Lesson 4: Boundary and Ethical Issues in Mental Health Practice


Attention

Having healthy boundaries between yourself and your clients as well as an understanding of professional ethics is very important. In this lesson we will be exploring what healthy boundaries are, professional ethics and why they are so important.


Learning Outcomes

Upon completion of this lesson's material, students will be able to:

  • Describe the professional responsibilities in community mental health care.
  • Identify how ethical theories, rules, and principles interact in the decisions of community mental health professionals.
  • Describe the rights of mental health patients in today's healthcare environment.

Teaching

Reading

Please read Slides on Boundaries in Mental Health: Ethics-and-Boundaries

Lecture

Professional boundaries define effective and appropriate interaction between professionals and the people they serve. Boundaries exist to protect both the professional and the client. In the mental health field any individual who is working with a client/consumer in a professional capapcity (getting paid to work with them or committed to volunteering for an organization or agency) is considered a professional. As a result you need to conduct yourself in a professional capacity. Professional behavior includes keeping client information confidential and maintaining a client's rights. This includes maintaining the confidentiality of a client's information. Confidentiality means you cannot share information about a client except to document as required by your agneciy and the third party payor (insurance provider) unless summoned by a court of law. We live in small state where everyone knows everyone. I joke that in Maine there is only 2-3 degrees of separation between individuals. If you start to share what you believe to be broad information about a client but with enough detail that your friend or family member figures who they are or where they live, you have just broken the confidentiality of the client. This also applies to accessing electronic records.

Here is a scenario that could play out in a number of different ways:

Let's say that you find out one of your ex-boyfriends is a client with your mental health agency. You might wonder what type of services he is receiving at the agency and why. If you let your curiousity get the better of you, you might decide to look him up in your agency's electronic medical record. You see he has become a client after an inpatient psychiatric hospital stay, he has a diagnosis of major depression and and that his case manager is your co-worker Margie. Now what do you do? Do you say something to Margie about him? Do you give her some additional information about him that he might not have shared with her? The answers are no and definately NO! First of all you broke a professional boundary by looking him up to begin with. If he is not your client you have no legal or professional need to access his information. You cannot speak to your co-workers about him either. There may be times you realize a client is also an aquantance of yours in some capacity (relative, friend, school mate, etc.). In those situation you need to notify your supervisor that you have had a prior personal relationship with that individual and discussion the most appropriate plan of action. It might be that you cannot accept that person as a client, for any relative that would certainly be the case. It might also be that if the case is brought up in group supervision (well all the employees in a specific role meet together to review and discuss their client) you excuse yourself from the room until the discussion is done. It all depends on your relationship with the person as well as in what capacity you are working. Supervision is crucial in situations like this.

Supervision is usually provided by a supervisor at your agency who oversees the work of yourself and your peers. The supervisor will meet with you on a regular basis to review your cases, help you problem solve situations and discuss any ethical dilemmas you may be encountering.

A boundary violation includes any behavior or interaction which, damages the client/consumer, the professional, and/or the work you are doing is a violation of professional boundaries. It is the victimization and exploitation of a patient by the professional. It is a betrayal of the sacred covenant of trust. This includes sexual and non-sexual misconduct.

Some of the information on boundaries above came from: https://professionalboundaries.com/faq.php

Please read more about boundaries and boundary violations: Professional Boundaries Document 08.2008

Ethics are professionally accepted standards of personal and business behavior, values and guiding principles. Codes of professional ethics are often established by professional organizations to help guide members in performing their job functions according to sound and consistent ethical principles (From: http://www.businessdictionary.com/definition/professional-ethics.html).

There are multiple Codes of Ethics in the field of mental health. It all depends which type of work you identify with such as social work, case management, counseling, rehabilitation or other types of mental health work. A code of ethics prescribes how professionals are to pursue their common ideal so that each professional may do the best she/he can at a minimal real or emotional cost to herself or himself and those she/he cares about (including the public). The code is to protect each professional from certain pressures (for example, the pressure to cut corners to save money) by making it reasonably likely (and more likely then otherwise) that most other members of the profession will not take advantage of her/his good conduct (From http://ethics.iit.edu/teaching/professional-ethics).

If you are a social worker then you follow the National Association of Social Workers (NASW) Code of Ethics.

The NASW Code of Ethics serves six purposes for social workers:

  1. The Code identifies core values on which social work’s mission is based.
  2. The Code summarizes broad ethical principles that reflect the profession’s core values and establishes a set of specific ethical standards that should be used to guide social work practice.
  3. The Code is designed to help social workers identify relevant considerations when professional obligations conflict or ethical uncertainties arise.
  4. The Code provides ethical standards to which the general public can hold the social work profession accountable.
  5. The Code socializes practitioners new to the field to social work’s mission, values, ethical principles, and ethical standards.
  6. The Code articulates standards that the social work profession itself can use to assess whether social workers have engaged in unethical conduct. NASW has formal procedures to adjudicate ethics complaints filed against its members.* In subscribing to this Code, social workers are required to cooperate in its implementation, participate in NASW adjudication proceedings, and abide by any NASW disciplinary rulings or sanctions based on it.

To read more about the NASW Code of Ethics and to see the entire code follow this link: https://www.socialworkers.org/pubs/code/default.asp

If your work has you identifying yourself as a professional Case Manager then you could consider accepting the Code of Professional Conduct for Case Managers and pursue becoming a Certified Case Manager through the Commission for Case Manager Certification (CCMC). Here is a guide to making ethical decision from the CCMC: http://www.cmbodyofknowledge.com/content/case-manager’s-ethical-decision-making

Part of the responsibilities of mental health workers include

  1. Protecting the rights of clients (to make sure their rights to freedom, self determination, choice of services and service providers, and more are protected)
  2. Telling the truth (There should be no occassions where a client is not told the truth and your documentations should always accurately reflect what you did and said)
  3. Respecting confidentiality (Keeping your client information private)
  4. Functioning as an advocate (Helping clients find their own voices or being a voice for a client who needs assistance in accessing services, benefits or supports)
  5. Accepting accountability for providing proper mental health care (As a professional you will be paid for providing the best services you can within your training and skills. You need to follow your professional ethics and your agency/employer policies and procedures.)

Read article Eye on Ethics - Client Rights - http://www.socialworktoday.com/news/eoe_0106.shtml

I would like for you to try the Baker Ethics Training Game App. This is a free app. I was unable to find a mental health ethics specific app but I liked the way this one made you think through you various options about a professional scenario. The app starts out with getting a call about an RFP. An RFP is a Request for Proposal. Organizations put out RFP requests when they are looking for another business to provide a service for them. Many times you can have multiple organizations replying to an RFP and there could be a lot of money that the business could earn if they are chosen as the supplier of the specific service.

I look forward to hearing what you think about this game.


Assessment

Lesson 4 Quiz

  1. Because clients have rights, healthcare professionals have responsibilities to tell the truth, respect confidentiality, function as an advocate, and accept accountability for providing proper mental health care. How do these attributes impact on community mental health professionals?
  2. If mental health professionals have a Code of Ethics to follow and know they need to maintain appropriate professional boundaries then why do you think boundary violations continue to occur regularly? What are some things you can do to reduce the likelihood of violating professional boundaries with clients?

Lesson 4 Discussion (for online class only)

Pick one part of one section of the NASW Code of Ethics and explain how you think that would apply when you work with mental health clients and why you believe the NASW believes this ethical issue is important.