By Astrid Van Den Broek
Summer 2005, Vol 8 No 4
You’re the only social worker in a small rural community and your supervisor has just ordered you to immediately remove two children from an abusive home. The catch? The children happen to be your niece and nephew. Or you’re the only psychotherapist in town and you and your husband need to buy a new car. But there are only two dealerships in town, one of which is owned by a client of yours. You can’t explain to your husband why you can’t shop there because that would break client confidentiality. But if you go there, your client might feel obliged to give you a special deal.
What would you do? In the former case, the social worker refused to intervene with her brother-in-law’s family and was fired. These are the types of dilemmas that Alison MacDonald, associate registrar of the Alberta College of Social Workers in Edmonton, hears about from small or remote communities.
In large cities like Toronto, Halifax or Vancouver with many health care professionals and the cloak of anonymity that comes with city living, such situations are less likely to arise; if they do, health care professionals have a code of ethics with clear guidelines around dual relationships with clients. But what if you’re the only social worker or nurse or physician in a small community like Gravelbourg, Saskatchewan, population 1,500, or Georgetown, Prince Edward Island, population 721? Chances are the boundaries separating your professional and personal life are less clearly defined than in larger communities. Non-sexual dual, or even multiple, relationships are virtually inevitable in small communities where everyone knows everyone else. Health care professionals may find themselves in the awkward position of relying solely on their own judgment to sort out boundary issues, or trying to adhere to a code of ethics that is clearly impractical for practice in small communities.
So what exactly are the ethics? Sexual relationships are leading ethics violators and that’s fairly standard across professions, says Mary Valentich, a professor emeritus with the University of Calgary Faculty of Social Work in Alberta. Other ethical agreements include maintaining confidentiality, working within your scope of practice, doing no harm and ensuring that outside interests do not jeopardize professional judgment. But there is inconsistency in codes of ethics, not only across practices, but also across the country. “Almost each profession has a code of ethics, but all of them have been at different stages of development with respect to boundary relationships,” says Valentich. “Most professions started out with some ethical codes about sexual relationships – those are clear-cut – but they weren’t as clear on non-sexual relationships.”
The Ontario College of Social Workers and Social Service Workers defines these non-sexual relationships, called dual relationships, as “a situation in which a College member, in addition to his/her professional relationship, has one or more other relationships with the client.” Yet in small or remote communities overlapping relationships are the norm. “In the small communities where we live and work, there’s a high likelihood that you have some degree of association with people either socially or biologically,” says Debra Samek, a social worker who provides services to small communities near Peace River, Alberta. “The idea that somehow you can separate your knowledge outside your office from what you learn inside becomes really challenging. It’s very difficult to maintain boundaries because of all the multiple roles you have with people. Codes of ethics talk about dual roles, but our experience is multiple relationships.”
Indeed, small and remote communities thrive on social networks; professionals are often expected to be part of those networks, to be active members of their communities. “While dual relationships can be problematic for health professionals, they’re seen positively in small communities,” says James Gripton, professor emeritus at the University of Calgary Faculty of Social Work. Limiting relationships can restrict the world health professionals work – and live – in. But as Samek knows, maintaining professional integrity while trying to be an integral part of the community can be a struggle. “You can be one of the most hated people in town,” she says. “You may be seen as someone whose job it is to take people’s children away. It can become really insular.”
The good news is that there are ways of adapting standard codes of ethics to small communities – practical, tried-and-true ways of helping health care professionals handle ethical dilemmas with more confidence. “The most important practical suggestion is to not practise in isolation because that’s when violations happen – when people depend on their own judgment around whether or not they’re in a dual relationship,” says Jo-Ann Vis, a social worker and lecturer with the Faculty of Social Work at Lakehead University in Thunder Bay, Ontario. “Chances are at that particular time, workers can’t see the forest for the trees and they either rationalize their relationship or they won’t even see it as an issue. So access to some type of supervision or consultation outside your community is key.”
Communication with clients is also critical, says Vis. Discussing any potential conflicts upfront makes a once-blurred ethical line just that much clearer. “You don’t want to deal with this after a problem has developed, which is what’s usually happening,” says Vis. “You want to be preventative not reactive; so if it’s a dual relationship you’re concerned about, you want to be able to discuss it with the client.”
Another useful strategy for dealing with dual relationship conundrums is to put in place a decision-making model to apply when these situations arise. “In a lot of ways, codes of ethics can be difficult because they are written in language that may be unclear or which a person can rationalize against,” says Vis. “Implementing an ethical decision-making model is a useful way to walk you through the steps toward a decision about how to deal with the situation.”
“If you’re working for an agency or practice or in a hospital, it’s a good idea to establish some sort of ethical response procedure or guideline,” says Vis. “That includes some protocol that would respect one code of ethics or some kind of policy manual. It would also have some strategies for response when an ethical issue is identified and would really identify some codes of conduct in black and white.”
Stay current, advises Vis. “Make sure you register for professional training workshops where you’re challenged to think about these ethical dilemmas. Read articles around the issues.”
These are solid guidelines around which to organize practice and professional behaviour; but health care practitioners also need practical tips for minimizing the likelihood of messy dual relationships.
Samek in Alberta doesn’t publish her phone number or address in the local phone book, so clients can‘t contact her at home. She has also asked her extended family not to give out her contact information because in a small town, people often call around for someone’s phone number. Samek also discusses ethics with her colleagues so she is not forced to make decisions on her own. But she has also had to resort to some safety measures. In small communities where health care professionals are relatively easy to track down, workers can be the target of anger if an act that was part of their job was carried out against someone in the community. “I once had an unwell man come to my home,” recalls Samek. “How do you maintain confidentiality while protecting yourself and your family? I had to warn my husband that if he saw a particular vehicle near our home, he should call the police.”
“The best thing that can be done in any agency or office is to have a discussion in the setting itself around non-sexual dual or multiple relationships; have people with whom you can talk over these sorts of issues,” says Valentich. “Developing a policy around dual or multiple relationships is also helpful. Take charge in advance if you can’t, so you can work out with your clients how you’ll handle yourselves in social situations.” That might mean talking with a client with an alcohol use problem about what to do if you meet at a party where you are drinking. “It really is the responsibility of the health practitioner to think about what they’re doing,” says Valentich. (For more practical strategies, see sidebar, previous page.)
“The real emphasis isn’t on rules – never do this, always do this, only do this,” says Paula Pasquali, director of Community Health Programs with the Department of Health and Social Services in Whitehorse, Yukon. “Rather, it’s agreeing with your colleagues or arriving at a decision on your own that this is the decision-making process you will use when you encounter a situation where you’re in more than one relationship with somebody,” says Pasquali, who has led workshops on multiple relationships in small communities. “If you commit to that strategy you have a real safeguard; you know that you will take into account all the relevant factors in order to decide how to deal with the situation.”
In the end, don’t count out instinct. “Trust your sense of discomfort in any situation,” says Valentich. “If there’s a little voice saying be careful, then assess the situation in more depth.” Samek agrees: “It’s the idea of going on that instinct; we have good instincts, so if something feels wrong, it probably is.”
In small communities, the boundaries separating your professional and personal life are less clearly defined than in larger communities.
“It’s very difficult to maintain boundaries because of all the multiple roles you have with people. Often codes of ethics talk about dual roles, but our experience is multiple relationships.”
• Create a model or chart comparing the similarities and differences between a friendship and a client/professional relationship. “For example, there’s usually an equality in a friendship with an open duration, while in a client relationship it’s time-limited,” says Mary Valentich, professor emeritus at the University of Calgary Faculty of Social Work. “Compare the power levels in each relationship and the scheduled aspect [professionals see clients during set appointments]. If you can think their way through the differences, that can help guide you.”
• “We encourage using good professional judgment rather than simply memorizing and adhering to a particular code of ethics,” says James Gripton, professor emeritus in the University of Calgary Faculty of Social Work. That means thinking the situation thorough to help determine what’s most critical – is there a violation or is that overridden by a more pressing need for help? If you’re a hospital psychologist and your daughter’s teacher comes in on a suicide attempt, the life-threatening behaviour is likely more pressing than the threat of a dual relationship, says Gripton.
• Health care professionals agree that creating a support system for yourself is important. Have a colleague or supervisor with whom to talk things over. They don’t necessarily have to be in the same town – a phone call away works.
• “If you’re working for an agency or practice or in a hospital, it’s a good idea to establish some sort of ethical response procedure or guideline,” says Jo-Ann Vis, a social worker and lecturer at Lakehead University in Thunder Bay, Ontario. “That includes some protocol that would respect one code of ethics or some kind of policy manual. It would also have some strategies for response when an ethical issue is identified and would really identify some codes of conduct in black and white.”
• Stay current, advises Vis. “Make sure you register for professional training workshops where you’re challenged to think about these ethical dilemmas. Read articles around the issues.”
• A good rule of thumb: Can you record it? “If you can’t record it anywhere – the relationship and what’s happening – there’s something going on,” says Valentich. “If you can’t write it down on the client’s record, there’s a problem. We’ve noticed that where codes have been broken, people haven’t kept records.”