Ethics Forum: Rural Social Work Practice: Maintaining Confidentiality in the Face of Dual Relationships

Ethics Forum: Rural Social Work Practice: Maintaining Confidentiality in the Face of Dual Relationships


Colleen Galambos, DSW, J.Wilson Watt, PhD., Kimberly Anderson, PhD, and Fran Danis, PhD

Abstract

Management of dual relationships and confidentiality in social work practice is an essential ethical task for all professionals. Practitioners face special challenges presented by the choice of practice environment and the differential client and community expectations that may be inherent in rural practice. This article addresses the challenge through an analysis of dual relationships, boundary management, and confidentiality in rural practice environments across micro and macro practice activities and settings. The nature of the ethical challenge of dual relationships and the preservation of confidentiality and privacy are explored and an analysis of special practice issues in the rural environment is provided. Tools and suggestions for rural practitioners are presented to use in the ethical management of boundaries with clients, colleagues, and organizations.
Keywords: dual relationships; confidentiality; privacy; rural social work practice; boundary management
Introduction

Managing dual relationships in social work practice can present many challenges to professional boundaries. These challenges are heightened in small communities and rural areas (Miller, 1998; Reamer 2001; Scopelliti et al., 2004), where dual and multiple relationships are a consequence of dense networks (Green & Mason, 2002; Green, 2003, Healy, 2004). A dual relationship can be defined as a set of multiple relationships in which one is professional, and the other(s) are of a social, financial, or professional nature (Campbell & Gordon, 2003). Dual relationships may create boundary issues for the practitioner. Reamer (2001) describes boundary issues as circumstances in which human service professionals encounter actual or potential conflicts between their professional duties, and their social, sexual, religious, or business relationships" ( p. 1).

A direct service issue that arises within rural social work practice from the increased likelihood of encountering dual relationships is the maintenance of client confidentiality and privacy. This article will explore this particular practice issue and provide guidelines on how to protect privacy and confidentiality from clinical, organizational, and community perspectives.
Literature Review

There is limited scholarship available that examines dual relationships in rural practice (Miller, 1998). There is an even smaller amount that examines confidentiality and privacy issues in rural areas. Green and Mason (2002) published one of the most extensive articles on this issue. They report on a research project that examined the experiences of social work and welfare practitioners practicing in rural areas in regard to personal and professional role boundaries. Three issues that emerged from the study concerning confidentiality were guarding privileged knowledge, the use of client-related knowledge gained informally, and rural service delivery considerations that protect client privacy and confidentiality. The authors point out that absolute confidentiality is difficult to obtain in rural areas. Ethical conflicts are often created between a practitioners duty to the client and a duty to others. The argument is made that confidentiality should be a guarantee against disclosures except in clearly defined circumstances such as situations in which there is suspected child abuse, when the client is suicidal, or when there is a threat to another person. Confidentiality is particularly challenged since rural social work practice involves working with communities, groups, teams, and other agencies. The authors also point out that clients may choose not to obtain services, because of their concerns about how confidential information is handled.

Barbopoulos & Clark (2003) acknowledge that privacy and confidentiality present particular challenges to practitioners providing direct services to rural clients. Client privacy is difficult to maintain, as people know one another and are more likely to be seen in the location in which services are provided. Rural communities also allow opportunities for nonprofessional interactions with clients, friends of clients, or relatives of clients.

In a survey of college therapists, Sharkin and Birky (1992) found that 95% of their sample had accidental meetings with clients. Nonprofessional interactions in rural settings run the gamut from minor accidental meetings to substantial overlapping relationships. In another study, Schank and Skovholt (1997) surveyed members of the Minnesota Psychological Association practicing in rural areas and found that all respondents reported overlapping relationships. These overlapping relationships included ones with multiple family members for 75% of the participants, and situations in which different clients had relationships with each other for 56% of the participants. Respondents reported that boundary setting was particularly important to the protection of client confidentiality. The authors assert that clear expectations and boundaries strengthen the therapeutic relationship and urge practitioners to obtain informed consent, protect confidentiality, and explain the limits of confidentiality discussing any overlapping relationships as essential to ensure sound professional practice in small communities.
Theoretical Framework

A social workers obligation to maintain confidences is linked to the deontological conception of morality. According to this theory, actions or rules are right if they comply with a principle or principles of obligation. Deontology maintains that actions are morally wrong because an action is classified as a moral violation. Deontologists believe that relationships carry with them certain obligations, such as obligations social workers have with their clients. These obligations include confidentiality and respect for privacy (Beauchamp, 1991; Frankena, 1973). The NASW Code of Ethics would be considered a set of rules that every social worker must abide in to prevent immoral behavior. Within this code, privacy and confidentiality is considered an ethical standard to be upheld by practicing social workers. Parameters are set related to the management of confidentiality within the boundaries of professional relationships. Other relevant Codes of Ethics, such as those developed by the Clinical Social Work Federation, the Canadian Association of Social Workers, and the American Psychological Association, also include confidentiality as an important ethical standard.

In addition to obligation duties, social workers as individuals can turn to virtue ethics for guidance. Theories of virtue depend on an assessment of moral traits that establish an individual's moral character. A moral virtue is a character trait that is morally valued. Aristotle, a virtue ethicist, maintained that the virtue of people consists of how well they do their work and their ability to function successfully. A virtue is a disposition, habit, quality, or trait of a person. He believed that there is an innate capacity for virtuous behavior which is developed through proper training and experience. Confidentialness and respectfulness for privacy are considered virtue standards (Beauchamp, 1991; Frankena, 1973). Applying this theory to the social work profession, social workers as individuals should aspire to cultivate confidentialness and respectfulness for privacy as character traits. To this end, guidelines are provided herein for clinical, organizational, and community practice to assist in the development of confidentialness and respectfulness for privacy for practitioners who work in rural environments.
Clinical Considerations and Guidelines

Dual relationships are inherent in rural social work practice and create challenges to maintaining client confidentiality (Boisen & Bosch, 2005). Confidentiality can be described as the regulation, both legal and ethical, that protect the clients rights of privacy (Green & Mason, 2002, p. 270). Privacy refers to the degree of control a client has over what happens to information about him/her held by the worker (Green & Mason, 2002). Although boundary violations (where the worker is manipulative, exploitive, coercive, or deceptive to the client) may occur in rural areas, boundary crossings may emerge more frequently. Boundary crossings refer to the mix of professional and personal relationships in which the anonymity of clients and workers can be unavoidably compromised (Healy, 2003).

Rural areas include strong community ties with ample opportunity for chance encounters and boundary crossings with clients (Healy, 2003). Essentially, rural social workers are never off-duty within their communities since they often live and work in the same town, causing professional and personal relationships to blend. To be a member of a rural community means that close knit bonds exist and there is the expectation to engage in cultural mores and community events. To be seen in the community and to support activities builds trust and support for the professional role. Information received in informal settings or outside the realm of professional relationships presents challenges to the practitioner. For instance, clients and social workers may encounter each other in the grocery store, place of worship, or little league baseball game. Clients may regard these times as opportunities to ask for further assistance. Boundary crossings are not always harmful (Reamer, 2003); however, it is important for the practitioner to develop skills in assessing the potential harm or benefit in boundary crossings that may present themselves in clinical practice and to discuss these situations with the client. Table 1 outlines some of the types of boundary crossings that may be encountered by the professional social worker.

Table 1. Client-Worker Boundary Crossings


Type


Definition


Examples
Business Transactions client-owned or client-employed businesses grocery store, gas station, bank, farm implement store, telephone and electrical companies
Community committees or clubs worker-client joint affiliation and memberships Parent Teacher Association (PTA), gardening and quilting clubs, 4-H, American Legionnaires, and Rotary club
Community events community-wide participatory activities fund raisers, parades, celebrations, dances, and dinners
Social events
activity attendance that supports community members athletic events, weddings, anniversaries, funerals, sporting events, hunting and fishing activities
Residence location geographical proximity between client and worker same neighborhood
Organizational location attendance at the same organizations schools, hospitals, and places of worship
Social and friendship networks mutual worker-client social networks spouses/partners, children, relatives, and friends
Incidental occurrences addressing each other in public places greetings on the sidewalk

The rural social worker is responsible for maintaining appropriate boundaries regarding confidentiality and the protection of client-related information. Although the National Association of Social Workers and state licensing boards set standards and parameters in regard to confidentiality and privacy matters, no guidelines or practice tools are offered to address these standards, particularly within rural areas.

The professional literature offers some guidance. Kagle and Giebelhausen (1994) advocate the avoidance of dual relationships whenever possible, and suggest rural practitioners work and live in different geographical regions. Other authors note that these solutions are often not possible in rural areas, and leave the practitioner with no direction on how to manage dual relationships in an ethical manner (Green & Mason, 2002; Healy, 2003; Evans & Harris, 2004).

Guidelines for Protecting Client Confidentiality
The authors present a set of guidelines that attempt to balance the protection of privacy while acknowledging that chance encounters occur in rural areas. The following practice guidelines account for the complex nature of dual or multiple relationships and the opportunities for boundary crossings in rural areas.

1. Always use informed consent procedures in professional relationships. A discussion of policy and ethical considerations, particularly confidentiality rules, is an important component to the client-worker relationship in rural areas. While addressing informed consent, discussions need to deal with the types of boundary crossings and their possible risks to client confidentiality. One way to manage this dialogue is to give the client a handout of Table 1 to highlight examples of boundary crossings. The use of Table 1 as a guideline may heighten the client and workers sensitivity to possible boundary crossings and their consequences, which may be further explored during the assessment process.
2. Include a discussion of dual relationships and potential for boundary crossings during the assessment process. In the completion of psychosocial assessments, include a discussion of relationships and activities that the client is engaged in that may present the potential for boundary crossings between the client and the worker. The use of genograms and eco-maps will help in this process. For instance, during the assessment process, a client genogram may uncover mutual relationships between the client and the worker, whereas a client eco-map may identify mutual social systems. When a potential conflict is discovered, the client and worker should engage in a mutual discussion about how potential encounters should be handled. This technique allows clients to take control of their privacy and reinforces their empowerment. In addition, this type of discussion strengthens the client-worker relationship as they work together to develop a plan of action that protects confidentiality.
3. Develop a plan of action regarding how boundary crossings will be handled. The development of a plan of action regarding boundary crossings prior to their occurrence enhances a clients ability to maintain control of his/her privacy. For instance, upon completing an eco-map, a worker may note that the client shares the same place of worship. A discussion of this association with the client will help each to prepare for chance encounters. Each discussion of mutual associations during the assessment process should include the development of a plan for how to address them. A plan of action should include points of choice making for clients, such as whether and how the client and worker should acknowledge each other in public places.
4. Conduct periodic evaluations on how boundary crossings are being handled. Exploring boundary crossings and their impact on client confidentiality needs to occur throughout the helping process. This evaluation should include a review of the plan of action, and a discussion of information, relationships, and mutual social systems not identified during the assessment phase. Also, any unplanned encounters should continue to be a point of discussion between the worker and client in regard to their impact on confidentiality and the helping relationship.

These guidelines are offered as suggestions for how social workers can manage client confidentiality, potential boundary crossings, and dual relationships in the delivery of services in rural areas. These guidelines are particularly suited for the practitioner working within a clinical practice.

However, agency attention to the issues of dual relationships, confidentiality, and privacy rights cannot be confined to micro and meso level practice issues. There are challenges at the macro level that involve the management of privacy and confidentiality within agencies and communities located in rural areas.
Macro Considerations and Guidelines

If little is known about how rural social workers in direct practice address dual relationships and confidentiality issues, even less is known about how these issues impact macro practice in rural areas. Organizations have multiple relationships with other organizations in the community and internally with their clients, and members of the board, staff, and volunteers. Social workers, in leadership positions in their organizations and within the community as a whole, have a number of responsibilities to manage dual relationships and protect client confidentiality.



Organizational Policies on Confidentiality
All organizations should have policies on confidentiality, which are shared with clients and staff. It is recommended that confidentiality policies include criteria for release of information about clients, the limitations of confidentiality, information about applicable state statutes and funder regulations, how to handle subpoenaed information, guidelines for what is included and excluded in permanent client files, and who has access to client files (Reamer, 2001; Wilson, 1978). Policies that address the protection of client information stored in computer files are also necessary to safeguard this material. Additionally, guidelines need to be developed on how staff use and manage e-mail communication that may include client information.

Clients should be informed in writing about the organizations confidentiality policies, as well as their limitations, especially with regard to disclosures of abuse of children, older adults, and persons with disabilities. Additionally, it is suggested that social work administrators include information about state laws that address whether certain professionals or persons working in specific types of agencies have privileged communication, and the limits of that privileged communication (Peterman & Dobos, 2004). One tool that can be used to inform clients of these policies is the development of a flyer that addresses boundary issues, confidentiality policies, and client rights (Kagle & Giebelhausen, 1994). This tool may be used within the helping relationship between client and worker, and may serve to enhance the client-worker relationship through providing an opportunity for talking openly and genuinely about client confidentiality and privacy rights.

Agency policies should also address the termination of employees, board members, or volunteers who violate organizational policy on client confidentiality. It is helpful to present policies on confidentiality and organizational expectations related to these policies at the time of hire or appointment.

Also, the employer needs to inform personnel of client confidentiality policies, and the consequences for violating such policies. All employees and volunteers, including board members of human service agencies, should receive training on this information. It is suggested that employees, volunteers, and board members sign a statement indicating they have been informed, understand, and agree to abide by the policies they received information on during the training. It is recommended that instruction on agency policies occur periodically to reinforce personnels knowledge and awareness of them.

Use of Consultants
Another area that may involve potential breaches of confidentiality by persons serving dual roles within the organization is the use of consultants (Yankey, 1998). Agencies should avoid hiring as a consultant someone who already has a relationship with the organization, whether they are board members, volunteers, or clients. As an administrative decision, it may be best to use out of town consultants. In consultation practice, the use of distance as a boundary may be more easily arranged than in direct community practice, and it is consistent with Kagle and Giebelhausens (1994) recommendation for rural practice management. Nevertheless, all consultants should be asked to sign a confidentiality pledge form. A professional social worker who functions as a consultant in the community should not accept an appointment with organizations where protection of confidentiality cannot be established. The status of former client of the agency on the part of the consultant or close personal relationship with former clients of an agency should rule out a consultation relationship with that agency.

Finally, more information is needed about how rural organizations handle dual relationships and confidentiality. Do models exist that create a balance between managing an agency and maintaining relationships in rural areas while protecting client confidentiality and respecting boundaries? How do rural agencies handle the protection of confidentiality between board members, staff, and clients in rural-based organizations? Are there ways in which organizations have organized their physical space (private waiting rooms, separate areas for entrance and exit) to ensure client confidentiality? More emphasis on these issues within the professional literature will help to strengthen rural social work practice.
Conclusion

Social work professionals must attend to ethical practices regardless of the practice environment or the level of system where the practice occurs. For the rural practitioner, special challenges to ensuring confidentiality and privacy rights for clients, colleagues, and organizations are related to the dense and complex interactions in rural communities. To address this special challenge of rural community practice, social workers must take special care in the management of agencies and in their interactions with clients to ensue that clients are empowered to participate in the management of their confidential information.


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