Eye on Ethics
The Perils of Countertransference
Most of the ethics cases on which I consult involve complicated ethical decisions concerning social workers' conflicting values, duties, and obligations. The most challenging ethical dilemmas require exceedingly difficult choices involving client confidentiality, dual relationships and boundary issues, conflicts of interest, informed consent, and documentation.
For example, social workers may have to choose between a client's fundamental right to confidentiality and the social worker's duty to disclose confidential information to protect a third party from harm. Or social workers may have to sort out complicated boundary issues when they live and work in rural communities, where it is often impossible to avoid dual relationships with clients.
Over the years, I have learned that not all ethical issues take the form of complex dilemmas. Rather, many of them involve ethical mistakes and social workers’ efforts to avoid them. Among the most common, in my experience, are mistakes triggered by social workers' intense reactions to clients' behaviors.
The Ethical Implications of Countertransference
According to the attorney, during the course of their clinical relationship, the client became increasingly concerned that her social worker, Mr. A., was critical of the client's parenting style. The client, the attorney reported, was especially concerned because her ex-husband’s attorney had subpoenaed Mr. A. in an effort to discredit and impeach the mother as part of the custody dispute.
The former client’s attorney then explained that the mother had asked Mr. A. for a copy of his clinical notes so she could review their contents and explore their legal implications pertaining to the custody dispute. The mother reportedly challenged the content and wording of several of Mr. A.’s entries in the clinical record. Mr. A. told the client he was offended by her request to review his records and her criticism of several of his clinical notes. Toward the end of one anger-filled telephone conversation, Mr. A. told the client that he could no longer be an effective therapist for her and abruptly hung up the telephone.
The former client subsequently sued Mr. A. and filed an ethics complaint against him, alleging that the social worker mishandled his management of the client's request to review the clinical record and the termination of their professional relationship. During a formal deposition, Mr. A. admitted that he “lost it” due to the intense anger he felt toward his client and, as a result, stopped recording clinical notes, abruptly terminated his clinical relationship with the client, and failed to refer the client to another clinician. All these admissions constituted evidence that Mr. A. violated prevailing ethical standards in the profession.
Seasoned clinical social workers are very familiar with the complex phenomenon of countertransference. They understand that their own feelings and responses to clients may be a conscious or unconscious reaction to clients' expressed emotional needs and behaviors in the context of the clinical relationship. Put simply, social workers’ actions are sometimes triggered by clients' challenging behaviors, and they respond in ways that are counterproductive clinically and violate ethical standards.
Beware the Slippery Slope: Practical Risk Management
• Boundaries and dual relationships: Social workers who experience client conflict must be careful to manage boundaries carefully. For example, Mr. A. cooperated with his estranged client’s ex-spouse and his attorney with regard to the custody dispute. The ex-spouse’s attorney sought information from Mr. A. in an effort to discredit the mother, Mr. A.’s client. In the client’s ethics complaint, she alleged that Mr. A. failed to maintain clear boundaries.
As the NASW Code of Ethics says, “Social workers’ primary responsibility is to promote the well-being of clients. In general, clients’ interests are primary” (standard 1.01); and “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]).
• Conflicts of interest: Social workers who become angry with a client must be careful not to respond impulsively and vindictively because doing so can easily generate a conflict of interest. For example, Mr. A.’s relationship with his client became more negative over time; eventually, Mr. A. collaborated with his client’s ex-spouse and his attorney, thus creating a conflict of interest.
According to the NASW code, “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]).
• Confidentiality and informed consent: Social workers who find themselves embroiled in conflict with a client must be careful to avoid any inappropriate disclosure of confidential information to third parties. On occasion, practitioners let their anger get the best of them, and they share confidential and privileged information without authorization. In response to a subpoena issued by the attorney representing the ex-spouse of Mr. A.’s client, Mr. A. disclosed confidential information, without the client’s consent, during a formal deposition. This violated NASW Code of Ethics standards.
• Documentation: Social workers are obligated to document clinically relevant information. When Mr. A. decided to stop recording notes because his client challenged the accuracy of several entries in the clinical record, Mr. A. violated the NASW code mandate that “social workers should include sufficient and timely documentation in records to facilitate the delivery of services and to ensure continuity of services provided to clients in the future” (standard 3.04[b]).
• Termination of services: Social workers who conclude they can no longer have a constructive therapeutic relationship with a client, for whatever reasons, have an ethical duty to terminate services properly and offer the client appropriate referrals. Mr. A.’s abrupt termination of his client constituted what lawyers call client abandonment.
Social workers sometimes experience conflict with clients. Wise clinicians explore the clinical implications of such conflict and manage their countertransference very carefully. In these instances, social workers should be equally aware of potential ethical pitfalls. Regardless of whatever anger a social worker feels toward a client, social workers must always respond professionally, mindful of an array of ethical risks that, if not handled skillfully, can harm clients—and themselves.
— 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.