SOCW6520 Walden Week 2 Bright Futures Ahead Agency Placement Discussion Post response that includes: Agency Placement (Bright Futures Ahead) www.brightfutu

SOCW6520 Walden Week 2 Bright Futures Ahead Agency Placement Discussion Post response that includes: Agency Placement (Bright Futures Ahead) An explanation of potential challenges in adhering to confidentiality in your field education experienceA description of agency policies or mandates with regard to confidentiality (HIPAA rules and follow accreditation for CARF conformance with policies and procedures. Confidentiality pertains to consumers, Electronic Health information, also and is client centered and only specific personnel working with consumer has access to consumer files)An explanation of potential challenges in communicating with clients within your agency References Saxon, C., Jacinto, G. A., & Dziegielewski, S. F. (2006). Self-determination and confidentiality: The ambiguous nature of decision-making in social work practice. Journal of Human Behavior in the Social Environment, 13(4), 55–72. Wulff, D. P., St George, S. A., & Besthorn, F. H. (2011). Revisiting confidentiality: Observations from family therapy practice. Journal of Family Therapy, 33(2), 199–21 Journal of Human Behavior in the Social Environment
ISSN: 1091-1359 (Print) 1540-3556 (Online) Journal homepage:
Self-Determination and Confidentiality
Catherine Saxon MSW , George A. Jacinto LCSW & Sophia F. Dziegielewski
To cite this article: Catherine Saxon MSW , George A. Jacinto LCSW & Sophia F. Dziegielewski
PhD, LCSW (2006) Self-Determination and Confidentiality, Journal of Human Behavior in the Social
Environment, 13:4, 55-72
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Published online: 23 Sep 2008.
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Self-Determination and Confidentiality:
The Ambiguous Nature of Decision-Making
in Social Work Practice
Catherine Saxon
George A. Jacinto
Sophia F. Dziegielewski
ABSTRACT. This article seeks to further clarify the ambiguous nature
of two of social work’s most important values: self-determination and
confidentiality. Previous research indicates that many ethical decisions
in social work practice are difficult to make; and, many times decisions
are made based on the worker’s values and experiences rather than on
written ethics, laws, and agency policy. To explore this concept further,
an open-ended survey instrument was distributed to 82 social work students after completing the required practice classes. The participants
were asked whether they would break confidentiality based on a specific
vignette and describe what decision was made and why. Results indicated that degree level (MSW versus BSW) proved to be a significant
factor related to whether and/or why the respondent would break confidentiality. In addition, students with more paid work experience were
more likely to question the issue of confidentiality and were more likely
to break it. Two issues reflected in the decision-making process involved
ensuring client safety and self-determination. In conclusion, this article
Catherine Saxon, MSW, is affiliated with and George A. Jacinto, LCSW, is Instructor, School of Social Work, University of Central Florida, Orlando, FL. Sophia F.
Dziegielewski, PhD, LCSW, is Professor and Director, School of Social Work, University of Cincinnati, Cincinnati, OH.
Address correspondence to: Dr. Sophia F. Dziegielewski, PhD, LCSW, Professor
and Director, School of Social Work, 4130 One Edwards Center, P.O. Box 210108.
University of Cincinnati, Cincinnati, OH 45221-0108 (E-mail: Sophia.Dziegielewski@
Journal of Human Behavior in the Social Environment, Vol. 13(4) 2006
Available online at
© 2006 by The Haworth Press, Inc. All rights reserved.
explores possible reasons for breaching confidentiality and pitfalls that
can occur for all professionals in making these types of decisions. Furthermore, it explores the ambiguous nature of problem solving in this
area, and suggests ways that social workers can improve their decisionmaking skills. [Article copies available for a fee from The Haworth Document
Delivery Service: 1-800-HAWORTH. E-mail address: Website: © 2006 by The
Haworth Press, Inc. All rights reserved.]
KEYWORDS. Confidentiality and social work, self-determination,
ethics and social work practice, ethics and confidentiality
Many American’s highly value a person’s right to self-determination
and privacy. In fact, “every person has a right to determine for himself
[or herself] when, how, and to what extent he [or she] wants to share (or
have shared) information about himself [or herself] with others”
(Loewenberg & Dolgoff, 1996, p. 76). To maintain a client’s privacy or
confidentiality requires that information learned regarding the client
should not be openly disclosed (Loewenberg & Dolgoff, 1996; Loewenberg, Dolgoff, & Harrington, 2000). Overall, confidentiality can be
a complicated process, since, there are certain circumstances in which
breaching it is sanctioned by both state laws and professional standards.
For example, confidentiality may be breached with or without the client’s consent in order to report instances of neglect and abuse. Other circumstances include times when a client may be a danger to self or
others, or when other compelling reasons exist, such as imminent harm
to a client or if the law requires disclosure. Most professionals agree that
there are situations in which breach of confidentiality is certainly justifiable and expected (Dunlap & Strom-Gottfried, 1998; Gothard, 1995).
Yet, the principles that surround maintaining confidentiality are important for gaining client trust and support from the client (Edwards, 1999).
Therefore, the purpose of this article is to preview this complex issue
and to examine the variability that can surround making such ethical decisions.
Throughout the years, maintaining ethical practice (including confidentiality) has been at the forefront in the field of social work. So important, in fact, that in 1996 the National Association of Social Workers
(NASW) modified the existing version of the Code of Ethics. This was
the first substantial revision in almost 20 years and only the third time
Saxon, Jacinto, and Dziegielewski
the Social Work Code of Ethics had received major revisions throughout the history of NASW. These changes “significantly expanded ethical guidelines and standards for social work practice” (Reamer, 1998,
p. 492). The importance and complexity of privacy and confidentiality
is evident since no less than 18 separate paragraphs of the Code of Ethics are devoted to these issues (Dickson, 1998).
The 1996 NASW Code of Ethics provides lengthy standards with regard to privacy and confidentiality, clearly stating that social workers
should “respect clients’ right to privacy . . . and . . . should protect the
confidentiality of all information obtained in the course of professional
service, except for compelling professional reasons” (NASW Code of
Ethics, 1996, Standard 1-1.07, p. 10). A social worker should make every attempt possible to adhere to the rules of confidentiality promoting
self-determination, but should also be aware that there are some situations that should not be kept confidential (Kirst-Ashman & Hull, 1993).
In most cases where maintaining confidentiality is an issue, consideration is needed in order to determine what is “sufficiently compelling to
warrant a breach of confidentiality” (Kopels & Kogle, 1994, p. 2).
As with other decisions made in social work practice, ethical decisions are not usually simple, right or wrong choices made without a
great deal of thought. Instead, they generally involve choosing between
two undesirable actions and neither choice may appear to be the correct
one, yet some considerations will outweigh others. For example, decisions must be made if maintaining the client’s right to self-determination may actually cause him or her harm (Strom-Gottfried & Dunlap,
1999). In social work practice, ethical decisions often must be made
quickly but with sufficient thought and attention to assure the right decision is made (Levy, 1993; Loewenberg, Dolgoff, & Harrington,
2000). Furthermore, although helpful as a guideline, the NASW Code
of Ethics does not provide specific direction when professional values
clash (Reamer, 1995).
The declared purposes for the Code of Ethics are to espouse ethical
conduct and to control ethical violations by establishing guidelines of
professional behavior (Berliner, 1989; Reamer, 1995). “[The] . . . code
of ethics cannot resolve all ethical issues or disputes or capture the richness and complexity involved in striving to make responsible choices
within a moral community” (NASW Code of Ethics, 1996, p. 4). Instead, a code of ethics describes values, principles, and standards to
which social workers “aspire and by which their actions can be judged”
(NASW Code of Ethics, 1996, p. 4). Although there have been numerous books written regarding the importance of ensuring ethics and val-
ues, and specifically addressing the issue of self-determination and
client confidentiality, few evidence-based studies specifically address
this issue. The purpose of this study is to explore whether or not social
work students would break confidentiality based on a specific vignette
and their reasons why.
After an exhaustive search, it was discovered that two studies in the
area of confidentiality were found that addressed issues concerning ethical dilemmas that arise in the field of social work with both individuals
and groups. A study by Holland and Kilpatrick (1991), conducted in Atlanta and the surrounding area in 1989, attempted to identify “dimensions of ethical judgment” used by 27 social workers (p. 138). All of the
social workers held Masters degrees in social work and each had a varying amount of experience in the field. Most of the social workers were
female and all were directly involved with clients. Holland and Kilpatrick (1991) contend that in order to appropriately consider ethical dilemmas social workers should be aware of, and not discount, their own
as well as their client’s current circumstances. When ethical situations
arise these issues are never simple and interpretation often requires a
“thoughtful content analysis of the participants’ values and commitments” (Holland & Kilpatrick, 1991, p. 138).
The study focused on analyzing various ethical issues that social
workers are exposed to regularly in their duties. In addition to defining,
addressing, and resolving the issues, the participants’ background and
associations were analyzed, as well as any professional happenings that
might have impacted the respondent. An interview format was used to
explore how practicing social workers comprehend and handle ethical
issues and their responses were examined in an attempt to recognize
“common themes and differences regarding these issues” (Holland &
Kilpatrick, 1991, p. 139).
The results of this study identified three dimensions that seemed to be
fundamental to the ways that social workers managed ethical dilemmas.
First, decisions were often based on a continuum ranging from “an emphasis on means to an emphasis on ends” (Holland & Kilpatrick, 1991,
p. 139). Reasons given for decisions made ranged from acknowledging
laws and procedures to focusing on gaining positive outcomes for clients. In the second dimension, social workers made decisions based on
interpersonal orientations that ranged from emphasizing client auton-
Saxon, Jacinto, and Dziegielewski
omy and freedom to stressing the importance of mutuality. For example, many respondents emphasized client self-determination over client
safety, while others justified denial of client self-determination in order
to protect the client from hurting him or herself. In the third dimension,
authority for ethical decisions was explored. In this area, responses varied from “reliance on internal or individual judgment to compliance
with external rules, norms, or laws” (p. 140). Many respondents based
their decisions on personal self-direction rather than agency policy, and
other respondents were more likely to follow the policies and laws.
Holland and Kilpatrick (1991) concluded that decisions made regarding ethical issues are most likely affected by prior experience, degree of professional, developmental and situational factors that include
the immediate organizational or professional context, the characteristics of their work roles, and the overall organizational culture. In closing, the authors observed that of the 27 respondents participating in
their study, not one participant referenced the NASW Code of Ethics as
a resource in helping make an ethical decision (Holland & Kilpatrick,
In a second study, Dolgoff and Skolnik (1996) investigated how 147
social workers make ethical decisions in the group setting. A survey instrument was used which consisted of background information and
seven vignettes that all involved competing ethical issues. Each vignette
was followed by an open-ended question, allowing for an explanation
of the action needed to resolve the dilemma. The seven vignettes consisted of ethical dilemmas involving group self-determination, primary
responsibility to client, confidentiality, self-determination, informed
consent, and authenticity. Also included was a list of sources that the
participant would use to assist with the decision-making. The choices
included practice wisdom, Code of Ethics, another professional code,
particular philosopher or religious teaching, book or journal article, or
other sources.
These authors concluded that the primary method used by social
workers in the group setting for making ethical decisions was practice
wisdom, which was highly influenced by contextual elements and personal values. In addition, the majority of the respondents sought compromise solutions rather than a specific yes or no type of answer.
Similar to Holland and Kilpatrick (1991), Dolgoff and Skolnik (1996)
showed limited use of the NASW Code of Ethics to assist with making
ethical decisions and additional instruction on the Code was suggested
to better prepare students for ethical decision-making.
Although the two studies mentioned above do not specifically address confidentiality and self-determination, these previous studies do
address ethical dilemmas in social work practice and how decisions are
made. In the present study, social work students were asked whether or
not they would break confidentiality and how they viewed client selfdetermination when presented with a situation where it was believed
that a client was unable to meet his or her own needs and care for him or
Eighty social work students at a large Southeastern university were
presented with a case scenario. The students had varying levels of education ranging from at the BSW and MSW level, with all participants
reporting that they had taken at least one or more social work practice
class. Five (6%) of the students were first-year BSW students; 21 (26%)
were second year BSW students; 12 (15%) were first-year MSW students, and the majority were (n = 44 or 54%) second-year MSW students. In terms of gender, the majority (n = 64 or 78%) of the sample
were female, and the remainder of the respondents (n = 18 or 22%) were
male. Participant ages ranged from 20 to 59 years, with the majority 57
or 70 percent between 20 and 29 years of age; 12 or 15% of the respondents were between the ages of 30 and 39; eight or 10 percent were between 40 and 49 years of age, and five or six percent were 50 to 59 years
old. Only 77 of the 80 respondents answered the question regarding race
with the majority of the sample (n = 61 or 81%) being Caucasian, eight
(10%) were Hispanic, four (5%) being African-American, three (4%) as
Asian, one (1%) as Hispanic/Asian. Additionally, the number of years
of paid social work experience differed among the participants with 79
(of the 80 respondents) answering the question and the majority (n = 47
or 59%) having no paid social work experience. Three (4%) of the respondents reported less than one year of experience, and 29 (37%) had
more than one year.
Case Vignette
The survey instrument consisted of two parts: demographic information and the case presentation. Demographic information included the
Saxon, Jacinto, and Dziegielewski
participant’s gender, age, race, education level (years of social work education), and paid social work experience. The case vignette (see Table
1 for copy of vignette) was presented and each participant was asked to
read it. Based on the information contained in the vignette, the respondent was asked to answer with a “yes” or “no” as to whether or not he or
she would break confidentiality. It was made clear in the vignette that
the social worker was concerned that the client would be unable to meet
his own activities of daily living and refused the social worker’s attempts to arrange to get him help. An open-ended response section allowed the respondent to explain why he or she chose yes or no in
response to the vignette. To ensure face validity, the initial case vignette
was pilot tested with four social workers that were asked to complete
and offer suggestions for improvement. Minor changes were made
based on these suggestions. Suggested changes included: gathering information regarding the academic level of the social work student, the
number of years of paid social work experience, and more space for respondents to explain why they chose yes or no to the vignette.
One hundred copies of the vignette were made and distributed in the
Spring 2001 semester to 100 social work students who were required to
attend a school-sponsored job fair. Of the 100 surveys distributed, 80
TABLE 1. Vignette
Mr. P is a 78-year-old man who has just been discharged from the hospital. He lives in an
apartment by himself. His brother lives in his own apartment in the same building. You are a
hospice social worker. It is Friday at 3:30 p.m. and you are visiting with Mr. P to complete an
initial psychosocial assessment. During your assessment you conclude that it is not safe for
Mr. P to be by himself because he is unable to meet his own self-care needs. Since he appears very weak, it is difficult for him to get out of bed on his own and he has no caregiver.
You discuss your concerns with Mr. P. Mr. P appears alert and oriented to person, place, and
time, and strongly declines any assistance. He states that he is not agreeable to move to an
assisted living facility or nursing home. Even if Mr. P agreed to some type of outside assistance, it would be impossible to have services in place in the next two days. You suggest to
Mr. P that maybe his brother could check in with him over the weekend, but Mr. P insists that
he will be fine by himself, and requests that you not inform his brother. His sister, who lives
out of state, will not be available to help for several days. Would you break confidentiality and
ask his brother to check in on Mr. P over the weekend?
Please explain your answer.
were completed and returned, equating to a response rate of 80 percent.
Once the completed surveys were collected, the data were analyzed. For
the open-ended responses (qualitative responses), it was necessary to
convert the narrative responses to categorical data that could be analyzed further. Once coded, each narrative response was examined and
then categorized accordingly.
The vignette required that 80 entry-level social workers complete the
survey and answer with either a “yes” or “no” response. Of the 80 student social workers (55 MSWs and 25 BSWs), 37 students (or 46.3%)
stated that they would break confidentiality. The remaining 43 (53.7%) respondents stated that they would not break confidentiality (see Table 2).
This response was broken down further by education level, where the
results showed that 36 percent (n = 20) of the MSW students would not
break confidentiality while the remaining 64 percent (n = 35), however,
would do so. For the BSW students, the results showed that 32 percent
(n = 8) would not break confidentiality while 68 percent (n = 17) would.
The narrative section of the survey allowed the participants to state
why they would or would not break confidentiality. The responses were
TABLE 2. Results of the Vignette
Overall results of Vignette
N = 80
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