremony may prove, in some special circumstances, to be therapeutically useful to a client (Anderson & Mandell, 1989; Chapman, 1997; Reamer, 1997, 1998a). A social worker at a community mental health center who worships, coincidentally, at the same church a client attends may help the client "normalize" the professional--client relationship. A social work educator who hires a student to serve as a research assistant may boost the student's self-confidence in a way that greatly enriches the student's educational experience.
Yet, other boundary crossings produce mixed results. A social worker's self-disclosure about personal challenges may be both helpful and harmful to the same client--helpful in that the client feels more connected" to the social worker and harmful in that the self-disclosure undermines the client's confidence in the social worker. The social work administrator of a residential substance abuse treatment program who hires a former client may initially elevate the former client's self-confidence and create boundary problems when the former client subsequently wants to resume the status of an active client following a relapse.
In light of the impressive range of boundary issues in the profession, it is important for social workers to have access to a conceptual framework to help them identify and manage the dual relationships they encounter. What follows is a typology of boundary issues in social work, based on several data sources: insurance industry statistics summarizing malpractice and negligence claims; empirical surveys of social workers and other professionals about boundary issues; legal literature and court opinions in litigation involving boundaries; and my experiences as chair of a statewide ethics adjudication committee and expert witness in a large number of legal cases involving boundary issues (Reamer, 2001a).
Boundary issues in social work can be placed into five conceptual categories revolving around five central themes pertaining to social workers: (1) intimate relationships, (2) pursuit of personal benefit, (3) emotional and dependency needs, (4) altruistic gestures, and (5) responses to unanticipated circumstances (see Table 1).
Many dual relationships in social work involve some form of intimacy. Typically these relationships entail a sexual relationship or physical contact, although they may also entail other intimate gestures, such as gift giving, friendship, and affectionate communication.
Sexual Relationships. A significant portion of intimate dual relationships entered into by social workers involves sexual contact (Akamatsu, 1988; American Psychological Association, 1989; Bouhoutsos, 1985; Bouhoutsos, Kolroyd, Lerman, Foster, & Greenberg, 1983; Coleman & Schaefer, 1986; Feldman-Summers & Jones, 1984; Gabbard, 1989; Gechtman, 1989; Pope, 1990; Pope & Bouhoutsos, 1986; Reamer, 1984, 1992, 1994; Sell, Gottlieb, & Schoenfeld, 1986). During a recent 20-year period, nearly one in five lawsuits (18.5 percent) against social workers insured through the malpractice insurance program sponsored by the NASW Insurance Trust alleged some form of sexual impropriety, and more than two-fifths (41.3 percent) of insurance payments were the result of claims concerning sexual misconduct (Reamer, 1995b). According to research evidence gathered by Brodsky (1986), the prototypical therapist sued for sexual misconduct is male, middle aged, involved in unsatisfactory relationships in his own life, provides counseling to a mostly female caseload, becomes sexually involved with multiple clients who are many years younger, discloses his personal problems to the clients with whom he is sexually involved, is lonely, and is isolated professionally. Of course, there are many documented cases involving female practitioners as well, albeit a much smaller number proportionately.
Sexual misconduct in the helping professions generally is a significant problem. National data suggest that between 8.0 percent and 12.0 percent of male counselors or psychotherapists and between 1.7 percent and 3.0 percent of female counselors or psychotherapists admit having had sexual relationships with current or former clients (Olarte, 1997). Insurance industry data suggest that inappropriate dual relationships in the form of sexual misconduct constitute the most frequent reason for lawsuits filed against mental health professionals (Reamer, 1994).
Although social workers generally agree that sexual relationships with current clients are inappropriate (NASW, 2000, Standard 1.09[a]), there is less clarity about social workers' sexual relationships with former clients. The Code of Ethics states clearly that, in general, sexual relationships with former clients are unethical: "Social workers should not engage in sexual activities or sexual contact with former clients because of the potential for harm to the client" (Standard 1.09[c]). However, in this same standard the Code also implies that exceptions may be warranted under extraordinary circumstances, for example, when the social worker is involved in a nonclinical relationship with 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. (Standard l.09[c])
Current ethical standards also prohibit social workers from engaging 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 clients. As the code asserts:
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. (Standard 1.09[b])
NASW's Code of Ethics (NASW, 2000) also contains standards that explicitly prohibit sexual relationships between social work supervisors or educators and supervisees, students, trainees, and other colleagues over whom they exercise professional authority (Standard 2.07[a]). In addition, the Code stipulates that social workers should avoid engaging in sexual relationships with professional colleagues when there is a potential for conflicts of interest (Standard 2.07[b]).
The profession's ethical standards are less clear with respect to nonclinical relationships that do not involve possible exploitation of authority. Social workers need to examine the unique circumstances surrounding intimate relationships between, for example, community organizers and community residents, or between social work researchers (program evaluators) and their clients (agency administrators), to determine whether they constitute a boundary violation that may lead to significant harm.
Physical Contact. Not all physical contact between social workers and clients is sexual in nature. Physical contact may be nonsexual and appropriate in a number of circumstances, for example, a brief hug at the termination of long-term treatment or placing one's arm around a distraught client in a residential program who just received bad family news. Such brief, limited physical contact is not likely to be harmful; many clients would 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). As Smith and Fitzpatrick (1995) observed:
There are also cultural factors to be considered. For example, in Montreal where the dominant culture is French--Canadian, kissing on both cheeks is a widely practiced greeting among friends and even casual acquaintances. When it occurs between a therapist and client (as it sometimes does on special occasions), it does not carry the erotically charged meaning it might elsewhere in North America. (pp. 502-503)
In contrast are situations involving physical touch that have more potential for psychological harm. In clinical relationships, physical touch may exacerbate a client's transference in destructive ways and may suggest that the social worker is interested in more than a professional relationship--for example, a clinical social worker provided counseling to a 28-year-old woman who had been sexually abused as a child. As an adult, the client sought counseling to help her understand the impact of the early victimization, especially pertaining to her intimate relationships. As part of the therapy, the social worker would occasionally dim the office lights, turn on soft music, and sit on the floor while cradling and talking with the client. In nonclinical relationships, too, physical touch may cause psychological harm. An example involved a social work administrator in a psychiatric hospital who was fired after evidence demonstrated that he sexually harassed two social workers on his staff in the form of inappropri ate physical contact in the workplace.
For the first time in the history of the social work profession, the current NASW Code of Ethics (NASW, 2000) includes a standard pertaining specifically to the concept of physical touch:
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. (Standard 1.10)
Counseling a Former Lover. Providing clinical services to someone with whom the social worker was once intimately, romantically, or sexually involved also constitutes a dual relationship. The relationship history is likely to make it difficult for the social worker and client to interact with each other solely as professional and client; inevitably the dynamics of the prior relationship will influence the professional--client relationship--how the parties view and respond to each other possibly in ways that are detrimental to the client's best interests. The Code of Ethics comments on this phenomenon:
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. (Standard 1.09[d])
Intimate Gestures. Boundary issues can also emerge when social workers and clients or colleagues engage in other intimate gestures, such as gift giving and expressions of friendship (including sending affectionate notes, for example, on the social worker's personal stationery). It is not unusual for clients to give social workers a modest gift. Certainly, in many instances a client's gift represents nothing more than an appreciative gesture. In some instances, however, a client's gift may carry great meaning. For example, the gift may reflect the client's fantasies about a friendship or more intimate relationship with the social worker. Thus, it behooves social workers to consider carefully the meaning of clients' gifts and establish prudent guidelines governing the acceptance of gifts. Similarly, gifts from a social work supervisor to a supervisee might be interpreted as evidence of favoritism, which may damage other employees' morale and pose a conflict for the supervisor when she must conduct personnel eva luations.
In many social services settings--such as family services agencies, community mental health centers, hospitals, rehabilitation facilities, schools, and public human services departments-staff are not permitted to accept gifts because of a potential conflict of interest or appearance of impropriety or are permitted to accept gifts only of modest value. Some agencies permit staff to accept gifts only with the understanding--which is conveyed to clients--that the gifts represent a contribution to the agency, not to the individual social worker.
There is consensus among social workers that friendships with current clients constitute an inappropriate dual relationship. There is less clarity, however, about friendships between social workers and former clients. Although social workers generally understand the risk involved in befriending a former client-due to the possibility of confused boundaries--some social workers argue that friendships with former clients are not inherently unethical and reflect a more egalitarian, nonhierarchical approach to practice. These social workers typically claim that emotionally mature social workers and former clients are quite capable of entering into new kinds of relationships following termination of the professional--client relationship and that such new relationships often are, in fact, evidence of the former client's substantial therapeutic progress.
Social workers involved in nonclinical relationships--such as social work researchers or community organizers--may argue that strict prohibition of relationships with former clients should not automatically apply to them. Again, social workers may need to examine critically the unique circumstances involved to determine the nature and extent of conflicts of interest and potential harm.
Beyond these various manifestations of intimacy, social workers can become involved in dual relationships that produce other forms of personal benefit. The personal benefit to the social worker may take the form of monetary gain, goods, services, or useful information.
Monetary Gain. In some situations social workers stand to benefit financially because of a dual relationship (Bonosky, 1995). In one case, the former client of a social worker in private practice decided to change careers and become a social worker. After graduating from social work school, the former client contacted the social worker for supervision (such supervision was required for a state license). The social worker was tempted to provide the client with supervision for a fee, in part because the social worker enjoyed their relationship and in part because of the financial benefit. The social worker also recognized that the shift in relationship from social worker--client to collegial would introduce a number of boundary issues. In another case, a client in a substance abuse program named the social worker in his will. Following the client's death and probate of the will, the client's family accused the social worker of undue influence (the family alleged that the social worker encouraged the client to b equeath a portion of the client's estate to the social worker and that the client was not mentally competent).
Goods and Services. On occasion social workers receive goods or services--rather than money--as payment for their professional services. In one case, a clinical social worker's client lost his insurance coverage, yet still needed counseling services. The client, a house painter, offered to paint the social worker's home in exchange for clinical services. The social worker decided not to enter into the barter arrangement; after consulting with colleagues the social worker realized that the client's interests could be undermined should some problem emerge with the paint job that would require some remedy or negotiation (for example, if the paint job proved to be inferior in some way). In another case, a social worker who worked as a geriatric consultant received several paintings from a client--an artist--as payment for services rendered. This social worker reasoned that accepting "goods" of this sort was not likely to undermine the professional--client relationship, whereas accepting a service might.
In 1996 NASW included, for the first time, a specific standard on barter. The NASW Code of Ethics Revision Committee struggled to decide whether to prohibit or merely discourage all forms of barter (Reamer, 1998a). On the one hand, bartering entails potential conflicts of interest; on the other hand, bartering is an accepted practice in some communities (Schank & Skovholt, 1997; Woody, 1998). Ultimately the committee decided to discourage barter because of the risks involved, at the same time recognizing that barter is not inherently unethical. Further, the Code establishes strict standards for the use of barter by social workers:
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. [italics added] (Standard 1.13 [b])
Useful Information. Social workers occasionally have an opportunity to benefit from clients' unique knowledge. A social worker with a complex health problem may be tempted to consult a client who is a physician and who happens to specialize in the area relevant to the social worker's illness. A social worker who is interested in adopting a child, and whose client is an obstetrics/gynecology nurse, may be tempted to talk to her client about adoption opportunities through the client's hospital. A social work administrator who is an active stock market investor may be tempted to consult one of the agency's clients who happens to be a stockbroker. A social worker with automobile problems may be tempted to consult a client who happens to be an automobile mechanic. In these situations there is clearly the potential for an inappropriate dual relationship, where a social worker engages with the client in a self-serving manner and where a social worker's judgment and services may be shaped and influenced by his or her access to a client's specialized knowledge. Conversely, relatively brief, casual, and non-exploitive conversations with clients concerning topics on which clients are expert may empower clients, facilitate therapeutic progress and the delivery of both clinical and nonclinical services, and challenge traditionally hierarchical relationships between social workers and clients.
Emotional and Dependency Needs
A number of boundary issues arise out of social workers' efforts to address their own emotional needs. Many of these issues are subtle in nature and some are more glaring and egregious. Among the more egregious are the following examples:
The administrator of a state child welfare agency that serves abused and neglected children was having difficulty coping with his failing marriage. He was feeling isolated and depressed. The administrator was arrested on the basis of evidence that he developed a sexual relationship with a 16-year-old boy who was in the department's custody and used illegal drugs with the boy.
A social worker in a private psychiatric hospital provided counseling to a resident who was diagnosed with paranoid schizophrenia. The social worker, who was religiously observant, began to read biblical passages to the client in the context of counseling sessions. The client was not religiously observant and complained to other hospital staff about the social worker's conduct.
A clinical social worker in private practice provided counseling to a 42-year-old woman who had been sexually abused as a child. During the course of their relationship the social worker invited the client home for several candlelight dinners, went on a camping trip with the client, gave the client several expensive gifts, and wrote the client several very affectionately worded notes on personal stationery.
A social worker in a public child welfare agency was responsible for licensing foster homes. The social worker, who was recently divorced, became very friendly with a couple who had applied to be foster parents and also became very involved in the foster parents' church. The social worker, who approved the couple's application and was responsible for monitoring the foster home placement in the couples' home, moved with her son into a mobile home on the foster parents' large farm.
A social work supervisor who was socially isolated in his personal life spent an inordinate amount of time supervising one staff member with whom he felt a special bond.
In contrast, some boundary issues are subtler. Examples include social workers whose clients invite them to attend important life cycle events (such as clients' weddings or graduations, or key religious ceremonies), social workers who conduct home visits and whose clients invite them to sit-down meals being served at the time of the visits, and social workers who themselves are in recovery and encounter clients or supervisees at Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) meetings. In these situations social workers sometimes disagree about the most appropriate way to handle boundary issues (Doyle, 1997). For example, some social workers are adamantly opposed to attending clients' life cycle events because of potential boundary problems (for example, the possibility that a client might interpret the gesture as an indication of the social worker's interest in a social relationship or friendship); others, however, believe that attending such events can be ethically appropriate and, in fact, therapeuti cally helpful as long as the clinical dynamics are handled skillfully. Some social workers believe that practitioners in recovery should never attend or participate in AA or NA meetings where clients or colleagues are present, because of the difficulty clients and colleagues may have reconciling social workers' professional roles and personal lives. Others, however, argue that recovering social workers have a right to meet their own needs and can serve as compelling role models to clients and colleagues in recovery.
Some boundary issues and dual relationships arise out of social workers' genuine efforts to be helpful. Unlike social workers' involvement in sexual relationships or dual relationships that are intentionally self-serving, altruistic gestures are benevolently motivated. Although these dual relationships are not necessarily unethical, they do require careful management using the protocol discussed later.
A social worker in private practice was contacted by a long-standing friend who was in the midst of a marital crisis. The friend told the social worker that she and her husband "really trust" the social worker and want the social worker's professional help. The social worker agreed to see the couple professionally, but later realized that it was very hard for him to be objective.
A social worker in a family services agency provided casework services to a client who had a substance abuse problem. The client asked the social worker if she would like to purchase wrapping paper that the client's daughter was selling as a school fundraiser.
A social worker in a community mental health center provided counseling over a long period to a young man with a history of clinical depression. The client asked the social worker if he would "say a few words" during the ceremony at the client's upcoming wedding.
A school social worker in a small rural community provided counseling services to a 10-year-old boy who struggled with self-esteem issues. In his spare time, the social worker coached the community's only basketball team, which was unaffiliated with the school. The social worker believed that the boy would benefit from joining his basketball team (for example, by developing social skills and new relationships).
The final category of boundary issues involves situations that social workers do not anticipate and over which they have little or no initial control. The challenge for social workers in these circumstances is to manage boundary issues in ways that minimize possible harm to clients and colleagues.
A social worker in private practice attended a family holiday gathering. The social worker's sister introduced him to her new boyfriend, who is the social worker's former client.
The client of a clinical social worker in a rural community was a grade school teacher. Because of an unexpected administrative decision, the client became the teacher in the classroom in which the social worker's child is a student.
A social work administrator in a community mental health center joined a local physical fitness club. During one of her visits, the social worker discovered that one of her clients is also an active member of the club.
Managing Dual Relationships
To manage boundary issues effectively, social workers must develop a clear understanding of what distinguishes ethical and unethical dual relationships. A dual relationship is unethical when it has several characteristics (Corey & Herlihy, 1997; Epstein, 1994; NASW, 2000; Reamer, 1998a, 2001b), such as that the relationship is likely to
* interfere with the social worker's exercise of professional discretion
* interfere with the social worker's exercise of impartial judgment
* exploit clients, colleagues, or third parties to further the social worker's personal interests
* harm clients, colleagues, or third parties.
Social workers must be especially careful to consider how cultural and ethnic norms are relevant to boundary issues (see NASW, 2000, Standard 1.05; see also Lee & Kurilla, 1997; Pinderhughes, 1994). For example, a social worker who conducts home visits may be reluctant to accept a family member's invitation to join the family for a meal, but may agree to have crackers and a nonalcoholic beverage so as not to violate the family's deep-seated ethnic norms related to offering food to guests. Similar issues may arise related to social workers' attending family life cycle events. A pregnant community organizer may need to be very tactful when residents of a largely ethnic community invite the social worker to a neighborhood-sponsored shower held in her behalf. The social worker would need to think through the implications of attending the event and accepting gifts. As the NASW Code of Ethics (2000) states,
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. [italics added] (Standard 1.06[c])
To protect clients and minimize possible harm--and to minimize the possibility of ethics complaints and lawsuits that allege misconduct or professional negligence--social workers should establish clear "risk management" criteria and procedures. 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.
First, social workers should always be vigilant in their efforts to be alert to potential or actual conflicts of interest in their relationships with clients and colleagues. Social workers should be cognizant of "red flags" that may signal a boundary problem. For example, clinical social workers should be wary of situations in which they find themselves attracted to a particular client, going out of their way to extend the client's counseling sessions (facilitated by scheduling the favored client at the end of the day), treating the client as someone "special," disclosing confidential information about other clients, acting impulsively in relation to the client, allowing the client to accumulate a large unpaid bill, and disclosing very personal details to the client (Simon, 1999). Similarly, nonclinical social workers (for example, administrators, researchers, community organizers) should be alert to comparable warning signs, such as granting extraordinary special favors to clients or colleagues and granting unprecedented exceptions to clients or colleagues who have not fulfilled contractual agreements.
Second, social workers should inform clients and appropriate colleagues when they encounter boundary issues, including actual or potential conflicts of interest, and explore reasonable remedies. Third, social workers should consult colleagues and supervisors; relevant professional literature, regulations, and policies; and ethical standards (relevant codes of ethics) to identify pertinent boundary issues and constructive options. Special care should be taken in high-risk circumstances. For example, clinical social workers who attempt to make decisions about a possible friendship with a former client should consider prevailing ethical standards that take into consideration such factors as the amount of time that has passed since the termination of the professional--client relationship; the extent to which the former client is mentally competent and emotionally stable; the issues addressed in the professional--client relationship; the length of the professional--client relationship; the circumstances surroundin g the termination of the professional--client relationship; the amount of influence the social worker has in the client's life; available, reasonable alternatives; and the extent to which there is foreseeable harm to the former client or others as a result of the new relationship (Ebert, 1997; Reamer, 1998a).
Fourth, social workers should design a plan of action that addresses the boundary issues and protects clients, colleagues, and third parties to the greatest extent possible. In some circumstances, protecting a client's interests may require termination of the professional relationship with proper referral of the client. It is particularly useful for social workers to imagine how a thoughtful panel of peers in the profession would perceive their course of action. Fifth, social workers should document all discussions, consultations, supervision, and other steps taken to address boundary issues (for example, consultation with colleagues or supervisors about whether to accept a client's invitation to attend a life cycle event or terminated services to a client when conflict of interest issues arise). Finally, social workers should develop a strategy to monitor the implementation of their action plan, for example, by periodically assessing with relevant parties (clients, colleagues, supervisors, and lawyers) wheth er the strategy minimized or eliminated the boundary problems.
To promote practitioners' actual implementation of this protocol, social workers can sponsor staff training and continuing education workshops. In addition to presenting conceptual content related to boundary issues and dual relationships, such workshops can role-play realistic cases scenarios to enchance social workers' ability to protect clients, colleagues, and third parties, and to reduce risk.
There is no question that social workers have developed a richer, more nuanced understanding of boundary issues in the profession. To further enhance this understanding, social workers must examine dual relationships that are exploitive in nature and those that are more ambiguous. Practitioners' firm grasp of boundary issues involving their intimate relationships with clients and colleagues, responses to their own emotional and dependency needs, pursuits of personal benefits, altruistic gestures, and responses to unanticipated circumstances with increase their ability to protect clients, colleagues, and themselves. Most important, skillful management of boundary issues enhances social work's ethical integrity, one of the key hallmarks of a profession.
Table 1 Central Themes in Dual Relationships Intimate relationships: sexual relationships physical contact services to former lover intimate gestures Personal benefit: monetary gain goods and services useful information Emotional and dependency extending relationship with clients needs: promoting client dependence confusing personal and professional lives reversing roles with clients Altruistic gestures: performing favors providing nonprofessional services giving gifts being extraordinarily available Unanticipated social and community events circumstances: joint affiliations and memberships mutual acquaintances and friends
Original manuscript received July 2, 1999
Final revision received October 27, 1999
Accepted November 29, 1999
Akamatsu, T. J. (1988). Intimate relationships with former clients: National survey of attitudes and behavior among practitioners. Professional Psychology: Research and Practice, 19, 454-458.
American Psychological Association, Committee on Women in Psychology. (1989). If sex enters into the psychotherapy relationship. Professional Psychology: Research and Practice, 20, 112-115.
Anderson, S., & Mandell, D. (1989). The use of self-disclosure by professional social workers. Social Casework, 70, 259-267.
Berliner, A. K. (1989). Misconduct in social work practice [Briefly Stated]. Social Work, 34, 69-72.
Besharov, D. J. (1985). The vulnerable social worker. Silver Spring, MD: National Association of Social Workers.
Bonosky, N. (1995). Boundary violations in social work supervision: Clinical, educational and legal implications. Clinical Supervisor, 13, 79-95.
Borys, D. S., & Pope, K. S. (1989). Dual relationships between therapists and clients: National study of psychologists, psychiatrists and social workers. Professional Psychology: Research and Practice, 20, 283-293.
Bouhoutsos, J. (1985). Therapist--client sexual involvement: A challenge for mental health professionals. American Journal of Orthopsychiatry, 55, 177-182.
Bouhoutsos, J., Kolroyd, J., Lerman, H., Foster, B. R., & Greenberg, M. (1983). Sexual intimacy between psychotherapists and patients. Professional Psychology: Research and Practice, 14, 185-196.
Brodsky, A. M. (1986). The distressed psychologist: Sexual intimacies and exploitation. In R. R. Kilburg, P. E. Nathan, & R. W. Thoreson (Eds.), Professionals in distress: Issues, syndromes, and solutions in psychology (p. 153-171). Washington, DC: American Psychological Association.
Brownlee, K. (1996). The ethics of non-sexual dual relationships: A dilemma for the rural mental health professional. Community Mental Health Journal, 32, 497-503.
Chapman, C. (1997). Dual relationships in substance abuse treatment. Alcohol Treatment Quarterly, 15, 73-79.
Coleman, B., & Schaefer, S. (1986). Boundaries of sex and intimacy between client and counselor. Journal of Counseling and Development, 64, 341-344.
Congress, B. P. (1996). Dual relationships in academia: Dilemmas for social work educators. Journal of Social Work Education, 32, 329-338.
Corey, G., & Herlihy, B. (1997). Dual/multiple relationships: Toward a consensus of thinking. In Hatherleigh Editorial Board (Ed.), The Hatherleigh guide to ethics in therapy (pp. 183-194). New York: Hatherleigh Press.
Doyle, K. (1997). Substance abuse counselors in recovery: Implications for the ethical issue of dual relationships. Journal of Counseling and Development, 75, 428-432.
Ebert, B. W. (1997). Dual-relationship prohibitions: A concept whose time never should have come. Applied & Preventive Psychology, 6, 137-156.
Epstein, R. (1994). Keeping boundaries: Maintaining safety and integrity in the psychotherapeutic process. Washington, DC: American Psychiatric Press.
Feldman-Summers, S., & Jones, G. (1984). Psychological impacts of sexual contact between therapists or other health care practitioners and their clients. Journal of Consulting and Clinical Psychology, 52, 1054-1061.
Gabbard, G. (Ed.). (1989). Sexual exploitation in professional relationships. Washington, DC: American Psychiatric Press.
Gechtman, L. (1989). Sexual contact between social workers and their clients. In G. Gabbard (Ed.), Sexual exploitation in professional relationships (pp. 27-38). Washington, DC: American Psychiatric Press.
Gifis, S. H. (Ed.). (1991). Law dictionary (3rd ed.). Happauge, NY: Barron.
Gutheil, T. G., & Gabbard, G. O. (1993). The concept of boundaries in clinical practice: Theoretical and risk-management dimensions. American Journal of Psychiatry, 150, 188-196.
Jayaratne, S., Croxton, T., & Mattison, D. (1997). Social work professional standards: An exploratory study. Social Work, 42, 187-199.
Kagle, J. D., & Giebelhausen, P. N. (1994). Dual relationships and professional boundaries. Social Work, 39, 213-220.
Kitchener, K. S. (1988). Dual role relationships: What makes them so problematic? Journal of Counseling and Development, 67, 217-221.
Kutchins, H. (1991). The fiduciary relationship: The legal basis for social workers' responsibilities to clients. Social Work, 36, 106-113.
Lee, C. C., & Kurilla, V. (1997). Ethics and multiculturalism: The challenge of diversity. In Hatherleigh Editorial Board (Ed.), The Hatherleigh guide to ethics in therapy (pp. 235-248). New York: Hatherleigh Press.
Levy, C. S. (1993). Social work ethics on the line. New York: Haworth Press.
Linzer, N. L. (1999). Resolving ethical dilemmas in social work practice. Boston: Allyn & Bacon.
Loewenberg, F., & Dolgoff, R. (1996). Ethical decisions for social work practice (5th ed.). Itasca, IL: F. E. Peacock.
National Association of Social Workers. (2000). Code of ethics of the National Association of Social Workers. Washington, DC: Author.
Olarte, S.W. (1997). Sexual boundary violations. In Hatherleigh Editorial Board (Ed.), The Hatherleigh guide to ethics in therapy (pp. 195-209). New York: Hatherleigh Press.
Pinderhughes, E. (1994). Diversity and populations at risk: Ethnic minorities and people of color. In F. G. Reamer (Ed.), The foundations of social work knowledge (pp. 264-308). New York: Columbia University Press.
Pope, K. S. (1988). Dual relationships: A source of ethical, legal and chemical problems. Independent Practitioner, 8, 17-25.
Pope, K. S. (1990). Abuse of psychotherapy Psychotherapist-patient intimacy. Psychotherapy and Psychosomatics, 53, 191-198.
Pope, K. S. (1991). Dual relationships in psychotherapy. Ethics and Behavior, 1, 21-34.
Pope, K., & Bouhoutsos, J. (1986). Sexual intimacy between therapists and patients. New York: Praeger.
Pope, K., Tabachnick, B., & Keith-Spiegel, P. (1988). Good and bad practice in psychotherapy: National survey of beliefs of psychologists. Professional Psychology, 19, 547-552.
Reamer, F. G. (1982). Conflicts of professional duty in social work. Social Casework, 63, 579-585.
Reamer, F. G. (1984). Enforcing ethics in social work. Health Matrix, 2, 17-25.
Reamer, F. G. (1990). Ethical dilemmas in social service (2nd ed.). New York: Columbia University Press.
Reamer, F. G. (1992). The impaired social worker. Social Work, 37, 165-170.
Reamer, F. G. (1994). Social work malpractice and liability. New York: Columbia University Press.
Reamer, F. G. (1995a). Ethics and values. In R. L. Edwards (Ed.-in-Chief), Encyclopedia of social work (19th ed., Vol. 1, pp. 893-902). Washington, DC: NASW Press.
Reamer, F. G. (1995b). Malpractice claims against social workers: First facts. Social Work, 40, 595-601.
Reamer, F. G. (1997). Ethical standards in social work: The NASW Code of Ethics. In R. L. Edwards (Ed,-in-Chief), Encyclopedia of social work (19th ed., Suppl., pp. 113-123). Washington, DC: NASW Press.
Reamer, F. G. (1998a). Ethical standards in social work: A critical review of the NASW Code of Ethics. Washington, DC: NASW Press.
Reamer, F. G. (1998b). The evolution of social work ethics. Social Work, 43, 488-500.
Reamer, F. G. (1999). Social work values and ethics (2nd ed.). New York: Columbia University Press.
Reamer, F. G. (2001a). Tangled relationships: Managing boundary issues in the human services. New York: Columbia University Press.
Reamer, F. G. (2001b). The social work ethics audit: A risk management tool. Washington, DC: NASW Press.
Rhodes, M. L. (1986). Ethical dilemmas in social work practice. Boston: Routledge & Kegan Paul.
Schank, J. A., & Skovholt, T. M. (1997). Dual relationship dilemmas of rural and small-community psychologists. Professional Psychology: Research and Practice, 28, 44-49.
Sell, J., Gottlieb, M., & Schoenfeld, L. (1986). Ethical considerations of social/romantic relationships with present and former clients. Professional Psychology: Research and Practice, 17, 504-508.
Simon, R. I. (1999). Therapist-patient sex: From boundary violations to sexual misconduct. Forensic Psychiatry, 22, 31-47.
Smith, D., & Fitzpatrick, M. (1995). Patient-therapist boundary issues: An integrative review of theory and research. Professional Psychology: Research and Practice, 26, 499-506.
Smith, J. (1999). Holding the dance: A flexible approach to boundaries in general practice. In J. Lees (Ed.), Clinical counseling in primary care (pp. 43-60). New York: Routledge.
Stake, J. E., & Oliver, J. (1991). Sexual contact and touching between therapist and client: A survey of psychologists' attitudes and behavior. Professional Psychology: Research and Practice, 22, 297-307.
St. Germaine, J. (1993). Dual relationships: What's wrong with them? American Counselor, 2, 25-30.
St. Germaine, J. (1996). Dual relationships and certified alcohol and drug counselors: A national study of ethical beliefs and behaviors. Alcoholism Treatment Quarterly, 14, 29-44.
Strom-Gottfried, K. (1999). Professional boundaries: An analysis of violations by social workers. Families in Society, 80, 439-449.
Woody, R. H. (1998). Bartering for psychological services. Professional Psychology: Research and Practice, 29, 174-178.
Frederic G. Reamer, PhD, is professor, School of Social Work, Rhode Island College, Providence, RI 02908; e-mail: email@example.com.
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|Author:||Reamer, Frederic G.|
|Date:||Jan 1, 2003|
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