Alberta Health Feedback to Alberta College of Social Workers Regarding Proposed Standard of Practice General Feedback: It is inappropriate for a regulated member to be authorized to engage in a sexual relationship with a patient or a former patient who has received psychotherapeutic treatment. Please revise the proposed Standard of Practice (i.e. F. 7 Prohibited Relationship ) to reflect this principle. The proposed Standard of Practice does not contemplate the provision of episodic care, specifically when a recipient of episodic care is to be deemed a patient and does not clearly establish what the professional boundaries around entering into a sexual relationship with a patient that received episodic care are and/or if they differ from those respecting a more long-term client/former client. Specific Feedback: Page # Excerpt of Standard Requested Revisions or Comments ACSW Response Excerpt of Standard 7 (l) PATIENT a. For the purposes of conduct described in the definition of sexual abuse, a client is a patient in the following circumstances: i. When professional services are provided to the client by the social worker and there is a reasonable expectation that services will extend beyond a single encounter; or ii. When the professional relationship has been formed and has not ended; or iii. When a social worker engages in conduct described in the definition of sexual abuse with a former client within 1 year from the date the individual ceased to be the social The difference between these two concepts is not clear and other professions have been able to rely on a singular definition for both provisions. A - Please provide a rationale for why two separate definitions for patient (i.e. one for sexual abuse and one for sexual misconduct) have been developed. In establishing the definition of patient, the term client has been used. However, Alberta Health notes that the definition of client includes in appropriate circumstances, students, supervisees, and other individuals under the professional authority of the social worker. It also includes guardians and corporate entities/organizations. The definition of patient needs to be revised to make it clear which portions of the definition client (e.g. students, supervisees, corporate organizations) can also be patients. 1 A - the explanation for this asymmetry regarding which clients are patients for complaints of sexual abuse versus complaint about sexual misconduct is: There is no defense of consent. All conduct of the nature contained in the definition of sexual abuse will be considered sexual abuse, whether or not was considered to be consensual, and will result in the mandatory cancelation of a practice permit; Some social workers have very episodic contact with the recipients of their services (eg. referral, crisis intervention) in which there is little expectation of recognizing they were a service recipient in the prior year. As a result, the requirement that there must be a reasonable expectation that services will extend beyond a single encounter exists to mitigate the risk that a social worker who unwittingly engages in a consensual sexual relationship with a former client of No Changes (l) PATIENT a. For the purposes of conduct described in the definition of sexual abuse, a client is a patient in the following circumstances: i. When professional services are provided to the client by the social worker and there is a reasonable expectation that services will extend beyond a single encounter; or ii. When the professional relationship has been formed and has not ended; or iii. When a social worker engages in conduct described in the definition of sexual abuse with
worker s client. b. For the purposes of conduct described in the definition of sexual misconduct, a client is a patient in the following circumstances: i. When professional services are, or have been, provided to a client or a former client by the social worker within the past year. B - The proposed Standard of Practice also needs to be reviewed by the ACSW, and any required changes should be made, to ensure that the ACSW is clear when the provisions in the proposed Standard are intended to only apply to the narrower definition of patient vs. when the broader definition of client applies. For example, the ACSW may not want all individuals who qualify as clients to be subject to the mandatory disciplinary sanctions that accompany the finding of unprofessional conduct involving sexual abuse or sexual misconduct of a patient. 2 single encounter social work services could be found guilty of sexual abuse resulting in cancelation of practice permit; Conversely, sexual misconduct is always unwelcome or objectionable behavior, whether a social worker provided services 1 time or 20 times to a client, and a social worker deemed to have committed sexual misconduct will be subject to mandatory suspension. B - This definition of patient has not been limited to clients receiving certain types of services. Thus, individuals who form part of a group or organization with whom there is a professional social worker relationship, would be patients for the purpose of the HPA provided they meet the definition of patient. We included these clients in the definition of patient intentionally. Romantic/sexual relationships with clients and former clients under our Standards of Practice is currently prohibited no matter who the client is. We are aware this definition is broad. We include a one year time period in the definition of patient to mitigate the broad definition of patient. Further, students and supervisees may also be clients and therefore could also be patients for the purpose of the HPA. a former client within 1 year from the date the individual ceased to be the social worker s client. b. For the purposes of conduct described in the definition of sexual misconduct, a client is a patient in the following circumstances: i. When professional services are, or have been, provided to a client or a former client by the social worker within the past year.
32 F.5 Dual/Multiple Role Relationship (b) A social worker will be aware of the potential for power imbalance and harm i. in entering or continuing a professional relationship when the social worker and the client also have a present or previous familial, social, emotional, financial, supervisory, teacher/student, administrative or Please revise this section to indicate that it is inappropriate to enter into a professional relationship with an individual where the social worker and the individual have a present familial, social, emotional, financial, supervisory, teacher/student, administrative or legal relationship. Alberta Health would suggest that if there is potential for power imbalance and harm, then a dual/multiple role relationship is appropriate. This section should be revised to clearly indicate 3 Given recent decision of a disciplinary hearing tribunal, which was upheld on appeal to a Committee of Council, an amendment to the definition of client has been proposed to include students, supervisees and other individuals under the professional authority of the social worker. Given the power differential and fiduciary duty, there is now common law authority that for Registered Social Workers, students are clients. The same logic goes for supervisees. We include this in the definition of Client with two parameters: 1) in appropriate circumstances; and 2) under the professional authority of the social worker; we establish substantial discretion to be able to proceed with students and supervisees being clients (and therefore patients ) in appropriate circumstances. We have amended the standards as per AH recommendations and proposed the general rule that dual/multiple role relationships are inappropriate (F.5). b. Due to the potential for power imbalance or harm, it is considered generally inappropriate for a social worker to: i. enter into or continue a professional relationship when the social worker and the client also have a present or previous familial, social, emotional, financial, supervisory, teacher/student, administrative or legal relationship, ii. enter a professional relationship when the social worker and the
legal relationship, ii. in entering a professional relationship when the social worker and the client had a previous sexual relationship. 33 F.6 Special Circumstances (a) A dual/multiple role relationship does not excuse a social worker from providing professional services in an emergency situation how the regulated member may determine what relationships are appropriate and factors that the regulated member may consider to help them determine if the dual/multiple role relationship is inappropriate. As F.5 indicates that social workers can provide treatment in conflict of interest situations where there is a dual/multiple role relationship, what this standard is trying to say is not clear. Please revise the language of this standard. 4 Special Circumstances are identified (F.6) when a dual/multiple role relationship may not be inappropriate. Factors to consider in determining a whether the risk of power imbalance or harm outweighs the need for services are enumerated. client had a previous sexual relationship. c. If a dual/multiple role relationship other than those noted in section F.7 below develops and is discovered after the professional relationship has been initiated, the social worker will seek supervision or, where no supervisor exists, consultation regarding the relationship and... a. Emergency situation: The ethical obligation to provide professional services in an emergency situation to a client may override the general rule that dual/multiple role relationships are inappropriate if: i. there is no other professional available to provide the services; or ii. harm would come to the client if the social worker does not provide the professional service. b. Unique attributes, specialized skills or services are required and are not otherwise available: A social worker may enter a dual/multiple role relationship or continue the professional relationship after the dual/multiple role relationship is discovered when unique attributes, specialized skills or services are required and are not otherwise available, for instance, in the case of a rural or remote community or when the service is very specialized AND
33 b) Notwithstanding section F.5, a social worker who is in a dual/multiple role It is not clear what portion of section F.5 this standard is in spite of. Especially Members will not be required to seek authorization or self-report when they the risk of a power imbalance or harm does not outweigh the need for specialized skills or services. (b.1) Factors to consider in determining whether there is more than a minimal risk of harm or power imbalance include but are not limited to: i. whether the client understands the inherent power imbalance that typically exists in a professional ii. whether sufficient time has passed since the end of the professional relationship given the nature and extent of the professional iii. the nature of the client s presenting issues; iv. the type of professional services provided by the social worker; v. whether the client has confided close personal or sexual information to the social worker; vi. the length and intensity of the former relationship with the client; vii. the level or degree of emotional dependence of the client on the social worker; and viii. the vulnerability of the client (factors to consider, but not limited to age, identity, ability, socioeconomic status etc.) No Changes 5
relationship may continue the professional relationship when unique attributes, specialized skills or services are required and are not otherwise available. 34 (c.1) For the purposes of the sexual abuse provisions in the Health Professions Act, a person receiving professional services from a social worker is not considered a patient if the social worker is their spouse or adult interdependent partner or if they are in a pre-existing sexual relationship with the social worker. given section F.5 authorizes treatment in conflict of interest situations. Need to revise this section to make it clearer how it applies. Further, this standard does not appear to contemplate situations where the conflict of interest, and potential harm caused by the conflict, outweighs the potential benefit of whatever unique attributes, specialized skills, etc. may be possessed or provided by the social worker. If this standard is intended to authorize treatment where treatment should otherwise not be authorized due to a conflict of interest, please revise this standard to either (i) require the regulatory college to approve the continued provision of services or (ii) require the regulated member to selfreport the continued treatment, including the type of treatment, circumstances around treatment and the specialized services that the social worker is providing. Please revise this statement to indicate that the pre-existing sexual relationship must be a pre-existing sexual relationship that is ongoing (required wording). enter into or continue a dual/multiple role relationship due to special circumstances. We have amended F.6 as specified in the feedback document to include that a sexual relationship must be pre-existing and ongoing for it to be exempt from the definition of sexual abuse under the Health Professions Act. c. It is considered to be unprofessional conduct for a social worker to provide professional services to a spouse, adult interdependent partner (as defined in section 3(1) of the Adult Interdependent Relationships Act) or person with whom they are in a preexisting and on-going sexual relationship unless the following 6
34 F.7 Prohibited Relationship (a) A social worker who is currently providing professional services to a client or has in the previous twenty-four (24) months provided professional services to a client (former client) will not i. engage in a sexual or romantic relations with the client or former client, or ii. enter into a financial relationship with the client, or A - Please provide a rationale for why conduct of the nature described in the definition of sexual abuse may not be deemed sexual abuse for the purposes of the HPA if it occurs after 1 year of a client ceasing to be a client; however, sexual or romantic relations with a client or former client are prohibited for at least 24 months following the completion of the professional relationship. Specifically, it is not clear why the ACSW would seek to establish two different timelines. B - Please make it clear that it is never appropriate to enter into a sexual 7 A - Sexual, romantic and financial relationships with any client or former client (within the past 24 months) are currently prohibited under section F.7 of our Standards of Practice (2013). The one year time frame included in the definition of patient is intended to apply specifically to patients and addresses the following issue: The mandatory sanctions are severe (cancelations of permit) and the one year time frame limits the mandatory application of those sanctions; after one year, the hearing tribunal would resume discretion to impose sanctions which is conditions are met: i. the professional services are provided in response to an emergency; and ii. another health professional is not readily available or the individual receiving services could suffer harm from delay in obtaining the services from another health professional. (c.1) For the purposes of the sexual abuse provisions in the Health Professions Act, a person receiving professional services from a social worker is not considered a patient if the social worker is their spouse or adult interdependent partner or if they are in a pre-existing sexual relationship with the social worker that is on-going. b. Although conduct of the nature described in the definition of sexual abuse may not be deemed sexual abuse for the purposes of the Health Professions Act if it occurs after 1 year of a client ceasing to be a client, sexual or romantic relations with a client and former client are prohibited for at least twenty-four (24) months following the completion of the professional relationship. Social workers should be aware that in certain circumstances the passage of time may not mitigate the inappropriateness of a sexual relationship with a former client, and accordingly, such conduct may be
former client in which there is an ongoing exchange such as a business partnership, and employer/employee relationship, or a contractual relationship. b) Although conduct of the nature described in the definition of sexual abuse may not be deemed sexual abuse for the purposes of the Health Professions Act if it occurs after 1 year of a client ceasing to be a client, sexual or romantic relations with a client and former client are prohibited for at least twenty-four (24) months following the completion of the professional relationship. Social workers should be aware that in certain circumstances, for instance, when psychotherapeutic treatment is provided, the passage of time may not mitigate the inappropriateness of a sexual relationship with a former client, and accordingly, such conduct may be considered unprofessional conduct. relationship with a client who has received psychotherapeutic treatment by amending the following statement as demonstrated: Social workers should be aware that in certain circumstances, for instance, when psychotherapeutic treatment is provided, the passage of time may not mitigate the inappropriateness of a sexual relationship with a former client, and accordingly, such conduct may be considered unprofessional conduct. C - Please include factors that a regulated member should consider in determining whether the formation of a sexual relationship with a former client is appropriate. Examples of factors include: The number of times that the regulated member and the patient had a professional interaction; The duration of the professional The nature of the professional interactions; Whether sufficient time has passed since the last professional interaction occurred; Whether the patient has confided personal information to the regulated member beyond that which was necessary for the purposes of receiving 8 desirable given the broad definition of patient. What might not be sexual abuse or sexual misconduct for the purposes of the Health Professions Act might still be unprofessional. B We have revised the Standards of practice to indicate that it will rarely, if ever, be appropriate to enter into a sexual relationship with a client who has received psychotherapeutic treatment and this conduct will be considered inappropriate. We disagree with using the word never as there are circumstances we cannot contemplate. C As per recommendation, we have included factors to consider in determining whether the formation of a sexual relationship with a former client is appropriate considered unprofessional conduct. (b.1) While a sexual relationship with a former client after 24 months is not prohibited, there are factors to consider in determining whether the formation of a sexual relationship is appropriate. Such factors include, but are not limited to: i. whether the client understands the inherent power imbalance that typically exists in a professional ii. whether sufficient time has passed since the end of the professional relationship given the nature and extent of the professional iii. the nature of the client s presenting issues; iv. the type of professional services provided by the social worker; v. whether the client has confided close personal or sexual information to the social worker; vi. the length and intensity of the former relationship with the client; vii. the level or degree of emotional dependence of the client on the social worker; and viii. the vulnerability of the client (factors to consider, but not limited to age, identity, ability, socio-economic status etc.) c. It will rarely, if ever, be appropriate
professional services; Whether the patient was emotionally dependent on the regulated member; and Whether the patient is particularly vulnerable as a result of factors such as: age, gender identity, socioeconomic status, or as a result of a mental, intellectual or physical disability for a social worker who has provided psychotherapeutic treatment to a client to engage in romantic/sexual conduct with the former client, regardless of the amount of time that has passed since the end of professional relationship. Such conduct is likely to be considered inappropriate indefinitely. 9