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Mental Health practitioners in rural settings are confronted with ethical dilemmas on a daily basis with regards to confidentiality, dual relationships, and boundary issues. The following article will address several situations involving these issues and practical solutions in handling these potential ethical dilemmas without compromising the practitioners commitment to their Professional Code of Ethics.
In small towns, people often joke that what you do beats you home, makes headlines in the local paper, or is the main topic of conversation at the beauty and coffee shops. For obvious reasons, confidentiality can be somewhat problematic for the practitioner.
As a school therapist, the clients I work with many times end up being one of the following: the child/children of a neighbor, my insurance agent, grocer, police officer, all the way down the line to my personal friends. It would be great if there was another school counselor to refer these cases to, but unfortunately, Im it! How can these ethical gray areas be dealt with?
to Set Boundaries on Gossip
By having releases signed, it covers me legally and puts the responsibility back on the clients and their providers to maintain confidentiality. Another issue faced almost on a daily basis is constantly being in situations where people are discussing children/parents that I am working with. The information being discussed may not even have any merit or, on the other hand, may be true.
It is very difficult not to want to set the record straight, but the best thing to do is to exit the area (teachers lounge, break room, local eating establishment) if at all possible. If you cant leave, you need to refrain from comment. If asked a question directly, it is best to tell people you cant discuss the case without a release of information signed by the client allowing you to do so.
Sometimes, people are not happy with this response, and on occasion, I have mentioned that Im sure they wouldnt want me to share their personal information if the tables were turned. This usually pacifies the majority, but as always, you cant please everyone.
Way to Handle Dual Relationship
If at all possible, one should try to limit these connections, especially if the person is your client in your professional capacity, as it puts the practitioner in a one-up position which skews boundaries, and may even cause the client to feel obligated to give you special treatment that they wouldnt give under other circumstances.
For example, you are working with one of the local law enforcement officers children, and he/she stops you for speeding. Upon seeing you, they say they will give you a warning. My response would be, If you didnt know me, would you give me a warning? If their response is no, they would give me a ticketI would have to insist that they write me up. Crazyyes, but ethically sound.
The best rule of thumb, again, is to try and avoid those dual relationships if at all possible. (If they cant be avoided, discuss openly with the client, up front, what problems could occur, and try to be active problem-solvers rather than reactive after the fact. Engage the client by empowering him/her to come up with a plan to assist in dealing with the potential issues that you both have brainstormed.
Boundaries in Public Places
I take Julie aside and model by whispering, Julie, it would be better if we could discuss this in a more private place. Would it work for you to come by my office tomorrow at 3:15pm? Julie says, Yes, and I respond, Great, Ill talk to you then. I then proceed to another section of the store and return to the produce on my way out of the store.
Ive just done two things. First, I gave Julie a definite time so she knew she would have a chance to talk, and secondly, Ive assisted her by modeling how she should be talking about private matters (i.e., voice tone and place).
Redirection to Set a Boundary
I reply in a soft voice, Thats great Tom. This is one of those things we talked about that is private. So next time, I know youll remember to tell me when we meet at school. What if I forget?, says Tom. Whisper to your teacher to write it down for you along with anything else youd like to tell me. Tom says, OK, Mrs. Brush, and rides off on his bike.
In this situation, the words were already out of Toms mouth before I could redirect him, so I tried to salvage the conversation by making it into a learning experience.
My response, Im not allowed to tell people who I work with. It is confidential. Well, shes been leaving her children alone while she goes out drinking. Weve told DHS (Dept. of Human Services), and they havent done a thing about it. I say, Thats frustrating. It sounds like you are really concerned about the children, and you have done everything within your power.
I politely excuse myself and exit the laundromat. Ive not broken confidentiality, as I didnt acknowledge that I work with Danielle, and I attempted to validate their concerns without engaging in the conversation.
Control of the Conversation
For example, Sara, a special education teacher, stops me outside the sanctuary and says, We need to have a meeting about Gonzales. They leave for three months every winter, and Hernandez is missing too much school. I respond, When is a good time to call you tomorrow to discuss this? Sara states, Call before 8:30am and... I quickly cut her off with Great - talk to you then, and head into the sanctuary.
I feel the best way to handle such occurrences is to be preventative. I tell clients up front that their lives are private, and what they have to say is very important. I discuss with them that in such a small town, we will likely run into each other, and I would prefer for them to call and set up an appointment, so I can give them the attention and privacy they deserve rather than discussing their personal lives in public.
When a person does start sharing information, I politely remind them about our initial conversation, and ask them to please call me at the office where we wont be interrupted and excuse myself. I also tell my clients that I will not take calls at home unless it is an emergency, and I define emergency as potentially life threatening events. I also give them 800 numbers for emergency hotlines.
I try to screen my calls at home, and if by chance someone calls, I ask if it is an emergency and explain that my time with my family is limited and ask that they contact me the following day during office hours.
I try to explain this to my friends before the situation arises and give them a list of resources if needed. As a last resort, I have completed ADHD evaluations, screened for depression and other mental health concerns with the agreement that the information would be given to another professional to assess. In those cases, I kept strictly to factual diagnosis symptomology as substantiated by the DSM-IV criteria.
You constantly need to be troubleshooting and thinking in a preventative fashion. It is helpful to discuss these ethical situations with the client in the initial visit, and give them the opportunity to make an educated decision on whether or not to pursue a therapeutic relationship with you or seek outside resources.
Most of all, dont become the Lone
Ranger. Make sure you have someone to discuss these ethical dilemmas with and
get feedback. This will also help you to avoid burnout, which is another dilemma
facing social workers that can be discussed at length at a later date.
Reflection Exercise #2
Peer-Reviewed Journal Article References:
Jensen, E. J., Wieling, E., & Mendenhall, T. (2020). A phenomenological study of clinicians’ perspectives on barriers to rural mental health care. Journal of Rural Mental Health, 44(1), 51–61.
Weinzimmer, L. G., Dalstrom, M. D., Klein, C. J., Foulger, R., & de Ramirez, S. S. (2021). The relationship between access to mental health counseling and interest in rural telehealth. Journal of Rural Mental Health, 45(3), 219–228.
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