The Ethics of Caring

March 19, 2014Linda McClain LCSW

Objectives

• Upon completing this workshop, learners will:• Increase their knowledge related to identifying and

crossing boundaries with clients.• Increase their understanding of common Ethical

Standards when working with clients. • Be able to access their disciplines code of ethics

Ethics

• the body of moral principles or values governing or distinctive of a particular culture or group: the Social Work Code of Ethics; the Mental Health Counselors Code of Ethics; the Marriage and Family Code of Ethics etc.

What is an Ethical Dilemma

• The Joint Commission defines an ethical dilemma as a situation in which acting on one moral conviction or belief means breaking another. It is a troubling situation in which the right course of action, or what “ought to be done,” is not in clear agreement. This is because different outcomes result from decisions, depending on which sincerely held values, duties, morals, principles, and/or obligations are used to justify the decision. The variety of potential outcomes as well as the variation in values, duties, morals, principles and obligations, create the conflict, hence the dilemma.

Is it Ethical?

Is it ethical to: Never Rarely Unsure Usually Always

Barter with a client or supervisee for goods or services?          

Provide therapy to a co-worker?          

Provide therapy to a friend?          

Accept a gift from a client?          

Purchase something from a client?          

Sell something to a client?          

Invite a client to a personal party or social event?          

Go out to eat with a client after a session?          

Accept a client's invitation to their wedding or special event?          

Become friends with a client after termination?          

Engage in sexual activity with a client?          

Talk about personal issues in a group you are leading?          

What is a boundary?

Making Decisions Involving Boundaries

• Imagine what might be the “best possible outcome” and the “worst possible outcome” from crossing the boundary.

• Consider the research on this boundary crossing.• Take into account guidance from professional guidelines,

ethics codes, legislative, case law and other resources.• Identify at least one colleague you can trust for honest

feedback.• Pay attention to any uneasy feelings, doubts, or confusions.

Making Decisions Involving Boundaries

• At the start of therapy and as a part of informed consent, describe to the client exactly how you work and what kind of therapy you do.

• Refer to a suitable colleague any client you feel incompetent to treat or who you do not fee you could work with effectively.

• Don’t overlook the informed consent process for any planned and obvious boundary crossing.

• Keep careful notes on any planned boundary crossing, describing exactly why in your clinical judgment this was or will be helpful to the client.

Cognitive Errors and Boundary Crossing Decisions

• What happens outside the psychotherapy session has nothing to do with the therapy.

Error #1.

Error # 2.

• Crossing a boundary with a therapy client has the same meaning as doing the same thing with someone who is not a client.

• Our understanding of a boundary crossing is also the client’s understanding of the boundary crossing

Error #3.

• A boundary crossing that is therapeutic for one client will also be therapeutic for another client.

Error #4.

Error #5

• A boundary crossing is a static, isolated event.

• If we ourselves don’t see any self-interest, problems, conflicts of interest, unintended consequences, major risks, or potential downsides to crossing a particular boundary, then there aren’t any.

Error #6.

• Self-disclosure is, per se, always therapeutic because it shows authenticity, transparency, and trust.

Error #7

What Can We Do When Boundary Crossings Go Wrong?

• Continue to monitor the situations carefully• Be open and non defensive• Talk over the situation with an experienced colleague who can provide

honest feedback and thoughtful consultation.• Listen carefully to the client• Try to see the matter from the client’s point of view• If the situation involves a formal complaint consult the hospital

attorney and references to malpractice complaints• Keep honest and accurate records of the situation.• Consider apologizing

Ethical Responsibilities to Clients

• Commitment to Clients• Self Determination• Informed Consent• Competence• Cultural Competence and Social Diversity• Conflicts of Interest and Dual Relationships• Privacy and Confidentiality• Access to Records taken from the NASW Code of Ethics

Ethical Responsibilities to Clients

• Sexual Relationships• Physical Contact• Sexual Harassment• Derogatory Language• Payment for Services• Clients Who Lack Decision Making Capacity• Interruption of Services• Termination of Services

taken from the NASW Code of Ethics

Ethical Responsibilities to our Colleagues

Do we have Ethical Responsibilities to our Colleagues?

Tips on Avoiding Ethical Pitfalls

1. Understand what constitutes a multiple relationship.2. Protect Confidentiality3. Respect Peoples Autonomy4. Know your supervisory Responsibilities5. Identify your client and role6. Document, Document, Document7. Practice only where you have expertise8. Know the difference between abandonment and

termination9. Stick to the evidence10. Be accurate in billing

References

Some of the content from today’s presentation was taken from the following sources:• Pope, K and Keith-Spiegel, P (2008), A Practical

Approach to Boundaries in Psychotherapy. Journal of Clinical Psychology vol. 64 #5 pages 638-652.

• Smith, Deborah, (2003), 10 Ways Practitioners can avoid frequents ethical pitfalls. Monitor on Psychology

• NASW CODE of ETHICS• The Joint Commission – Standards on Ethics

Links to Professional Codes

• Marriage and Family Therapists http://www.aamft.org/imis15/content/legal_ethics/code_of_ethics.aspx

• Mental Health Counselors http://www.amhca.org/assets/content/CodeofEthics1.pdf

• Nurses http://www.nursingworld.org/codeofethics• Psychologists http://www.apa.org/ethics/code/index.aspx• Social Work

http://www.socialworkers.org/pubs/code/code.asp• Substance Abuse Counselors

http://www.naadac.org/index.php?option=com_content&view=article&id=185&Itemid=113