RURAL PRACTICE AND DUAL RELATIONSHIPS
Kevin Geraghty, LCSW, ACSW, BCD
from the Priv ate Practice Section Connection, Spring 2005
Even after serving as ethics chair of the Committee on Inquiry in Idaho, and from that position, reviewing standards and literature regarding dual relationships, the topic requires continuing exploration. More than half of the consultations requested during my time as ethics chair involved dual-relationship issues. These were not headline-grabbing, sexy stories. They were the predicaments of rural social workers who wanted some advice about how to handle the treatment needs of a client who happened to also be their son’s algebra teacher or their family dentist. These are the realities of life in a small community that must be factored into any discussion of boundaries (Schrank & Skovholt, 1997).
Overlapping social relationships will occur at school functions, church and social gatherings, or even when going out to eat. Overlapping business relationships include the engagement of landscapers, auto mechanics, or builders who may show up to work at your house before you know about the boundary problem. Overlapping relationships present problems for other family members as well. Social workers who treat children might come home to find a client at the dinner table, ready for a sleep over. Social workers in urban and suburban settings can choose to practice, shop, worship, or socialize at locations that minimize exposure to dual relationships. When they run into a boundary issue, they can choose other, possibly less convenient, options. The communities I heard from often had only one high school, one grocery store, one Alcoholics Anonymous meeting. Although social workers had been trained to avoid dual relationships, this position is often so impractical as to alienate rural practitioners who must consider, “What do they know about my life and my work?” These social workers need the support of others in the profession who can live with ambiguity and creative boundary setting. What they often get instead is the mentoring of a local physician or attorney who may share in the predicament, but offer their own kind of solution. When social workers are less clear about their unique professional identity, we invite further ambiguity.
A quick review of the literature will yield clear guidelines on dual relationships (Kagle & Geibelhausen, 1994; Reamer, 2003) that serve to begin a discussion, but not to end it. In an excellent investigation of one of the most distressing complications of practice, Mattison et al., (2002) pointed out the merits and limitations of different definitions of the term “ex-client.” They correctly noted the ambiguity of our own code of ethics on this issue. Social workers in Chicago may choose the most conservative view, “once a client, always a client,” organizing their practice around that concept. A rural social worker needs this view with some cases, but also needs the flexibility to use other definitions in other cases.
Social workers might consider the decisionmaking model proposed by Gottlieb (1993). It includes three basic dimensions: power, duration, and termination. This model suggests that relationships of high power— meaning high personal influence on the client—require more stringent boundaries. Duration, or the length of treatment, is a consideration, because clients who have had brief consultations will have a lower risk of boundary crossings than clients who receive long-term treatment. When considering terminating the client-social worker relationship, we also consider the odds of on-going contacts versus a single episode of treatment. Clients who have repeat or ongoing professional contact are clearly a higher risk when considering boundary crossings. Rating these three factors involves some professional intuition, which is far from foolproof.
What reasonable steps would serve the social worker in a rural practice? I propose some attitudinal, as well as, behavioral steps. In terms of basic attitude, do not assume that there is a clear and relevant ethical standard that you simply don’t know or forgot. In my experience as ethics chair for the NASW Iowa chapter, many callers were surprised that coming to an ethical decision required a lengthy conversation and still left them a bit uneasy. Acknowledge the code as a living, evolving document that can only be advanced by way of your practice experience.
Social workers ought to adopt the notion of boundary crossings as distinct from boundary violations (Reamer, 2003). This added flexibility keeps us on the scene, looking for practical solutions when treatment options are few. Don’t assume that clients don’t understand or don’t care about these issues, even when they appear that way. We can do our culture the favor of returning ethics to lunch counter and water cooler discussions. Within confidentiality limits, we ought to say, out loud, “Here’s my dilemma.” Plain talk about professional standards is the single best way to grow in professional identity. We can also advance public knowledge and respect of the profession in that same moment. It won’t come down to having perfect answers so much as having an open process that articulates our values in a real-world setting. The thoughtful discussion based on, “Let’s keep talking because there is no easy solution,” is generally well respected (outside of our current federal administration). Other ingredients include clear expectations about how boundary crossings will be handled, along with sticking to scheduled appointment times and time limits, and vigilance on confidentiality and good documentation. Practice gets a bit easier in a rural community after a number of people go through this process with you. Word gets around pretty quickly.
A more sophisticated, and perhaps private, question should be asked many times over. “Am I taking this action for the benefit of the client’s treatment, not simply for the immediate benefit of the client, and clearly not for my own benefit?” At the risk of being too basic, I have to point out that this distinction between the immediate benefit of the client versus the benefit of the client’s treatment is worth a moment’s thought. A significant number of boundary issues are resolved when social workers remind themselves of the limited and focused role they have in providing treatment.
Case Example: A social worker was treating a local business owner for depression. In the course of a session, the client described a plan he was considering to sell off some real estate in town. The social worker belonged to a church that was looking to provide a youth activity center, and the property was a good fit. The social worker put the two parties together, believing that his client would benefit, along with the community.
If the social worker had thought about the treatment plan for depression, and remained
focused on that plan, he would have seen the real estate tip as a potential benefit to
his client, but not a benefit to the treatment plan. A host of difficulties flow easily from
this misstep, including the over-identification of the social worker with one church at
the perceived expense of the others. In fact, when the sale erupted into a dispute over an underground oil tank removal, no one felt the benefit of the social worker’s good intentions. In a small community rife with boundary crossings, a tightly focused treatment plan can save the day. Although the social worker believed he had put the client’s interests first, he clearly failed in his obligation to avoid a dual relationship that could have been avoided. Two other central
principles emerge here: impaired objectivity and risk of exploitation. Whenever a social worker performs two or more roles, the expectations and obligations of each role will probably diverge to some degree, even if they don’t openly conflict. Seeing that divergence as a risk of impaired objectivity or possible exploitation allows the social worker to keep a boundary crossing from becoming a violation.
Social workers in rural settings have good reason to brush up on community organization
and group work skills, even in private practice settings. Using these skills, social workers can align available resources with mental health support systems. There are often a number of ministers, priests, scout leaders, teachers, and others who perform this role but are not in touch with each other. They will often welcome the networking possibilities and the chance to consult with a well-trained professional. With attention to confidentiality, this kind of group eases the pressure to provide services that would constitute a dual relationship. These support services also provide a termination option in some cases, when a lower level of care would be more appropriate.
Finally, social workers in smaller communities need the fresh air of peer review more often than they usually get it. The high rate of boundary crossings won’t even allow complaining to a spouse about some anonymous client when the spouse will likely know whom you are describing. As worldwide business organizations have embraced the “virtual team” comprised of members from different continents, social workers can follow suit with that technology, using virtual peer review to help those in isolated communities.
Kevin Geraghty, LCSW, ACSW, BCD, is the EAP Coordinator of Saint Alphonsus Regional Medical Center in Boise, ID where he also maintains a small private practice. He can be reached at
References
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.
Fletcher, J. (1966). Situation ethics – The new morality. Philadelphia: The Westminster Press.
Gottlieb, M.C. (1993). Avoiding exploitive dual relationships: A decisionmaking model. Psychotherapy, 30, 41-48.
Kagle, Jill Doner, & Geibelhausen, Pam Northrup (1994). Dual relationships and professional boundaries. Social Work, 3(2), 213-221.
Mattison, D., Jayaratne, S., & Croxton, T. (2002). Client or former client? Implications of ex-client definition on social work practice. Social Work, 47(1), 55-65.
Reamer, Frederic G. (2003). Boundary issues in social work: Managing dual relationships. Social Work, 48(1), 121-134.
Schank, J.A., & Skovholt, T.M. (1997). Dual relationship dilemmas of rural and small community psychologists. Professional Psychology: Research and Practice, 28, 44-49.
Simon, R. I., & Williams, I. C. (1999). Maintaining treatment boundaries in small communities and rural areas. Psychiatric Services, 50, 1440-1446.
Resources
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.