Eye on Ethics

Boundary Challenges Outside of the Office — Home-Based Services
By Frederic G. Reamer, PhD
September 2018

Social workers receive extensive training on the subjects of boundaries and dual relationships. Typically, the training addresses issues that arise when social workers provide services to clients in office-based settings. Examples include responding to clients who ask questions about social workers' personal lives, invite social workers to important life events (such as weddings and graduation ceremonies), send social workers Facebook friend requests, and offer gifts to social workers.

But some challenging boundary issues arise outside of traditional office-based services, especially when social workers provide services in clients' homes. Home-based programs include hospice care, foster care, elder care, home health care, early intervention services for children, services to families that struggle with child behavior management, services for people with major mental illness who live in a group home, and probation supervision. Typical services include assessment, counseling, behavior therapy, case management, mentoring, crisis intervention, and consultation.

A principal advantage of home-based services is that social workers have the opportunity to observe clients in their "natural" environments. Many clients are more relaxed in their own spaces and, of course, home-based services are convenient for clients who then do not have to travel to social workers' offices.

Along with the many advantages of home-based services are a number of noteworthy challenges, mostly related to managing professional boundaries. Typical office-based services minimize the likelihood of boundary ambiguity and confusion. Visits are structured, do not take place in clients' personal spaces, and typically are provided in confidential settings (such as private offices).

In contrast, home-based services are often less formal and structured. Clients may feel in greater control because the services are provided on their "turf." Along with the advantages of home-based services come several boundary-related challenges. Despite social workers' best efforts, it may be difficult to protect sensitive and confidential information. Depending on the home's configuration, it may be difficult for social workers and clients to find truly private space in which to talk; the only quiet space may be in the client's bedroom, for instance.

Also, home-based services can be filled with distractions; other household members may come and go during the course of the visit and insert themselves in the conversation. A concerned neighbor may knock on the door during a visit or offer comments to a social worker who is entering or leaving the home.

A common challenge for social workers who meet with clients in their homes arises when clients invite social workers to join in a meal. Typical instances include social workers employed by home health-care agencies that serve older adults and programs that provide in-home services for foster families or high-risk families (for example, family preservation programs that provide intensive in-home services for families following allegations of child abuse or neglect).

It's not unusual for social workers to visit a home at mealtime and be invited to join the family at the kitchen or dining room table. In some cultures, sharing a meal—breaking bread—is a meaningful way to connect and a signal that the family is accepting the social worker. Members of some cultural and ethnic groups may be reluctant to trust a social worker who is unwilling to break bread with the family. A social worker who doesn't accept the family's invitation to join them for a meal—presumably because of concerns about maintaining boundaries—may risk insulting the family, even if inadvertently. This could jeopardize the social worker's rapport with the family and efforts to develop a strong therapeutic alliance.

Managing Complex Boundaries
I always advise social workers who provide home-based services to confer with colleagues and supervisors about how to manage these unique boundary challenges. Role-playing common scenarios as part of agency-based in-service training can be helpful. In one program that serves high-risk families, staffers agreed that visiting social workers could finesse situations where families invite them to join in a meal by saying diplomatically that they were not particularly hungry but would be happy to have a cup of tea or coffee, a gesture that tends to be culturally acceptable and that helps establish and preserve comfortable relationships with clients. If families are insistent despite social workers' efforts, practitioners may need to explain that their employer or their profession's ethical standards do not permit this kind of activity.

That said, in some contexts sharing a meal may be quite appropriate. In some programs where services are provided outside of an office, it would be very reasonable to eat meals with clients, especially when the activity is connected to treatment and intervention goals. Here are a couple of examples:

• A social worker worked in a group home for adolescents who do not have stable families. The social worker's clients gather routinely for meals in the group home's dining room. The program model includes having the social worker, who serves all of the group home's residents, join in meals occasionally to enhance relationships.

The social worker is careful to avoid engaging in treatment-related conversation or disclosing too much personal information during the meal. Her goal is to engage with the residents informally and to talk about "safe" issues (for example, current events, sports, popular music, television shows) that do not involve deeply personal, sensitive, or confidential matters.

• A social worker works in a community-based group home that serves adults with schizophrenia. One of the program's goals is for clients to learn a range of independent living skills, such as taking the public bus and eating in restaurants. As part of the service delivery model, the social worker occasionally takes a public bus with clients, they find a local restaurant, and eat together. The clients learn how to order food, pay the bill, and leave a tip.

The NASW Code of Ethics acknowledges the complexity of boundaries and dual relationships in social work. In fact, the code recognizes that some boundary issues may be unavoidable. The bottom line is that social workers are obligated to manage boundary challenges in a way that minimizes the likelihood of harm to clients: "Social workers should not engage in dual or multiple relationships with clients or former clients in which there is a risk of exploitation or potential harm to the client. In instances when dual or multiple relationships are unavoidable, social workers should take steps to protect clients and are responsible for setting clear, appropriate, and culturally sensitive boundaries. (Dual or multiple relationships occur when social workers relate to clients in more than one relationship, whether professional, social, or business. Dual or multiple relationships can occur simultaneously or consecutively.)" (standard 1.06[c])

One key way to minimize risk when social workers are flexible with boundaries is to ensure that the agency develops written policies and protocols that acknowledge the ways in which social workers can use versatile boundaries to meet clients' needs and reach program goals. Also, I recommend that social workers document events—such as visits to restaurants with clients who receive home-based services—so that they are transparent about the elastic boundaries and clearly acknowledge that they are consistent with the program's service-delivery model and clients' goals. This documentation can be enormously helpful in the unlikely event that an outside party raises questions (for example, if a member of the community happens to see a social worker out and about with a client).

Context matters with respect to managing boundaries. It's impossible to develop strict ethics protocols that social workers can follow in every service-delivery setting. One size doesn't fit all. Rather, social workers should be mindful of broad ethical standards related to boundaries, seek consultation, use their judgment, and document accordingly.

— Frederic G. Reamer, PhD, is a professor in the graduate program of the School of Social Work at Rhode Island College. He is the author of many books and articles, and his research has addressed mental health, health care, criminal justice, and professional ethics.