Ebook Fundamentals of case management practice - Skills for the human services (4th edition): Part 1

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Case Management Practice

Skills for the Human Services

Nancy Summers

Harrisburg Area Community College

FUNDAMENTALS OF

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Fundamentals of Case Management

Practice, Skills for the Human Services,

Fourth edition

Nancy Summers

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To my parents, whose humor and wisdom about people and relationships

formed the foundation for my work with others

Preface xiii

Section 1 Foundations for Best Practice in Case Management

Chapter 1 Ethics and Other Professional Responsibilities for

Human Service Workers 1Introduction 1

Language and Ethics 2Dual Relationships 2Value Confl icts 6The Rights of Individuals Receiving Services 10Confi dentiality 13

Privacy 17Health Insurance Portability and Accountability Act 17Social Networking 20

Privileged Communication 21When You Can Give Information 21Diagnostic Labeling 24

Involuntary Commitment 25Ethical Responsibilities 26Protecting a Person’s Self-Esteem 27Stealing from Clients 29

Competence 30Responsibility to Your Colleagues and the Profession 31Professional Responsibility 33

Summary 34Talk it Over 34Exercises I: Ethics 34Exercises II: Ethically, What Went Wrong? 37Exercises III: Decide on the Best Course of Action 41Exercises IV: What is Wrong Here? 42

Chapter 2 Case Management: Definition and Responsibilities 43Introduction 43

A History of Case Management 44Why We Use Case Management 44Assessment 45

Planning 46Creating an Individualized Plan 49Linking 52

Monitoring 53Advocacy 53Service Coordination 55Levels of Case Management 57Separating Case Management from Therapy 59Case Management in Provider Agencies 60Managed Care and Case Management 61Underlying Principles: Hope and Self-Determination 63Generic Case Management 65

Summary 65Exercises I: Case Management 66Exercises II: Decide on the Best Course of Action 69Chapter 3 Applying the Ecological Model: A Theoretical Foundation

for Human Services 71Introduction 71

Seeking a Balanced View of the Client 72The Three Levels 74

Looking at What the Person Brings 74Looking at What the Context Brings 75Developmental Transitions 76

Developing the Interventions 77Working with the Generalist Approach 78Macro Level Interventions are Advocacy 79Summary 79

Exercises I: Looking at Florence’s Problem on Three Levels 80Exercises II: Designing Three Levels of Intervention 81

Section 2 Useful Clarifications and Attitudes

Chapter 4 Cultural Competence 85Introduction 85

Culture and Communication 85Your Ethical Responsibility 86Where Are the Differences? 86Strangers 88

Anxiety and Uncertainty 89Thoughtless versus Thoughtful Communication 90Dimensions of Culture 94

Obstacles to Understanding 99Competence 101

Summary 102Exercises I: Testing Your Cultural Competence 103Chapter 5 Attitudes and Boundaries 107

Introduction 107Understanding Attitudes 107Basic Helping Attitudes 108Reality Check 111

How Clients Are Discouraged 111

Seeing Yourself and the Client as Completely Separate Individuals 114

Erecting Detrimental Boundaries 116Transference and Countertransference 116Summary 117

Exercises I: Demonstrating Warmth, Genuineness, and Empathy 118

Exercises II: Recognizing the Difference—Encouragement or Discouragement 123

Exercises III: Blurred Boundaries 124Chapter 6 Clarifying Who Owns the Problem 127Introduction 127

If the Client Owns the Problem 128

If You Own the Problem 131

If You Both Own the Problem 131Summary 132

Exercises I: Who Owns the Problem? 133Exercises II: Making the Strategic Decision 135

Section 3 Effective Communication

Chapter 7 Identifying Good Responses and Poor Responses 137Introduction 137

Twelve Roadblocks to Communication 138Useful Responses 142

Summary 150Exercises: Identifying Roadblocks 150Chapter 8 Listening and Responding 153Introduction 153

Defi ning Refl ective Listening 154Responding to Feelings 154Responding to Content 158Positive Reasons for Refl ective Listening 160Points to Remember 160

Summary 162Exercises I: How Many Feelings Can You Name? 162Exercises II: Finding the Right Feeling 162

Exercises III: Refl ective Listening 163Chapter 9 Asking Questions 169

Introduction 169When Questions Are Important 170Closed Questions 170

Open Questions 171Questions That Make the Client Feel Uncomfortable 172

A Formula for Asking Open Questions 173

Summary 175Exercises I: What Is Wrong with These Questions? 176

Exercises II: Which Question Is Better? 178Exercises III: Opening Closed Questions 179Exercises IV: Try Asking Questions 181 Chapter 10 Bringing Up Difficult Issues 183

Introduction 183When to Use Confrontation 184The I-Message in Confrontation 185Asking Permission to Share Ideas 190Advocacy: Confronting Collaterals 190

On Not Becoming Overbearing 191Summary 193

Exercises I: What Is Wrong Here? 193Exercises II: Expressing Your Concern 195Exercises III: Expressing a Stronger Message 197 Chapter 11 Addressing and Disarming Anger 199

Introduction 199Common Reasons for Anger 199Why Disarming Anger Is Important 200Avoiding the Number-One Mistake 201Erroneous Expectations for Perfect Communication:

Another Reality Check 202The Four-Step Process 203What You Do Not Want to Do 205Look for Useful Information 207Managing an Angry Outburst 207Summary 208

Exercises I: Initial Responses to Anger 209Exercises II: Practicing Disarming 209 Chapter 12 The Effective Combination of Skills 211

Introduction 211Combining Skills and Attitudes 212Communication Skills That Facilitate Change 213Trapping the Client 218

From Adversarial to Collaborative 219Case Manager Traps 221

Summary 224 Chapter 13 Putting It All Together: Exercises 227

Introduction 227Exercise I 227Exercise II 228Exercise III 231Exercise IV 233Exercise V 235

Section 4 Meeting Clients and Assessing Their Strengths

and Needs

Chapter 14 Documenting Initial Inquiries 237

Introduction 237Guidelines for Filling Out Forms 238Steps for Filling Out the New Referral or Inquiry Form 238Evaluating the Client’s Motivation and Mood 240

Steps for Preparing the Verifi cation of Appointment Form 242Summary 243

Exercises I: Intake of a Middle-Aged Adult 243Exercises II: Intake of a Child 244

Exercises III: Intake of an Infi rm, Older Person 244 Chapter 15 The First Interview 245

Introduction 245Your Role 246The Client’s Understanding 246Preparing for the First Interview 246Your Offi ce 247

Meeting the Client 248Summary 252

Chapter 16 Social Histories and Assessment Forms 253

Introduction 253What Is a Social History? 254Layout of the Social History 254How to Ask What You Need to Know 255Who Took the Social History 262

Social Histories in Other Settings 266Writing Brief Social Histories 266Using an Assessment Form 270Taking Social Histories on a Computer 271The Next Step 272

Summary 272Exercises I: Practice with Social Histories 273Exercises II: Assessment of a Middle-Aged Adult 273Exercises III: Assessment of a Child 274

Exercises IV: Assessment of an Infi rm, Older Person 274Exercises V: Creating a File 275

Chapter 17 Using the DSM 277

Introduction 277

Is DSM Only a Mental Health Tool? 278

Cautions 278Who Makes the Diagnosis? 279Background Information 279Using the DSM 283

Making the Code 288Additional Information 290Summary 291

Exercises: Using the DSM 291

Chapter 18 The Mental Status Examination 295

Introduction 295Observing the Client 296Mental Status Examination Outline 297Summary 314

Exercises: Using the MSE Vocabulary 314 Chapter 19 Receiving and Releasing Information 317

Introduction 317Sending for Information 317

If You Release Information 317Directions for Using Release Forms 318Examples of the Release Forms 320When the Client Wants You to Release Information 321When the Material Is Received 321

Summary 322Exercises I: Send for Information Related to a Middle-Aged Adult 323

Exercises II: Send for Information Related to a Child 323Exercises III: Send for Information Related to a Frail, Older Person 323

Exercises IV: Maintaining Your Charts 323 Chapter 20 Planning for Positive Change and Recovery 325

Introduction 325How People Do Not Change or Recover 326What Is Change? 326

What Is Recovery? 327Physical Health Is Part of Wellness 328Self-Determination 328

Relationships that Support Recovery 329Collaboration 329

Encouragement as Part of Recovery 330Stages of Change 334

Summary 338Exercises: Helping People Change 339

Section 5 Developing a Plan with the Client

Chapter 21 Developing a Service Plan at the Case Management Unit 341

Introduction 341Involving the Client and the Family 342Using the Assessment 343

Creating the Treatment or Service Plan 346How to Identify the Client’s Strengths 347Individualized Planning 348

Understanding Barriers 348Sample Goal Plan 349Summary 350

Exercises: Broad Goal Planning 350

Chapter 22 Preparing for a Service Planning Conference or Disposition

Planning Meeting 353Introduction 353

What You Will Need to Bring to the Meeting 354Goals for the Meeting 354

Preparing to Present Your Case 355Making the Presentation 356Sample Presentation 357Collaboration 358Follow-Up to Meeting 359Summary 359

Exercises: Planning 360 Chapter 23 Making the Referral and Assembling the Record 361

Introduction 361Determining Dates 362Sample Referral Notifi cation Form 363The Face Sheet 364

Summary 366Exercises: Assembling the Record 367 Chapter 24 Documentation and Recording 369

Introduction 369Writing Contact Notes 370Labeling the Contact 370Documenting Service Monitoring 371Documentation: Best Practice 372Government Requirements 374

Do Not Be Judgmental 375Distinguish Between Facts and Impressions 376Give a Balanced Picture of the Person 376Provide Evidence of Agreement 376Making Changes to the Plan 376Summary 377

Exercises: Recording Your Meeting with the Client 377Exercise I: Recording Client Contacts 378

Exercise II: Using Government Guidelines to Correct Errors 383Exercise III: Spotting Recording Errors 384

Section 6 Monitoring Services and Following the Client

Chapter 25 Monitoring the Services or Treatment 385

Introduction 385What Is Monitoring? 386The Financial Purpose of Monitoring 386Collaboration with Other Agencies 388Advocating 388

Leave the Offi ce 389Responding to a Crisis 390Follow-Up 391

Summary 391

Chapter 26 Developing Goals and Objectives at the Provider Agency 393

Introduction 393Client Participation/Collaboration 394Expect Positive Outcomes 394Objectives 396

Combining Goals and Treatment Objectives 397Finishing Touches 398

Summary 401Exercises: Developing Goals and Objectives 401 Chapter 27 Terminating the Case 409

Introduction 409

A Successful Termination 410The Discharge Summary 412Summary 415

Exercises I: Termination of a Middle-Aged Adult 415Exercises II: Termination of a Child 415

Exercises III: Termination of a Frail, Older Person 415 Chapter 28 Taking Care of Yourself 417

Introduction 417Failing to See Yourself as an Effective Tool 417While Attempting to Understand Others, Failing to Understand Yourself 418

Consistently Underestimating Clients and Wearing Yourself Out 419

Developing Unhealthy Relationships Away from the Agency 422Failing to Develop Other Stimulating and Rewarding

Interests 423Summary 423Exercises I: Preserving Your Energy 424Exercises II: My Strengths and Weaknesses 424Exercises III: Setting Course 425

Appendix A Ten Fundamental Components of Recovery 427Appendix B Wildwood Case Management Unit Forms 429Appendix C Work Samples 455

Appendix D Grading the Final Files 463References 467

Index 469

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In a small nonprofi t agency handling cases of domestic violence, a woman answers the phone She assesses the caller’s concerns, accurately notes the caller’s ambivalence on the inquiry record, and readily connects the caller to the person most able to assist.

Down the street a young man acting as a case manager in a substance abuse detox center handles intake calls from physicians’ offi ces He competently notes the main concerns for incoming patients and asks the questions he knows will give him information that doctors and therapists will need later as they work with these new admissions His notes are clear and useful

How long did it take these two people to acquire these skills? Did they acquire this ability well after being hired in a social service agency, or did they arrive with a clear degree of competence?

individuals would not usually give a DSM diagnosis, it is useful for individuals

enter-ing the fi eld to be knowledgeable about what such a diagnosis is and what is meant by

an Axis I or Axis II diagnosis In this way, conversations among professionals will not

be misunderstood

Today individuals with a sparse education or with recent college degrees are finding themselves thrust immediately into roles for which they have had little formal training It is important, therefore, to fi nd a method for teaching the actual

human service experience at the entry level Fundamentals of Case Management

Prac-tice: Skills for the Human Services, fourth edition, seeks to provide that experience in a

thorough, step-by-step process that leads the reader from intake through monitoring

to termination

Preface

New in the Fourth Edition

New material has been added to this fourth edition to bring the textbook up to date

Added to this edition:

A new DVD demonstrating the skills from the textbook

• Additional ethical considerations

• Additional vignettes that pose dilemmas for students to consider

• How to write brief social histories

• New exercises

Fundamentals for Practice with High Risk Populations (Summers, 2002) has been

published as an adjunct to this text, giving students information and scenarios

on populations in which they are interested or with whom they intend to work

Chapters cover topics such as case management with children and their lies, survivors of rape and violence, older people, issues with drug and alcohol dependence, and mental illness and mental retardation Each chapter features information about specifi c populations and provides exercises and intake forms

fami-This textbook also contains a set of forms that can be copied (see the Appendix)

These forms, taken from actual social service settings, give the reader an nity to practice accuracy and skill in handling social service forms and records and

opportu-in organizopportu-ing opportu-information

If you do not wish to cover all of the populations discussed in the text on risk populations and instead want to focus on specifi c populations, you can order

high-individual chapters from Fundamentals for Practice with High Risk Populations

(Sum-mers, 2002) Please visit http://www.textchoice2.com/ to view chapters online and

to build your custom text You can pick chapters about specifi c populations and create individualized booklets that you can bundle with this text If you would like more information about custom options, please contact your local customer service representative You can locate your representative by using our rep fi nder at http://

custom.cengage.com/

Format

For each chapter in the workbook, basic information is laid out, followed in most chapters by many exercises that prompt the reader to handle real issues and practice real skills Each of the chapters on case management describes one of the case man-agement responsibilities followed by exercises to practice applying the information

As readers progress through the text, they gradually assemble fi les on specifi c cases

Students can create and monitor believable fi ctional clients using one of the high-risk

populations discussed in Fundamentals for Practice with High Risk Populations

(Sum-mers, 2002) Classroom discussions about these cases and the best disposition for each

of them are not unlike the discussions that occur every day in a variety of social vice settings

ser-Organization of the Textbook

The organization of the textbook follows a logical progression, beginning with the most basic foundation for good practice, moving to what is in the student’s mind about other people, followed by what the student will say to others The second half

of the book follows a similar process, beginning with the person’s fi rst contact with the agency and the assessment and planning process through all the case manage-ment procedures to termination

In Part One, “Foundations for Best Practice in Case Management,” readers are introduced to important foundation pieces for this fi eld Ethics and ethical issues, the reasons for case management, and the importance of the ecological model in assess-ment and planning give readers an introduction to professional basics

In Part Two, “Useful Clarifi cations and Attitudes,” readers are invited to ine what in their thinking will impede effective helping in the social service setting

exam-Beginning with issues of cultural diversity and moving to the role of personal tudes and boundaries, this part concludes with information and exercises related

atti-to determining who owns the problem Each chapter in this part contains exercises encouraging readers to examine realistically their own attitudes and judgments

Part Three, “Effective Communication,” begins by introducing the reader to good and poor responses, with exercises that help students see the consequences of poor communication Chapters on listening and responding, asking questions, bring-ing up diffi cult issues, responding to emotions, confronting problematic behavior, and disarming anger are included The part ends with a chapter on the effective applica-tion of what students have just learned and exercises designed to have students prac-tice all the communication skills in order to smooth out the communication and allow

it to become natural and responsive

In Part Four, “Meeting Clients and Assessing Their Strengths and Needs,”

readers begin to take inquiries for services Forms are provided that ask for basic information, teaching the student what is important to fi nd out in that fi rst call This part also includes a chapter on preparing for the fi rst interview, helping the reader become sensitive to issues that clients might have at a fi rst meeting A chapter on social histories and assessment forms teaches students how to use these to assemble

relevant information Introductions to the DSM and to the mental status

examina-tion allow the reader to become familiar with the vocabulary and the informaexamina-tion most important to other professionals in the human service field Students are encouraged to begin noting how a person seems to them at the time of con-tact The chapters and classroom discussions will help students pin down what is

important to note In this part, readers also practice completing release of tion forms for the clients they have developed in the classroom setting, mastering which records are useful and which are not A new chapter on planning for meaning-ful change rounds out this part.

informa-Part Five, “Developing a Plan with the Client,” allows readers to further velop a plan for those clients for whom they have created phone inquiries Here, indi-vidually or in planning teams, according to the instructor’s process, students develop realistic plans for their clients A chapter is included instructing students on how to prepare for and participate in team planning In the fi nal chapters, students refer cases

de-to providers of services and learn about documentation and recording

Part Six, “Monitoring Services and Following the Client,” is the fi nal part, and

it begins with a chapter on monitoring services and treatment Students switch to the role of a worker in the agency of a provider of service and take the general goals given them by case managers and develop specifi c goals and objectives to be accomplished within stipulated time lines In this part, readers also learn the importance of monitor-ing cases from a case management perspective, how to terminate the case, and the importance of self-care by the worker to avoid burnout Numerous documentation exercises provide opportunities for students to begin writing professional notes and keeping good records

To the Students

It is always a challenge to know what skills and information you will need on the fi rst day of your fi rst job Even when you are already working in the fi eld and managing many of the tasks well, you often do not know for certain why agencies choose to do things one way as opposed to another This textbook seeks to empower you to func-tion competently and to know why you are proceeding or should be proceeding with clients in a particular way

In Fundamentals of Case Management Practice, you will follow a specific

se-ries of steps, beginning with what you are thinking and how to think ethically in client–worker relationships, continuing through your communication with clients, and ending with your putting together hypothetical case fi les and managing those hypothetical cases

Throughout the course you will fi nd yourself in discussions with others about possible treatment or service plans or the dynamics of a person’s situation Use these discussions to learn more about collaboration and to increase your ability to partici-pate in the same sort of discussions in the agency where you will work

Many students have taken this textbook to work with them and have found it both useful and realistic Students have contributed their experiences on the job to make this textbook replicate as nearly as possible the issues and concerns you will encounter in your work with other people

Further, in developing your hypothetical clients, you may want to refer to

Fun-damentals for Practice with High Risk Populations (Summers, 2002) In that textbook, six

populations commonly served by social services, such as those associated with tic violence, substance abuse, or mental health issues, are detailed so that you will

domes-be very familiar with their issues and likely problems It is also possible to purchase individual chapters from that textbook on the population or populations that interest you Each chapter will give you information on common problems, diagnoses, medi-cations, treatments, and other considerations such as legal issues or common medical problems each specifi c population often experiences See the instructions on how to order specifi c chapters in the earlier section of this Preface titled “New in the Fourth Edition.”

To the Instructor: Suggestions for Using This Text

This text can be used to take students step-by-step through the case management process outside of the often harried and pressured atmosphere of a real social ser-vice agency When the student is ultimately confronted with the actual situation, the routine and expectations will not be new Chapters are broken down into each step

in the process Students progress according to their skill levels, fi nally creating cases and caseloads with you acting as the supervisor, much as a supervisor would act in

an actual agency Without the urgency, you will have time to let students look up information, discuss possible diagnoses, and develop sound interventions under your

guidance For example, exercises on the DSM and on the mental status examination

have a number of possible answers Your discussion with your students, similar to the discussions that take place in agencies about these possibilities, is more important than the actual answers that are chosen

Most chapters include exercises to help students practice their skills Often eral versions of the same exercise are provided It is useful to students to begin in small groups to address the issues posed in the exercises Their discussions and the ideas and concerns they bring back to the larger class are consistent with discussions held in social service agencies Later, versions of the exercises can be used as tests,

sev-or you can go back to them at a later time to make sure students continue to practice their skills

It is extremely useful for students to apply the skills described in this book to specifi c populations To do this, you can use this book in conjunction with my other

book, Fundamentals for Practice with High Risk Populations (Summers, 2002) After

stu-dents have read the chapters on the specifi c populations you have assigned or on those that are most interesting to them, they can create a fi ctional “typical” client that they can then walk though all the exercises from intake to termination Case notes would refl ect the common problems encountered by the population, and intake would de-scribe a common reason for seeking services among people in this population This gives students a good beginning look at how cases come in and unfold while clients are receiving services

Details on six high-risk populations are provided in Fundamentals for Practice

with High Risk Populations (Summers, 2002) A detailed chapter on children and their

families gives students information on how to include others involved in the child’s life and how to coordinate all the various entities with whom the family interacts

Another chapter focuses on domestic violence and rape, including how these issues affect children

A third chapter looks at substance abuse and includes the common social and medical issues that arise for this population This chapter also includes the com-mon challenges this population presents to case managers and gives tips for how to handle these Mental health and mental retardation each are featured in chapters, giving common problems and issues, diagnoses, and treatments Finally, there is a chapter focusing on aging that includes both medical and social issues for this pop-ulation All the chapters include an assessment form for that population taken from actual agencies that work with that population, and all the chapters give the most typical diagnoses and medications used with each population Where a population has special considerations the student should know, these are included as well

For example, in the chapter dealing with issues most likely to affect women, there

is a discussion of how women’s programs and agencies differ in their approach to clients from other social service agencies To order specifi c chapters related to spe-cifi c populations, see instructions in the earlier section of this Preface titled “New

in the Fourth Edition.”

Benefits and Advantages

This material has been used in my own classroom for 30 years and has been updated

to meet current social service trends Students have commented that using this text

is like walking from the classroom into the social service setting with very little lost time in learning the actual process Instructors teaching the practicum course have

used the word empowered when describing what this text has done to give students

confi dence and skill in their fi rst encounter with a social service position ers as well often contact me to say how well prepared students are who have used this textbook

Employ-Three positive features of this textbook make it especially useful in preparing students to work in this fi eld:

1 The text gives very basic information a person needs to handle each of the tasks described Theoretical information can be found in many other places, and thus the concentration and focus are on what is important to note, think about, docu-ment, and pass on in each step of the human service process

2 Numerous exercises create very real situations for students to consider and handle These exercises are based on real experiences taken from my 23 years

of practice in human services and from the experiences of many others who ciously contributed to this book Doing the exercises and participating in the classroom discussions that follow will expose students to an extremely broad range of possible circumstances and diffi culties in the fi eld

3 The book contains forms that give students an opportunity to practice ing information at various times throughout the management of the case These forms can be copied and used to create fi les on clients developed by the stu-dents Using each form a number of times gives students practice in preparation for real clients in real social service settings.

compil-These features, when taken together, create a nearly realistic social service setting in the classroom, giving the instructor many opportunities to strengthen student skills and sensitivity

In addition, Fundamentals for Practice with High Risk Populations (Summers, 2002)

supports students with applicable details and considerable information on various at-risk populations This textbook acts as a reference so that the hypothetical clients students develop are real with entirely likely problems Students can use the material found in this supplemental textbook to develop realistic clients, create useful service plans, and make appropriate referrals

na-At the Dauphin County Executive Commission on Drugs, Alcohol and Tobacco,

I want to thank John Sponeybarger for his help in formulating realistic plans and vices I am grateful to Ruby Porr for her ideas based on her work as a service provider and to Ruby Porr, Aimee Bollinger Smith, Karen Polite, and Barbara Miller who use this textbook and had suggestions for additions to the text

ser-I would like to thank Christopher D Carrol MSc., Ken Thompson, M.D., and Paolo Delvecchio, of the substance Abuse and Mental Health Services Administra-tion in the Department of Health and Human Services I am grateful for the support and information my husband, Martin Yespy, contributed to this work His unfailing support of these textbooks and the useful material and information he brought from the fi eld of crisis intervention have enhanced this work

I am grateful to my editor, Seth Dobrin, who has given me support, guidance, and good information when needed He has tirelessly worked with me to produce a better textbook

The two students, Danica Zirkle and Keyanna Watkins, who organized and then participated in the DVD deserve considerable gratitude for all the work they did to keep everyone on track The students who participated in the vignettes, writing and rehearsing their work also deserve my gratitude for all their hard work

They are Catherine Wrighstone, Tom Moulfair, Sean Taney, Michele Anthony, and Alison Kilgore Many thanks to Michelle Beahm again for participating in the the DVD and giving her ideas to make the vignettes more realistic Brian Peterson and his crew from Motion Masters provided considerable direction and made the

fi lming smooth and effortless My thanks to all of them for the time they spent with us

I would also like to thank the reviewers of this textbook for their helpful ments: Jackie Abel, Lake Area Technical Institute; Arturo Acosta, El Paso Community College; Susan Barnett, Northwestern State University; Chrys Ramirez Barranti, California State University—Sacramento; Karen Benton, Urbana University; Paula Gelber Dromi, California State University—Los Angeles

com-Ethics and Other Professional Responsibilities for Human Service Workers

Introduction

Ethical principles are the foundation of good human service practice In fact, workers who do not practice within ethical parameters cannot be called professional True pro-fessionals understand their ethical obligations and seek guidance when they do not

Each social welfare profession, from psychologists to social workers to human service workers, develops a set of ethical principles appropriate to the practice Most profes-sions monitor the behavior of their members with regard to these principles, singling out those who violate ethics codes for disciplinary measures

Ethical principles are generally created in order to protect and prevent the exploitation of the individuals who come to us for service In the work we do, there is considerable opportunity to exploit vulnerable people because the people who seek our help are dependent upon us for the aid they need Any violation of their trust on our part will only compound the person’s problems Ethical principles provide guidelines

to protect individuals from exploitation However, when professionals practice within the parameters of ethical principles, the public can feel confi dent that their interests will be respected and protected Thus, ethical principles inform the decisions we make that affect clients, and they provide guidance in choosing the approaches we take with clients

In this chapter, we will look at some ethical guidelines common to all the ing professions Failure to know and follow these guidelines in your future practice can result in dismissal from an agency or, worse yet, in a civil suit brought against you for a violation of the ethical code wherein the violation caused damage to the

help-1

person Although violations of ethical principles may have negative consequences for you and your career, they are always extremely destructive for the individual, who is already vulnerable.

Language and Ethics

Language in the social services is a funny thing After a word is adopted to describe people who use a service, that word becomes pejorative over time and a new word

meaning the same thing is sought In social services, we have gone from patient (which implied people seeking services were all mentally ill) to client and fi nally

to consumer.

Client was meant to denote that the person was being served by a case manager

in a relationship much like a lawyer–client relationship This originally conferred an obligation on the part of the case manager to give good service to someone paying,

in some manner, for that service However, as with all words describing people who

use social services, the word client developed a negative connotation and the word

consumer was increasingly used instead Consumer also implied the person was paying

for good services from the case manager

With the Recovery Model (see page 427) and the emphasis on partnerships between case managers and the people seeking services, those words are no longer considered appropriate The concern is that these words denote a difference in status

between case manager and those they serve Thus, in recent years, the terms client and consumer have given way to person or individual, and in many cases no term is used

but rather the person’s name is used instead

In this textbook, we subscribe to the idea that case managers and the people they serve are in a partnership to which each brings a certain degree of expertise In your

work, we strongly encourage you to drop the use of the words consumer and client and adopt what is seen as the more respectful terms of individual and person.

However, having said that, there are places in this textbook where using person and individual alters the meaning of the sentence and the point that is being made

For that reason, in this textbook, we need to use client to denote a person seeking

professional services from a professional case manager in order for the point to make sense This is in no way meant to diminish the person who does seek service, but rather to make our points more coherent

Dual Relationships

A dual relationship occurs when you and a person to whom you are giving services have more than one relationship You may be this person’s case manager as well as her cousin, her boyfriend, or her customer at her beauty salon Or you may be a person’s case manager and also his employer for your yard work, his Sunday school teacher, or his Little League coach In other words, a dual relationship occurs when you are in

two different relationships with a person, one related to your position as the person’s case manager and the other unrelated to that role.

The fi rst rule is to avoid all dual relationships Your practice gives you a position

of power People tend to look up to you as someone who can provide real assistance

Furthermore, you might be the one who will determine when a person can return

to work, or you may be the person who reports an individual’s attendance in your program—attendance that keeps that person out of jail It is possible that you could exploit or give the appearance of exploiting this power In addition, there is enormous potential for a confl ict of interest

Suppose, for example, that your supervisor tells you on Thursday afternoon that you have been chosen to represent the agency at a big dinner being given to honor

a county offi cial at the Hilton Hotel on Saturday night This gives you little time to prepare You need to get your hair cut and styled You call a man who receives services from you who is a hair stylist, and prevail on him to work you in at the last moment

He does you a favor and sees that you get a good appointment You are very grateful,

go to the wonderful dinner, and think little more about it

Several months later this man calls you He has a need for a prescription refi ll from his psychiatrist It is Friday afternoon, and the psychiatrist will not be back in the agency until the following Wednesday He feels you should be able to do this favor for him because of the favor he performed for you He does not have time to see the psychiatrist regularly, he tells you When you refuse to call in a prescription for him without the doctor’s prior knowledge, he cannot understand why you are being

“so rigid.” He indicates that he thought the two of you were friends who helped each other out when needed

Whatever you do in this situation, you will lose If you call in the prescription, you will have violated an agency rule that a person must be seen at regular inter-vals by his psychiatrist before medications can be refi lled This could cost you your position or result in a disciplinary action On top of that, you could start down a very slippery slope with this individual He may come to expect special favors from you and offer you special, very tempting favors related to his business in return On the other hand, if you do not call in the prescription, you have alienated someone who needs the services of your agency You have created a barrier to his feeling comfort-able with you and getting the help he needs in the future The individual is harmed

A relationship that was or could have been useful to him in resolving problems is now something else The opportunity for real progress is diluted with issues of friendship and favoritism

From a shortsighted point of view, you and this person may see the convenience

of exchanging favors as trivial and unrelated to the therapeutic relationship In the long run, however, when scenarios such as the one just described occur, the rela-tionship can never return to a professional one; and if in the future this individual

is in acute need, you may no longer be able to provide the professional intervention needed

In some very small, rural communities, it is not possible to avoid dual tionships entirely In those situations, after doing all that you can to make other arrangements, you must talk with the person about the possible problems that

rela-could arise and how each of you must avoid these problems together Then the person has the choice to continue the relationship, fi nd other arrangements, or dis-continue services altogether.

Gifts from People You Serve

Although gift giving by those whom you serve does not pose a dual relationship, people who bring gifts for you do pose a particular confl ict of interest It is usually best to avoid accepting gifts and keep the relationship professional Often, though not always, gifts are the person’s way of manipulating the situation “I’ll give you this item and you accept it Next time you owe me something” or “I gave you this lovely thing

I am such a nice person Even you think so or you would not have taken my gift How can you then refuse to give me what I want?” People need to learn to express their desires clearly rather than by using gifts

Gifts are not always manipulative, however For example, a case manager ing in a fuel assistance program worked closely with a family The husband was injured when an automobile he was working on at a garage slipped on the lift Unable

work-to work, the family’s meager resources began work-to dry up The wife managed work-to fi nd work in a greenhouse, but as winter approached, she was laid off and the expenses, particularly for fuel, increased The couple had two children, both in elementary school, and they struggled to clothe and feed them as the wife sought another job

The case manager saw this family through their diffi culties by getting them fare checks, seeing that the husband enrolled in the community college for courses

wel-in high-tech auto repair while his wel-injuries healed, and fi ndwel-ing school clothes for the children The husband did well in school that winter and set a good example for his children, who seemed to do better in school than they had the previous year The wife returned to the greenhouse in the spring and found that not only was she needed

as a manager, but there was also a strong possibility she would have a year-round tion there

posi-Elated by how well things were going and how much better the future looked, the couple came to see the case manager one day in the early summer and brought her a pot of black-eyed Susans from the greenhouse “We just wanted you to have these for all you have done for our family,” the husband said, smiling expansively

The husband and wife looked pleased and happy Obviously the couple was proud to now be in the position to be able to give something too It was important to them not

to see themselves as the recipients of handouts all the time, but to be able to also give something to someone who had been helpful to them

Refusing a gift in such circumstances can be interpreted as rejection If the worker had said, “Oh, I can’t accept that You’ll have to give it to someone else,”

a person might have heard a different message: “You are the client and I am the benevolent worker I help you, but you can never get to the position where you could possibly do anything for me I don’t need anything you could give me; but you, on the other hand, are a poor soul in need of my help.”

If your agency has a policy against your personally accepting gifts, try to fi nd

a way to accept a gift of this sort on behalf of the agency In this case, the worker

planted the fl owers in a planter near the door of the agency This was a better solution than outright rejection of the gift.

The rule is to be very careful about accepting gifts from people you serve ever an individual offers a gift, make a note in the person’s record of the offer as well

When-as whether the gift wWhen-as accepted or rejected and why

Sexual or Romantic Relationships

Individuals who come to human service workers for help often feel isolated, aged, and misunderstood The relationship they form with a respectful, concerned worker may make them feel understood and appreciated for the fi rst time This re-lationship may be so comforting that people attempt to turn it into something more permanent, more personally meaningful

discour-It is not uncommon for people to fall in love with their workers in what we call

“transference.” In a sense, such individuals transfer to the workers the attributes they are seeking in another person They may assume the love and affection they are seek-ing will be forthcoming from their workers because the workers have been so kind and helpful These people fall in love with their workers because of an erroneous per-ception: They see concern and encouragement as gestures of love and affection—as

an invitation to create more than a professional relationship

Countertransference also can occur It is not unusual for workers who are harried and overworked, and possibly coping with diffi culties in their personal lives, to fi nd the willing ear of a person to whom we give services very supportive The people we serve are often attractive, sensitive people who can convey warmth and support when case managers are most vulnerable

Take, for example, Kent, a case manager Kent’s wife left in the middle of a day morning, and Kent was to be at work that afternoon at 3:00 Though he fought hard to dissuade her from going, she left For the rest of the day before work, Kent tried to get some money from their joint account, tried to fi nd out where his wife was going, and tried to make some decisions He arrived at work feeling exhausted and bitterly betrayed

Tues-That evening, Kent made a home visit to Lucy’s house Lucy had fi rst come to the agency with extreme depression, but she was doing so well now that Kent was considering terminating these follow-up visits Lucy, an artist, greeted Kent warmly

She had put on a pot of tea and made some banana bread for his visit Gratefully Kent sank down on her sofa Instead of asking Lucy how things were going for her, whether she had enough medication, and whether she had any medication questions, Kent found himself talking about his upsetting day

In response to Lucy’s fi rst remark, “You don’t look very well tonight, Mr Paulman,”

Kent heard himself pour out the day’s events; then he went on to talk at length about how his marriage had unraveled He felt comforted by Lucy’s interest in him as she listened intently Here was a person who appeared to respect him as a professional and as a person Here was a woman willing to listen to his problems Here was a warm retreat from the job and the problems of the day where Kent could feel safe and supported

Kent never intended for a real relationship to develop between Lucy and himself

In fact, as he left that night, he told himself that he might have crossed a dangerous line and that he should avoid further contact of this sort with Lucy Nevertheless, based on that evening, Lucy called; and because Kent was lonely, his life was uncertain, and he was fi lled with anger and bitterness about his situation, he continued to see Lucy, fi nd-ing in her a warm, supportive person, someone who could reassure him by her presence that he was attractive and interesting

The relationship moved from his visiting in her home after work to his staying overnight at her house to his moving in his belongings and beginning to live there

They went out on dates The furtiveness of these activities only made the relationship seem more romantic and important Finally, a supervisor discovered the relation-ship, and Kent lost his job After 3 years, he and Lucy have separated, and Kent is not working in the human service fi eld anymore because he violated such an essential ethic Instead, he sells appliances in a local store Lucy became depressed when the relationship ended and has entered treatment again

The person responsible for maintaining a professional relationship regardless of personal feelings is the case manager Regardless of how you feel about the person on your case load or how that person apparently feels about you, you are the responsible party You will be penalized if the relationship crosses from professional to intimate

It is always assumed that the individual you are serving is the vulnerable party

Figure 1.1 lists some warning signs that indicate when a worker or an individual receiving services might be moving away from a professional relationship and toward

a personal one Make certain you are familiar with these signs

PLEASE NOTE!

It is a violation of all ethical codes, and in most states against the law, to engage in a sexual or romantic relationship with a person receiving ser-

vices from you This is clearly exploitation It is never tolerated You must be

aware that, although attractions can occur between those receiving service and those who provide service, acting on those attractions is entirely unethi-cal in professional practice and illegal in most states as well

Value Conflicts

Generally, the person’s values and your values have little to do with why the ual is seeking services from you Sometimes, however, religious, moral, and political values play a pivotal role in the problems people bring to agencies It is rare for case managers to get deeply involved in such primary problems, but it can happen

individ-First, you can be prepared by consciously knowing yourself and your feelings about certain value-laden issues Then, if a confl ict of values occurs between you

Warning Signs from the Client

The client shows overt sexual interest in the worker either through conduct or

• verbally

The client describes dreams that are increasingly sexual in which the worker is

• prominently involved

The client is excessively interested in the worker’s private life

• The client inquires about the worker’s relationship with his or her spouse and

• children

The client attempts to give the worker romantic gifts (Be careful about accepting

• gifts from a client Note every such offer in the record, along with whether the gift was accepted or rejected and why.)

The client wants to see the worker outside the offi ce in places such as restaurants or

• movie theaters

The client gives the worker romantic poetry or brings in romantic articles and

• books

The client dresses in seductive attire

• The client interprets the worker’s statements of concern for the client to mean the

• worker has a romantic interest in the client

The client repeatedly hugs and touches the worker

• The client indicates a desire to be special to the worker

•

Warning Signs from the Worker

The client is prominent in the worker’s dreams

• The worker looks forward to seeing the client, more so than other clients

• The worker begins to see the client as more understanding than others in the worker’s

• life

The worker inquires about the client’s sexual life and fantasies when these are not

• relevant to case management

The worker is more interested in this client’s attire than in the attire of other

• clients

The worker is more concerned with his own attire on days when he will see the

• client

The worker begins to see the client as a person without issues or problems or

mini-• mizes these so that the client seems more acceptable as a partner or friend

The worker takes many innocuous actions the client might interpret to mean the

• worker has a special interest in him or her

Source: Based on a list created by attorney O Brandt Caudill (1996) Used with permission.

FIGURE 1.1 Warning signs that the worker–client relationship may become too personal

and an individual you are serving, you should be able to tell that person that the confl ict exists and may interfere with services You can begin to inventory some of your own attitudes and strong feelings by completing the self-assessment exercise

Self-Assessment Exercise: Possible Values Confl icts When Helping Others

Look at each description of a person or group of people, and assign a number to each

1 Give the description a 1 if you think you could work with the person or group

2 Give the description a 2 if you think you could work with the person or group, but would fi nd it uncomfortable or diffi cult

3 Give the description a 3 if you could not work with the person at all

1 A woman who wants you to help her feel comfortable with her decision to have an abortion

2 A man who frequently brings up his fundamentalist religious beliefs

3 A homosexual couple who want help in improving their relationship and resolving their interpersonal confl icts

4 An interracial couple seeking premarital counseling

5 A man from Iran who strongly opposes the equality of women and talks about women working in denigrating tones

6 A man who has for years been getting more welfare than he is entitled to receive by using certain tricks he developed to beat the system

7 A man and woman who say they want to improve their marriage, but the man will not end his affair with a second woman

8 A white couple seeking help for behavior problems with their adopted son, who is African American

9 A man who makes it clear he often disciplines his children by using corporal punishment

10 A person who refuses to discuss feelings and says that all that matters are facts and logic

11 A woman who has chosen prostitution as a way to support herself and her children

12 A gay man dying of AIDS who comes in with his lover to resolve confl icts around how he contracted the disease

13 A man seeking help to curb his extreme abuse of his wife

14 A woman who sexually molested her son

15 A lesbian couple seeking to adopt a child

16 A woman dying of breast cancer who wants to take her own life

17 A person who relies heavily on cocaine to get through the day

18 A couple who are openly anti-Semitic

19 A vocal member of the Ku Klux Klan

20 An orthodox Muslim who cannot always see you because his appointments often interfere with his times of prayer

FIGURE 1.2 Self-assessment exercise

can no longer be objective, you are extremely uncomfortable with the person because

of her or his values, or you feel compelled to counteract the individual’s values by imposing your own

For example, a human service worker who did not personally believe in birth control (including tubal ligation) was a case manager for individuals with developmen-tal disabilities When a young couple on her caseload decided to marry, she became actively involved in discouraging them from the idea, particularly when she learned that the woman planned to have a tubal ligation so that they would not have children

The families of the two individuals supported the marriage The people were high functioning, each one had a job, and each had the support of other community agencies.

In the months before the wedding, the case manager did not attempt to transfer the cases to another case manager Instead, she harangued the couple about the sins

of birth control and of marriage without children, and about the unwise decision to marry at all, given their “mental impairment.” The families complained to the agency, asking that she stop pressuring these vulnerable individuals Twice the supervisor dis-ciplined the worker When the worker persisted—visiting the couple’s minister who would perform the ceremony, the supervisor where the man worked, and the woman’s parents—she was fi red from her position

The worker’s behavior was harmful to this couple For those two people, who had always relied on a case manager who had seemed to be wise, the worker introduced uncer-tainty and fear Her constant negative warnings damaged their fragile self-confi dence and self-esteem For them, what should have been a happy decision, supported by family and friends, became a decision fraught with anxiety Family and friends had to work long and hard to restore their confi dence in their original decision

This is an example of the worst possible way to handle a values conflict

In this situation, the worker attempted to impose her own point of view, her own personal values, on the couple She denied them the right to choose for themselves and interfered in what was largely a personal and family issue unrelated to case management

Avoiding Value Conflicts

Following are some rules for avoiding value confl icts and ensuring that individuals get professional service from you:

1 Be respectful of attitudes and lifestyles that differ from your own

2 Never practice prejudice toward minorities, those with disabilities, or those differing in sexual preference

3 Always give your best service to a person, even when you disagree with the person

4 Never attempt to change the individual’s values to coincide with your own

Using Values to Motivate People

When people come in seeking assistance, they are usually hoping to make things ter in their lives than the way they are right now In the course of your time with them, it is important to explore the values that caused them to seek help Find out what goals people have for themselves if their situations were better, and what values those goals refl ect Here we are looking at the things that people value for themselves:

bet-being a good parent, living an independent life, living free of the symptoms of phrenia, or being free of cocaine addiction The person is envisioning something up ahead that involves a goal or value dear to that person

schizo-You often learn about people’s values when you ask them where they would like

to be in 5 years What you hear when they answer will point to what they hold tant for themselves and those around them When people are having trouble making changes that will move them toward their personal goals and visions, it is helpful for the worker to know what the individual’s values are and to look at the person’s situa-tion with those values on the table

impor-The Rights of Individuals Receiving Services

Anyone who gives service in one of the helping professions must be familiar with the rights of the person and make a particular effort to see that people understand they have rights when they seek help Often people mistakenly assume that they have few or no rights when they come in for services In addition, professionals may fail

to inform individuals of their rights because it is easier to work with people who are vulnerable, dependent, and uninformed This, of course, sets up a situation in which

it is easy to exploit the person The purpose of educating people about their rights is

to allow them the opportunity to become active participants in their care and partners

in decisions that affect them

Most agencies prepare clients’ rights handbooks for those receiving services

to keep as a reference A hospital for the mentally ill would include the right to be released from the hospital as soon as care and treatment in that setting are no longer required Nearly all agencies inform people that they have the right to participate in the development and review of their treatment plan People generally have the right

to participate in major decisions affecting their care and treatment Most of those who are involuntarily committed to an inpatient setting have the right to refuse treatment

to the extent permitted by laws in that state or the right not to be transferred to another facility without clear explanations regarding the need for the transfer Inpa-tient units stipulate it is the person’s right not to be subjected to harsh or unusual treatment The hospital may also spell out the fact that the individual may keep and use personal possessions, or the person must be informed about why something is being removed In most settings, people have the right to handle personal affairs and

to practice the religion of their choice

In outpatient settings, people have the right to a fl exible and responsive ment plan, the right to expect an individualized plan of service, and the right to make suggestions and express concerns Often there is a procedure individuals can follow if they are dissatisfi ed with the worker assigned to them or the service plan laid out by the agency

treat-The following sections discuss some important rights that belong to those receiving services

The Right to Participate in Planning

When you sit down with someone to begin planning what services would work best

or what treatment would be most effective, you each bring unique perspectives to the

table You have a detailed understanding of what is available, which services work ter than others, and where people on your case load can receive treatment or service tailored to them A person comes to the table with information about themselves that

bet-is useful when planning Putting these two pieces of information together makes for

a more effective plan People who work with you feel that they have had a part in the planning and therefore, some control over the direction of their care This makes it more likely that the plan will be followed or that your individuals will tell you if they see the need for a change

It is for this reason that we do not just disrespectfully tell people what their service

or treatment plan will be without consulting them fi rst

The Right to Self-Determination

Educating people and informing them about their rights are both done so that clients can exercise the right to self-determination Paramount to any relationship between professionals and their clientele is the right to self-determination People have the right to do research about their diagnosis or problem and to question the treatment plan or make suggestions People have the right to withdraw from treat-ments and services they fi nd are not helpful People have the right to decide when and for how long they will use services (unless their involvement with the agency

is based on an involuntary court commitment) People have the right to choose their own goals

Often this presents a problem for a worker who feels compelled to look after the best interests of the individual One of the hardest lessons you will ever learn

is how to let people make mistakes and learn from those mistakes You can make suggestions and express concerns, but ultimately clients have the right to determine what they will do You may feel strongly, for example, that one individual is not ready

to walk away from the agency; and you may feel certain that the person’s doing so prematurely will result in further problems with alcohol In fact, your client leaves treatment against your advice and eventually does end up with another DUI charge

Although your worst fears and predictions came true, you cannot know for sure that the work with you and the new charge were not important learning opportunities In other words, people have the right to test the waters, so to speak, and to learn that they are not as ready as they thought they were

Increasingly, however, self-determination means more than this More and more funding sources and governments, as we shall see in the next chapter, are asking case managers to go beyond simply arranging for services in collaboration with the client They are asking case managers to encourage people to articulate what their vision of a healthy, productive future would look like As people do better on medi-cations and remain in their communities, how they function in those communities—

how they contribute, feel secure, and pursue their own interests—becomes more important Self-determination now takes on the future beyond the social and emo-tional problems that were the original reason for seeking help Now people are being energized by their case managers to explore and create a better tomorrow of their own making

Informed Consent

A person receiving services always has the right to consent to these services or draw from them In making this decision, the person must be informed enough to make a wise decision When the individual is informed and consents to treatment,

with-we call that informed consent Making certain that a person can give informed consent

begins with the intake, during which the agency policies are explained and choices of treatment or services are outlined This level of information should continue through-out the entire relationship between the individual and the agency until termination

This means that people informed about treatment or services can make their own decisions with regard to the services

The following list contains items that should be addressed when relevant to the person’s services The person has the right to be informed about:

1 Any side effects, adverse effects, or negative consequences that could occur as a result of treatment, medications, or procedures

2 Any risks that might occur if the person elects not to follow through with ment or services

3 What is being offered to the individual, including what the treatment is, what will be included, and any potential risks and benefi ts

4 Any alternate procedures that are availableSome of the people with whom we work have a limited capacity to understand all the details of service and treatment It is our task to fi nd an appropriate balance between too much and too little information and to make our information clear and easy to understand

Informed consent consists of the following three parts, or criteria All must be present in order to say that the individual gave informed consent:

1 Capacity The individual has the ability or capacity to make clear, competent

decisions in his or her own behalf

2 Comprehension of information The person clearly understands what is being told

to him or her To make sure that this is so, give your information carefully and always check to be sure the person understands what you have told him or her

3 Voluntariness The person gives his or her consent freely with no coercion or

pres-sure from the agency or the professional offering the service

Currently laws and courts are recognizing more and more often the person’s right

to self-determination When we fail to tell those we serve the information they need in order to give informed consent, we run the risk of being found negligent, particularly

if the treatment or service involved was unusual

The Right to be Informed of Changes and Decision

There are times, however, when you are working with a person who cannot participate

People who are confused, have severe developmental disabilities, or are psychotic often are not capable of planning or giving input Letting them know what will happen is still

respectful One case manager’s client, Mindy, was hospitalized when she became chotic as a result of schizophrenia Mindy barely responded to treatment and the decision was made to transfer her to a longer-term care facility The nurses on the hospital unit made the arrangements for transportation and who would help with the transfer from the unit to the ambulance.

psy-The case manager had agreed to the transfer and came in a few hours before

it was to take place to talk to Mindy about it The nurses were incredulous Mindy was in a room with only a mattress on the fl oor because she had taken her room apart several times She was uncommunicative and had been yelling at voices she heard

“She isn’t going to understand a word you tell her,” one of the nurses remarked theless, the case manager went to Mindy’s room, sat down on the bare mattress on the fl oor and began to describe in some detail what was going to happen Mindy grew quiet She never looked at her case manager, but she appeared to be listening intently

Never-When the orderlies came to take her to the ambulance she went without resistance

Did Mindy really understand what her case manager told her? Is that really the point? The point is that this case manager respected her client’s right to know what plans had been made for her The right to know what treatments and services have been planned and the right to participate to the degree a person is capable are impor-tant ways professionals demonstrate respect for the people they serve

Confidentiality

Confi dentiality is both an ethical principle and a legal right It is the most basic right

of any person, either in treatment or receiving services, to know that what the person

is sharing in your offi ce will remain confi dential It is important to protect als to whom we give service by not disclosing their personal situations without the people having authorized such a disclosure Today, under new laws discussed in the text that follows, agencies have very specifi c guidelines for protecting confi dentiality

individu-Release of Information Form

Not many years ago a person seeking services, particularly from a public agency, signed

a blanket permission statement allowing information to be shared with others as the agency and the worker saw fi t Today, release of information forms must state specifi -cally to whom the information is being released and must be time limited (good for

3 months, 1 year, and so on) Do not use forms that are not specifi c in this manner

New regulations now stipulate what is permissible on a release of information form

Release of Information Regarding HIV/AIDS

In most states, release of information forms for releasing information regarding a client’s HIV/AIDS status must specifi cally state that you may release information regarding the person’s HIV status All references to HIV/AIDS must be deleted from the record unless the client signs a separate form that specifi cally states that you have

permission to release this information If you are asked to release information about

a person who is HIV1 and the person signs a release form, the law in most states specifi es that it is not good enough to simply remind that person that his case contains references to his HIV status and get his verbal permission to release the information anyway You also must have his written permission If the person has not given you written permission, you must delete all references to HIV/AIDS, including the fact that he may have been tested and the test was negative

If your state does not have such a law, you are still responsible for protecting your client and must be alert to the possible harm such a release might cause the person In such a situation, it is wise to involve the person in a discussion about the release of this sort of information or, if the individual is unable to participate in such a discussion, to take steps to protect that individual from undue bias

In some instances, workers have informally notifi ed their friends and tances in other agencies of a person’s HIV1 status, thinking they were doing these people a favor In fact, this behavior is entirely unethical and can lull other workers into believing they know who is and who is not HIV1 We can never actually know this for certain because of the length of time it takes for the disease to register positive

acquain-on a blood test A persacquain-on can be positive early in the illness and still have negative blood tests For this reason, workers should use universal precautions with every client when those precautions are called for Workers who fail to use universal precautions

on the false assumption that they know the individual is not HIV1 place themselves

in-all of it This kind of sharing of information is unacceptable, and most agencies do not allow students or volunteers to read anything before they have signed a pledge to honor the confi dentiality of the clients and you feel these students thoroughly under-stand the critical importance of protecting confi dentiality.

Guarding Confidentiality on the Phone and in Other Conversations

Other situations also provide opportunities for violating confi dentiality For instance, a person receiving services from your agency may also be receiving services from a local physician Suppose someone calls, claiming to be the physician’s nurse and needing

to know at once what medications the client is taking She may really be the cian’s nurse, or she may be a person posing as the nurse in order to determine that the person is using your services and the level of his problem Even if she is the nurse, the person may wish to keep his physician uninformed about the involvement with your agency All agencies have procedures for such situations in the event of a real emergency You, however, must never openly and automatically acknowledge that an individual is being seen in your agency, no matter how important and offi cial the other person seems to be In the case of a seeming emergency, refer the call to your su-pervisor unless you know the emergency workers or emergency room personnel well enough to recognize their voices

physi-When a request for information is presented in a situation that is not an gency, here is how you might handle the request:

emer-YOU : Hello.

CALLER : Hi This is Ann Taylor I’m a counselor at Marlboro Middle School, and

I’m calling about Jimmy Smith Did he and his mother keep their ment with you today?

appoint-YOU : I’m sorry, I can’t help you with that Would you have Mrs Smith sign a

re-lease of information form stating what it is you need to know, and if Jimmy Smith is known to us, we can send you that information

In this situation you do not give any hint that the client is known to your agency

By saying “if this person is known to us ,” you do avoid letting on whether the ent is or is not

cli-Another way to violate confidentiality is to talk about your cases with your friends and relatives, leaving out the names Others may be able to piece together the identity of the person you are talking about based on other information they possess

In this way, they may discover far more about a person than that person ever intended them to know

Minors and the Infirm

Take special care to protect the confi dentiality of minors and the infi rm (individuals who are frail, sick, and are unable to fully participate in decisions about their care)

Not all systems respect confi dentiality to the degree that we in the helping sions are committed to doing it.

profes-In one children’s case management unit, parents were routinely urged to sign blanket release of information forms When the school requested information on a child being seen, all the information was sent to the school It was stamped in red

letters with the word confi dential, and it was sent to the school psychologist

Never-theless, school clerical personnel assisted in typing and fi ling information for the psychologist and generally read the information sent by the case management unit

Having no training in confi dentiality, these clerical people talked among themselves about students, sharing personal information they had learned Many times they passed on to teachers tidbits of what amounted to gossip This information shared outside the professional context and without professional understanding jeopardized the progress of the children and the relationship of their parents with the school personnel As these children moved through the school system, the gossip followed them Always be very careful about what information you release Remember that information given about a child can follow that child all through school, prejudicing responses to that child

In another case, a woman with a developmental disability got a job at the police department as a cleaning woman She was told that she needed to bring in her “records from mental health” so the police could know why she went there

She arrived at the case management unit, pleased about the job and ready to give all her records away The case manager talked to her about the wisdom of retain-ing most of the information as confidential In the end, a short statement was released, with the client’s permission, giving only the most general information about her relationship with the mental health/mental retardation case manage-ment unit It is important to remember that older people or individuals who do not have the capacity to protect themselves can be easily led to sign releases regarding information that might best be kept confidential The responsibility belongs to you to protect your clients from unnecessary intrusions into their per-sonal information

Minimum Necessary Rule

Before releasing information, ask yourself whether you are about to release more formation than is needed for this other business or organization to accomplish its work with the client For example, Melissa was a case manager who knew a worker in a remedial education program where one of her clients, Jill, was attending Although the program needed to know why Jill was referred and what goal the referral was in-tended to accomplish, they did not need to know that Jill was arrested once for a DUI and that Jill’s father was in prison for murdering a neighbor When dealing with other organizations not engaged in treatment, release only what that organization needs to work effectively with the client If the client authorizes you in writing to disclose more, only then would you do so

in-When You Can Break Confidentiality

The law in all states does make exceptions The following are circumstances that allow you to break confi dentiality:

1 When you must warn and protect others from possible harmful actions by the client For instance, you or your agency must warn another party if your client is intent on harming that other party In addition, you should notify the police

2 When the person needs professional services For instance, if the person has taken an overdose of medication and is in the emergency room (ER), the ER staff may call, needing to know what prescriptions the client was taking in order

to give the proper antidote

3 When you must protect people from harming themselves An example might be people who are threatening to take an overdose of their medications with the intention of committing suicide or people who appear so depressed or desperate that they are talking about ending their lives

4 When you are attempting to obtain payment for services and the payment has not been made Your agency would refer a person for nonpayment only after rea-sonable attempts had been made to remind the person of this obligation and only if the individual had made no effort to arrange even minimal payment

5 When obtaining a professional consultation from your supervisor regarding how best to proceed with a case in the course of normal supervision

Privacy

Privacy is very much related to confi dentiality Siegel (1979) calls it “the freedom of individuals to choose for themselves the time and the circumstances under which and the extent to which their beliefs, behaviors, and opinions are to be shared.” Stadler (1990) calls it “the right of persons to choose what others may know about them and under what circumstances.” Privacy is invaded or altered under some circumstances, and people need to be informed of those circumstances The point you should stress with the people you serve is the fact that third-party payers will have access to diagnoses and, in some cases, to actual records or summaries of records The agency must provide this access in order to be paid for the services it has rendered Many individuals are unaware of this fact or unaware of the extent of the information being shared They should have this situation explained to them This allows people to make an informed decision about whether to pay for services themselves and not involve the insurance company

Health Insurance Portability and Accountability Act

The federal Health Insurance Portability and Accountability Act (HIPAA) was passed

in 1996 in part to ensure that people did not lose medical coverage when they changed jobs Title II of the act contains the security and privacy mandates These contain

stringent rules for protecting a client’s health information, and most social service agencies must adhere to these rules Where state laws are more stringent than this federal act, the state laws take precedence Failure to follow the guidelines set forth

in HIPAA can result in fi nes from $100 to $250,000 and from 1 to 10 years in prison for those individuals and institutions with the ultimate responsibility for safeguarding patient privacy

The new rules apply to case management and to care coordination and cover not only formal records but also personal notes and billing information When you begin work at your agency, they will see that you are informed of their policies and proce-dures under this act

Disclosure

Under the new rules, “disclosure” is defi ned as occurring when health information is released, transferred, or divulged outside the agency This includes allowing access

to patient fi les to others not working for the agency The material in question is often

referred to as protected health information (PHI).

Agency Requirements

In order to comply with HIPAA, every agency must have the following:

1 A statement of the agency’s privacy and confi dentiality procedures, particularly

as it relates to releasing patient information This statement must be given to every client of the agency It is considered a notice clarifying how health infor-mation will be used and stipulating the client’s privacy rights This is a public document and can be posted in waiting rooms and on websites

2 A form that people sign and return to the agency indicating that they have received the statement on confi dentiality policies

3 A privacy officer who is familiar with HIPAA requirements and can oversee implementation within the agency and resolve privacy issues as they arise

4 A set of safeguards to protect client records

The privacy concerns addressed by HIPAA were raised because of the ing demand by insurance companies, employers, and others for detailed information

increas-on clients and patients, often in excess of what was necessary to process claims

Security and Privacy

Security in the act refers to procedures to protect health information from ate access by others These procedures usually include controls on who has physical access to the records, security of work areas and record storage areas, and destruction

inappropri-of duplicate or obsolete fi les Electronic security measures are also instituted, such as changing passwords and encryption

Privacy refers to the person’s right to keep specifi c information private and cludes the agency’s release of information policies and the rights of the individual in this matter