It turns out though – that even though we are assisting people in finding their way – their choices and their desired outcomes aren’t up to us.  One of the main tenets of social work is self – determination.

The National Association of Social Workers states self-determination is an ethical principle of professional practice.

 “Social workers respect and promote the right of clients to self-determination and assist clients in their efforts to identify and clarify their goals. Social workers may limit clients’ right to self-determination when, in the social workers’ professional judgment, clients’ actions or potential actions pose a serious, foreseeable, and imminent risk to themselves or others.”

It is imperative that a social worker is aware of their own value system and beliefs so they aren’t subconsciously or subtly moving the client to the clinician’s goals.  You want to act for your client’s best interest but who decides what that is?

Maybe you are a social worker providing case management to an individual in the community who is struggling with medical needs.  The client is diagnosed with diabetes and has dangerously high blood sugars because he isn’t interested in following the diet.  If he continues to disregard the diet it is possible his kidneys could fail and he will have to go on dialysis or he may lose a limb.  As the social worker you may be thinking the choice to follow the diet is obvious but the client doesn’t agree.  What could you do?  You would discuss with him the consequences of not following the prescribed diet and explore the barriers and his feelings.  However, if the client still says “I get it, I am not going to follow the diet.  It is just not important to me” then that is OK.  The social worker doesn’t get to say – let’s throw out all the unhealthy food or I’m not going to help you get assistance if you don’t follow the diet.  His choice may not be the same choice you or I might make but it is still his choice.

Clients often make life choices we wouldn’t choose for ourselves.  Sometimes people prefer to be homeless rather than live in an apartment.  Sometimes people will choose to cheat on their spouse.  Sometime people will stay in a job that seems to be completely unhealthy.  Someone could choose to not take psychotropic medication and still function in the community.   A client’s religious or other cultural values might feel abhorrent to you but it is not on the social worker to change them but to meet the client where they are at and let them live their own destiny.  It can be frustrating for a social worker because you want so much for your client’s to be successful.  Each of the clients we work with know themselves better than we know them.

I had a client once who left a destructive and abusive marriage and really struggled with self-confidence.  Almost immediately after the separation the client came in and said she met someone on an internet dating site.  She went on to share all these reservations she had regarding the man.  Within 2 months she was engaged to him.    In my head – I’m thinking “this seems like a really bad idea.”  She ended up being engaged for about a year and then married this man.  Now, they have been married about 4 years and this relationship seems to be the most stable and affirming that the client has ever been in.  I definitely wanted what I believed was in best for this client but if I had pushed her to what I thought was going to be better for her – I would have been wrong.  She knew herself better than I knew her.

Of course there are times when safety and well-being take precedence over self-determination.  A social worker will use their professional judgement to make that decision.  There are obvious situations such as when a client is suicidal with a plan or planning to cause destructive harm to another where the decision to act against the client’s choice is relatively.   However, deciding to limit a person’s self-determination is often not clear cut at all.

How can you make sure you are encouraging client self-determination?

• Start by asking the clients what they want for themselves? Ask those open-ended questions and see where it goes.
• Help them clarify their goals and set concrete hopes. Make sure they are the client’s goals – not what you think they should work on.
• Be cautious of having an agenda. There might be things you want to cover in a session but the client should determine where the conversation goes.
• Ask yourself – Is this what the client wants or is it me who thinks this is a good idea?
• Is what the client plans to do put them or someone else at imminent risk for harm.
• Consult with other social workers to get different perspectives.
• Remind yourself that your client’s reactions and their situation is not about you.
• Ask yourself – Is there a really good reason I am taking away this person’s right of choice?

As a social worker, self-determination is a value I have a huge affinity for. I have found there are times when I am in a room full of professionals and everyone is stating what they think will be best for the client regardless of what the client is saying they actually want.  As a social worker, I am sometimes the lone voice advocating for the individual’s choice.

Perhaps one of the reasons I became a social worker is that I want to choose my own path and I believe that each person should be able to choose theirs and this career gives me a way to fight for people.

What are ethics?  What does it mean to be ethical?   Ethics are different than the law.

The law is about what is legal.  For example, everyone talks about the Health Insurance Portability and Accountability Act (HIPPA.)  This is a law.  Choosing not to follow this or other laws could lead to criminal charges, convictions, prison and/or monetary fines and other penalties.

Ethics are about the “should.”  Ethics are what choice a person “ought” to make.   There are not necessarily legal ramifications for not being ethical (although there could be professional or moral consequences.)  Ethics are where a person asks- “What is the best decision in this situation.”  Unfortunately, when you are working with complex clients the best choice isn’t always obvious.  Many times a professional will have to choose between several not so ideal choices and decide which choice is least harmful.

As a social worker your ethical quandaries will be many.  One of my jobs is assisting individuals transitioning out of a nursing home into the community.  An ethical dilemma I might have is deciding where the line is between the individual’s right of self-determination to decide their own life and decisions that are adversely affecting their safety. If a person wants to live in the community and I don’t think they are going to be successful I would have to scrutinize if they are able to cognitively understand the ramifications of moving to the community or if they are not able to reasonably make a decision.

Another ethical dilemma might be when working with a teen in private practice.  Maybe the youth discloses their use of illicit drugs.  In my state, youth over 12 have the right to confidentiality in therapy – even from their parents – unless very specific circumstances are present.   My ethical question might be figuring out when the youth’s drug use is covered under confidentiality and when it becomes a situation where I need to break confidentiality.  Ethical dilemmas come in all shapes and sizes.  A dilemma may be wondering if you should accept food from a client or if it is OK to do a session at the coffee shop just this one time because the client’s car broke down and they can walk there.  Every day in the social work field you will have to use your judgment to make ethical decisions.

Some ideas to help with making ethical decisions.

• Training – Take continuing education classes and seminars. Learn about the populations you work with.  Learn about the presenting problems and learn about quality interventions.  A professor once mentioned in my classes that there will always be more to learn about people.  There is no way to no everything there is to know about people.  A social worker’s practice is people.  Don’t stop learning.
• Supervision – Especially for newer therapists having a supervisor provide feedback on your cases can be beneficial. Consider supervision from a more experienced Practioner whenever you start a new specialty or undertake a new field.
• Consultation – Talk to other therapists and receive feedback about your interventions. Every month I meet with a group of therapists to discuss the cases with which we struggle.  This is so invaluable.  Another therapist can provide just the added insight to give a better perspective.
• Be open to feed back. I know a therapist who doesn’t really consult.  She sometimes asks other therapists for their opinions on a case but she isn’t really looking for honest feedback.  She is looking for validation in her choices.   Having someone just agree with all your choices is not going to ensure you are practicing ethically.
• Keep adequate records of interventions.  The member deserves an appropriate health record.  It also ensures that you have a place where your reasoning and decisions are noted.
• Join a professional organization. If you are a social worker one option is that you can join the National Association of Social Workers.  In almost every specialty there is a professional association providing support.  These professional organizations can assist you with keeping up to date with best practice and standards for your chosen area.

In your day to day work it may be beneficial to identify the different ethical dilemmas that pop up and examine how you made your choices.  If you have other ideas on ways to maintain an ethical practice please share!