Risk
by Allan Barsky, J.D., MSW, Ph.D.
Social workers use a variety of methods to analyze and manage ethical issues: consulting with a supervisor, applying the NASW Code of Ethics, using a decision-making model for critical thinking, and applying ethical theories such as deontology (duty based ethics) or teleology (choosing actions that maximize positive consequences) (Barsky, 2010). Many agencies and some social work ethicists are strong proponents of a risk management approach to handling ethical issues (Lopez, 2014). According to this approach, workers should identify the risks of various courses of action so they can determine which course of action to take.
Risks may include possible harm to clients, workers, the agency, or others. Further, workers need to be attentive to various forms of harm, including the possibility of negative physical, psychological, social, spiritual, legal, ethical, and financial consequences. Once the worker has chosen a particular course of action, the worker should then use problem-solving strategies to pre-empt or reduce the risks of the particular course of action.
Risk management is an ongoing process (Reamer, 2013). Once a worker has embarked on a particular course of action, the worker should continue to monitor, identify, and respond to risks, as they may change, even within the course of a single intervention. Additional risk management strategies include: maintaining clear documentation of client contacts, goals, objectives, and treatment decisions; consulting with supervisors and attorneys; maintaining appropriate boundaries with clients; adhering to relevant laws; and keeping current on practice standards, research, and theory in your areas of practice (Zur, 2011).
Rationale for Risk Management
The purpose of risk management is to identify potential problems before they occur, allowing the worker and agency to make choices to avoid, minimize, or mitigate potential harm. Although avoiding harm to clients, workers, and others may be a valid ethical goal, at least part of the rationale for risk management is to avoid the legal consequences of causing harm—for instance, being sued for malpractice, having to pay compensation, losing one’s license to practice, or putting the agency’s legal status at risk. By pre-empting and managing risks, workers and agencies can make strategic choices about which types of risks to accept and which to avoid. Some agencies have designated officials whose role is to help the agency manage risk. Other agencies leave it up to practitioners and their supervisors to manage risks.
Case Application
To illustrate a risk management approach, consider the following situation.
Serena is a clinical social worker who is working with Bob, a client diagnosed with borderline personality disorder. As a competent evidence-based practitioner, Serena consults the research literature and identifies the following therapies as having a strong evidence base for helping clients with borderline personality disorder. (Note: These three are provided as examples; there are certainly other evidence-based therapies that could be considered.)
- Dialectical behavior therapy (DBT), which includes teaching behavioral skills and meditation to help clients regulate emotions and improve relationships
- Cognitive behavioral therapy (CBT), which helps clients identify inaccurate, negative, or ineffective thinking, and practice more functional ways of thinking and behaving
- Somatic Re-Experiencing Therapy (SRT), in which the client delves into past experiences of trauma (such as child sexual abuse) to re-experience and resolve deep-seated issues
According to Serena’s interpretation of the literature, each of these interventions involves risk. She concludes that SRT carries the greatest risks. Because the client is re-experiencing past traumas, the client may be retraumatized, experience severe distress, and perhaps develop suicidal ideation. So, according to a risk management approach, should Serena reject the use of SRT? It is certainly the riskiest of the options she is considering. However, Serena is also concerned that the other approaches deal primarily with the symptoms of borderline personality disorder, rather than the underlying cause. Without addressing the underlying cause, Serena can help Bob manage problems related to distressing emotions, relationship issues, and dysfunctional patterns of behavior. Serena would like to use SRT to help Bob resolve deeper issues. Still, she is afraid that doing SRT leaves both the client and herself at too great a risk. If Bob suffers from the intervention, he could complain to her agency, to the NASW, or to her licensing body. He could also sue her for malpractice. Serena recommends DBT to Bob, noting that DBT is the least risky of the therapies she is considering.
Limitations of Risk Management
Risk management is essentially a teleological approach to ethics, focusing on the consequences of different courses of action. One drawback of this approach is that workers and agencies may place too much emphasis on risks, not giving enough weight or attention to potential benefits. Serena, for instance, opts for DBT not because it has the greatest potential benefits, but because it avoids particular risks.
Although a risk-averse approach to decision-making may protect social workers and agencies from lawsuits and other negative consequences, clients may be deprived of services that can provide the greatest benefits (e.g., interventions that treat underlying causes rather than dealing with surface issues and symptoms). Another limitation of risk management is that it may cause workers and agencies to avoid serving the most vulnerable and needy populations, because doing so entails additional risk.
Consider, for instance, an agency that decides not to serve divorcing couples, suicidal patients, clients with borderline or antisocial personality disorder, or clients with a history of litigation, simply because there is a higher level of risk than working with other clients (Zur, 2011). In such cases, workers and agencies may be focusing on protecting the worker and agency, rather than making the best interests of the client the primary concern.
A final risk of risk management is that it encourages workers and agencies to do the “least risky thing” rather than the “right thing.” According to a deontological approach, there are certain universal duties that we should follow, regardless of the risks and consequences. For instance, we should behave honestly and respectfully. We should also promote social justice.
Consider a plan to use civil disobedience to challenge racism or other forms of discrimination. People using a risk aversion approach might reject civil disobedience because it is inherently risky. Consider how many social work and social justice interventions involve significant risk. Consider also how avoiding risky interventions may also mean precluding the potential benefits of such interventions.
A Benefits-Risks Approach
To ameliorate some of the limitations of a risk management approach, consider the use of a benefits-risk approach. This approach fits with the strengths perspective of social work, encouraging workers to identify and build on positives rather than simply focusing on risks or negatives. Using a benefits-risks approach, workers and agencies identify both the benefits and risks of particular courses of action. When making choices about how to proceed, they make informed decisions, taking into account the benefits and risks to all parties, with particular attention to the impacts on clients (as per Standard 1.01 of the NASW Code of Ethics, 2008).
If Serena and Bob were to use this approach, they would discuss the risks and benefits of various models of intervention and jointly decide which intervention to use. They might decide to use SRT, despite the relatively high risks of this approach. Although they would take risks to Serena and her agency into account, Serena and Bob could have frank discussions about how to manage these risks, as well as how to manage (and enhance) the potential benefits.
A benefits-risks approach fits with informed consent (Standard 1.03), as clients have a right to make treatment choices based on full information. For instance, Bob might decide to try a less risky approach first. If the less risky approach does not work, they can consider more risky approaches. They may also decide that Serena does not have sufficient training and skill, in which case Bob could be referred to a more experienced worker (thus enhancing benefits and minimizing risks).
In some cases, social workers, clients, and agencies may also decide to pursue a particular approach because of the potential good, even if the good is uncertain or the risks are relatively high. A benefits-risks approach allows decision makers to determine what level of risk they are willing to accept. However, they make this decision without a preconceived bias toward risk aversion.
The ethical principle of “nonmaleficence” suggests that practitioners should “do no harm.” The principle of beneficence suggests that practitioners should “do good,” even when there may be some risks of harm (Barsky, 2010).
References
Barsky, A. E. (2010). Ethics and values in social work. New York: Oxford University Press.
Lopez, A. (2014). Social work, technology, and ethical practices: A review and evaluation of the National Association of Social Workers’ Technology Standards. Social Work in Health Care, 53 (9), 815-833.
National Association of Social Workers (NASW). (2008). Code of ethics. Retrieved from http://www.naswdc.org
Reamer, F. G. (2013). Social work in a digital age: Ethical and risk management challenges. Social Work, 58 (2), 163-172. doi: 10.1093/sw/swt003
Zur, O. (2011). Guidelines for ethical risk management. Retrieved from http://www.zurinstitute.com/risk_management_guidelines.html
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.