Dual Relationships: The Challenges for Social Workers in Recovery

Transcription

1 Dual Relationships: The Challenges for Social Workers in Recovery Laura E. Kaplan ABSTRACT. Over the last ten years there is increasing focus in social work literature about non-sexual dual relationships. This has included consideration of different types of dual relationships that occur primarily during or after the establishment of professional social worker-client relationship. However, the specific concerns facing social workers who are themselves in recovery from substance use disorders remain absent from these discussions. This article identifies challenges facing social workers in recovery from substance use disorders who also work with clients dealing with these disorders. Recommended actions and policies that can assist professionals and agencies in balancing personal and practice issues are presented. [Article copies available for a fee from The Haworth Document Delivery Service: HAWORTH. address: <docdelivery@haworthpress.com> Website: < by The Haworth Press, Inc. All rights reserved.] KEYWORDS. Dual relationships, ethics, social workers in recovery, substance use disorder treatment Laura E. Kaplan, PhD, LISW, is Assistant Professor, Department of Social Work, College of Social and Behavioral Sciences, University of Northern Iowa, 38 Sabin Hall, Cedar Falls, IA ( laura.kaplan@uni.edu). Journal of Social Work Practice in the Addictions, Vol. 5(3) 2005 Available online at by The Haworth Press, Inc. All rights reserved. doi: /j160v05n03_06 73

2 74 JOURNAL OF SOCIAL WORK PRACTICE IN THE ADDICTIONS INTRODUCTION In the last ten years, concern with ethical behavior in the professional role of social workers has expanded (Congress, 1996; Kaplan, 2001; Reamer, 2003). There is a growing literature in social work and other helping professions (counseling, psychology, marriage and family therapist) about ethics in general and relationship boundaries in specific. Discussions on the concepts of dual relationships, boundary crossings, and boundary violations appear regularly, however, strategies for managing dual relationships in the form of consumer-provider roles, particularly in the addictions field, are rarely offered. The issue of dual or multiple relationships in addiction and substance abuse treatment is quite a murky one. It is difficult and sometimes impossible to identify clear ethically appropriate behaviors for providers who are also in recovery from substance use disorders. Guidelines between respect for the client and the provider, respect for the healing process of both, and respect for professional codes of ethics become quite complex. This article addresses non-sexual dual relationship issues confronting social workers who are in recovery from substance use disorders (alcohol and other drugs) and who work with clients who are also in recovery. The employment of consumers as providers is common in many areas of social and mental health services today. Agencies such as HIV/ AIDS organizations, domestic violence shelters, rape crisis centers, and alcohol and drug treatment and prevention programs now staffed by professionals, emerged from grassroots movements of people in response to their own needs. Though these services may have started as peer programs, most evolved into organizations with blended staff consisting of volunteers, paraprofessionals, and professionals who were, or are, also consumers. Consumers as providers contribute to services in unique and positive ways because of their understanding of clients personal experiences associated with treatment, personal recovery struggles, and their familiarity with the institutional systems (Carlson, Rapp, & McDiarmid, 2001). However, with the enhanced knowledge and experience consumer-providers bring there are also challenges for themselves, their clients, and their agencies. Though the concept of consumer-provider is often associated with para-professionals, this is a temporal definition as more individuals seeking employment in recovery fields acquire professional degrees and certifications. Dual relationships occur with the multiple roles consumer-providers take when the provider and client share relationships outside the professional one. The

3 purpose of this article is to bring to light an issue that has not been addressed adequately in dual relationship discussions. That is, the specific situations of social workers who are in recovery and whose paths cross those of clients also in recovery. This article will briefly review the place of social work in the addictions field, examine the common definitions of dual relationships, review what the literature and codes of ethics have to say about these, and explore the challenges faced by addiction professionals who are themselves in recovery. Finally, it will offer suggestions for agencies and practitioners. Social Work Practice in Addictions Laura E. Kaplan 75 Social workers have been a force in substance abuse treatment dating back to Mary Richmond s work in alcoholism diagnosis and treatment at the start of the 20th century (Straussner, 2001). Interest in information and support for social workers in the addictions field is evidenced by the emergence of an Alcohol, Tobacco, and Other Drugs specialty section in the National Association of Social Workers (NASW) in the last ten years. Although some research reports low involvement of MSW social workers in the addiction field, there is a growing representation of BSWs in the area (Sun, 2001). Clients present with substance abuse and addiction problems in all settings and assessment of these issues is an important aspect of treatment. In a survey of 1,620 social workers completed by the Practice Research Network (PRN) for the NASW (2000), 697 (43%) reported screening clients for substance abuse disorders. Of these, 454 (28%) had diagnosed clients with substance abuse as a primary, secondary, or co-occurring disorder. A 1995 National Association of Alcoholism and Drug Abuse Counselors (NAADAC) survey of its members, many of whom had either bachelors or master s social work degrees, found that 58 percent were in recovery from chemical addiction (Doyle, 1997). A 1987 survey of social workers in New York City (n = 198) reported that 60 percent (119) had family members or friends with substance abuse problems, 39 percent (77) had immediate family members with problems, and 43 percent (85) knew another social worker with alcohol or drug problems (Fewell, King, & Weinstein, 1993). Although no data is available on the number of social workers in recovery from addictions, one could expect that there is crossover between segments of the social work population, individuals recovering from substance use disorders, and those in the substance abuse and addictions field.

4 76 JOURNAL OF SOCIAL WORK PRACTICE IN THE ADDICTIONS Discourse on the issue of impaired social workers appears in many places, including the Code of Ethics (NASW, 1999), NASW Policy Statements ( ), and in the literature for at least ten years (Reamer, 1992; Siebert, 2003). The focus of these sources is on dealing with an impaired professional. While this is certainly a critical issue, it is also important to consider what is needed to help the professional who is returning or entering practice after treatment. Definitions of Dual Relationships A variety of criteria are used in defining dual relationships. These include definitions based on roles, conceptualizations of boundaries, the timing of the relationship in the course of one s career, or specific types of behaviors. Not all dual relationships, however, are deemed inappropriate or problematic. We may consider brief encounters with clients while eating at restaurants, shopping, or sitting next to a client on a bus are examples of non-problematic situations at one end of a continuum. On the other end of the continuum are sexually intimate relationships. Between these extremes lies a grey area in which dual relationships, or encounters between professional and client, are less likely to be addressed in the literature. The following is a brief overview of the types of dual relationships most commonly addressed in the literature. Roles Many dual relationships occur when a professional and a client take on additional roles with one another outside of the primary professional relationship. Tension arises when one considers the wide range of roles and the settings and practices in which they occur. These roles may include friend, teacher, employer, sexual partner, community member, neighbor, employee, co-members of community or religious group, acquaintance, customer, relative, research subject, supervisee, or business associate (Anderson & Kitchener, 1998; Bonosky, 1995; Congress, 1996, 2001; Kagle & Giebelhausen, 1994; Pope, Tabachnick, & Keith-Speigel, 1987). It seems that level of intimacy of the professional and dual relationships may influence the determination of appropriateness and risk of exploitation.

5 Laura E. Kaplan 77 Boundaries The concepts of boundary crossings and boundary violations (Gutheil & Gabbard, 1992) are critical to the discussion of dual relationships. Boundary violations occur in those relationships involving a conflict of interest, exploitation, or harm, and which are detrimental to the client in the therapeutic relationship. Boundary crossings are more likely to occur in small rural communities where, for example, clients may work in shops frequented by service providers. In such relationships, boundaries may be crossed but should be done so with awareness and respect. The risk of harm can be minimized by the actions and information shared between the parties. Timing The timing of dual relationships presents another source of tension. The literature, as in the National Association of Social Workers (NASW) Code of Ethics (1999), primarily focuses on dual relationships during or after termination of the professional relationship, and again, particularly with sexual relationships (Kaplan, 2001). However, in the field of substance abuse, a dual relationship might involve a current professional relationship that was preceded by a previous nonprofessional type of relationship (Carlson, Rapp, & McDiarmid, 2001; Congress, 1996; Kagle & Northrup Giebelhausen, 1994). Behaviors Some behavior indicators, ranging from hugging and kissing to bartering for services or shaking hands with a client (Pope, Tabachnick, & Keith-Speigel, 1987), are seen as ways professionals cross boundaries or engage in problematic dual relationships. Dual relationships may be determined to be problematic because of concerns with risks of, or actual exploitation of the client, and because the professional s judgment may be impaired (Kaplan, 2001). Central to these issues is the perception of power differentials in the professional/client relationship and client s inherent vulnerability in such a situation (Congress, 1996; Doyle, 1997; Holtzman, 1981; Jacobs, 1991). We can see from this brief overview that the conceptualization of, and issues concerning dual relationships are complex. Social workers, particularly when they and their clients are members of marginalized groups or live in rural areas, must be conscious of the multiple roles they

6 78 JOURNAL OF SOCIAL WORK PRACTICE IN THE ADDICTIONS take on. The risks for exploitation or harm as a result of a dual relationship will vary according to the type of professional relationship (including the existing power differential and level of intimacy, such as psychotherapy services vs. information and referral services); the setting of the professional relationship; the setting and situation of the secondary relationship; the length of time in the relationships; and the timing of the dual role in relation to the professional role (Kaplan, 2001). Dual Relationships and Professional Codes of Ethics The increasing concern over dual relationships in the literature during the last decade has also found its way into the ethics codes of professional organizations. They first emerged in the NASW Code of Ethics in 1992 (Reamer, 1998). Codes of ethics have a variety of time limits on the formation of non-sexual dual relationships occurring after the termination of professional services. According to the NASW Code of Ethics in Standard 1.06 (2000): Social Workers should not engage in dual or multiple relationships with clients or former clients in which there are a risk of exploitation or potential harm to the client. In instances when dual or multiple relationships are unavoidable, social workers should take steps to protect clients and are responsible for setting clear, appropriate, and culturally sensitive boundaries. The American Psychological Association (APA) and American Association for Marriage and Family Therapists (AAMFT) codes have similar statements. The National Association of Alcohol and Drug Addiction Counselors (NAADAC) Code of Ethics (1995) Principle 9 on client relationships states: The NAADAC member shall not engage in professional relationships or commitments that conflict with family members, friends, close associates, or others whose welfare might be jeopardized by such a dual relationship. The NAADAC member shall not exploit relationships with current or former clients for personal gain, including social or business relationships. As in the other professional codes, the NAADAC speaks only to dual relationships with current or former clients, stating members should not

7 Laura E. Kaplan 79 exploit relationships. Toriello and Benshoff (2003) note that not all states that have credentialing processes require alcohol and drug counselors to follow NAADAC standards; in 1997, only 14 of the 40 states with credentialing required counselors to follow NAADAC standards. Thus, there may be several codes of ethics one professional is expected to follow, and the language in these may be in actual or perceived conflict. Codes of ethics for substance abuse counselors and for many professionals (social workers, counselors, marriage and family therapists, and psychologists) do not specifically address issues related to practitioners in recovery from addictions (Doyle, 1997). Though Doyle suggests that the guidance of AA may be the most helpful, this may bring about confusion between the personal values and beliefs of personal recovery and the professional role. The fact that treatment often incorporates AA and other twelve-step programming may serve to blur the lines further between professional and personal roles and add to difficulties in balancing professional and personal ethics. Although all of the codes reviewed address the general area of non-sexual dual relationships that follow the termination of the professional relationship, they do not address those occurring before it. This brings up several problematic issues (e.g., prior friendships, business relationships, church affiliations), but for the purpose of this article, only the recovery group affiliation is considered. It is important to remember that codes of ethics are guidelines rather than rulebooks for professional behaviors. A professional should not rely solely on a code of ethics (due to the ambiguity of language in many standards, this would be indeed difficult to do) in determining ethical action. Supervision, evidence based practice, agency procedures, ethics codes, and laws should be part of the critical thought process leading to ethical practice. Codes of ethics are an important part of the process providing information on the culture of the profession, areas that may become ethically problematic conflicts of interest,... issues of professional courtesy,... rules that govern how professionals should behave to enhance and maintain a profession s integrity... and... address issues that concern professionals duty to serve the public interest (Reamer, 1998). That said, how helpful are codes of ethics for social workers who are in addiction recovery facing dual relationships in the addictions field? Though the exact number of social workers in recovery and the number who are members of NAADAC and NASW are not available, it is likely that some social workers are members of both and are also mem-

8 80 JOURNAL OF SOCIAL WORK PRACTICE IN THE ADDICTIONS bers of Twelve-Step recovery programs, including peer support groups such as Social Workers Helping Social Workers. The NASW Code of Ethics (1999) acknowledges that some dual relationships are unavoidable, however, the language in the code emphasizes the relationship should be avoided if there is a risk of harm or exploitation. The NAADAC (1995) code emphasizes that exploitation should be avoided as seen above in Principle 9. The vagueness of this principle can result in tension. What do Twelve-Step programs inform us about balancing dual relationships? Alcoholics Anonymous, the oldest program in the U.S., will be used as an example. Dual Relationships and Twelve-Step Programs Alcoholics Anonymous offers guidance for members employed in the alcoholism treatment (AA, 2003). These recommendations come from AA members whose opinions vary. Some suggest counselors should refrain from using AA in any part of their job title, should not act as an AA sponsor for people who are clients (former clients or sponsees who become clients are not addressed), should not facilitate AA meetings in the work setting, and AA member names should not be used in fundraising. One member stated, Speaking to troubled alcoholic clients, maybe you could help them with your own story but it is also possible this might hinder their own affiliation with AA. They may not understand your motive.... Remember that what you do can affect yourself, your listeners, and AA as a whole, to sum up, I d say examine your conscience fearlessly, then pray for guidance in each case (AA, 2003). We see that the AA philosophy is agreeable to members working in the field, but it also encourages careful consideration of behaviors in balancing the worlds of recovery and professional life. However, the guidance remains quite vague. If the recovering professional attends Twelve-Step meetings with clients, might this be considered helpful role modeling supporting a recovery program rather than conflict of interest? Although both codes are concerned with client welfare and the importance of doing no harm, it is left to the individual to determine the potential harm. This is standard for codes; however, a broader range of critical thinking is needed to determine potential conflicts and appropriate behaviors. Attending Twelve-Step meetings with clients and sponsoring clients in recovery groups are not uncommon practices in addiction treatment programs. These practices likely occur more often within programs using volunteer or para-professional staff. As professional-

9 Laura E. Kaplan 81 ization of roles expands, re-evaluation of more traditional practices must take place. Policies and discussion in treatment settings to help staff balance the traditional methods of supporting client recovery with ethical behaviors and personal recovery are needed. This balance of variation in codes, traditional methods, and personal recovery program guidelines becomes more difficult for social workers and clients living and working in communities wherein dual relationships are everyday occurrences. The less detailed or less stringent the ethical behavior expectation may be, the more appropriate and reasonable the guide, particularly in smaller more remote and rural communities where the recovery support network is more limited (Doyle, 1997). The necessity of being equally responsible to multiple behavior expectations brings into question issues of ethical relativity. One may tend to believe whichever best fits the situation is the most appropriate, inferring that what constitutes ethical behavior is largely a personal decision reflecting one s own belief system rather than a rational systematic process of decision-making. Social workers balance their personal and professional ethics as a matter of course, and often this includes issues around crossing or violating boundaries in dual relationships; too often, however, this process occurs in isolation, without consultation or supervision with others. Dual Relationships and the Professional Literature There is little in the social work literature addressing the issues of recovering social workers in the addictions field. Reamer (2000), chair of the NASW Code of Ethics revision committee, argued that there are variations in the risks involved in dual or multiple relationships, giving the following explanation and example: Superficial contact... will not introduce difficult issues in the professional-client relationship. At the other extreme are dual or multiple relationships that are clearly problematic... The social worker who was in recovery and attended Alcoholics Anonymous meetings with her client could harm him as a result of the confused boundary issues. The client might have difficulty distinguishing between the social worker as a professional and the social worker as an acquaintance who is also in recovery. This confusion could interfere with the so-

10 82 JOURNAL OF SOCIAL WORK PRACTICE IN THE ADDICTIONS cial worker s professional effectiveness and with the client s recovery. (pp ) In Reamer s example, the social worker accompanied the client to an AA meeting. However, the same confused boundary issues would occur if they attend the same meetings arriving separately since attendees at Twelve-Step meetings regularly disclose intimate information. This disclosure may be from the social worker or from the client who shares information that was not divulged in the professional relationship, not only affecting boundaries but confidentiality and privacy issues as well. It appears the guidance in this passage is to avoid attendance at AA meetings with clients. We can see the tension that can set in for the recovering social worker trying to behave ethically when looking at the following statements by Reamer (2003) where he groups together dual relationship activities of attending clients weddings, having dinner during a home visit, and attending Twelve-Step meetings, and notes that there is disagreement in practice: Some social workers are adamantly opposed to attending clients life cycle events because of potential boundary problems (for example, the possibility that a client might interpret the gesture as an indication of the social worker s interest in a social relationship or friendship); others, however, believe that attending such events can be ethically appropriate and, in fact, therapeutically helpful as long as the clinical dynamics are handled skillfully. Some social workers believe that practitioners in recovery should never attend or participate in AA or NA meetings where clients or colleagues are present, because of the difficulty clients and colleagues may have reconciling social workers professional roles and personal lives. Others, however, argue that recovering social workers have a right to meet their own needs and can serve as compelling role models to clients and colleagues in recovery. (p. 128) In this passage there seems to be less concern that attendance at AA is clearly problematic, rather that there may be a difference of opinion among social workers, some of whom believe involvement in Twelve- Step meetings with clients is acceptable. Consistent messages are important in helping social workers balance personal and professional ethical behaviors. This variation in emphasis on what is ethical behavior illustrates the importance of teaching social workers and students how to reason through ethical practice decisions rather than a case based

11 methodology that encourages an if this happens, then do this reasoning process. Differences in the interpretation of case examples in the literature may reinforce the idea of the decision-making process as being one of individual preference, i.e., relativistic, rather than rational and systematic. Additionally, even in good decision-making models, such as the social work ethics audit (Reamer, 2000), use of the 155 standards of the NASW Code of Ethics (1999)... requires specialized knowledge (Reamer, 2000, p. 361). Further, with the understanding that the purpose of a code of ethics is not to give specific answers to specific dilemmas, the lack of clarity in the literature may simply add to the confusion. A critical point in the consideration of ethical decision-making is that the Council of Social Work Education required integration of ethics into the graduate social work curriculum is less than 5-years-old (CSWE, 2001). Many social workers in the field graduated prior to this requirement and do not have information about the ethics knowledge base or moral reasoning levels of practitioners. Such information can enhance practitioners ethical reasoning in complicated issues. On a positive note, many states now require continuing education hours in ethics for licensure. Education can assist professionals in thinking about how to balance the dual roles arising in practice. Specific attributes that may intensify the tension or help to clarify the level of risk involved in these dual relationships are indicated below. Challenges Laura E. Kaplan 83 It is common for people struggling with substance use disorders to make attempts at recovery in Twelve-Step groups prior to entering a formal treatment program. Thus, professionals in recovery may know individuals from Twelve-Step meetings who later become their clients. While these meetings are anonymous, they do involve the sharing of intimate information during the sessions. The confidentiality of information and identification of attendees can be problematic. The professional may have shared intimacies in meetings known to a new client. Alternatively, the potential client may share information at a meeting that he would prefer future counselors not to know. It is simplistic to suggest that since the information shared in meetings is confidential there is no danger outside of meetings. Once heard, it can influence perceptions and judgments. The information may concern criminal activities or abusive behaviors, and all shared information concerns issues of privacy and the right to share with others what and when one chooses. How might we be respectful of the professional s and the potential cli-

12 84 JOURNAL OF SOCIAL WORK PRACTICE IN THE ADDICTIONS ent s disclosure choices? Can we even consider ways of respecting choices without seeing into the future to learn if their paths will cross in the treatment realm? The parameters of self-disclosure within the counseling setting are a subject of ethics and supervision discourse. There is a gap in the discourse about self-disclosure in anonymous support meetings. This may be due to the requirement of anonymity of the groups; however, participants know the information heard in a meeting, even if not shared outside of it. What we know influences our perceptions about people and the world, so we must assume that what a client (future, current, or former) knows about a treatment provider will have influence on the professional relationship. Of course, the opposite is true as well what the social worker knows about the client from the community or recovery meetings will influence the professional relationship as well. For the professional trying to practice ethically, this can be problematic. For example, a social worker attended NA meetings for several years with a woman who used drugs during her pregnancy, behavior about which the social worker has strong feelings and opinions. The woman is now entering treatment with this social worker. While at times the social worker may have the option of not taking a specific client, this is not possible in every agency all the time. Balancing the many aspects of dual relationships for recovering social workers employed in addictions is challenging. For professionals practicing in smaller suburban and rural areas, the challenges of dual relationships are greater because alternatives (e.g., referring clients to other professionals, attending different Twelve-Step meetings) are more limited. Though ethical codes and the literature address some issues around conflicts of interest that are similar to dual relationships, an important point is not addressed. Ethics codes, and laws that use them for a base, are offered for the protections of the client and the professional. A dichotomy is inherently part of these roles; one is either a professional or a client. Such dichotomy may not apply here as professionals in recovery may be said to bridge between these two roles. While we have guidelines, procedures, practices, and policies on what to do when a social worker is impaired and in crisis, we fail to address how to ethically practice when one is taking care of oneself but may be both a professional and client. When clients relapse, providers may struggle with personal beliefs about recovery and with questions about their professional abilities (Juhynke & Culbreth, 1994). Additionally, individuals in recovery use an array of support strategies for maintenance. Many mental health,

13 Laura E. Kaplan 85 HIV/AIDS, and substance use disorder programs are moving towards harm reduction models of care, which may be in conflict with the theoretical model and/or personal beliefs of professionals in recovery (Zelvin & Davis, 2001). Such personal struggles become ethical ones in the work setting. As in any professional-client relationship, the concept of the power differential between the client and social worker in recovery may indicate level of risk. Many clients are in treatment and/or Twelve-Step programs because they are court ordered. Court ordered treatment presents an ethical dilemma for social workers. While a full discussion of this is outside the scope of this article, it is important to note that the social worker working with court ordered substance abusing clients has an increased actual and perceived power in his or her ability to influence whether the client goes to jail or stays in treatment in the community (Doyle, 1997). Clients know that the social worker has increased power, and may even perceive it to be greater than it is in reality. If the client also knows the social worker is in recovery, the client may perceive it as an opportunity to grasp control of the relationship psychologically by having personal information about the professional. Thus we see that issues related to the personal life of the recovering social worker may influence risks in dual relationships. Self-awareness is critical to being an effective professional. Knowing what personal issues may impede our ability to help others, our awareness of thoughts and feelings about clients and their problems, and awareness of our own life struggles influence how we behave in our professional roles. For instance, if a social worker is recently widowed or in the midst of a difficult divorce, the decision to withdraw temporarily from direct practice with clients experiencing the same problem would likely be made within supervision discussions. Such discussions may be less open when the social worker is in recovery or relapsing. While agencies generally have policies limiting duties of impaired professionals and those who may be in recovery but have relapsed, professional complications may arise. Recovering or relapsing social workers who attend community programs may have clients who know they have more recovery time than the professional does. Even without relapse, the social worker sharing her personal process of recovery in a 12-step meeting may be divulging information to future, present, or past clients. The following section discusses recommendations and strategies that may prove helpful in the determination of ethical practice in this area.

14 86 JOURNAL OF SOCIAL WORK PRACTICE IN THE ADDICTIONS Recommendations The most consistent recommendation for dealing with any ethical dilemma in the literature is the use of supervision (Carlson, Rapp, & McDiarmid, 2001; Doyle, 1997; Kaplan, 2001; Reamer, 2000 & 2003). When considering dual relationships, some authors argue for increasing specificity in codes of ethics, although they do not specify addiction recovery as one of the issues (Brownlee, 1996; Pearson & Piazza, 1997; Lamb, Woodburn, Lewis, Strand, Buchko, & Kang, 1994). Other general recommendations include continuing education in ethics, and decision-making models using specific dilemma vignettes (Kaplan, 2001). Again, however, most authors do not specifically address concerns of the social worker in recovery. While substance abuse and dependency treatment agencies are more likely to have specific policies regarding employment of consumer-providers, of people in recovery, and issues around relapse, clients with substance abuse problems are seen in all other settings, including mental health, long term and life threatening diseases, aging, domestic violence, and child and adult protective services. While these employers may offer assistance for impaired professionals through policy and employee assistance programs, they may not consider the specific ethical struggles related to employees who are in recovery (similar struggles occur for professionals who have personally experienced other problems such as violence and other trauma). All service agencies, in discussion with social workers, need to develop appropriate policies to assist providers and clients in traversing boundary issues. But first it is important to acknowledge that: 1. There are professionals and others on staff involved in Twelve- Step and other community based personal recovery support programs, 2. Social workers may be responsible for following multiple codes of ethics in practice, 3. Ethics education is new to the social work curriculum and many practitioners do not have this background, 4. Clients seen at the agency will have substance abuse problems that will have to be addressed (28% of all clients have primary, secondary, or co-occurring substance abuse issues), and 5. While there may be boundary crossings between these workers and clients, boundary violations are to be avoided.

15 Laura E. Kaplan 87 In light of these realities, the following are recommended: 1. These issues must be discussed in safe, supportive, and confidential settings such as supervision and professional peer support groups, 2. Discussions about parameters of self-disclosure, privacy, boundaries, confidentiality, harm risk, and release of information must take place in supervision, 3. Professional, administration, and consumer discussions concerning these issues need to inform agency policy, 4. Clear policies and procedures on impairment, community support for recovery, and relapse of professionals and other staff need to be established, 5. Policies on Twelve-Step sponsorship of former and current clients should be developed in all agencies, not just those treating clients with substance use disorders, 6. Establishment of clear procedures to resolve clients concerns about dual relationships, anonymity in community recovery groups, and associated issues is essential, 7. Regular provision of continuing education on ethics, for all social workers, needs to be established. It should include a critical, thoughtful process of issues in everyday practice rather than focusing on unusual case-based dilemmas, and 8. Programmatic supports for agency and individual service providers should include skills and knowledge in working with nonsexual dual relationships that naturally occur in communities. For example, supervision and discussion groups should specifically address dual relationship concerns, clarification of policies, new peer support groups for professionals in communities, and access to web based recovery support groups within agency settings. Social workers often work in isolation, seeing clients more than they see co-workers. This increases the risk of making poor decisions, particularly related to boundaries. Agencies must provide opportunities for staff to openly discuss concerns and share/learn strategies to strengthen ethical practice. Agencies must have a clear, accessible resolution process when disagreements about boundaries arise. At the start of the therapeutic relationship, social workers are responsible for clearly defining limits of confidentiality, boundaries of the relationship, and, with the client, discussing concerns they both have if

16 88 JOURNAL OF SOCIAL WORK PRACTICE IN THE ADDICTIONS they share community involvements such as Twelve-Step program memberships. Monitoring these parameters throughout the course of the relationship is critical. It is best to clarify clients concerns about their own and the worker s self-disclosure in meetings and strategies for dealing with these early in the relationship. This includes concerns related to the power differential, i.e., if the client is court ordered to treatment and/or Twelve-Step programs. The client must be considered first when deciding what is or is not problematic in dual relationships. Trust is essential in the therapeutic relationship and if the client is unlikely to trust the professional because of his or her perceptions about the dual relationship, then the social worker should consider the secondary relation as problematic. Of course, clients may not have the ability, for various reasons, to assess or articulate their own feelings or thoughts about dual relationship issues. Social workers must be keenly aware of this possibility and not assume there is no risk simply because the client does not voice concern. Reamer (2003) suggests the following protocol: 1. Be alert to potential or actual conflicts of interest. 2. Inform clients and colleagues about potential or actual conflicts of interest; explore reasonable remedies. 3. Consult colleagues and supervisors, and relevant professional literature, regulations, policies, and ethical standards (codes of ethics) to identify pertinent boundary issues and constructive options. 4. Design a plan of action that addresses the boundary issues and protects the parties involved to the greatest extent possible. 5. Document all discussions, consultation, supervision, and other steps taken to address boundary issues. 6. Develop a strategy to monitor implementation of action plan (p. 130). CONCLUSION The key to determining risk in dual relationships for social workers in recovery is open discourse that leads to greater practice skills, knowledge, and explicit policies within the agency, between professionals, and between professionals and their clients. This open discourse must be mirrored in the professional literature and, importantly, between professional organizations. The professional associations and credentialing organizations must move to collaboration in reducing the confusion of multiple codes of ethics, credentialing, and licensing. The more consistent professional standards are across specialty areas, the more individ-

17 Laura E. Kaplan 89 uals will be able to determine ethical practice. It is ironic that each code addresses the importance of keeping good boundaries and yet the boundaries between the codes and associations themselves can create conflicts for professionals. The problem of being responsible to multiple professional codes of ethics complicates the role of the professionals. To assist social workers and other professionals in traversing the murky waters of dual relationships, we must broaden the discourse. It is imperative to have clear and open discussion on all levels individual practice, agency process, research, and inter and intra professional organizations in order to aid social workers in recovery in determining best ethical practices. REFERENCES Alcoholics Anonymous. (2000). AA guidelines for AA members employed in the alcoholism field. Anderson, S., & Kitchener, K. (1998). Nonsexual posttherapy relationships: A conceptual framework to assess ethical risks. Professional Psychology: Research and Practice 9(1), Bonosky, N. (1995). Boundary violations in social work supervision: Clinical, educational, and legal implications. The Clinical Supervisor 13(2) Brownlee, K. (1996). Ethics in community mental health care. The ethics of non-sexual dual relationships: A dilemma for the rural mental health professional. Community Mental Health Journal 32(5), Carlson, L., Rapp, C., & McDiarmid, D. (2001). Hiring consumer-providers: Barriers and alternative solutions. Community Mental Health Journal 37(3) Congress, E. (1996). Dual relationships in academia: Dilemmas for social work educators. Journal of Social Work Education 32(3) Doyle, K. (1997). Substance abuse counselors in recovery: Implications for the ethical issue of dual relationships. Journal of Counseling & Development, July/August, Gutheil, T., & Gabbard, G. (1992). Obstacles to the dynamic understanding of therapist-patient sexual relations. American Journal of Psychotherapy XLVI(4) Holtzman, B. (1981). Who s the therapist here? Dynamics underlying therapist-client sexual relations. Smith College Studies in Social Work Jacobs, C. (1991). Violations of the supervisory relationship: An ethical and educational blind spot. Social Work 36(2) Juhynke, G., & Culbreth, J. (1994). Clinical supervision in addictions counseling: Special Challenges and solutions. ERIC Digest. Retrieved September 18, 2004 from Kagle, J.D., & Giebelhausen, P. N., (1994). Dual relationships and professional boundaries. Social Work 39(2)

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