Being Conscientious: Ethics of Impairment and Self Care

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Impairment

by Allan Barsky, JD, MSW, Ph.D.

     Nobody is perfect. We all have bad hair days...or worse. We might have the flu or another physical illness. We might be suffering emotionally from marital discord or loss of a parent. We might be experiencing financial hardships. We might be dealing with an existential crisis, wondering about our purpose in life or as a professional social worker. So, what are our ethical obligations when we are experiencing physical, emotional, social, or spiritual distress?       

     The NASW Code of Ethics (2008) informs us that our primary obligation is to our clients (Standard 1.01). Unfortunately, it does not provide much guidance on what to do if personal problems are interfering with our professional responsibilities to our clients, or to our employer and the profession of social work. Although it is not explicitly stated in the Code of Ethics, I would submit that self care is an ethical obligation, implicitly required by Standard 1.01 and other ethical obligations to which we aspire.

    The primary ethical standard on impairment is 2.09, which states:

(a) Social workers who have direct knowledge of a social work colleague’s impairment that is due to personal problems, psychosocial distress, substance abuse, or mental health difficulties and that interferes with practice effectiveness should consult with that colleague when feasible and assist the colleague in taking remedial action.

(b) Social workers who believe that a social work colleague’s impairment interferes with practice effectiveness and that the colleague has not taken adequate steps to address the impairment should take action through appropriate channels established by employers, agencies, NASW, licensing and regulatory bodies, and other professional organizations.

    Basically, these provisions require social workers to address impairment in their colleagues. The underlying concern is protection of clients. If a worker’s impairment affects the quality of service, then the client is at risk. If we have an obligation to deal with a colleague’s impairment, then why not have an obligation to deal with our own?

    Perhaps it sounds obvious. If a social worker is unable to perform her professional duties in a competent manner, of course the worker will do whatever is necessary to take care of herself before returning to work. Unfortunately, there are a number of circumstances in which workers might continue to work despite impairment:

• A worker with depression or burnout might lack awareness about the existence or consequences of this condition.
• A worker who contracts a sexually transmitted disease might be too embarrassed to disclose this condition to anyone at the workplace.
• A worker going through a high conflict divorce might be too financially distressed to afford taking a leave from work.

    In each of these cases, the worker continues to work, putting clients at undue risk. Given the interpersonal nature of social work practice, it is important to consider the psychosocial consequences of impairments. Some conditions, such as burnout, might result in depersonalization or lack of caring with clients. Other conditions might result in over-identification or problematic countertransference with clients. Although one could argue that the aforementioned workers are not intentionally harming clients, consider what strategies they could use to pre-empt the harm: self awareness, supervision, feedback from colleagues, and therapy.

    It is easy to say that social workers need to be aware of impairments and take action to ensure that they are not putting clients at risk because of any impairment. In practice, however, raising self awareness may be challenging. Some conditions, including addictions, develop slowly and insidiously. It may be hard for a worker to discern when drinking problems have developed to the point at which they are affecting work. Alternatively, a worker may be in denial about a problem because it is too hard (psychologically or culturally) to admit to having a problem. One method that workers can use to raise awareness of possible impairments is to conduct periodic  self-assessments of their conscientiousness.

    Conscientiousness refers to the attending to one’s job or duties in a manner that is careful, attentive, thorough, and ethical. Conscientiousness has been found to be one of the best predictors of professionalism in health care practice (Burford, Carter, Morrow, Rothwell, Illing, & McLachlan, 2011). Rather than asking, “Do I have an impairment that is affecting my practice?” workers can ask themselves the following types of behavior-oriented questions:

• Have I been showing up to work on time (or have I had a pattern of missing appointments or showing up late)?
• Have I been completing all my work tasks?
• Have I been completing my work tasks in a rigid or minimal manner?
• Have I been maintaining a professional appearance, including how I dress and groom myself?
• Have I been adhering to the highest principles of ethical practice (including maintaining client confidentiality, demonstrating respect for clients, and avoiding boundary violations)?
• Have I been following best practices and evidence-based interventions with clients?
• Have I been acting in a way that clients and co-workers can trust me as a reliable social worker?
• Have I been taking steps to continuously improve my competence and the effectiveness of my practice?

    Answering “no” to any of these questions may indicate a need for further exploration and action. As the Transtheoretical Model of Change suggests, you do not need to admit having a problem to commit to making changes (Prochaska & Norcross, 2002).

    Ongoing supervision is a vital mechanism for raising awareness about the presence and potential impacts of a worker’s impairments. Although a supervisor’s role does not include providing therapy to supervisees, supervisors do have a responsibility to monitor worker issues that may affect practice with clients. Ideally, the worker has a trusting relationship with the supervisor, making it easier for the supervisor to address possible impairment concerns with supervisees. If a worker does not take appropriate action to address concerns that are affecting clients, supervisors may impose corrective or disciplinary actions—including suspension or dismissal.     

    Supervisors do need to follow relevant agency policies and laws, including the Americans with Disabilities Act. This statute may require offering accommodations for workers with disabilities (which may include various physical or psychological impairments). Ideally, the worker and supervisor work collaboratively on a plan that allows the worker to obtain the help or support he needs, as well as ensuring clients receive the services they need.

    In some instances, colleagues may provide you with feedback regarding concerns that are affecting the quality of your practice. When confronted, you might be inclined to respond defensively. Listen carefully to feedback from co-workers. If you feel defensive or apprehensive about talking further with them, simply thank them for their feedback. Then, find someone with whom you would feel safe discussing these concerns further—perhaps a supervisor, trusted colleague, or a therapist.

    There is a saying that goes, “The cobbler’s son has no shoes.” Similarly, many social workers do not access the biopsychosocial help they may need for their personal or family concerns. If you have biopsychosocial concerns that may be affecting practice, make sure to access help as soon as possible. Early intervention may prevent much greater problems. Many agencies have an employee assistance program or insurance that covers various forms of help. Helping yourself helps you and your clients. From an ethics perspective, it is also the right thing to do!

References

Burford, B., Carter, M., Morrow, G., Rothwell, C., Illing, J., & McLachlan, J. (2011). Professionalism and conscientiousness in healthcare professionals: Progress report for Study 2—Development of quantitative approaches to professionalism. Durham, UK: Medical Education Research Group School of Medicine and Health Durham University. Retrieved from http://www.hpc-uk.org/assets/documents/1000361BProfessionalismandconscientiousnessinhealthcareprofessionals-progressreportS2.pdf.

National Association of Social Workers. (2008). Code of ethics of the national association of social workers. Washington, DC: NASW Press.

Prochaska, J. O., & Norcross, J. C. (2002). Stages of change. In J. C. Norcross (Ed.), Psychotherapy relationships that work (303-313). New York: Oxford University Press.

Dr. Allan Barsky is Professor of Social Work at Florida Atlantic University and former 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 (Oxford University Press), and Clinicians in Court (Guilford Press). The views expressed in this article do not necessarily reflect the views of any of the organizations with which Dr. Barsky is affiliated.