Podsocs - podcasts for social workers

Transcription Podsocs 32: Boundary Issues and Ethics: In Conversation with Frederic Reamer

Thank you to Rachel Rohde for this transcription

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Hello, and welcome to Podsocs, the podcast for social workers on the run. Brought to you by a bunch of social workers from Griffith University in Australia.
I’m Tricia Fronek, one of that bunch, and we’re just basically really glad you found us. So, happy listening.

Tricia: Now we’re very happy to welcome Frederic Reamer to Podsocs today, Welcome. Welcome Ric.

Frederic: My pleasure to be with you.

Tricia: Now, Ric, today we are going to talk about social work, human service practice and ethics and some of the issues that arise in practice. How did you first get interested in this area?

Frederic: I became a social worker in the 1970’s and I had no intention on focusing on ethical issues. My primary interest was criminal justice and continues to be a strong interest of mine. I had worked in prisons for a number of years. I continued to work in prisons approximately one day a week and when I was a doctoral student at the University of Chicago in the 1970s. This was around 1976 I discovered that in my work in prisons I was encountering a wide range of challenging ethical issues and realised that I had not received much training and I took some time to look at the literature in social work with regard to ethical issues. In those days that meant going to a card catalogue, may it rest in peace.

Tricia: (Chuckles)

Frederic: Going to the abstract that were actually in book form on shelves, having to going into the library we call them stacks looking for journal articles, of course, this is now this is mostly electronic and I quickly discovered that there was very, very little scholarship on ethical issues in social work which puzzled me because I had been doing some reading about the emergence of the field of bio-ethics, ethics in health care, ethics in medicine which students of ethics know blossomed in 1970’s. And I was at the University of Chicago at the time. There was a small group of medical ethicists, bioethicists there and I sought them out to explore the possible connections between what was then called applied ethics and social work, and I developed a couple of very nice relationship with scholars at the University of Chicago. I still had some course work to complete at the university and in addition to my social work courses I took a number of doctoral level courses in the moral philosophy department and my primary goal was to try to draw connections between moral theory and social work, between this emerging field of applied, or practical ethics and social work and it was a very lonely enterprise because there were very, very few social workers at the time who had any interest in this. And as I said a moment ago there was virtually no scholarship, so that’s what started me on this ahh journey which all these years later continues to be a passion of mine. I am stunned by the complexity of the issues I continue to encounter and, and perhaps we’ll explore these later, issues that I never dreamed possible back in those years. Today, for example, I am involved in many cases involving social workers use of digital and electronic technology, social media, social networking, the ethical issues that have emerged are very complex and back in the 1970’s none of this existed of course and it’s quite humbling. My ability to forecast these issues back then was quite limited and umm it gives me pause now, who knows what issues we will face in years to come.

Tricia: So Ric, what sought of issues are arising with social media?

Frederic: Well their quite complex and wide ranging, so for example I have been an expert witness, that’s what we call it in the United States when a professional is subpoenaed to testify in legal proceedings whether it’s a licencing board hearing or a court case where there is litigation. I’ve been an expert witness in a number of cases now where practitioners use of digital and electronic technology has been the focus of attention. For example, clinicians who offer counselling services, psychotherapy, using email, using video conferencing, using what is called avatar therapy or cyber therapy and they never meet the client. The client may live a great distance away and there are now some ethical issues emerging having to do with confidentiality issues, informed consent issues, even boundary issues.

I recently testified in a case on the west coast of the United States, where a social worker used his personal email account to communicate with a client. The social worker sent her poetry that the social worker had written and I had to testify about the ethical implications of using one’s personal email account to communicate with a client, particularly when the email exchange is occurring very late at night outside of work hours. This is a case where the client became very confused about the boundaries and the social worker ultimately was sanctioned by the licensing board because of his inability to address ethical issues related to boundaries, dual relationships and so forth. Just about 5 weeks ago I testified in another case, another licensing board case in a different state in the United States and a social worker had a complaint filed against her by a client. They had extensive contact on Facebook. The clinical relationship deteriorated and the former client claimed that she became very confused about the nature of her relationship with the social worker. The client had access to a great deal of personal information about the social worker, knew about her political views, her sexual orientation, she was able to see photographs of the clinician and in my testimony in this case I had to comment on the boundary issues associated with social networking. In addition I have consulted on cases in recent months, I cannot even say recent years because so many of these digital and electronic tools are relatively new.

In recent months I’ve also consulted on cases where social workers have used very novel and somewhat controversial electronic tools to provide psychotherapy so, for example, there are websites where individuals who live great distances from a social worker can engage with a social worker who agrees to provide email therapy. They never talk on the phone. They don’t use video conferencing. The client buys a package of email exchanges and they engage in discussion about relationship issues or depression or anxiety, addictions, what have you. A number of states in the United States’ licensing boards are developing regulations that require social workers who provide services electronically to be licensed in their particular jurisdiction even though the social worker may live in another jurisdiction a great distance away.

So social networking, email, text messaging, the complexity, the wide range of uses I’m now seeing is overwhelming and one of the challenges is we don’t have very carefully formed ethical standards or regulations governing social workers’ use of this technology. In some ways we are building a boat in the middle of a rushing stream.

Tricia: Ric, why are these boundaries so important in practice?

Frederic: Well boundaries in general we know are important because if they are not managed well, clients can be harmed. I mean that’s the bottom line, and in some of my recent work I have developed a typology of boundary and dual relationship issues that I think are critically important in social work. So they include some of the challenges we are encountering with social workers’ use of digital and electronic technology. We know that these boundary challenges have been around since social work was invented in the late 19th Century so, for example, in this typology that I developed I present 5 different themes. Some boundary issues have to do with what I call intimacy. Social workers who become involved in a sexual relationship with a former client. A social worker who becomes a very close friend of a client where there’s an intimate element even if it’s not sexual. Social workers who self-disclose intimate information to clients or former clients where there’s an element of intimacy. If those boundaries aren’t handled well that can undermine the quality of care that clients receive their therapeutic progress and so on.

A second theme that I focus on in this typology that I developed has to do with what I call emotional and dependency needs. I know that’s a mouthful but what I mean by that is that social workers sometimes engage in problematic dual relationships with clients because of their wish to address challenges in their own lives. So social workers who give clients gifts, social workers who are available outside of work hours, social workers who give clients their personal um mobile phone numbers so that clients can reach them if need be. And if one looks at these cases there’s evidence that the social worker is engaging in these ambiguous boundaries in part to meet his or her own needs, their own emotional or dependency needs to use the jargon.

A third theme that I focus on in my typology has to do with what we, what I call personal benefit these are instances where social workers may hire a former client who’s in the construction industry to do work on the social workers home. Where a social worker consults with a client who is a physician or an account so the social worker benefits from the client’s expertise, the social worker who accepts a gift from a client where there’s an element of personal benefit.

A fourth theme that I focus on has to do with what I call altruism, my understanding, my experience is that social workers overwhelmingly are very compassionate people, very dedicated, very ethical, very earnest, they care a great deal about their clients and what I have found over the years is that sometimes these altruistic instincts can create boundary problems. Social workers who give clients gifts, social workers who share personal information because they think it’s going to be helpful to the client. Social workers who perform favours for clients, they give them a ride because the client doesn’t have transportation, they loan a client money and it may be very well meaning and it can create profound boundary problems that can interfere with the social workers ability to truly help the client.

And the final theme that I have focused on in my work on boundaries has to do with what I call unavoidable and unanticipated circumstances. Very reputable, very professional social workers who live in small and rural communities who inevitably encounter clients in the food store, the church, the synagogue, social situations. It is impossible for them to avoid encounters and social workers have to develop exquisite skill in managing boundaries in these circumstances, So when you put all of this together, one has a um I think a rich textured array of complex boundary challenges in social work and I think this is a perfect example of how our profession has matured.

When I began to pay close attention to ethical issues in the 1970’s we didn’t even use the term boundary issue. We didn’t use the term dual relationship. Now we did use other terms. We talked about transference and counter transference and so forth but I think now we have a much more mature, much more sophisticated, much more nuanced understanding of boundary issues and its, its I think a lovely example of how our profession has evolved in its understanding of ethical issues. When I think about what ethics meant in the 1970’s and what ethics means today, I am rather astonished at the evolution, at the transformation.

Tricia: Ric, I imagine dual relationships in that boundary between friendship and professional is one of the most hardest to manage and the one that practitioners do struggle with the most.

Frederic: There’s no question that among the challenging ethical issues in social work, the boundary and dual relationship arena is the most challenging. That is certainly my experience and what I often say is that in social work ethics there are some cases that have what we call bright lines where we can clearly distinguish between right and wrong. Everyone understands that it’s unethical to engage in sexual relationship with a client. There’s a bright line. Everyone understands that it’s unethical to falsify records or to forge documents or to embezzle money from one’s agency. These are the bright line cases. And what I’ve come to understand is that in social work ethics, the most challenging cases have fuzzy lines, fuzzy borders. They are not black and white. There are no bright lines. They are cases that are filled with grey and they are cases that are filled with multiple shades of grey if with regard to boundaries and dual relationships for example, there are the clear cut cases where we have what in the trade we call boundary violations, sexual misconduct that kind of thing but there’s another set of cases that ethicists refer to as boundary crossings, not boundary violations, but boundary crossings where there may be very reasonable dual relationships. I don’t believe for example that all dual relationships are unethical. I think some are, I think some are not, for example, I know that some social workers, some agencies hire former clients, clients who are in recovery for example clients who have coped with persistent and chronic mental illness and who are stable who are handling their lives quite well and they have a great deal to contribute to people who are struggling in the way they once struggled.

Do I think it’s unethical in every instance for an agency, for a social worker to hire a former client? I do not think so, what I think is that it has to be handled exquisitely skilfully. This is a boundary crossing. A former client is now a colleague, a former client may now spend social time with a former therapist as a colleague in an agency and it requires a great deal of skill to create reasonable guidelines to minimise risk to the former client, now colleague, to minimise risk to the social worker, that’s one example. Here’s another example, I do not think that clinician or social worker self-disclosure is always unethical, I don’t think there’s a bright line I think some forms of self-disclosure are unethical where clinicians may share very intimate, very personal information with clients where one has to ask whose needs are being met by this self-disclosure. Is this a prelude to an inappropriate dual relationship?

On the other hand, I think, and I’ve written this in some of my own work that some forms of self-disclosure can be profoundly helpful, profoundly therapeutic, I refer to this as judicious self-disclosure and the challenge is for social workers to think conceptually about what kind of self-disclosure, what kind of content under what circumstances, for what purposes, whose needs are being met. The same thing with gifts and invitations. I don’t believe social workers should reject all gifts from clients. I think some gifts are very inappropriate. They raise questions about the nature of the relationship between the client and the practitioner and I think in other instances rejecting a gift would be very insensitive, um perhaps unethical to reject the gift. There may be cultural issues involved, where in that culture in Australia, in that culture in the United States, in that culture in the UK, wherever, in Taiwan, where the gift from the client, a modest gift carries great cultural meaning and to reject it would be very hurtful. What social workers ought to do I believe is develop criteria, develop conceptual frameworks to help them think through how to manage these ambiguous boundary related situations - under what circumstances should I self-disclose, under what circumstances should I accept a gift, under what circumstances should I accept an invitation from a client and how do I document this in my case notes to protect everyone?

So, I prefer to focus primarily on the grey in social work ethics, I do get involved in many cases of black and white because I do get subpoenaed often to testify in licensing board cases and litigation. I prefer, however, to wrestle with the difficult issues where in my experience, very reasonable, very dedicated, very smart, very principled social workers can examine the identical set of facts and reach different conclusions about how the circumstances ought to be handled. I think that happens with regard to boundaries and dual relationships I think it happens with regard to confidentiality issues. It happens with regard to informed consent issues. We can march up and down the line. Every key ethics challenge in social work I think has its share of black and white issues and lots of grey issues.

Tricia: So, Ric is that where decision making models come in and actually pre-thinking what sort of issues might arise before they happen?

Frederic: That’s exactly the way I think about it and here too I think social work as a profession and social work ethicists’ thinking has matured tremendously. So when I began my work in the 1970’s very few people were thinking conceptually about ethical decision making.

By the early 1980’s, there was a very small group of social work scholars I was among them and several of us developed conceptual frameworks as a way to organise our thinking about how to approach difficult ethical judgements. If you take a look at my work and the work of several colleagues, you will see outlines of issues to think about, questions to raise as we approach complex ethical issues. I would never maintain that there is a formulaic solution to complex ethical issues, so even though my work and the work of others includes conceptual frameworks, step 1, step 2, step 3, that kind of thing. I do not believe that these are the equivalent of equations where we can enter the data, figure out how to weight each of the variables, push a button on the computer and come out with an unequivocal clear cut answer. Rather I think the value of these conceptual frameworks is that they help us organise our thinking. They help us highlight issues that warrant attention and I believe that systematic, rigorous conceptualisation of ethical decision making, greatly enhances the likelihood that we will protect clients, protect ourselves and yet I do not believe that these decision making protocols or decision making frameworks guarantee a nice tidy simple answer and I think its useful to use as an analogy what social workers truly understand with regard to clinical work.
For example, we have known for over a century that its helpful to have systematic frameworks for clinical assessment, clinical decision making. We teach this in social work programs worldwide, it that it’s important to conduct a biopsychosocial spiritual assessment, it’s important to systematically look at clients’ clinical challenges to come up with a treatment plan. We value these conceptual frameworks, but I don’t, I don’t know any social work educator who would guarantee that the use of these conceptual frameworks will produce a clear cut, unequivocal clinical plan. I think we agree that its important to think conceptually, that this enhances the likelihood that we will be able to assist clients, but I don’t think anyone believes that conceptual frameworks guarantee simple tidy solutions and I think the same goes for ethics. I think that the conceptual frameworks we now have in social work are so much more sophisticated, so much more rigorous than the ones that existed in the early 1980’s and I think we approach ethical decision making much more effectively as a result, recognising again we cannot guarantee simple solutions to complex problems.

Tricia: How important are codes of ethics in this?

Frederic: Well, this is a very interesting issue, if one takes a look at the ethical decision-making framework that I developed and that I embrace, I argue that social workers ought to think very systematically about a variety of issues, who is likely to be affected by the social worker’s judgement. The client, the social worker the agency, third parties, and so on, are there values conflicts involved, are there conflicts between the social workers values, the clients values, are there conflicts between the social workers values and social works values, are there duties and obligations that clash, in what ways are ethical and moral theories relevant to the decision making and by the way, that’s what I was doing primarily during the late 1970’s and 80’s identifying ways in which ethical theory, moral theory might pertain to and inform ethical judgement.

I encouraged social workers to think about whether laws and statutes and regulations are relevant to ethical judgments, I think they are relevant to some ethical decisions and I think they’re basically irrelevant to many others where there are no laws or regulations or statutes and this gets to your question, I think social workers should always consider prevailing ethical standards as they are reflected in codes of ethics or codes of conduct. In some nations they are called codes of conduct in other nations they are called codes of ethics. When I became a social worker in the 1970’s the code of ethics for the national association of social workers in the United States was one-page long. At that time, I don’t think there was a great deal of value in consulting that code of ethics. That’s not a criticism that’s what codes of ethics were like in the 1970’s. They were like the hypocratic oath. They were like the boy scout, girl scout oath, they were meant to inspire they highlighted values, but they were not designed to help practitioners make difficult ethical judgments. In the United States the second code of ethics was ratified in 1979 that was a much more ambitious code and that code lasted in the United States until 1997.

I was privileged to have chaired the national task force in the United States that wrote the current code of ethics, the first version of which was ratified in 1997, the current code of ethics in the united states the national association of social workers code is 29 pages long the hard copy. 29 pages long, so in my career I have gone from a 1 page code of ethics to a 29 page code and as the person who was privileged to have chaired the committee that wrote the code, I can tell you that we did our best to keep this current code short. We did not want it to be excessively long because we knew that that would minimise the likelihood that practitioners would use it. Despite our best efforts to produce a relatively short code of ethics, we ended up with a 29-page code.

Now I am biased. I chaired the committee that wrote it. I truly believe that social workers ought to consult that code of ethics when they face difficult ethical judgments, I think it is chock full of rich, conceptual guidance. I think it is replete with sophisticated nuance, the distinction between a boundary violation and a boundary crossing, subtleties involved with conflicts of interest and informed consent, the tension between the concept of self-determination and professional paternalism, the complexities involved in disclosing confidential information without client consent, the challenges involved in electronic communications with clients. Issue, after issue, after issue. None of these were mentioned in the code of ethics that was in effect when I became a social worker and few of these were reflected in the 1979 code of ethics adopted by the National Association of Social Workers. The current code is long because we have learnt so much and while I do not think a code of ethics can guarantee a clear answer, I do think it can provide rich, sophisticated and helpful conceptual guidance, so whereas codes of ethics at one time were suitable for framing and inspirational I now think that codes of ethics in Australia, I think you have a very fine code of ethics, in the U.K. there is a very fine code of ethics, in Canada there is a very fine code of ethics. These are very helpful guidelines and sources and we should not kid ourselves into thinking that they will provide simple answers whenever we encounter a complex ethical challenge.

Tricia: Ric, one final question. How important is professional supervision in negotiating all this grey and complexity?

Frederic;Well, I am a staunch supporter of not only supervision, but consultation in the face of difficult ethical issues and in social work of course we distinguish between consultation and supervision. In fact there is now a rich literature on the concept of ethics consultation. In hospitals, for example, there are now ethics consultants. Their job is to provide ethics consultation to social workers and others who encounter difficult ethical challenges.
That is different from supervision. So I often explain to my students and colleagues, ethics consultation involves exchange of ideas, of perhaps advice between and among colleagues in those circumstances. However the social worker who receives advice is not obligated to accept the advice, collegial consultation is more horizontal supervision on the other hand is more vertical where the supervisor has a fiduciary obligation to monitor the work of the supervisee, to give advice. There’s often an expectation that the supervisee will accept the advice of the supervisor or possibly disagree with it and challenge it, but there is that hierarchical relationship. I firmly believe that social workers who encounter difficult ethical issues have a fundamental duty, a fundamental obligation to not be a solo pilot that they ought to seek out consultation, peer consultation when it’s available and they ought to seek out the council of a supervisor. Um when a supervisor is available, now for example someone who is in private or solo practice does not have a supervisor so they I think have a responsibility to obtain ethics consultation with colleagues - that horizontal consultation I referred to but in the typical agency setting there should be supervision available and I firmly believe that good ethical decision making includes discussions with a supervisor, not that the supervisor necessarily knows the answer, not that the supervisor necessarily gives sage advice but I do think that consultation with a supervisor increases the likelihood that the social worker will identify relevant ethical issues. I believe 2 heads, 3 heads are better than 1.

In the United States, we have many court cases where the role of the supervisor was a critical element in the discourse in a court of law or in a licensing board case, I have often had to testify about the expectation that social workers will consult with supervisors if a social worker does not consult with a supervisor that can be used against the social worker in a licensing board case in a court case. There is a legal concept, it’s a Latin phrase, respondeat superior – translation ‘let the master respond’ - and I apologise for the, the sexist language but it’s an old term. ‘Let the master respond’ and this is a well-known legal concept that has its origin in common law that suggests that when there is a supervisor, a supervisor has a duty to monitor the work of the supervisee and I believe that should include informing a supervisee that the supervisee should bring to the attention of the supervisor any ethical issues that emerge in the supervisees work that the supervisee has a duty to raise these issues with the supervisor so they can put their heads together to try to come up with a reasonable resolution of a difficult challenge involving perhaps disclosure of confidential information without a clients consent, or the management of difficult boundary issues, or termination of services to a client who’s not compliant, or the handling of a conflict of interest, whatever it happens to be, so my decision making framework, you will see that one of the steps is, consult with colleagues, consult with supervisors when they are available.

Tricia: It also means that cultures or organisational culture needs to include boundaries as an open issue so that people can discuss it, because sometimes I think people don’t know their crossing is a dangerous boundary until it happens

Frederic: I think that’s absolutely right that some of the responsibility here is at the organisational level, some of the responsibility is at the administrative level and I think organisations and administrators have a duty to identify ethical issues that are likely to come up in their unique settings and to provide training and guidelines for staff.

The ethical issues that surface in a school with young children are very different from the ethical issues that arise in a nursing home or an HIV/ AIDs program or an addictions program or in a psychiatric facility or in a prison and I think one has to be sensitive to the different cultures that exist across different practice settings and try to identify and anticipate ethical issues that are unique to those settings. In addition since we’ve mentioned culture, one of the challenges in social work is identifying cultural differences so that social workers who practice in Australia with aboriginal clients have to be sensitive to certain cultural norms and issues. They may be profoundly different from those faced by a social worker in Japan or a social worker in Taiwan or a social worker in the United States, or Canada, or wherever.

So, as I’ve had the opportunity to lecture about ethics in a variety of nations, I have been amazed at the profound differences in understanding of the concept of privacy, the concept of confidentiality, the concept of boundary, the concept of dual relationship. I recently lectured in Taiwan and had these wonderfully engaging conversations with Taiwanese social workers about how differently they approach confidentiality when they work with clients, how different their understanding is of boundaries compared to social workers in the United States, several years ago I had the opportunity to work with social workers in Japan the concept of informed consent, the concept of privacy in my travels in Japan is profoundly different from what I encounter in the United States and I suspect I would find some of that in Australia as well while I do think there, we have very similar understandings about some issues we’ve learned so much about, subtle and sometimes not so subtle differences in what these ethics concepts mean in different cultures.

Tricia: Ric, thank you so much for being on Podsocs, we’ve had a lot of requests to talk about boundaries and dual relationships, so we really are very grateful that you’ve given us your time. Thankyou.

Frederic: It has been my pleasure thank you for the invitation

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Interview ENDS: 39.36