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Eye on Ethics

Use of Self and Ethics Risk Management
By Frederic G. Reamer, PhD
February 7, 2011

I once consulted on a licensing board case in which a disgruntled client alleged her clinical social worker violated the profession’s ethical standards. The seasoned social worker, Jeremy, had provided counseling services primarily to the mother of a 10-year-old boy. The boy’s mother and father were involved in bitter divorce proceedings and a protracted custody dispute. The mother sought counseling to help her cope with symptoms of depression and suicidal ideation.

Jeremy and the mother met regularly for more than two years. During many clinical sessions, the mother focused on the rage she felt toward her son’s father who, she said, was vindictive and manipulative. Jeremy included the father in six clinical sessions to discuss parenting issues and, over time, agreed with the mother that the father’s behaviors were harming his son. In fact, Jeremy collaborated with the mother on a letter he wrote to the family court judge to support the mother’s petition for sole custody of the child.

Over time, however, conflict emerged in the relationship between Jeremy and the mother. According to Jeremy, the mother became unreasonably demanding of the his time, called him at home, and insisted on reviewing and requesting changes in his clinical notes. The client’s time-consuming efforts to micromanage Jeremy’s clinical notes led him to cease keeping records. During one telephone conversation when the mother called Jeremy at his home on a weekend, Jeremy confronted the client angrily, informed the client that she would need to find another clinician, and abruptly hung up the telephone.

When the father’s lawyer subpoenaed Jeremy to testify in a deposition during the custody dispute, Jeremy shared his concerns about the mother’s troubling behavior. Shortly thereafter, the mother filed a licensing board complaint against Jeremy alleging that he failed to maintain his commitment to her as the primary client, disclosed confidential information in a deposition without proper consent, failed to maintain proper clinical notes, and terminated the social worker-client relationship abruptly and without proper referral.

Social Workers’ Use of Self
During the course of a career, it is not unusual for clinical social workers to encounter clients who engage in challenging behaviors. Clients’ behaviors may be contentious and demanding, and social workers may find themselves struggling with complex counter-transference reactions. Astute social workers know they must be vigilant in their efforts to identify counter-transference issues in their clinical relationships with clients and skillfully manage them to ensure clients’ needs are addressed appropriately. Doing so requires extraordinary self-awareness, insight, self-restraint, professionalism, and clinical acumen and expertise.

Throughout the profession’s history, social workers have learned about the importance of skillful “use of self.” Ordinarily, the concept refers to clinical social workers’ conscious and deliberate reflections on the ways in which their own personality traits, attributes, values, beliefs, life experiences, and cultural, ethnic, and religious heritage influence their work with clients. Historically, social workers’ discussion of “use of self” has been limited to clinical phenomena. However, the concept is also central to the skillful management of ethical dilemmas. As in the case involving Jeremy, whose client filed a licensing board complaint against him, social workers’ careful use of self can enhance their ability to adhere to ethical standards, protect clients’ rights, and minimize the likelihood of an ethics complaint or ethics-related lawsuit.

During my conversations with Jeremy prior to the formal licensing board hearing, he readily admitted that he “lost it” with his client and failed to monitor and address his own complex feelings of anger and frustration arising from their challenging clinical relationship. In the aftermath, Jeremy was well aware of the counter-transference issues and their clinical implications, but it took time for him to recognize the ethical implications of his responses to his client’s behaviors.

The “Use of Self” and Ethics Risk Management 
Social workers who firmly grasp the concept of “use of self” are better equipped to skillfully manage ethically challenging situations with clients. First and foremost, social workers must protect their clients’ rights even, and perhaps especially, when the clients’ behaviors toward the clinician are troubling and challenging. In addition, social workers should address ethical issues with an eye toward preventing errors that exacerbate the risk of ethics complaints and ethics-related litigation. Several practical steps can help.

• Know thyself.Skillful social workers know they must pay close attention to their own feelings that arise in their relationships with clients. Social workers should think about their use of self and counter-transference when they handle ethical issues as well as when they face clinical challenges.

Ask yourself, “How might my feelings about my client be affecting my ethical judgment?” Jeremy, for example, readily admitted after the fact that his growing sense of frustration and irritation with his client led to his mishandling of several ethical issues. Jeremy stopped taking clinical notes because he resented his client’s requests to review his notes and the client’s occasional challenging of their content. He disclosed confidential information in a formal deposition without his client’s consent because, he said in hindsight, it provided him with a seductive opportunity to expose his client’s misconduct. Jeremy also understood in retrospect that his impulsive decision to abruptly terminate the clinical relationship without proper referral and termination was a shortsighted attempt to rid himself of a difficult client.

Had Jeremy taken a step back to closely examine the ways in which his own values, beliefs, and life experiences were affecting his response to the client, it is more likely that he would have protected his clients’ rights and prevented the licensing board complaint.

• Seek consultation and supervision. Like airline pilots, social workers should have available the equivalent of a copilot and air traffic control when navigating daunting storms. Being a solo pilot can be exciting and liberating, but knowing when to seek consultation and supervision is essential. The adage “two heads are better than one” has endured because it is true. As the NASW Code of Ethics says, “Social workers should seek the advice and counsel of colleagues whenever such consultation is in the best interests of clients” (standard 2.05[a]).

• Review ethical standards. During Jeremy’s licensing board hearing, the board carefully reviewed two sets of ethical standards to assess whether Jeremy had violated his client’s rights. The first was drawn from the state’s licensing regulations, which set forth the ethical standards to which licensed social workers are held. Second, the board identified relevant standards in the NASW Code of Ethics because the state’s licensing law specifically requires social workers to adhere to this code. Both the state’s licensing regulations and the Code of Ethics include specific standards related to the ethical issues that Jeremy faced concerning his commitment to his client, conflicts of interest, client privacy and confidentiality, documentation of clinical services, consultation with colleagues, and termination of services.

The board concluded that Jeremy violated these standards based on evidence that he undermined his client’s interests, engaged in a conflict of interest with his client, breached his client’s privacy and confidentiality when he testified in the deposition without her consent, failed to document several clinical sessions, and abandoned his client by terminating services to her abruptly and without proper referral.

During this painful process, Jeremy learned a great deal about ethics risk management. Most of all, Jeremy learned that wise social workers understand the powerful influence of use of self in both clinical and ethical decision making.

— Frederic G. Reamer, PhD, is a professor in the graduate program of the School of Social Work, Rhode Island College. He is the author of many books and articles, and his research has addressed mental health, healthcare, criminal justice, and professional ethics.