Journal of Social Work Values & Ethics

Professional Boundaries in Dual Relationships: A Social Work Dilemma

By Lynn Milgram Mayer, MSW, Ph.D.
The Catholic University of America, National Catholic School of Social Service

Abstract

Social workers have traditionally been underutilized by Head Start programs. With the increasing emphasis on the professionalization of Head Start staff, it is pertinent to explore issues that social workers would face in this practice context. One such issue is the risk of engaging in dual relationships between parent-employees and social workers in this practice context. This ethical dilemma is explored through review of the literature, consideration of two case examples, and application of a modified ethical problem-solving model (Joseph, 1985). After evaluation of three alternatives, one option is recommended.

Ethical Dilemma, Dual Relationship, Social Work, Head Start, Ethical Problem-solving 

Introduction

Originally, Head Start was grounded in research which suggested that programs could help poor children be prepared for school and, thereby, compensate for their economic disadvantage (Hofferth, 1992). At that time, Head Start was viewed as a community action effort “aimed at improving whole communities by giving parents and community members new opportunities to participate in the nurturing and education of their children (Kuntz, 1998, p.1). Initially, few social workers were hired (Frankel, 1997; Zigler, 1997). However, as Head Start approaches its 40^th birthday, the staffing debate over providing jobs for community members versus upgrading services through hiring outside professionals continues. The philosophical heart of this ongoing debate – remaining true to Head Start’s anti-elitist ideological roots versus professionalizing service – stems from a federal directive to hire parents of currently or formerly enrolled children (Head Start Program Performance Standards Final Rule 45 CFR Part 1304, 1996). While the drive to professionalize has an impact on all Head Start services, the increasing complexity of the needs of Head Start children and families make the issue of professionalization particularly relevant to the provision of mental health services (Gould, 2002).

When professionals, such as social workers, are hired by Head Start and Early Head Start programs, the federal directive places them in work environments in which 28% or more of all program staff members are parents with children currently or formerly enrolled in Head Start (ACF, 2004). In this practice context, social workers find themselves in collegial employee relationships or in administrative and supervisory employer–employee relationships with current or former clients. Thus, once social workers are hired, the philosophical staffing debate shifts focus from professionalizing Head Start staff to ethical dilemmas involving professional boundaries and dual relationships. According to Reamer (2000), boundary issues confront social workers who are engaged in more than one relationship with their clients, and these boundary issues put the social workers at risk and require careful evaluation. As such, within this practice context, dual relationships may raise numerous ethical issues revolving around confidentiality, role conflict, quality of services, and self-determination. Therefore, this article reviews the literature on dual professional relationships, presents a case example that illustrates the difficulties with dual relationships in Head Start, utilizes an adapted model of ethical problem-solving (Joseph, 1985), proposes and evaluates three alternatives, and presents a second case example that demonstrates the use of the recommended solution.

Literature Review

As defined by the NASW Code of Ethics (1999), dual relationships occur “when social workers relate to clients in more than one relationship, whether professional, social, or business” (p.9). Dual relationships can occur in both therapeutic, clinical settings, and non-therapeutic, community-based settings. When social workers are employed by Head Start, the dual relationships that they find themselves in are primarily professional, but could also be characterized as social depending on the situation. These relationships could reflect either a therapeutic or non-therapeutic context depending on the design of the individual Head Start program. Dual relationships are considered to be a conflict of interest for social workers when there is a risk of potential exploitation or harm (NASW, 1999). Due to conflicting opinions surrounding their appropriateness, dual relationships have recently been a central focus of discussion in the social work literature (DuMez & Reamer, 2003; Freud & Krug, 2002; Mattison, Jayarante, & Croxton, 2002; Reamer, 2003). Gripton and Valentich (2003) argue that part of the difficulty stems from a failure to adequately address dual relationships in codes of ethics. As such, the literature highlights both the potential benefits and problems associated with dual relationships in both clinical and community practice settings; therefore, literature on both perspectives is reviewed.

Potential Benefits of Dual Relationships

From the literature, it is evident that dual relationships do exist in social work practice in both clinical and community practice settings. These relationships can be productive if handled properly. Dual relationships should be viewed on a continuum as not all dual relationships are unethical or harmful (Bader, 1994; Corey, Corey, & Callanan, 1998; Reamer, 1998). Rather than a negative, the blending of roles in dual relationships is regarded either as a natural part of human life or as an inevitable outcome due to power differentials within the therapeutic relationship (Bograd, 1993; Brown, 1994).

The client’s right to self-determination, a long standing social work value, is pertinent in the consideration of the ethics of dual relationships (Freedburg, 1989; Hancock, 1997). Failure to support this right would be unethical action on the part of the social worker who has “a moral injunction to uphold the rights of clients to a life of self-fulfillment and noninterference” (Manning, 1997, p. 227). The Head Start Performance Standards Final Rule (1996), including the standard to hire parents, was written with an underlying respect for self-determination: “family development planning and service provision will be grounded in the belief that families, including those whose problems seem overwhelming, can identify their own goals and strengths and needs, and are capable of growth and change” (U.S. DHHS, 1994, p.13). Bass (1996) supports this interpretation, indicating that social services in Head Start are designed to empower parents by giving them the opportunity to make decisions regarding their strengths, weaknesses, need for help, and mechanism for getting help.

Vodde and Giddings (1997) suggest that dual relationships may lead to an improved sense of empowerment: “when aspects of nonsexual dual relationships are used in the service of greater connectedness, more honesty, integrity for both parties, and an increase in the power and self-determination of the client, the relationship may become enhancing or empowering” (p. 63). Bograd (1993) indicates that “some even argue that dual relationships offer protection against the damage done within the traditional model of therapy because they do not reinforce the therapist power advantage” (p.12). According to Tomm (1993), dual relationships prevent the social worker from dehumanizing a client by forcing her or him to respond to the client as a unique person. Dual relationships may also serve to make the client less vulnerable, enhance reality testing, and provide productive role models (Schank & Skoyholt, 1997; Tomm, 1993; Vodde & Giddings, 1997).

Potential Problems with Dual Relationships

While evidence of dual relationships is found in the literature in a variety of practice contexts, including community action agencies, clinical practice, social work education, and substance abuse treatment, it is clear that these relationships may lead to ethical dilemmas and violations. Dual relationships can be problematic because the possibility exists that the social worker will put her or his needs first and will utilize impaired judgment (Bader, 1994; Vodde & Giddings, 1997; Herlihy and Corey, 1992). In their study of attitudes and practices regarding dual professional roles, Borys and Pope (1989) found that almost half of the respondents in the study felt that it was unethical to employ a client. Three primary areas of objection to dual relationships include: boundary issues, role confusion, and power exploitation.

Boundaries exist to protect the client from misuse by the social worker and to establish the professional nature of the relationship (Borys, 1994; Brown, 1994; Gabbard, 1994; Pope & Vasquez, 1991). Whether the social worker is working in a community or clinical setting, the helping relationship is considered to be a professional relationship and can be adversely affected by boundary issues, including boundary confusion, boundary crossing, and boundary violations. While boundary crossings may not be unethical inherently, as are boundary violations, they do have the potential for harm (Reamer, 2003). According to Reamer (1995), “it is essential that social workers maintain clear and unambiguous boundaries in their relationships with clients. Effective practice depends on a clear delineation of professional roles. Worker-client relationships that are based on confused boundaries can be very destructive” (p. 105). When the boundaries are confused or crossed as they are in dual relationships, it is not helpful to the client, the social worker, or the agency (Congress, 1996; Ramsdell & Ramsdell, 1993). Hancock (1997) characterizes boundary issues as unethical. Boundary confusion, boundary crossing, and boundary violation may reinforce maladaptive beliefs and negatively impact self-esteem and separation-individuation issues for the client (Borys, 1994).

Issues of role conflict are likely to materialize when social workers engage in dual relationships with clients as they are either taking on more than one role with the client or the client is taking on more than one role. Ramsdell and Ramsdell (1993) indicate that role confusion for both the client and the counselor is likely. According to Jones (1984), “the agent may not know which of two or more well-defined social roles is appropriate in the circumstances in which he finds himself” (p. 609). Jones (1984) characterizes differing expectations as a conflict of prima facie duties. The role confusion could easily lead to difficult situations for both the client and the social worker:

… the patient may misinterpret confrontation or painful interventions as reflections of the therapist dissatisfaction with the product or service the patient is providing in the other role… Alternatively, the therapist may be hard pressed to adaptively resolve any actual dissatisfaction he or she may find in the patient’s work (Borys, 1994, p. 271).

The dynamics of power clearly are a potential problem stemming from dual relationships, as the possibility of exploiting or harming the client is evident (Reamer, 1998). According to Kagle and Giebelhausen (1994), “in any dual relationship, the practitioner’s influence and the client’s vulnerability carry over into the second relationship. Even if no sexual intimacy occurs, the practitioner is in a position to subordinate the client’s interests to his or her own” (p.215). As a result of the first relationship, the client can never be equal to the social worker in terms of power (Pope & Vasquez, 1991). When the imbalance of power is increased, the social worker’s ability to meet the client’s needs is further jeopardized (Brown, 1994). As a result of the power differential, “even an ethical practitioner may unconsciously exploit or damage clients or students, who are inherently vulnerable in the relationship. Once the clarity of professional boundaries has been muddied, there is a good chance for confusion, disappointment, and disillusionment on both sides” (Bograd, 1993, p.7). As such, the social worker is possibly in jeopardy of violating the fiduciary obligations inherent in the social work contract (Kutchins, 1991).

An organization that permits dual relationships may experience significant detrimental outcomes. Dual relationships may have a negative impact on the client in numerous ways: for example, “a client who comes to feel exploited by a dual relationship is bound to feel confused, hurt, and betrayed. This erosion of trust may have lasting consequences” (Herlihy & Corey, 1992, p. 14). While the impact on the individual client is the first concern, the dual relationship may also have broader repercussions on the organization. For instance, Ramsdell and Ramsdell (1993) indicate that confidentiality is likely to be diminished in cases of dual relationships, a circumstance which would have a negative impact on the agency’s credibility. Furthermore, employing parents would likely produce a ripple effect as other clients might resent that one parent has been picked for a “special relationship” (Herlihy & Corey, 1992, p.15).

Case 1

The following practice case example is presented to illustrate the problems that can arise from dual relationships within the context of Head Start. The case is from an Early Head Start program that was administered by a social worker. While the social worker administrator was not in a direct, therapeutic relationship with the client, the social worker felt that the boundary issues from participating in multiple relationships with the client negatively impacted the professional helping relationship.

Yolanda, an Early Head Start Program parent, was hired by the program director to provide center-based child care to toddlers. At the time of hire, Yolanda had two children; one was in the infant room and the other was in the mobile infant room. Her assignment to the toddler room was to ensure that Yolanda was not working in the same classroom as her children. From her previous experience working with young children and her training in early childhood development, Yolanda initially appeared to have the basis for becoming a talented early childhood professional. However, over time, she became increasingly focused on the care that one of her children, the infant, was given to the detriment of the children in her care. As her focus on her youngest child’s care increased, she spent more and more of her day watching her daughter through the window of the room, neglecting the toddlers for whom she was the primary caregiver. She then became fixated on how her infant daughter was exposed to self-feeding once she turned one year of age and insisted that her daughter must always use utensils. Yolanda wanted food to be used as a reward and as a punishment for table manners, a practice which was strictly prohibited in the Early Head Start Program. Yolanda began to refer to other children in the program as “animals” if they were self-feeding with their hands and not using utensils. Resentment began to build among the other staff members, who felt that Yolanda was constantly “spying” on them and criticizing them and that she was not providing appropriate care to the children in her primary caregiving group. This situation began to create a division among the staff and to impact on the quality of service that Yolanda was receiving as a parent in the program. Yolanda became increasingly distressed and irrational while at work, which further impacted the quality of care she was providing to the toddlers. The social worker program administrator met with Yolanda on several occasions to discuss her job performance. When the situation did not improve, the social worker was faced with terminating her employment.

Ethical Dilemma

Reamer (1990) defines ethical dilemmas as involving decisions the social worker makes about intervening, the nature of the professional relationship, the role of the government, and the distribution of resources. In this case, the ethical dilemma centered around issues of self-determination, confidentiality, and quality of service. When Yolanda was first hired, the potential role conflict that she would experience between being a parent and an employee was discussed. In particular, the difficulties in working in the same child care setting with her children were explored. Yolanda expressed her belief that the role conflict would be something that she could manage, and the social worker felt that to deny her the opportunity would impinge upon her right to self-determination. Confidentiality was at issue as Yolanda was privy to information about other program participants who were her friends. Furthermore, confidentiality was complicated as other parents in the program, as members of the Policy Council, had to approve the decision to terminate Yolanda. The quality of service to children was also an issue as Yolanda was neglecting the children in her care to focus on one of her own children. In addition, quality of service to Yolanda was also an issue as she was creating tension among the staff. Her family support worker felt put in the middle and conflicted about confidentiality, which created tension in their relationship and negatively impacted the professional helping relationship. The ethical dilemmas faced included self-determination v. quality of services to children, and self-determination v. quality of services to parent. Other ethical dilemmas in this case example centered on issues of confidentiality and role conflict.

Values and Salient Ethical Principles

A number of societal and social work values relate to the question of dual relationships in Head Start programs in general and to Case 1 in particular. Values are part of the ethical decision-making process because “the ethical model of decision-making is a values-inclusive process model which differs from a generic problem-solving model in that it is geared to surface value and ethical conflicts and to utilize ethical principles in its decision-making process” (Joseph, 1985, p.6).

The value of autonomy would lead to the belief that Yolanda should retain the ability to decide if she wants to become employed by the program, as part of the right to self-determination. A second critical value is the dignity and worth of the person, which would lead to the decision that Yolanda is able to decide if pursuing employment with the program is a good decision for her. This value relates to the principle that “social workers respect the inherent dignity and worth of the person” (NASW, 1999, p.5). Privacy, another pertinent value, is the philosophical base of confidentiality, which could be negatively affected by Yolanda’s employment as she is privy to confidential information on other children and families in the program. Yolanda’s family support worker also felt that her confidentiality as a client was at risk.

Well-being, a multi-faceted value, has many implications in this situation. First, there is the well-being of the children enrolled as the “programs are only as good as the individuals who staff them” (US DHHS, 1994, p.18). Second, there is the well-being of the parents. If the parent cannot handle the role conflict inherent in working for the program, then employment could be said to diminish well-being as in Case 1. Third, there is the well-being of the social worker. The program administrator in the case example experienced role-conflict from employing the parent and from working to reconcile incompatible policies (Erara, 1991). Fourth, the well-being of the other staff members is at risk, as was evident in Case 1.

Importance of human relationships is also a relevant social work value. Social workers are taught to “recognize the central importance of human relationships” (NASW, 1999, p.6) and to use their relationship with the client as a mechanism for change. As demonstrated in the literature review, it can be argued effectively that dual relationships lead to positive aspects of the human relationship by increasing empowerment and decreasing power disparity. If the human relationship is to be based on partnership, the parent should be given the opportunity to be an active decision maker in how she or he is utilizing all aspects of the program. However, it can also be demonstrated that dual relationships have the ability to harm the client and create a compromised human relationship. If the dual relationship does not enhance the well-being of the parent, but instead diminishes the parent’s well-being, it violates the social work principle. By engaging in a dual relationship, the nature of the human relationship between social worker and parent changes dramatically, as was evident in Case 1. The relationship between the caregiver and the children in care was also affected. Furthermore, the dual relationship could possibly affect the relationship of the parent to other parents and to other staff members.

Integrity also plays a role in this consideration, as a dual relationship requires the social worker to consider whether her or his action in hiring the parent is responsible and trustworthy. If the social worker hires a parent more to fill a vacant position than because of the needs of the parent, she or he would be lacking in integrity. The social work value of service reinforces integrity by establishing that the needs of the clients are to be placed above those of the social worker and that the social worker needs to question whether or not she or he is providing appropriate service to the child and to the family. While there are overlaps between service delivery to the children and to the parent, the underlying value can lead to different decisions when thinking of the enrolled children versus thinking of the parents.

Evaluation of Options

Three alternatives to this ethical dilemma are presented. As per the adapted ethical problem-solving model, it is imperative to generate and evaluate alternatives after explicating the pertinent values (Joseph, 1985). Each alternative presented meets Rothman’s (1998) criteria of being reasoned and considered, indicative of a realistic course of action, and possible for implementation by the social worker. Ethical principles and theories are applied in the discussion of each alternative as per the ethical problem-solving model (Joseph, 1985). A case example to illustrate the strongest option is provided.