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Confidentiality in Social Work Practice: Challenges and Ethical Dilemmas (Part II)

Report of a Simmons Research Study

By Emily Feaster, Wellington Johnson, Kathleen Kelps, Helena Levine, Carolyn MacDuffie, Kathleen Millstein, Anna Rubley, David Sandler, Pam Sinotte*

FOCUS Newsletter - December 1998

This is the second of two articles reporting the findings of a research project conducted at Simmons College School of Social Work. The research was conducted during the 1997-1998 academic year as part of a year long research seminar under the direction of Dr. Kathleen Millstein. (Part one was printed in the November issue of FOCUS)

Part II
When we, a group of ten second-year Simmons MSW students, and our professor, launched our research project to learn about the challenges and ethical dilemmas related to confidentiality confronting today’s social workers, we discovered that our research questions were indeed timely. We developed an anonymous questionnaire with two objectives. The first objective was to learn more about social workers’ beliefs, practice actions, and agency resources regarding confidentiality (reported in Part I in last month’s issue of FOCUS). The other research objective was to identify the ethical dilemmas social workers face maintaining confidentiality and the ways that they handle these dilemmas. The data revealed both expectable and surprising information.

Frequently Encountered Ethical Dilemmas
One of our major objectives was to find out in which areas of practice social workers most frequently encounter ethical dilemmas. For the purposes of clarity, we defined "ethical dilemma” as "a situation in which a practitioner feels pulled in two directions and is not sure what to do.”

We asked the responding practitioners to indicate in which of 52 areas they had experienced at least one dilemma. The average number of dilemmas was eleven. It was very clear from our social work sample that ethical dilemmas related to confidentiality were a common practice experience.

The most frequently encountered dilemmas (reported by 25% or more of our respondents) were those outlined in the accompanying table.

It was not surprising to us that these areas would present social workers with ethical dilemmas related to confidentiality. These are practice areas which require multiple systems involvement as well as legal mandates and obligations. That practitioners indicated that they most often encountered dilemmas when working with adult clients, followed by adolescent clients, and then child clients was also not surprising, as it is reflective of the case loads that the responding practitioners carried. The seventh most frequently encountered dilemma, however, was surprising to us; almost one third of the practitioners indicated that they had experienced a dilemma when a client had reported to them the unethical behavior of another mental health professional.

How Social Workers Handled Ethical Dilemmas
We then explored the ways that social workers handled their ethical dilemmas involving confidentiality. Social workers are using supervisors and colleagues, not professionals in law and ethics, as their main resources. An overwhelming number of respondents reported handling their ethical dilemmas through consultation with either their supervisors (80.1%) or colleagues within their own practice setting (73.5%). These findings were consistent with data from other parts of the study, which stressed the importance of supervision as a resource for social workers.

Over half of the respondents indicated that they had discussed their dilemmas with their clients, and 42.4% said they consulted with administration within their practice setting. Attorneys were consulted by over a third of the respondents; 37.1% consulted with their practice setting attorneys, and 3% had consulted with private attorneys. A significant number of clinicians (27.2%) had used an NASW resource in resolving their ethical dilemmas; 15.9% said they had referred to the NASW Code of Ethics, 11.3% had called the NASW Ethics Hotline. We were encouraged by the data that indicated that practice settings had their own ethics committees; 4.6% of the subjects had used such a resource.

Our respondents indicated that they also used more informal resources. Over a third of the clinicians, for example, indicated that they had consulted with colleagues outside their own practice setting, and 11.9% consulted with their own family members. In addition, some social workers (6.6%) had not considered their situation a dilemma until it was resolved, and many (31.8%) said that they had not consulted anyone about their dilemma, but had resolved it on their own.

Finally, we want to share some recommendations based on our findings:
Almost all of our respondents (98%) reported experiencing at least one ethical dilemma, and as was previously stated, the average number of dilemmas experienced was 11. This clearly shows that ethical dilemmas related to confidentiality are not exceptional, but expectable.

The majority of our respondents indicated that their agencies (126 out of 152) have policies which address issues of confidentiality, and approximately 90% of those agencies have written policies. It seems striking to us, however, that any agency in 1998 would not have policies on confidentiality, and we would like to stress that it is essential that all agencies have written policies on confidentiality that include statements about collaborative relationships, third party payers, discussion of case material in supervision, and limits to confidentiality. We would also like to stress that it is essential that social workers review and discuss agency policies on confidentiality with each client. These discussions should occur not only at the beginning of the treatment but throughout the treatment process.

The most powerful and consistent trend which ran throughout our study was the significant numbers of practitioners who are looking to their supervisors as resources for discussing concerns about client confidentiality. This clearly indicates a strong need that support and training be offered for social work supervisors on ethical dilemmas related to confidentiality, the process of identifying and resolving ethical dilemmas, and collaborative relationships, legal issues, and managed care.

As practitioners, we all need to increase our attention to the complex and changing requirements of insurers for client information and to the ethical and practice implications of such requirements.

We feel that social workers also need forums where they can discuss the nature and limits of confidentiality and of ethical issues, and we would like to suggest that continued efforts to form ethics committees within practice settings could be one way to provide this resource.

We have found a need for more research conducted by social workers on the nature of dilemmas related to confidentiality in social worker practice. It is clear from our study that social workers are making decisions about what to tell to whom and under what circumstances. We need to know more about how social workers make these decisions and why. Through continued research in this area, more information can be gathered to better insure resources to social workers and quality care to our clients.

* Cristin Bengston and Lea Tolin were also participants in the research project.


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