Man Puzzle
by Allan Barsky, J.D., MSW, Ph.D.
Social workers often suggest that self-determination is a cornerstone of the profession. In fact, the first two standards in the NASW Code of Ethics (2008) say that our primary obligation is to our client and that we should honor a client’s right to self-determination
Self-determination is built on the values of autonomy and respect for the dignity and worth of all people. So, given the primacy of self-determination, how is it that social workers can ethically justify working with clients who are mandated to social work services? By definition, if a client is mandated to services, isn’t the social worker breaching the client’s right to self-determination? Do involuntary clients have a right to self-determination, and if so, what does self-determination mean in such a context?
Let’s start by considering what the NASW Code says about self-determination:
Standard 1.02: Social workers respect and promote the right of clients to self-determination and assist clients in their efforts to identify and clarify their goals. Social workers may limit clients’ right to self-determination when, in the social workers’ professional judgment, clients’ actions or potential actions pose a serious, foreseeable, and imminent risk to themselves or others.
Note that this standard does not specifically speak to the issue of involuntary clients. Its one exception to self-determination arises when a client poses “a serious, foreseeable, and imminent risk to themselves or others.” This exception typically applies to situations of suicidal or homicidal ideation—thus, if a client is about to commit suicide or homicide, the worker is ethically justified in taking steps that run counter to client self-determination to protect the client or potential victim.
Ethically speaking, the Code is giving priority to the principle of protecting life over the principle of respecting self-determination. This could include initiating processes that may result in involuntary admission to a psychiatric facility. Note, however, that committing a client involuntarily should be considered a course of last resort.
Standard 1.02 does not say social workers may ignore self-determination. It says they may limit self-determination. Implicit in this language is the notion of the “least intrusive” course of action. As much as possible, social workers should honor self-determination. Given that involuntary commitment is highly intrusive, social workers should first consider less intrusive approaches. This includes approaches that respect and expand self-determination as much as possible, without undue risk to the life of the client or other person. Consider the following alternatives:
- Using crisis intervention strategies to de-escalate the client’s suicidal or homicidal thoughts and plans.
- Developing a voluntary safety plan with the client that may include protective care or monitoring by family members, friends, or other informal support systems.
- Requesting the client’s permission to inform the intended target of the crime.
- Offering the client alternatives, such as a referral to another mental health professional for a second opinion, or to a physician who can prescribe appropriate medication.
Working with suicidal or homicidal clients is not the only situation in which social workers serve involuntary clients. Clients may also be mandated into services when:
- They are involved in the criminal justice system (e.g., convicted of a crime, placed on probation, or given parole with a requirement to participate in counseling or other social work services).
- They are involved in the child protection system because of allegations or findings of child abuse or neglect.
In these situations, our legal system is basically saying that the safety of others (the public, children, and so forth) is more important than self-determination.
The NASW Code has just one standard that specifically refers to involuntary clients:
Standard 1.03(d): In instances when clients are receiving services involuntarily, social workers should provide information about the nature and extent of services and about the extent of clients’ right to refuse service.
This standard recognizes that, even though involuntary clients are being pressured into services, they still have certain rights. First, social workers need to inform clients about the services being offered. For instance, what are the purpose and goals of the services, what model of intervention will be used, what does research say about the benefits and risks of the services, and what are the expectations of the client as a participant in the services? Although providing such information does not constitute informed consent, it does provide informed notice.
Further, even when clients are mandated into services, social workers do not physically force clients into the services. As the above standard explains, workers should inform clients about the extent of their right to refuse services. In particular, workers should clarify what the client is mandated to do, and what the client may refuse to do. The worker should also help clarify the consequences if the client does not fulfill what has been mandated (e.g., will the client go back to court or to incarceration, will the client be denied access to his/her children?). If the client needs legal advice, the worker should ensure that client has access to such advice.
Social workers should also go beyond what Standard 1.03(d) states and strive to honor self-determination as much as possible. Self-determination is not simply an either/or situation. Although social workers should recognize that self-determination may be imperfect for involuntary clients, workers are able to enhance self-determination through various strategies:
- Social workers may engage clients by empathizing with clients, acknowledging pressures on the client, building trust, and validating client concerns, so the client is more willing to participate in services.
- Social workers may empower clients by helping them set goals and objectives that they genuinely want to pursue—even if they did not initially choose to participate in services.
- Social workers may offer clients a range of choices, including which methods and models of intervention will be used (e.g., individual vs. family counseling, cognitive vs. narrative therapy).
- In appropriate cases, social workers may advocate with authorities to honor client wishes and revise court orders or other mandates.
It may be easy for people to say, “This person committed a heinous crime. He doesn’t deserve self-determination,” or “These parents abused an innocent child. Of course, we have to take away their rights.” As professional social workers, however, we realize that respect for the dignity and worth of people includes ALL PEOPLE, including those who have harmed others or pose risks of serious harm. Honoring self-determination as much as possible may be more difficult with some clients than with others. For the profession of social work, this is a challenge that we accept with conviction and pride.
Dr. Allan Barsky is Professor of Social Work at Florida Atlantic University and Chair of the National Ethics Committee of the National Association of Social Workers. He is the author of Ethics and Values in Social Work (Oxford University Press), Conflict Resolution for the Helping Professions (Brooks/Cole), and Clinicians in Court (Guilford Press). The views expressed in this article do not necessarily reflect the view of any of the organizations with which Dr. Barsky is affiliated.