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Eye on Ethics

Ethical Challenges in Nontraditional Programs
By Frederic G. Reamer, PhD
October 2017

Several years ago I visited a program that serves high-risk adolescents who struggle with behavioral and mental health issues. I was told by program staffers that most of the teens were referred for services after traditional office-based individual and family counseling proved ineffective. Most of the teens had difficulty in school; many struggled academically, and some had been suspended or expelled. Many of the teens' parents reported that their children were defiant at home, using drugs, and getting in trouble. Also, many of the teens had been diagnosed with depression, anxiety, ADHD, and/or bipolar disorder.

Putting on my ethics hat, I was intrigued when I learned that clinicians in this program, including social workers, do not meet with the teens for traditional 50-minute counseling sessions in private offices, primarily because this approach had not been particularly effective with this client population. Rather, the clinicians meet with clients in unstructured outdoor nature settings to enhance the likelihood that the teens will engage in counseling. Sometimes, in the middle of a counseling session clinicians and teens will find themselves in the middle of a downpour; they will set up a lean-to for protection and continue their work. Sometimes they will share meals and the teens and staffers will spend night after night camping outdoors.

Social workers trained in the ways of traditional counseling might find these details troubling, in light of the blurry boundaries. They might ask whether this unorthodox treatment approach violates prevailing ethical standards in the profession.

In my view, they don't. It happens that the program I visited is licensed by the public child welfare agency in the state where it is located, hires licensed mental health professionals, including clinical social workers, and is reimbursed by major insurance companies for many of its clinical services. In other words, this is not an offbeat, fly-by-night program. The program is an impressive example of what is known as wilderness therapy (also called outdoor behavioral health).

The wilderness therapy model emerged primarily in the 1970s. Wilderness therapy programs offer highly structured intensive therapy in remote locations that remove adolescents from the distractions available in their home communities (such as television, music, computers, cars, drugs and alcohol, movies, and delinquent peer groups). The challenges of living full-time outdoors and developing wilderness survival skills help teens develop self-confidence, problem-solving skills, and prosocial behaviors. Common wilderness therapy activities include education about outdoor and wilderness survival, team-building exercises, some academic coursework (sometimes coordinated with the teen's home school to help the teens stay at grade level), individual and group counseling, hiking, rock climbing, and other expeditions. Family members often participate in counseling sessions via mobile phones and travel to the program site for family sessions. Often, families are advised to send their struggling teen first to a wilderness therapy program and then to a therapeutic or "emotional growth" boarding school, rather than return the teen to their home community environment.

My visit to the wilderness therapy program and my discussions with staffers taught me a valuable lesson about ethics. Some nontraditional, unorthodox treatment approaches are ethically problematic. I have testified in several legal cases where evidence suggested that practitioners were using very odd and controversial treatment approaches that were not widely accepted in the profession. Some of these interventions involved inappropriate touch, confrontation, and, in my view, bizarre boundary violations (such as traveling with a client, sharing a room at a bed and breakfast, exchanging gifts, and going on a camping trip together, all in the name of therapy). In contrast, wilderness therapy is widely accepted in the behavioral health field in spite of its use of nontraditional interventions and boundaries.

Ethics and Nontraditional Interventions
In some instances, social workers may endorse the use of nontraditional and experimental interventions, despite the fact that the interventions may expose clients and themselves to some degree of risk. In controversial cases, a cross-section of experienced, reasonable, and prudent colleagues can disagree about whether certain novel or controversial interventions are unethical, negligent, or effective. For example, some clinicians argue vigorously that holding therapy is a helpful, constructive approach when working with some clients. Others, however, argue that this approach is filled with clinical and legal risk and that practitioners should avoid its use. In this and many other instances, thoughtful and principled clinicians may examine the known facts about the relative advantages and disadvantages of a nontraditional intervention and disagree about the appropriateness of its use.

Social workers can best protect clients and themselves by following several steps that a reasonable and prudent social worker should and would take in deciding whether to use a nontraditional, experimental, unorthodox, or controversial clinical intervention or technique.

• Consulting colleagues. Social workers who consider the use of nontraditional and unorthodox interventions should consult colleagues who have specialized knowledge or expertise related to the particular approach. Social workers in private or independent practice should discuss these issues in peer consultation groups. Social workers who are named in ethics complaints and lawsuits can help demonstrate their competent decision making by showing that they sought consultation.

• Obtaining proper informed consent. In general, for consent to be considered valid, the following standards must be met: (1) coercion and undue influence must not have played a role in the client's decision; (2) clients must be capable of providing consent; (3) clients must consent to specific procedures and intervention approaches; (4) the forms of consent must be valid; (5) clients must have the right to refuse or withdraw consent; and (6) clients' decisions must be based on adequate information.

• Obtaining proper supervision. Social workers who have access to a supervisor should take full advantage of this opportunity. Supervisors may be able to help social workers decide on the appropriateness of nontraditional and unorthodox interventions. Also, social workers who are sued or named in an ethics complaint can help demonstrate their competent decision-making skills by showing that they indeed sought supervision.

• Reviewing relevant ethical standards. It is critically important that social workers become familiar with and consult standards in the NASW Code of Ethics pertaining to the use of nontraditional and unorthodox interventions. As these standards make clear, social workers should always base their decisions about the use of nontraditional and unorthodox interventions on prevailing ethical standards concerning practitioners' duty to provide services only in substantive areas where they have demonstrated competence.

• Reviewing relevant regulations, laws, and policies. Social workers who are considering the use of nontraditional and unorthodox interventions should always review relevant regulations, laws, and policies (both public policies and agency policies). For example, some states prohibit the use of "conversion therapy" designed to change minor clients' sexual orientation and gender identity.

• Reviewing relevant literature. As the Code of Ethics makes clear, social workers should always stay current with relevant professional literature, especially literature pertaining to practitioners' use of nontraditional and unorthodox interventions.

• Obtaining legal consultation when necessary. Practitioners who use nontraditional and unorthodox interventions could increase their risk for legal exposure. Thus, it behooves social workers who consider using such interventions to obtain a legal opinion about relevant risks from a lawyer who specializes in professional malpractice and negligence.

• Documenting and evaluating decision-making steps. Thorough documentation can help protect social workers who are named in ethics complaints and lawsuits (that is, documentation provides evidence that a social worker obtained timely consultation and supervision concerning the use of a nontraditional and unorthodox intervention; obtained a client's informed consent prior to the delivery of services; reviewed relevant practice and ethical standards, literature, statutes, and regulations; and, when necessary, sought legal consultation).

Nontraditional interventions have the potential to provide profound assistance to people who struggle in life and provide the social work profession with useful innovations. Other nontraditional interventions can be profoundly harmful. Ethical social workers take diligent steps to know the difference.

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