Ethics and Other Professional Responsibilities for

Human Service Workers

Introduction
Ethical principles are the foundation of good human service practice. In fact, workers who do
not practice within ethical parameters cannot be called professional. True professionals understand
their ethical obligations and seek guidance when they do not.

Each social welfare profession, from psychologists to social workers to human service workers,
develops a set of ethical principles appropriate to the practice. Most professions monitor the behavior
of their members with regard to these principles, singling out those who violate ethics codes for
disciplinary measures.

Ethical principles are generally created in order to protect and prevent the exploitation of the
individuals who come to us for service. In the work we do, there is considerable opportunity to exploit
vulnerable people because the people who seek our help are dependent upon us for the aid they need.
Any violation of their trust on our part will only compound the person’s problems. Ethical principles
provide guidelines to protect individuals from exploitation. However, when professionals practice within
the parameters of ethical principles, the public can feel confi dent that their interests will be respected
and protected. Thus, ethical principles inform the decisions we make that affect clients, and they
provide guidance in choosing the approaches we take with clients.

In this chapter, we will look at some ethical guidelines common to all the helping professions.
Failure to know and follow these guidelines in your future practice can result in dismissal from an agency
or, worse yet, in a civil suit brought against you for a violation of the ethical code wherein the violation
caused damage to the person. Although violations of ethical principles may have negative consequences
for you and your career, they are always extremely destructive for the individual, who is already
vulnerable.

Language and Ethics

Language in the social services is a funny thing. After a word is adopted to describe people who
use a service, that word becomes pejorative over time and a new word meaning the same thing is
sought. In social services, we have gone from patient (which implied people seeking services were all
mentally ill) to client and fi nally to consumer.

Client was meant to denote that the person was being served by a case manager in a
relationship much like a lawyer–client relationship. This originally conferred an obligation on the part of
the case manager to give good service to someone paying, in some manner, for that service. However,
as with all words describing people who use social services, the word client developed a negative
connotation and the word consumer was increasingly used instead. Consumer also implied the person
was paying for good services from the case manager.
 With the Recovery Model (see page 427) and the emphasis on partnerships between case
managers and the people seeking services, those words are no longer considered appropriate. The
concern is that these words denote a difference in status between case manager and those they serve.
Thus, in recent years, the terms client and consumer have given way to person or individual, and in
many cases no term is used but rather the person’s name is used instead. In this textbook, we subscribe
to the idea that case managers and the people they serve are in a partnership to which each brings a
certain degree of expertise. In your work, we strongly encourage you to drop the use of the words
consumer and client and adopt what is seen as the more respectful terms of individual and person.
However, having said that, there are places in this textbook where using person and individual alters the
meaning of the sentence and the point that is being made.

For that reason, in this textbook, we need to use client to denote a person seeking professional
services from a professional case manager in order for the point to make sense. This is in no way meant
to diminish the person who does seek service, but rather to make our points more coherent.

Dual Relationships
A dual relationship occurs when you and a person to whom you are giving services have more
than one relationship. You may be this person’s case manager as well as her cousin, her boyfriend, or
her customer at her beauty salon. Or you may be a person’s case manager and also his employer for
your yard work, his Sunday school teacher, or his Little League coach. In other words, a dual relationship
occurs when you are in two different relationships with a person, one related to your position as the
person’s case manager and the other unrelated to that role.

The first rule is to avoid all dual relationships. Your practice gives you a position of power.
People tend to look up to you as someone who can provide real assistance. Furthermore, you might be
the one who will determine when a person can return to work, or you may be the person who reports
an individual’s attendance in your program—attendance that keeps that person out of jail. It is possible
that you could exploit or give the appearance of exploiting this power. In addition, there is enormous
potential for a confl ict of interest.

Suppose, for example, that your supervisor tells you on Thursday afternoon that you have been
chosen to represent the agency at a big dinner being given to honor a county offi cial at the Hilton Hotel
on Saturday night. This gives you little time to prepare. You need to get your hair cut and styled. You call
a man who receives services from you who is a hair stylist, and prevail on him to work you in at the last
moment. He does you a favor and sees that you get a good appointment. You are very grateful, go to
the wonderful dinner, and think little more about it.

Several months later this man calls you. He has a need for a prescription refi ll from his
psychiatrist. It is Friday afternoon, and the psychiatrist will not be back in the agency until the following
Wednesday. He feels you should be able to do this favor for him because of the favor he performed for
you. He does not have time to see the psychiatrist regularly, he tells you. When you refuse to call in a
prescription for him without the doctor’s prior knowledge, he cannot understand why you are being “so
rigid.” He indicates that he thought the two of you were friends who helped each other out when
needed.
Whatever you do in this situation, you will lose. If you call in the prescription, you will have violated an
agency rule that a person must be seen at regular intervals by his psychiatrist before medications can be
refilled. This could cost you your position or result in a disciplinary action. On top of that, you could start
down a very slippery slope with this individual. He may come to expect special favors from you and offer
you special, very tempting favors related to his business in return. On the other hand, if you do not call
in the prescription, you have alienated someone who needs the services of your agency. You have
created a barrier to his feeling comfortable with you and getting the help he needs in the future. The
individual is harmed.A relationship that was or could have been useful to him in resolving problems is
now something else. The opportunity for real progress is diluted with issues of friendship and favoritism.

From a shortsighted point of view, you and this person may see the convenience of exchanging
favors as trivial and unrelated to the therapeutic relationship. In the long run, however, when scenarios
such as the one just described occur, the relationship can never return to a professional one; and if in
the future this individualis in acute need, you may no longer be able to provide the professional
intervention needed.

In some very small, rural communities, it is not possible to avoid dual relationships entirely. In
those situations, after doing all that you can to make otherarrangements, you must talk with the person
about the possible problems that could arise and how each of you must avoid these problems together.
Then the person has the choice to continue the relationship, fi nd other arrangements, or discontinue
services altogether.

Gifts from People You Serve

Although gift giving by those whom you serve does not pose a dual relationship, people who
bring gifts for you do pose a particular confl ict of interest. It is usually best to avoid accepting gifts and
keep the relationship professional. Often, though not always, gifts are the person’s way of manipulating
the situation. “I’ll give you this item and you accept it. Next time you owe me something” or “I gave you
this lovely thing. I am such a nice person. Even you think so or you would not have taken my gift. How
can you then refuse to give me what I want?” People need to learn to express their desires clearly rather
than by using gifts.

Gifts are not always manipulative, however. For example, a case manager working in a fuel
assistance program worked closely with a family. The husband was injured when an automobile he was
working on at a garage slipped on the lift. Unable to work, the family’s meager resources began to dry
up. The wife managed to find work in a greenhouse, but as winter approached, she was laid off and the
expenses, particularly for fuel, increased. The couple had two children, both in elementary school, and
they struggled to clothe and feed them as the wife sought another job.

The case manager saw this family through their diffi culties by getting them welfare checks,
seeing that the husband enrolled in the community college for courses in high-tech auto repair while his
injuries healed, and fi nding school clothes for the children. The husband did well in school that winter
and set a good example for his children, who seemed to do better in school than they had the previous
year. The wife returned to the greenhouse in the spring and found that not only was she needed as a
manager, but there was also a strong possibility she would have a year-round position there.

Elated by how well things were going and how much better the future looked, the couple came
to see the case manager one day in the early summer and brought her a pot of black-eyed Susans from
the greenhouse. “We just wanted you to have these for all you have done for our family,” the husband
said, smiling expansively. The husband and wife looked pleased and happy. Obviously the couple was
proud to now be in the position to be able to give something too. It was important to them not to see
themselves as the recipients of handouts all the time, but to be able to also give something to someone
who had been helpful to them.

Refusing a gift in such circumstances can be interpreted as rejection. If the worker had said, “Oh,
I can’t accept that. You’ll have to give it to someone else,” a person might have heard a different
message: “You are the client and I am the benevolent worker. I help you, but you can never get to the
position where you could possibly do anything for me. I don’t need anything you could give me; but you,
on the other hand, are a poor soul in need of my help.”

If your agency has a policy against your personally accepting gifts, try to fi nd a way to accept a
gift of this sort on behalf of the agency. In this case, the worker planted the flowers in a planter near the
door of the agency. This was a better solution than outright rejection of the gift.

The rule is to be very careful about accepting gifts from people you serve. Whenever an
individual offers a gift, make a note in the person’s record of the offer as well as whether the gift was
accepted or rejected and why.

Sexual or Romantic Relationships

Individuals who come to human service workers for help often feel isolated, discouraged, and
misunderstood. The relationship they form with a respectful, concerned worker may make them feel
understood and appreciated for the fi rst time. This relationship may be so comforting that people
attempt to turn it into something more permanent, more personally meaningful.

It is not uncommon for people to fall in love with their workers in what we call “transference.”
In a sense, such individuals transfer to the workers the attributes they are seeking in another person.
They may assume the love and affection they are seeking will be forthcoming from their workers
because the workers have been so kind and helpful. These people fall in love with their workers because
of an erroneous perception: They see concern and encouragement as gestures of love and affection—as
an invitation to create more than a professional relationship.

Countertransference also can occur. It is not unusual for workers who are harried and
overworked, and possibly coping with diffi culties in their personal lives, to find the willing ear of a
person to whom we give services very supportive. The people we serve are often attractive, sensitive
people who can convey warmth and support when case managers are most vulnerable.

Take, for example, Kent, a case manager. Kent’s wife left in the middle of a Tuesday morning,
and Kent was to be at work that afternoon at 3:00. Though he fought hard to dissuade her from going,
she left. For the rest of the day before work, Kent tried to get some money from their joint account,
tried to fi nd out where his wife was going, and tried to make some decisions. He arrived at work feeling
exhausted and bitterly betrayed.

That evening, Kent made a home visit to Lucy’s house. Lucy had fi rst come to the agency with
extreme depression, but she was doing so well now that Kent was considering terminating these follow-
up visits. Lucy, an artist, greeted Kent warmly. She had put on a pot of tea and made some banana bread
for his visit. Gratefully Kent sank down on her sofa. Instead of asking Lucy how things were going for her,
whether she had enough medication, and whether she had any medication questions, Kent found
himself talking about his upsetting day.

In response to Lucy’s first remark, “You don’t look very well tonight, Mr. Paulman,” Kent heard
himself pour out the day’s events; then he went on to talk at length about how his marriage had
unraveled. He felt comforted by Lucy’s interest in him as she listened intently. Here was a person who
appeared to respect him as a professional and as a person. Here was a woman willing to listen to his
problems. Here was a warm retreat from the job and the problems of the day where Kent could feel safe
and supported.

Kent never intended for a real relationship to develop between Lucy and himself. In fact, as he
left that night, he told himself that he might have crossed a dangerous line and that he should avoid
further contact of this sort with Lucy. Nevertheless, based on that evening, Lucy called; and because
Kent was lonely, his life was uncertain, and he was fi lled with anger and bitterness about his situation,
he continued to see Lucy, finding in her a warm, supportive person, someone who could reassure him by
her presence that he was attractive and interesting.

The relationship moved from his visiting in her home after work to his staying overnight at her
house to his moving in his belongings and beginning to live there. They went out on dates. The
furtiveness of these activities only made the relationship seem more romantic and important. Finally, a
supervisor discovered the relationship, and Kent lost his job. After 3 years, he and Lucy have separated,
and Kent is not working in the human service fi eld anymore because he violated such an essential ethic.
Instead, he sells appliances in a local store. Lucy became depressed when the relationship ended and
has entered treatment again.

The person responsible for maintaining a professional relationship regardless of personal

feelings is the case manager. Regardless of how you feel about the person on your case load or how that
person apparently feels about you, you are the responsible party. You will be penalized if the
relationship crosses from professional to intimate. It is always assumed that the individual you are
serving is the vulnerable party.

Figure 1.1 lists some warning signs that indicate when a worker or an individual receiving
services might be moving away from a professional relationship and toward a personal one. Make
certain you are familiar with these signs.

PLEASE NOTE!

It is a violation of all ethical codes, and in most states against the law, to engage in a sexual or
romantic relationship with a person receiving services from you. This is clearly exploitation. It is never
tolerated. You must be aware that, although attractions can occur between those receiving service and
those who provide service, acting on those attractions is entirely unethical in professional practice and
illegal in most states as well.
Value Conflicts
Generally, the person’s values and your values have little to do with why the individual is
seeking services from you. Sometimes, however, religious, moral, and political values play a pivotal role
in the problems people bring to agencies. It is rare for case managers to get deeply involved in such
primary problems, but it can happen.

First, you can be prepared by consciously knowing yourself and your feelings about certain
value-laden issues. Then, if a conflict of values occurs between you and an individual you are serving,
you should be able to tell that person that the conflict exists and may interfere with services. You can
begin to inventory some of your own attitudes and strong feelings by completing the self-assessment
exercise in Figure 1.2.Second, if a severe conflict of values exists, you might need to make arrange-
ments to transfer the person to another case manager. You would not do this because of a simple value
conflict, but you should try to make such a transfer if you find you can no longer be objective, you are
extremely uncomfortable with the person because of her or his values, or you feel compelled to
counteract the individual’s values by imposing your own.

For example, a human service worker who did not personally believe in birthcontrol (including
tubal ligation) was a case manager for individuals with developmental disabilities. When a young couple
on her caseload decided to marry, she became actively involved in discouraging them from the idea,
particularly when she learned that the woman planned to have a tubal ligation so that they would not
have children.The families of the two individuals supported the marriage. The people were
highfunctioning, each one had a job, and each had the support of other community agencies.

In the months before the wedding, the case manager did not attempt to transfer the cases to
another case manager. Instead, she harangued the couple about the sins of birth control and of
marriage without children, and about the unwise decision to marry at all, given their “mental
impairment.” The families complained to the agency,asking that she stop pressuring these vulnerable
individuals. Twice the supervisor disciplined the worker. When the worker persisted—visiting the
couple’s minister who would perform the ceremony, the supervisor where the man worked, and the
woman’s parents—she was fi red from her position.

The worker’s behavior was harmful to this couple. For those two people, who had always relied
on a case manager who had seemed to be wise, the worker introduced uncertainty and fear. Her
constant negative warnings damaged their fragile self-confidence and self-esteem. For them, what
should have been a happy decision, supported by family and friends, became a decision fraught with
anxiety. Family and friends had to work long and hard to restore their confi dence in their original
decision.

This is an example of the worst possible way to handle a values conflict. In this situation, the
worker attempted to impose her own point of view, her own personal values, on the couple. She denied
them the right to choose for themselves and interfered in what was largely a personal and family issue
unrelated to case management.
FIGURE 1.1

Warning Signs from the Client

• The client shows overt sexual interest in the worker either through conduct orverbally.

• The client describes dreams that are increasingly sexual in which the worker is prominently involved.

• The client is excessively interested in the worker’s private life.

• The client inquires about the worker’s relationship with his or her spouse and children.

• The client attempts to give the worker romantic gifts. (Be careful about accepting gifts from a client.
Note every such offer in the record, along with whether the gift was accepted or rejected and why.)

• The client wants to see the worker outside the offi ce in places such as restaurants or movie theaters.

• The client gives the worker romantic poetry or brings in romantic articles and books.

• The client dresses in seductive attire.

• The client interprets the worker’s statements of concern for the client to mean the worker has a
romantic interest in the client.

• The client repeatedly hugs and touches the worker.

• The client indicates a desire to be special to the worker. Warning Signs from the Worker

• The client is prominent in the worker’s dreams.

• The worker looks forward to seeing the client, more so than other clients.

• The worker begins to see the client as more understanding than others in the worker’s life.

• The worker inquires about the client’s sexual life and fantasies when these are not relevant to case
management.

• The worker is more interested in this client’s attire than in the attire of other clients.

• The worker is more concerned with his own attire on days when he will see the client.

• The worker begins to see the client as a person without issues or problems or minimizes these so that
the client seems more acceptable as a partner or friend.

• The worker takes many innocuous actions the client might interpret to mean the worker has a special
interest in him or her.
FIGURE 1.2

Self-Assessment Exercise: Possible Values Conflicts When Helping Others

Look at each description of a person or group of people, and assign a number to each.

1 Give the description a 1 if you think you could work with the person or group.

2 Give the description a 2 if you think you could work with the person or group, but would find it
uncomfortable or diffi cult.

3 Give the description a 3 if you could not work with the person at all.

1. A woman who wants you to help her feel comfortable with her decision to have an abortion

2. A man who frequently brings up his fundamentalist religious beliefs

3. A homosexual couple who want help in improving their relationship and resolving their interpersonal conflicts

4. An interracial couple seeking premarital counseling

5. A man from Iran who strongly opposes the equality of women and talks about women working in denigrating
tones

6. A man who has for years been getting more welfare than he is entitled to receive by using certain tricks he
developed to beat the system

7. A man and woman who say they want to improve their marriage, but the man will not end his affair with a
second woman

8. A white couple seeking help for behavior problems with their adopted son, who is African American

9. A man who makes it clear he often disciplines his children by using corporal punishment

10. A person who refuses to discuss feelings and says that all that matters are facts and logic

11. A woman who has chosen prostitution as a way to support herself and her children

12. A gay man dying of AIDS who comes in with his lover to resolve conflicts around how he contracted the disease

13. A man seeking help to curb his extreme abuse of his wife

14. A woman who sexually molested her son

15. A lesbian couple seeking to adopt a child

16. A woman dying of breast cancer who wants to take her own life

17. A person who relies heavily on cocaine to get through the day

18. A couple who are openly anti-Semitic

19. A vocal member of the Ku Klux Klan

20. An orthodox Muslim who cannot always see you because his appointments often interfere with his times of
prayer

Avoiding Value Conflicts

Following are some rules for avoiding value confl icts and ensuring that individuals get
professional service from you:

1. Be respectful of attitudes and lifestyles that differ from your own.

2. Never practice prejudice toward minorities, those with disabilities, or those differing in sexual
preference.

3. Always give your best service to a person, even when you disagree with the person.

4. Never attempt to change the individual’s values to coincide with your own.

Using Values to Motivate People

When people come in seeking assistance, they are usually hoping to make things better in their
lives than the way they are right now. In the course of your time with them, it is important to explore
the values that caused them to seek help. Find out what goals people have for themselves if their
situations were better, and what values those goals reflect. Here we are looking at the things that
people value for themselves:being a good parent, living an independent life, living free of the symptoms
of schizophrenia, or being free of cocaine addiction. The person is envisioning something up ahead that
involves a goal or value dear to that person.

You often learn about people’s values when you ask them where they would like to be in 5
years. What you hear when they answer will point to what they hold important for themselves and
those around them. When people are having trouble making changes that will move them toward their
personal goals and visions, it is helpful for the worker to know what the individual’s values are and to
look at the person’s situation with those values on the table.

The Rights of Individuals Receiving Services

Anyone who gives service in one of the helping professions must be familiar with the rights of
the person and make a particular effort to see that people understand they have rights when they seek
help. Often people mistakenly assume that they have few or no rights when they come in for services. In
addition, professionals may fail to inform individuals of their rights because it is easier to work with
people who are vulnerable, dependent, and uninformed. This, of course, sets up a situation in which it is
easy to exploit the person. The purpose of educating people about their rights is to allow them the
opportunity to become active participants in their care and partners in decisions that affect them.

Most agencies prepare clients’ rights handbooks for those receiving services to keep as a
reference. A hospital for the mentally ill would include the right to be released from the hospital as soon
as care and treatment in that setting are no longer required. Nearly all agencies inform people that they
have the right to participate in the development and review of their treatment plan. People generally
have the right to participate in major decisions affecting their care and treatment. Most of those who
are involuntarily committed to an inpatient setting have the right to refuse treatment to the extent
permitted by laws in that state or the right not to be transferred to another facility without clear
explanations regarding the need for the transfer. Inpatient units stipulate it is the person’s right not to
be subjected to

harsh or unusual treatment. The hospital may also spell out the fact that the individual may keep and
use personal possessions, or the person must be informed about why something is being removed. In
most settings, people have the right to handle personal affairs and to practice the religion of their
choice.

In outpatient settings, people have the right to a fl exible and responsive treatment plan, the
right to expect an individualized plan of service, and the right to make suggestions and express concerns.
Often there is a procedure individuals can follow if they are dissatisfi ed with the worker assigned to
them or the service plan laid out by the agency.

The following sections discuss some important rights that belong to those receiving services.

The Right to Participate in Planning

When you sit down with someone to begin planning what services would work best or what
treatment would be most effective, you each bring unique perspectives to the table. You have a detailed
understanding of what is available, which services work better than others, and where people on your
case load can receive treatment or service tailored to them. A person comes to the table with
information about themselves that is useful when planning. Putting these two pieces of information
together makes for a more effective plan. People who work with you feel that they have had a part in
the planning and therefore, some control over the direction of their care. This makes it more likely that
the plan will be followed or that your individuals will tell you if they see the need for a change.

It is for this reason that we do not just disrespectfully tell people what their service or treatment
plan will be without consulting them first.

The Right to Self-Determination

Educating people and informing them about their rights are both done so that clients can
exercise the right to self-determination. Paramount to any relationship between professionals and their
clientele is the right to self-determination. People have the right to do research about their diagnosis or
problem and to question the treatment plan or make suggestions. People have the right to withdraw
from treatments and services they find are not helpful. People have the right to decide when and for
how long they will use services (unless their involvement with the agency is based on an involuntary
court commitment). People have the right to choose their own goals.

Often this presents a problem for a worker who feels compelled to look after the best interests
of the individual. One of the hardest lessons you will ever learn is how to let people make mistakes and
learn from those mistakes. You can make suggestions and express concerns, but ultimately clients have
the right to determine what they will do. You may feel strongly, for example, that one individual is not
ready to walk away from the agency; and you may feel certain that the person’s doing so prematurely
will result in further problems with alcohol. In fact, your client leaves treatment against your advice and
eventually does end up with another DUI charge.

Although your worst fears and predictions came true, you cannot know for sure that the work
with you and the new charge were not important learning opportunities. In other words, people have
the right to test the waters, so to speak, and to learn that they are not as ready as they thought they
were.

Increasingly, however, self-determination means more than this. More and more funding
sources and governments, as we shall see in the next chapter, are asking case managers to go beyond
simply arranging for services in collaboration with the client. They are asking case managers to
encourage people to articulate what their vision of a healthy, productive future would look like. As
people do better on medications and remain in their communities, how they function in those
communities—how they contribute, feel secure, and pursue their own interests—becomes more
important. Selfdetermination now takes on the future beyond the social and emotional problems that
were the original reason for seeking help. Now people are being energized by their case managers to
explore and create a better tomorrow of their own making.

Informed Consent
A person receiving services always has the right to consent to these services or with-draw from
them. In making this decision, the person must be informed enough to make a wise decision. When the
individual is informed and consents to treatment,we call that informed consent. Making certain that a
person can give informed consent begins with the intake, during which the agency policies are explained
and choices of treatment or services are outlined. This level of information should continue through out
the entire relationship between the individual and the agency until termination.

This means that people informed about treatment or services can make their own decisions
with regard to the services.

The following list contains items that should be addressed when relevant to the person’s services. The
person has the right to be informed about:

1. Any side effects, adverse effects, or negative consequences that could occur as a result of treatment,
medications, or procedures

2. Any risks that might occur if the person elects not to follow through with treatment or services

3. What is being offered to the individual, including what the treatment is, what will be included, and
any potential risks and benefi ts

4. Any alternate procedures that are available

Some of the people with whom we work have a limited capacity to understand all the details of
service and treatment. It is our task to fi nd an appropriate balance between too much and too little
information and to make our information clear and easy to understand.

Informed consent consists of the following three parts, or criteria. All must be present in order to say
that the individual gave informed consent:

1. Capacity. The individual has the ability or capacity to make clear, competent decisions in his or her
own behalf.

2. Comprehension of information. The person clearly understands what is being told to him or her. To
make sure that this is so, give your information carefully and always check to be sure the person
understands what you have told him or her.
3. Voluntariness. The person gives his or her consent freely with no coercion or pressure from the
agency or the professional offering the service.

Currently laws and courts are recognizing more and more often the person’s right to self-
determination. When we fail to tell those we serve the information they need in order to give informed
consent, we run the risk of being found negligent, particularly if the treatment or service involved was
unusual.

The Right to be Informed of Changes and Decision

There are times, however, when you are working with a person who cannot participate. People
who are confused, have severe developmental disabilities, or are psychotic often are not capable of
planning or giving input. Letting them know what will happen is still respectful. One case manager’s
client, Mindy, was hospitalized when she became psychotic as a result of schizophrenia. Mindy barely
responded to treatment and the decision was made to transfer her to a longer-term care facility. The
nurses on the hospital unit made the arrangements for transportation and who would help with the
transfer from the unit to the ambulance.

The case manager had agreed to the transfer and came in a few hours before it was to take
place to talk to Mindy about it. The nurses were incredulous. Mindy was in a room with only a mattress
on the fl oor because she had taken her room apart several times. She was uncommunicative and had
been yelling at voices she heard. “She isn’t going to understand a word you tell her,” one of the nurses
remarked. Nevertheless, the case manager went to Mindy’s room, sat down on the bare mattress on the
floor and began to describe in some detail what was going to happen. Mindy grew quiet. She never
looked at her case manager, but she appeared to be listening intently.When the orderlies came to take
her to the ambulance she went without resistance.

Did Mindy really understand what her case manager told her? Is that really the point? The point
is that this case manager respected her client’s right to know what plans had been made for her. The
right to know what treatments and services have been planned and the right to participate to the
degree a person is capable are important ways professionals demonstrate respect for the people they
serve.

Confidentiality
Confidentiality is both an ethical principle and a legal right. It is the most basic right of any
person, either in treatment or receiving services, to know that what the person is sharing in your offi ce
will remain confidential. It is important to protect individuals to whom we give service by not disclosing
their personal situations without the people having authorized such a disclosure. Today, under new laws
discussed in the text that follows, agencies have very specifi c guidelines for protecting confi dentiality.

Release of Information Form

Not many years ago a person seeking services, particularly from a public agency, signed a
blanket permission statement allowing information to be shared with others as the agency and the
worker saw fit. Today, release of information forms must state specifi cally to whom the information is
being released and must be time limited (good for 3 months, 1 year, and so on). Do not use forms that
are not specifi c in this manner.New regulations now stipulate what is permissible on a release of
information form.

Release of Information Regarding HIV/AIDS

In most states, release of information forms for releasing information regarding a client’s
HIV/AIDS status must specifi cally state that you may release information regarding the person’s HIV
status. All references to HIV/AIDS must be deleted from the record unless the client signs a separate
form that specifi cally states that you have permission to release this information. If you are asked to
release information about a person who is HIV1 and the person signs a release form, the law in most
states specifi es that it is not good enough to simply remind that person that his case contains
references to his HIV status and get his verbal permission to release the information anyway. You also
must have his written permission. If the person has not given you written permission, you must delete
all references to HIV/AIDS, including the fact that he may have been tested and the test was negative.

If your state does not have such a law, you are still responsible for protecting your client and
must be alert to the possible harm such a release might cause the person. In such a situation, it is wise
to involve the person in a discussion about the release of this sort of information or, if the individual is
unable to participate in such a discussion, to take steps to protect that individual from undue bias.

In some instances, workers have informally notifi ed their friends and acquaintances in other
agencies of a person’s HIV1 status, thinking they were doing these people a favor. In fact, this behavior
is entirely unethical and can lull other workers into believing they know who is and who is not HIV1. We
can never actually know this for certain because of the length of time it takes for the disease to register
positive on a blood test. A person can be positive early in the illness and still have negative blood tests.
For this reason, workers should use universal precautions with every client when those precautions are
called for. Workers who fail to use universal precautions on the false assumption that they know the
individual is not HIV1 place themselves at undue risk.

Collegial Sharing
Out of respect for individuals, you should ask them for permission before sharing information
with colleagues from whom you are getting opinions or supervision, unless the case is going to be
discussed in the normal course of supervisory meetings with a regular supervisor. Likewise, you cannot
share information with student interns without making certain the students have signed agreements to
observe strict confidentiality while acting as part of the agency. Suppose you are working in an agency
and have been asked to give a student a view of what you do. To illustrate what you have told the
student, you show her several case fi les. She reads the cases and discovers that one of them is the
boyfriend of her cousin. What she reads in the fi le is alarming to her, and she decides her cousin should
not be dating the client. She leaves the agency and begins to share information with the cousin, causing
considerable conflict among family members and anguish to the cousin, who knew part of the story but
not all of it. This kind of sharing of information is unacceptable, and most agencies do not allow students
or volunteers to read anything before they have signed a pledge to honor the confi dentiality of the
clients and you feel these students thoroughly understand the critical importance of protecting confi
dentiality.
Guarding Confidentiality on the Phone and in Other Conversations
Other situations also provide opportunities for violating confi dentiality. For instance, a person
receiving services from your agency may also be receiving services from a local physician. Suppose
someone calls, claiming to be the physician’s nurse and needing to know at once what medications the
client is taking. She may really be the physician’s nurse, or she may be a person posing as the nurse in
order to determine that the person is using your services and the level of his problem. Even if she is the
nurse, the person may wish to keep his physician uninformed about the involvement with your agency.
All agencies have procedures for such situations in the event of a real emergency. You, however, must
never openly and automatically acknowledge that an individual is being seen in your agency, no matter
how important and offi cial the other person seems to be. In the case of a seeming emergency, refer the
call to your supervisor unless you know the emergency workers or emergency room personnel well
enough to recognize their voices.

When a request for information is presented in a situation that is not an emergency, here is how
you might handle the request:

YOU: Hello.

CALLER: Hi. This is Ann Taylor. I’m a counselor at Marlboro Middle School, and I’m calling about Jimmy
Smith. Did he and his mother keep their appointment with you today?

YOU: I’m sorry, I can’t help you with that. Would you have Mrs. Smith sign a release of information form
stating what it is you need to know, and if Jimmy Smith is known to us, we can send you that
information. In this situation you do not give any hint that the client is known to your agency. By saying
“if this person is known to us . . . ,” you do avoid letting on whether the client is or is not.

Another way to violate confidentiality is to talk about your cases with your friends and relatives,
leaving out the names. Others may be able to piece together the identity of the person you are talking
about based on other information they possess. In this way, they may discover far more about a person
than that person ever intended them to know.

Minors and the Infirm

Take special care to protect the confi dentiality of minors and the infi rm (individuals who are
frail, sick, and are unable to fully participate in decisions about their care). Not all systems respect
confidentiality to the degree that we in the helping professions are committed to doing it.

In one children’s case management unit, parents were routinely urged to sign blanket release of
information forms. When the school requested information on a child being seen, all the information
was sent to the school. It was stamped in red letters with the word confi dential, and it was sent to the
school psychologist. Nevertheless, school clerical personnel assisted in typing and fi ling information for
the psychologist and generally read the information sent by the case management unit. Having no
training in confidentiality, these clerical people talked among themselves about students, sharing
personal information they had learned. Many times they passed on to teachers tidbits of what
amounted to gossip. This information shared outside the professional context and without professional
understanding jeopardized the progress of the children and the relationship of their parents with the
school personnel. As these children moved through the school system, the gossip followed them. Always
be very careful about what information you release. Remember that information given about a child can
follow that child all through school, prejudicing responses to that child.

In another case, a woman with a developmental disability got a job at the police department as
a cleaning woman. She was told that she needed to bring in her “records from mental health” so the
police could know why she went there. She arrived at the case management unit, pleased about the job
and ready to give all her records away. The case manager talked to her about the wisdom of retaining
most of the information as confidential. In the end, a short statement was released, with the client’s
permission, giving only the most general information about her relationship with the mental
health/mental retardation case management unit. It is important to remember that older people or
individuals who do not have the capacity to protect themselves can be easily led to sign releases
regarding information that might best be kept confidential. The responsibility belongs to you to protect
your clients from unnecessary intrusions into their personal information.

Minimum Necessary Rule

Before releasing information, ask yourself whether you are about to release more information
than is needed for this other business or organization to accomplish its work with the client. For
example, Melissa was a case manager who knew a worker in a remedial education program where one
of her clients, Jill, was attending. Although the program needed to know why Jill was referred and what
goal the referral was intended to accomplish, they did not need to know that Jill was arrested once for a
DUI and that Jill’s father was in prison for murdering a neighbor. When dealing with other organizations
not engaged in treatment, release only what that organization needs to work effectively with the client.
If the client authorizes you in writing to disclose more, only then would you do so.

When You Can Break Confidentiality

The law in all states does make exceptions. The following are circumstances that allow you to
break confidentiality:

1. When you must warn and protect others from possible harmful actions by the client. For instance, you
or your agency must warn another party if your client is intent on harming that other party. In addition,
you should notify the police.

2. When the person needs professional services. For instance, if the person has taken an overdose of
medication and is in the emergency room (ER), the ER staff may call, needing to know what prescriptions
the client was taking in order to give the proper antidote.

3. When you must protect people from harming themselves. An example might be people who are
threatening to take an overdose of their medications with the intention of committing suicide or people
who appear so depressed or desperate that they are talking about ending their lives.

4. When you are attempting to obtain payment for services and the payment has not been made. Your
agency would refer a person for nonpayment only after reasonable attempts had been made to remind
the person of this obligation and only if the individual had made no effort to arrange even minimal
payment.

5. When obtaining a professional consultation from your supervisor regarding how best to proceed with
a case in the course of normal supervision.
Privacy
Privacy is very much related to confi dentiality. Siegel (1979) calls it “the freedom of individuals
to choose for themselves the time and the circumstances under which and the extent to which their
beliefs, behaviors, and opinions are to be shared.” Stadler (1990) calls it “the right of persons to choose
what others may know about them and under what circumstances.” Privacy is invaded or altered under
some circumstances, and people need to be informed of those circumstances. The point you should
stress with the people you serve is the fact that third-party payers will have access to diagnoses and, in
some cases, to actual records or summaries of records. The agency must providethis access in order to
be paid for the services it has rendered. Many individuals are unaware of this fact or unaware of the
extent of the information being shared. They should have this situation explained to them. This allows
people to make an informed decision about whether to pay for services themselves and not involve the
insurance company.

Health Insurance Portability and Accountability Act

The federal Health Insurance Portability and Accountability Act (HIPAA) was passed in 1996 in
part to ensure that people did not lose medical coverage when they changed jobs. Title II of the act
contains the security and privacy mandates. These contain stringent rules for protecting a client’s health
information, and most social service agencies must adhere to these rules. Where state laws are more
stringent than this federal act, the state laws take precedence. Failure to follow the guidelines set forth
in HIPAA can result in fi nes from $100 to $250,000 and from 1 to 10 years in prison for those individuals
and institutions with the ultimate responsibility for safeguarding patient privacy.

The new rules apply to case management and to care coordination and cover not only formal
records but also personal notes and billing information. When you begin work at your agency, they will
see that you are informed of their policies and procedures under this act.

Disclosure
Under the new rules, “disclosure” is defi ned as occurring when health information is released,
transferred, or divulged outside the agency. This includes allowing access to patient fi les to others not
working for the agency. The material in question is often referred to as protected health information
(PHI).

Agency Requirements
In order to comply with HIPAA, every agency must have the following:

1. A statement of the agency’s privacy and confi dentiality procedures, particularly as it relates to
releasing patient information. This statement must be given to every client of the agency. It is
considered a notice clarifying how health information will be used and stipulating the client’s privacy
rights. This is a public document and can be posted in waiting rooms and on websites.

2. A form that people sign and return to the agency indicating that they have received the statement on
confidentiality policies.
3. A privacy officer who is familiar with HIPAA requirements and can oversee implementation within the
agency and resolve privacy issues as they arise.

4. A set of safeguards to protect client records.

The privacy concerns addressed by HIPAA were raised because of the increasing demand by
insurance companies, employers, and others for detailed information on clients and patients, often in
excess of what was necessary to process claims.

Security and Privacy

Security in the act refers to procedures to protect health information from inappropriate access
by others. These procedures usually include controls on who has physical access to the records, security
of work areas and record storage areas, and destruction of duplicate or obsolete fi les. Electronic
security measures are also instituted, such as changing passwords and encryption.

Privacy refers to the person’s right to keep specific information private and includes the
agency’s release of information policies and the rights of the individual in this matter.

Oral Communications
The law states that agencies are to make “reasonable efforts” to safeguard clients’ information.
This extends to oral communications. Taking precautions to protect oral communications means:

• Not discussing a person’s personal health information where others can hear

• Avoiding situations with clients where there is no privacy, particularly privacy from other clients

• Lowering your voice when discussing clients with others in the agency

Release of Information Form

Under HIPAA, the form signed by the person or a legal representative of the person must ad
here to the following:

• The entire form must be in plain, understandable language, and it must be signed and dated.

• There must be a description of the information to be used.

• The form must name the recipients of this information.

• Those who will disclose the information, such as the agency or a therapist, must be named on the
form.

• The form must have an expiration date.

• There must be a statement describing the purpose of releasing the information.

• There must be instructions telling the client how to revoke the form.

• A statement must be included to indicate that the information may not be as protected once it is
released.

• If the agency will receive money for the information (for example, payment from an insurance
company), this must be stated on the form.
• The form must make clear clients’ rights to a copy of the authorization they have signed.

It is assumed that reasonable steps will be taken to release only the minimum information
necessary to support the purpose of the release. When the purpose is continued care of the person or
when the person requests that more information be released, it is expected that more information will
be released. Any request for the entire client record, however, needs detailed justifi cation.

Individually Identifiable Health Information

Individually identifiable health information includes demographic information (such as age,
gender, income, or race) and other information that identifi es the individual or could reasonably be
thought to identify the individual. Information that relates to an individual’s past, present, or future
condition is also included in this category.

People have the right to ask that their information be restricted. They may indicate, again in
writing, that information is not to be shared with family or friends. These requests are generally
honored except in medical emergencies. In addition,clients may ask, in writing, that mail from the
agency not be sent to their home address or that calls from the agency not be made to their home
telephone, and the agency must honor these requests.

A client may ask, in writing, for a written list of how their PHI was disclosed. The request can
extend as far back as 6 years. Note that clients can specifi cally request how information is to be shared
or restricted, but must always do so in writing. A person not able to write such a request may need the
help of a case manager.

Accessing the File

Under the new HIPAA guidelines, people now have a right to:

1. Read their fi les

2. Make copies of their records

3. Make corrections or additions to their fi les, as long as the changes are accurate

As noted earlier, such requests must be presented in writing to the agency and must be
accommodated within a specifi c time period. Individuals who are going to amend their fi les must state
the reason for amending the record in the written request. Client representatives, such as guardians,
have the same access and rights as do clients. There may be times when the person will need the help of
the case manager to formulate that request.

The rights discussed here are guaranteed under federal law; thus, it is illegal to discourage or
threaten people when they make these requests. Currently there is evidence that people who have read
their charts and received clear information are less likely to sue for malpractice or create other legal
problems. It is not a good idea, however, to just hand someone a chart and provide no explanations for
technical information that may be written there. This potentially creates misunderstanding. If at all
possible, sit with the individual and carefully review the important points in the chart. Answer questions
and explain what has been written so the person understands what is written and does not draw
erroneous conclusions or conclusions that could lead the person to believe there is an adversarial
relationship described in the chart.
Social Networking
We think of social networking as something we do with friends, entirely unrelated to our work,
an activity we engage in on our own time. Contributions to Facebook, MySpace, and other social
network sites are assumed to be private and just among friends. In reporting on nurses fi red for posting
on Facebook, WHTM abc27News (Harrisburg, Pennsylvania) noted, “So you’re in your own home, on
your own computer, on your own time, typing on Facebook. It could be your undoing.”

During the winter of 2010, a group of about 13 emergency room workers were fired from a
major hospital in Harrisburg, Pennsylvania, for their social networking activities, activities they assumed
to be private. In this case, the emergency room workers had established a Facebook page where they
discussed their day’s activities with one another. While no patients were actually named, patients were
referred to in exasperated and derogatory terms and their illnesses and personal characteristics were
described in some detail.

The article quotes one nurse as saying, “The one posting I put was, ‘That lady was crazy.’ There
was no name mentioned, those were the only four words I said.” However, the hospital fired this
woman who was shocked. “I would never have thought that what I posted in the privacy of my own
home would have ever ended up being the big mess that it is,” she said.

The workers contended that because the page was unrelated to their work at the hospital and
activities on the page took place on their own time, they should not be fired. The hospital argued that
the page violated HIPAA laws in that anyone who had access to the page could put enough information
together to identify individual patients. Social networking pages are generally not as private as we like to
assume. Friends of friends can gain access, sometimes inadvertently. In this case the nurses and others
did not exercise good ethical judgment. Anyone coming across this site would not have felt comfortable
using emergency room services at this hospital.

Many ethical codes have not caught up with social networking as an ethical consideration. That
does not excuse you or others from exercising sound judgment about when, with whom, and how you
discuss your clients.

Privileged Communication
Clients and workers alike talk about privileged communication without truly knowing what it is.
First of all, it is a legal concept. It protects the right of a person to withhold information in a court
proceeding. It is a right that belongs to the client. It does not belong to the worker or the agency.

All states have a law that stipulates what communication between a client and professional shall
be considered privileged in order to protect the client from the dis- closure of confi dential information
during a court proceeding. These laws designate who is to be considered a professional. A number of
years ago there was a case in which a man who committed a murder confessed this murder in an
Alcoholics Anonymous (AA) group. He tried to invoke the right of privileged communication, but the
courts denied it because the state law did not specifi cally name AA as a group protected by this statute.
 Only clients can invoke privileged communication in order to protect themselves. Professionals
and agencies cannot use it to protect themselves. If the client waives the right to privileged
communication, the professional or agency has no grounds to withhold information. Clients waive this
right if they sue your agency or if they use their condition as a defense in a legal proceeding.

When You Can Give Information

At certain times, you can provide information about people in a court proceeding. In some
situations, you are required to do so.

Legal Proceedings
In a legal proceeding, you may give information about people under the following conditions:

1. You are acting in a court-appointed capacity, such as that of guardian or payee.

2. You or your agency is sued for malpractice.

3. The court mandates that you turn over certain information.

4. The individual uses a mental condition as a defense or as a claim in a civil action.

Protecting Clients and Others from Harm

Other situations in which you can give information about people relate to your responsibility to
protect clients and those connected with them from harm. These situations are:

1. When you believe the person intends to commit suicide

2. When a child under 16 years old is believed to be the victim of a crime such as sexual or physical
abuse or sexual exploitation

3. When you determine the person needs to be hospitalized for a mental condition

4. When the person has told you of his intention to commit a crime, harm another person, or harm
himself

Intention to Harm Another

On October 27, 1969, Prosenjit Poddar killed Tatiana Tarasoff and set in motion court
proceedings that brought about changes in the way confi dentiality is viewed. That October, Poddar was
a patient of Dr. Lawrence Moore at Cowell Memorial Hospital at the University of California, Berkeley.
Moore, a psychologist, was told by Poddar of his intention to kill Tatiana Tarasoff. Moore contacted
campus police, who briefly detained Poddar but released him when he appeared to the police to be
rational.Apparently, Dr. Powelson, Moore’s supervisor, directed that no further action be taken to
detain Poddar. No one warned Tatiana Tarasoff of the danger she faced, and as a result she lost her life.

The Tarasoffs brought charges against the professionals in this case for failure to warn the victim
of the impending danger. When the California Supreme Court eventually heard the case, the court ruled
that therapists cannot escape liability merely because Tatiana herself was not their patient. When a
therapist determines . . . that his patient presents a serious danger of violence to another, he incurs an
obligation to use reasonable care to protect the intended victim against such danger. (Tarasoff v.Regents
of the University of California, 1976)

The steps the court included were warning the intended victim, warning others who would
apprise the intended victim of the danger, and warning the police. The court went on to state:

We recognize the public interest in supporting effective treatment of mental illness and in protecting the
rights of patients to privacy, and the consequent public importance of safeguarding the confi dential
character of psychotherapeutic communication. Against this interest, however, we must weigh the
public interest in safety from violent assault.

The opinion closed with the following:

We conclude that the public policy favoring protection of the confidential character of
patientpsychotherapist communication must yield to the extent to which disclosure is essential to avert
danger to others. The protective privilege ends where the public peril begins.

This case established a “duty to protect” for individuals who treat patients who appear to
present an imminent danger to an identifi able person or persons. The ruling appears to apply mainly to
therapists, but here the waters are muddy. Human service professionals in all states have taken the
position that if such circumstances were to occur in the course of their work, the courts would fi nd
them negligent if they had not exercised the precautions laid out in the Tarasoff case. Most states now
have statutory or binding case law that establishes the duty to warn, but some do not. Regardless, you
must assume that the courts would fi nd you or your agency negligent if you failed to take the
precautions outlined in the Tarasoff ruling. It is unlikely that you would be excused from liability because
you are a case manager, and not a therapist.

Rarely would you make the decision to warn alone. If you believe a person poses an imminent
danger to another identifi able person or persons, you must take the matter up at once with your
supervisor. If your supervisor is not available for consultation and you believe you cannot wait, notify
the police.

In a step down unit for the mentally ill, a man living there left one evening. No one knew where
he was going, and when he didn’t come home that late evening, the staff became alarmed. He had been
talking about going back to the farm where he grew up to “evict those people who put us out.” In fact,
the family had sold the farm, and the people living there were the owners. At this point, the worker
determined that the family at the farm should be warned. The supervisor, unfamiliar with the law,
resisted, even though she would have ultimately been responsible had something happened. Later the
worker ran into the director of the agency and asked her opinion. Immediately the director told the
worker to contact the people at the farm and let the police in that jurisdiction know he might come to
the farm. In fact, the man did show up and talked about the need for the owners to move out. He did
not pose a threat, but the fact that he might have done so was important to consider. In this case, the
police returned him to the step down unit where his behavior was discussed with him. This supervisor’s
lack of understanding about the law could have caused problems for the client, the people living at the
farm, and the agency.
Mandated Reporting
All states have laws requiring professionals to report the abuse and neglect of children. In some
states, laws require human service workers to report elder abuse. The definition of child abuse and elder
abuse varies from state to state. Professionals who must report abuse and neglect under the law are
called “mandated reporters.” The laws in each state stipulate who is a mandated reporter; variations
exist among the states in regard to which professionals are considered mandated to report.

Even in states where there is no mandate to report elder abuse, there may be protective
services for the elderly to which you can report suspected abuse of an older person. You have an ethical
responsibility not to ignore abuse of this type, regardless of the law. It is your responsibility to protect
clients, particularly individuals who cannot protect themselves.

Diagnostic Labeling
Agencies that rely on a diagnosis in order to be paid for service by a third-party payer (such as
an insurance company, Medicare, or Medicaid) need to inform people of that fact. People rarely
understand that labels are used in this way, and most people do not know what the labels are or what
they mean. They are rarely clear about the fact that the information will be passed on to their insurance
companies. People need to know this, so they can then decide whether to continue to receive services
from the agency. Some individuals may elect to leave the agency or to pay for the services themselves,
without involving their insurance companies, as a means of ensuring their privacy. Unless they are
informed, they will not know they have these choices.

Another point about diagnosing people is that practitioners use the categories of illness to know
which treatment to use and how to develop the most effective treatment plan. Much research has been
done to link the best treatments with each of the diagnostic categories. People will appreciate the need
for a diagnostic label if they understand this. What may appear to people as simple respect, kindness,
good communication, or personal support on the part of their therapists may actually be the use of well-
developed treatment modes.

Involuntary Commitment
Generally, an involuntary commitment occurs to a facility that specializes in inpatientental
health care. It could be a unit in a general hospital in the community where the clients live, a private
psychiatric hospital, or, in some cases, a partial hospitalization program where people receive treatment
during that portion of the day they are most at risk.

Patients have a right to expect the least restrictive form of treatment. If they need hospitalization but
not a locked ward, they should not be locked up 24 hours a day. If they can get the care they need in a
partial hospitalization program, they should not have to go into the hospital. In discussing the
movement to deinstitutionalize mental patients, Bednar, Bednar, Lambert, and Waite (1991) wrote,
“treatment should be no more harsh, hazardous, or intrusive than necessary to achieve therapeutic aims
and to protect clients and others from physical harm.”

The courts take seriously their responsibility to commit individuals in need of psychiatric care
who are unable to obtain it because of a current severe impairment. In making the commitment, the
courts make it clear that the purpose is treatment, and not punishment for behavior. For that reason,
court commitment proceedings are often less formal and more pleasant than criminal proceedings.
Students may observe these proceedings if they choose, as the proceedings are public. If you are
involved in a commitment procedure, be sure to document all the steps you take in order to protect
yourself from liability.

The criteria for committing someone against her will are as follows:

1. The person poses a danger to self or to others, and possibly one or more of the following:

2. The person has a severe mental illness or a mental illness that is currently acute.

3. The person is unable to function in occupational, social, or personal areas. The impairment is severe
enough that the person cannot provide adequate self-care.

4. The person has refused to sign a voluntary commitment for treatment, so that an involuntary
commitment is the last resort; or the person is incapable of signing such a commitment or of choosing
appropriate treatment.

5. The person can be treated once committed; that is, known treatments and medications can relieve
the acute condition the person is experiencing at present.

6. The commitment adheres to the criteria of the least restrictive treatment setting.

Ethical Responsibilities
Responsibility for the individual’s welfare while the person is in your program is yours. The
person views you as an authority. No matter how inexperienced you feel, when people work with you,
they will see you as the person with all the answers. For this reason, you will have considerable infl
uence over what your clients decide to do. It is important to keep their needs at the forefront of your
planning and delivery of services.

Burdening Clients with Your Problems

Sometimes people in human services use clients to meet their own needs. You could, for
instance, burden the person with your own problems. You might say things such as “Oh, that happened
to me too” or “Wait until you hear what happened to me!” You might have had a bad day and want to
talk to someone about it, and so you tell your client all about it, as Kent did with his client Lucy.

Meeting Your Needs

Do not ask the individual to do something that meets your needs or is not in the best interest of
your client. Because of the influence you have with this person, it is easy to influence a client to do
something that is benefi cial to you. You might get the client involved with a friend of yours who sells
insurance, or you might ask the client to go on television with you or to do an interview about the
client’s condition for the paper. There might be some payoff for you, but because the person could have
considerable difficulty saying no to you, it is imperative that you never place your client in this situation.
Often the media wants to interview a person with schizophrenia or a recovering alcoholic. Inform
members of the media that they will have to locate their own interviewees.
Insisting on Your Solutions
You may have a need to look effi cient, innovative, or particularly therapeutic, and so you might
try to give your clients solutions to their problems. You may have had a similar problem at one time and
feel there is only one good way to resolve it—the way you used to resolve it, a way your clients can use
without experiencing the hard knocks you took fi guring it out. You might be tempted to lecture, to
discuss your situation and how it compares with theirs, or to warn your clients. None of these actions
will help your clients to grow by fi nding their own solutions.

Another way you can make clients do what you want them to do is to treat clients rudely if they
fail to use your solutions or to move quickly enough toward a solution. Being rude is not the same thing
as being fi rm. You can set limits, but it is inappropriate to treat people brusquely for not improving or
for not taking what you suggest as healthy measures.

Exploiting Dependency
Clients are naturally vulnerable. They come to you at a time in their lives when they are hurt,
upset, and disorganized—a time when it is easy to come to rely on another person. You are in a position
to exploit this vulnerability by maintaining the client in a dependent position long after such dependency
is useful for the client. For example, you might enjoy having clients call you about the details and
decisions of their lives. It might make you feel important or needed. You might encourage them to lean
on you for assistance in matters they could manage themselves. Be very careful not to allow this sort of
relationship to develop.

In one support group run by a psychiatric nurse, individuals gathered once a week to discuss
their problems. Most of the participants were also depressed. A student, Grace, from the local college
joined the group and was an active participant for about 2 years. During that time, the nurse who led
the group often went out to lunch with Grace and was extremely encouraging. It appeared in retrospect
that the nurse had developed dual relationships with a number of group participants, eating with them,
inviting them to her house, and going to plays and concerts with them. The nurse explained that this
was her way of supporting her clients.

Grace completed her associate’s degree and her bachelor’s degree before she was accepted at a
graduate school in another state. She told the group and the nurse in charge that she was no longer
depressed and that she felt she was ready to move on now. She shared her good news about her
acceptance to graduate school. Instead of showing pleasure and encouragement, the nurse became
angry. She told Grace that she was trying to deny her need for the group and for the nurse. She ridiculed
Grace’s acceptance to graduate school, telling Grace she was not ready for such a large step and would
surely fail. When Grace continued with her plans, the nurse stopped speaking to Grace and encouraged
others to stop speaking to Grace as well. This is an example of a group leader, a worker, who could not
tolerate the fact that her clients would not always need her. The group was meeting her needs, which
she was clearly putting before the needs of her clients.

Protecting a Person’s Self-Esteem

We can all agree that denigration of people, whether through verbal or physical abuse, is
unethical, and in some cases illegal. You may believe that you are highly unlikely to encounter such
behavior except in extremely unusual cases. Nevertheless, it is wise for you to understand that some
workers are tempted to treat people this way. There are four reasons this is likely to happen.

Unpleasant People
Just as in any other walk of life, there are people in social services who are not pleasant people.
They are unpleasant in many different aspects of their lives, and they are insensitive to the toll it takes
on others, particularly clients who are uncertain of their self-worth.

Need for Power

There are workers whose own sense of self-worth seems uncertain to them. They choose fi elds
where they will have a degree of power over others. In this way they seek to elevate themselves at the
expense of people they can clearly believe are poor souls. These individuals make life diffi cult for clients
simply because they can, because they have the power to do so.

For example, one student reported that while she was on a fi eldwork assignment, she and the
staff and clients were all having soft drinks together. A client approached the worker in charge and
timidly asked if he could have more ice for his drink. The worker responded with, “No, you don’t need
any more ice. If your drink is warm, it is because you are so slow drinking it. Go back and join the others
and drink up.” After the client turned and walked away, the worker leaned over and helped himself to
ice for his drink, laughing as if this was a joke.

Lack of Support for Workers

Social service workers who lack support from their supervisors or administration often lean
together for support. They tend to develop a we–them attitude with regard to the clients, feeling the
need to do whatever they must to support each other and hold clients apart. In one unit, adolescents
were housed together after committing offenses. The least experienced staff came on in the evening,
and that is when the teens would challenge the authority of the staff. Calls for help and requests for
information and training on how to better handle the evening shift were ignored by the administration.
Left alone with little support or knowledge, the staff resorted to coercion, often physical coercion, to
manage the disruptive situation. In the end, the staff was blamed for using excessive force, but the lack
of support and interest in these workers by supervisors and the administration contributed signifi cantly
to the way these adolescents were treated.

Isolated with Unpredictable Behaviors

Workers in group homes, partial programs, or evening residential programs often are left alone
without support when clients are exhibiting unpredictable behavior. Fear and a need to control the
behavior and the situation can lead workers to use verbal, and even physical, abuse. For instance, two
workers, one a student in a field work placement and the other out of social work school only a year,
were in a group home for the mentally ill. One evening, after one of their clients clearly became manic,
the student made a number of calls to supervisors. Supervisors responded irritably. It was their time off,
they complained; the workers would have to fi gure it out for themselves. That’s what they were being
paid to do. A subsequent request to call in the crisis team was similarly denied. The two students spent
the evening and all night with a client who was increasingly out of control with no supervision or
support. Agencies that do not provide good support for less skilled workers are open to having workers
band together against the clients in self-defense.
 One problem new workers can encounter is fi nding themselves working for the first time in a
place where they question the treatment of clients. If this happens to you, those in charge may tell you
that this is the “real world” and that what you learned in school is impractical and does not apply. In
these situations, the new workers clearly have entered situations that developed among the other
workers long ago.Workers who encounter such abusive situations have a choice of either reporting the
abuse or looking for work in a place where people are treated ethically, but they do not have a choice
about their own behavior.

Ethically you are charged with the care of the client. That includes the person’s feelings of
worth. Ethically your behavior toward people should help enhance their view of themselves as worthy.
Behaviors on the part of social service workers that subtract from a person’s sense of self-worth are
entirely unethical.

Stealing from Clients

It goes without saying that it is illegal and certainly unethical to take money or things belonging
to clients. We have looked closely at how people lose their privacy. Gossip,giving information to
strangers without a release form signed by the client, and releasing more information than is needed are
all ways that people can lose their privacy or lose control of their information when they are being
served by social service personnel. As previously noted, HIPAA laws outline the right to privacy and the
protection of peoples’ health information. However, workers can steal from individuals in other ways
without even thinking about it. When you enter other people’s lives and those people are not in a
position to protect themselves, they are just as vulnerable as you are when you allow service or repair
people into your home when you are not there to protect it.

There are two ways workers steal from clients. Both of these are theft and are entirely unethical:

1. Workers can steal a person’s privacy.

2. Workers can steal a person’s esteem and sense of worth.

Consider how people can be robbed of their self-esteem and self-worth. Vulnerable and unsure
of themselves, perhaps feeling awkward and dismayed over needing to ask for help, people come for
assistance with precious little self-confi dence and self-esteem. What self-esteem they do have is
needed for support in their struggle to regain their health or recover from bad habits. Workers have an
opportunity at this point to reassure and encourage or to steal that sense of self-esteem and self-worth.
It happens when people are denigrated, spoken to rudely or brusquely, called names, or ignored when
they are present. It happens when people are made fun of, treated cruelly, shamed, and ridiculed or
forced to perform actions they are incapable of performing at the time.

Let’s look at some examples. Kimberly had a long-standing battle with schizophrenia. When her
mother was diagnosed as terminally ill, she called a crisis hotline to talk about this pending loss. The day
her mother died she called again and the worker replied, “Didn’t we discuss this before?” When
Kimberly said they had “but my mother died today,” the worker went on, “well, do you have anything
else to talk about because if you don’t you are wasting my time.”
 Peter had been sober for 2 months when he began to drink again. He felt bad about it and
fearful that he would go on a binge, so he sought out the worker at the detox unit assigned to him.
When the worker fi nally took him into his offi ce, he said to Peter, “So you couldn’t stay off the bottle!
What a loser. I guess you know that by now.”

In an after school program for teens with behavior problems, Curt was telling his worker that he
could not return to school until he had completed the program. “I have no time for you. Grow up and
complete it,” said the worker, and with that she walked out of the room. For the rest of the afternoon
and evening she refused to acknowledge Curt, invite him to eat with the others, or respond when he
approached her. She would look past him or turn to another client. I am sure that as you read about
these incidents you felt these were egregious examples of workers mistreating clients or patients, but in
many settings rude and often unkind communication is used frequently, either because workers feel
harried or because they see this as a way of motivating people or because it makes them feel important.
For the truly professional worker, it means that you will decide consciously that you will never knowingly
subtract from a person any sense of self-worth or selfesteem. If you can make this promise to yourself,
you will be conscious of how even your most casual remarks can either steal something of value or
enhance the health of the people you help.

Competence
A signifi cant characteristic of professionals is their ability to clearly know their limitations.
Ethical professionals do not try to do work for which they have not been trained. Recognizing the limits
of one’s training and experience is very important. This means that you will be aware of areas where you
could use some help or direction and that you will seek assistance when you need assistance. You will
ask those who have more experience or education to assist you rather than attempting to do work for
which you are not qualified.

In addition, seek additional training throughout your career. Most certification and licensing
programs require that individuals obtain further training on a yearly basis. Even if you are not part of
such a program, you have an ethical responsibility to increase your skills, knowledge, and understanding
of the fi eld in which you work.

Responsibility to Your Colleagues and the Profession

We all have an ethical responsibility to protect our clients. Sometimes our clients need to be
protected from those who are charged with their care. Nearly every professional code of ethics contains
statements supporting the ethical responsibility of the professional to take action when a colleague is no
longer able to function effectively or is openly violating ethical guidelines.

Impaired Workers
A social service worker is considered impaired when he or she is no longer functioning
effectively due to substance abuse, mental illness, or personal problems. In such cases, impaired
workers are so consumed with their problems that they are no longer able to focus on the needs of
clients. In other words, they are distracted, focused on things other than their professional
responsibilities, and often neglectful to the point of endangering clients.

If Someone with Whom You Work Becomes Impaired

If you fi nd yourself in a situation where a coworker appears to be impaired and therefore
unable to be effective, you have an ethical obligation to take action. Generally the first action to take is
to talk privately with the person who seems to be having problems. Point out your concerns and listen
to any explanations you receive. Explore ways to help the person resolve the problems.

Usually agencies have established procedures for handling concerns about colleagues who are
thought to be impaired. Sometimes, if the person holds a professional license, the licensing board is
notified so it can take appropriate steps to curtail the individual’s opportunity to practice until the
personal problems are resolved.

In one outpatient unit where clients received medications, it became obvious that one of the
RNs was taking some medication for herself. At fi rst the staff was not sure how to handle this. The RN
was the supervisor. She did the pill count, but the workers noticed that clients ran out of medications
sooner than expected with numerous seemingly reasonable explanations. The staff was torn between
wanting to let someone know and fearing that they could be wrong. Finally, in a staff meeting one
member remarked that she was concerned that the clients were so often out of medication and she
wanted to better understand how that happened so the agency could take steps to correct it. When the
RN became defensive and refused to participate in the discussion, the staff went with their concerns to
the administration.

If you have concerns about how to proceed, it is useful to discuss your concerns with a senior
professional. Here you may be able to clarify whether and to what extent clients are endangered by the
behavior you have observed, and how the behavior indicates that your colleague is impaired.

If You Become Impaired

Ethically you have a responsibility to refrain from activities that may lead to your own
impairment. Should you become impaired for whatever reason, you have a further ethical responsibility
to resolve your problems if they will interfere with your ability to practice. Practicing with clients if your
physical, mental, or emotional problems will interfere to the detriment of the clients is unethical. It is
important to have good self-awareness and be alert to the possibility that personal problems are
interfering and having a negative impact in your work with clients. If this is the case, you have an ethical
responsibility to seek help and to limit or cease your work with clients until your own problems are
resolved.

Roy had had a drinking problem off and on all his adult life. He managed to hide it well enough
to function in college and in his work as a case manager for many years. When his wife left, however, he
began to drink more and missed work more consistently. A coworker noticed the problem and talked to
Roy about getting help, but Roy brushed him off. Soon after, Roy began seeing one of the clients who
also had a drinking problem and had come to the center for both her depression and her alcoholism.
Roy kept this relationship secret, and the couple drank in bars that other case managers would not
frequent. One night Roy and his girlfriend got into a fight at the bar where they had gone after dinner.
The bartender asked them to leave; the fight moved to the street, Roy beat his girlfriend, and the police
were called. Only when Roy ended up in jail, his career and marriage in a shambles, and his addiction
out of control did he sober up enough to agree he needed help. Roy served his time, was terminated
from his position as a case manager, and began outpatient treatment for his addiction. He is currently
working as a night watchman for a furniture store.

It is often difficult to admit that we have problems, particularly when we work in a field where
people expect us to have healthy answers to their issues. Nevertheless, problems are part of life and
they always present opportunities for growth. Denying our own problems is not healthy and further
impairs our ability to be useful social service workers in the future. Address your own problems as they
occur as part of a lifelong pursuit of health and wisdom.

Ethical Violations
This chapter has put forward some of the common ethical standards and issues you will
encounter, but it is not entirely comprehensive. You may encounter situations in which you have
questions about what is ethical and what is not. Consult your code of ethics and talk to senior
professionals about your concerns. Not all situations present clear-cut ethical options.

Sometimes you may have a colleague who is seemingly violating an ethical principle. A
discussion with your colleague about your concerns is often the first step you might take, describing
what you have observed and your concerns about your observations. If no satisfactory resolution
results, you must then express your concerns to senior professionals or the administration in order to
end the unethical behavior. Your agency will likely have a procedure for reporting unethical behavior; if
so, that procedure should be followed.

Professional Responsibility
Finally, remember that you represent an agency and that it is your responsibility to establish a
relationship with your person that is befi tting of the agency. This will affect your relationship with the
person in two ways.

First, know the parameters of your agency and operate within them. If you work for an agency
that gives out food and fuel to the poor, do not attempt to do mental health counseling. If you are a
case manager in a drug and alcohol unit, do not attempt to arrange foster care for one of your client’s
children except through the agency designated to handle that. If you work in a shelter for battered
women, do not try to do drug rehabilitation. When a person needs services that fall outside the
particular focus of your agency, make a referral to another agency that can best handle the problem.

The second way your relationship with the client is affected is related to dual relationships.
Remain professional. Limit your contact to the focus of your agency and to the focus of that particular
person’s problems. Do not invite people home to dinner, take them home with you for the night, or
become socially involved with them because you feel sorry for them.

Perhaps you are in the ER giving assistance to a woman who has been raped in her home. You
are working for a rape crisis center. It is late. The woman you are interviewing is terrifi ed of going
home. You call crisis intervention to arrange for temporary lodging, but they are currently out of the offi
ce on a call and will have to “get back to you.” The woman has tried unsuccessfully to reach two family
members but has reached only their answering machines. Finally, in desperation, you take the woman
home with you. You would rather do this than sit in the ER all night because you have to be at a meeting
in the morning. The woman is educated and seems very pleasant and refined. She goes home with you,
spends the night at your house, and returns with you to the agency in the morning, where they help her
obtain temporary housing and see that she gets safely to work.

Two months later you begin to receive calls from the woman, who seems to want a friendship
with you. She has found your number in the phone book. Soon after this, you receive a call in the middle
of the night. It is the same client. She has had a fi ght with her boyfriend, and now she wants to stay with
you. You tell her she cannot do that, and she becomes hysterical. In the next several weeks, she appears
at your house several times, asking to stay with you. Always there is some reason she cannot stay where
she is currently living. She knows your phone number, so she calls frequently. You have to be very fi rm
in order to set limits; sometimes it is hard to do.

This story about a worker taking someone home is not all that unusual; it does happen. Rarely,
however, is a person who is hurting and vulnerable able to reestablish a professional relationship with
such a worker, complete with boundaries and limits, once the worker has extended this kind of
friendship or kindness.

Summary
This chapter is particularly important because it involves your ethical obligation to the client and
outlines some legal concepts you must follow to protect your client and yourself. The primary issue is
always the welfare of the client. That must come before all other considerations. When we choose this
line of work, we deliberately choose to work with vulnerable people who cannot be expected to protect
themselves or to know their rights. It becomes our responsibility to see that clients are well protected
and are treated or given service under the highest ethical standards.

Common codes of ethics, including the Code of Ethics of the National Association of Social
Workers (NASW) and the Ethical Standards of Human Service Professionals, can be found in Codes of
Ethics for the Helping Professions (Brooks/ Cole, 2004).

Now that you are thoroughly familiar with your ethical and legal responsibilities, it is time to
turn to case management as a basic area of practice in which ethical behavior is expected and informs
your decisions.