A (small) ethical question

I’m in the midst of a lot of professional training, both for work and for my side hustle (“clinical supervision” doesn’t roll off the tongue as nicely “side hustle”). I love continuing education: I love being with other social workers; I love reading case studies; I love doing exercises about theoretical framework. (It turns out I kind of miss being in graduate school). Because clinical social workers are required to have ethics training every two years, a lot of my recent continuing ed programming has involved some ethics credits. We start, always, with the most egregious examples of social work ethical dilemmas: stealing from your workplace (BAD); falsifying documentation (PRETTY BAD); having sex with a client (SO VERY BAD). Those ethical questions have straightforward answers: don’t do that shit. It’s the grayer stuff that I like to turn over. And today I’d like to turn a personal one over with you.

Don’t freak out! I am not involved in any egregiously bad activities! It’s definitely one of the gray ones.

I have a patient I really like: she’s bright and funny and interesting. She has a fascinating career. I’m sure that if we met in a different setting, I would strive to be her friend. But we haven’t met in a different setting; I’m offering her counseling, not friendship. And sometimes I find myself forgetting that.

I write often about use of self and counter-transference but I don’t think I’ve yet touched on this: what happens when we really like our clients? Obviously we like most of them; social workers typically like people. I’m talking about the unique problem of liking a client personally, the way you would like a new friend for instance, and how to manage that.

In my current job, I’ve met almost 300 different patients. Of those, there are maybe 3 that I’ve bent the rules for: seen them for a whole hour instead of the usual 30 minutes, provided a few more personal details than I normally do with my patients. See? Nothing egregious. But definitely gray.

I had a colleague once who told me, when I worked in hospice, that if you get attached to one out of every one hundred patients, you’re ok. Any more than that and you should take a good hard look at your practice. I’ve passed that advice along a dozen times, at least; it makes sense to me. I’m not causing any harm here, to my patients or to myself. I won’t overstep any boundaries: we won’t meet for coffee or see each other outside of this professional setting. But I do want to pause and consider what it means that these people get a little more from me than my other patients get. Being mindful of how much of ourselves we give is one of my favorite ethical questions. Do I give less to the patients that make my skin crawl? Do I give more to the ones that are pleasant and friendly? Do I give too much or too little based on my own feelings? And, ethically speaking, is it ok if there are (small) differences in the care I provide?

The cool and also deeply frustrating thing about ethics is that there are often no clear answers; there are multiple scenarios and variables to walk through. In this case, I lean towards the side of giving myself permission to be a human person who sometimes gives a little less or a little more, depending on the circumstance. Of course I’ll always examine my practice and look closely for signs of trouble. But I also want to allow myself that one in a hundred; it’s part of what makes the work worth doing.

Photo by Dil on Unsplash

Practicing within my scope

I can tell you a lot about physical illness. I can tell you about how particular cancers metastasize; I can tell you how the body begins to fail at the end of life. In nursing homes and as a medical case manager and in hospice, I became well versed in the way that physical health impacts mental health. I consider myself an expert in that field. Switching to a therapist role has been challenging of course, but I went to grad school; I was sure I would be able to transfer the majority of my skills into this new role.

And I have! Mostly. But last week I was caught off guard during a session with a patient and I can’t stop thinking about it. In the course of what was already a fairly intense conversation, one of my patients disclosed a history of childhood sexual abuse. The breath nearly went out of me. Anxiety rose in my chest. My first thought was: I don’t know how to handle this.

Not exactly helpful for my patient.

My second thought was how I could help her. Perhaps the best thing for her is to see another therapist. One of the ethical obligations we have as social workers is to practice within our scope of knowledge and experience. If this were a question on the LCSW exam, the answer would be to refer out. In fact, I’m quite sure this was a question on my LCSW exam. I’m not a trauma expert; I’m just not equipped to treat her. I’m going to have to refer her to someone else.

But I hesitate to do so at our very next meeting. This patient has been in therapy off and on for many years and I’m the first therapist she’s told. She’s entrusted me with a major confession and I’m not sure it’s appropriate to immediately terminate with her and send her to someone else. This needs to be handled with care. 

So, what are my next steps? First of all, I can honor what she told me. I can thank her for being vulnerable and open and for trusting me to hold her grief and pain and not run from it. I can acknowledge how incredibly difficult it must have been to say the words out loud. (I did that in the moment but I believe it bears repeating). Secondly, despite everything I've been saying about referring her to someone else, I can continue to treat her for a few sessions. She was referred to me for help developing strategies to deal with stress and pain; I can still help her with that. Lastly, I can start to lay the groundwork for referral. I can’t one day say, “Ok, it’s been great, I’m going to send you to someone else now.” Instead, we have to have an ongoing conversation about my role and her needs and where the two may not intersect.

I’m also taking this to supervision. Like, it may be the only thing I talk about for the entire hour.

This is a theme I keep returning to: we cannot work alone. We have to have not just the support of a more seasoned clinician, but also the objectivity of one. All the self-introspection in the world cannot replace the objectivity of someone else. Additionally, I think it’s also necessary to have a confidante in a supervisor. Despite knowing that the best thing is to refer this patient to someone who is qualified to help her, a part of me feels guilty that I can't provide the help she needs. I trust my supervisor to validate that feeling and help me examine it critically. I also trust him to help me find the right words to say to her the next time I see her.

My biggest hope is that I do this right. With supervision support, I think I can.

Photo by Sébastien Marchand on Unsplash