Setting Clear and Ethical Boundaries with Clients (Abbreviated 6) - 5 hrs

One area of therapy that tends to cause me a great deal of emotional struggle is that of empowering clients. I believe we often confuse our actions as empowering when in reality, we are enabling them.

“Fixing” Problems?
There is a distinct difference between “empowering” and “enabling.” In practice, empowering is the process of assisting the client to solve their own problem or issue through self action. The therapist provides an avenue or process that helps the client improve their life situation through full self participation.

Enabling is better described as the therapist improving the situation by appearing to “fix” the problem without true involvement of the client. Effective empowerment relies a great deal on appropriate and accurate assessment of the entire problem or issue. Enabling often results due to an inaccurate assessment which leads to the temporary “fixing” of a problem that was identified inappropriately. Often times, social workers “fix” problems the client never identified.

The following situations are common to mental health professionals. Read each scenario and think about your response as if you were the therapist.

A. Washing Machine: Enable or Empower?
A group of professionals have gathered at a case conference for a young boy who is receiving multiple services in a community. Participants in the meetings include: several special education staff persons, a mental health therapist, a mental health case manager, an elementary principal, two school psychologists, a social and rehabilitation social worker, and a school social worker.

The mother and step-father were invited but were not present at the meeting. The young boy was also absent from the meeting. The meeting was to focus on transitioning the young boy from a special needs school into a regular education setting.

Indentifying problems and issues. The meeting progressed quickly. Many of the participants began identifying “problems” and “issues.” Parent participation, medication, attendance, and hygiene were the major identified areas. The one issue that seemed to be a focus for several of the participants was the young boy’s hygiene. It seems he had come to school without bathing and his clothes were quite dirty. Someone noted that he wore the same clothes several days in a row.

Another added that the boy had told her, they were washing clothing in the bathtub. Before too long, the plan began to include buying a washing machine for the family. After discussion, someone directed a question to the social and rehabilitation social worker. The question went something like this, “Can’t SRS try to find a way to purchase a washing machine for them?” The worker’s response was one filled with frustration.

She pointed out that the family had already received assistance in paying the deposit for a house rental, monthly rent, had received financial aid in paying back energy bills, and finally that she didn’t think the washing machine was an option. She also pointed out that there was a laundromat a few miles away and that a relative had offered the family access to their washing machine.

Some in the group heard the worker’s response but others continued to argue the importance of a washing machine. “If it’s right there, they’ll be more likely to use it,” was a comment overheard several times in the discussion.

With continued disagreement, the meeting ended with no commitment to pursue the washing machine. Several left the meeting upset and believing the family was not receiving adequate service.

Boundaries Set by Values: In this first scenario, it was believed the washer would somehow change the boy and his family’s perspective on cleanliness. The reality is that the family did not value clean clothes or maintaining clean bodies. Plus, the family’s absence from the meeting truly stated the amount of investment the family had in the interventions. Their absence should have halted any decisions on intervention. Many services and interventions were provided, but it appears there is little to no investment from the family.

B. Transportation Dependency?
A second scenario describes another meeting in progress. Present at this meeting was a middle school principal, two middle school teachers, a school nurse, a school social worker, and a school psychologist. The issue at hand was the habitual tardiness and truancy of a 14-year-old female. Historically, the team had sent a social worker to the girl’s home to bring her to school. Some days, this process would occupy two to three hours of the social worker’s day.

Attendance during the past three semesters had not improved. This particular meeting had been scheduled to discuss attendance and the current intervention plan. In this meeting, the social worker stated she didn’t feel she should continue going to the student’s home and bringing her to school as the intervention was not effective. The group was not in favor of addressing the truancy issue through the legal system and verbalized that the social worker needed to continue picking up the student if her attendance was dependant upon this service. The social worker left the meeting with no new plan of intervention.

The Boundary of “Responsibility”: In this second example, the team failed to accept that the current plan of intervention was not resulting in success, and the team was unwilling to reassess the situation to create a new intervention. Unfortunately, the girl continued to miss school and rely on the social worker to pick her up and bring her to school. Neither the teenage girl, nor her parents, ever assumed responsibility for getting her to school. No improvement was noted.

C. Get a Job!
Another scenario involves a family of four that lives in a small community of about 500. Both parents live in the home but are not employed. There are two teenage boys ages 14 and 16. The family was referred as the boys were not attending school, and local law enforcement observed both boys out past curfew.

During an initial intake, income was addressed and the mother shared that the family survived off a social security disability check received for the youngest boy. He was diagnosed with ADHD and depression and had received disability moneys for three years. Historically, neither parent qualified for disability moneys. The mother had been diagnosed with depression but was not involved in treatment. Their house was inherited from a relative, and they paid no rent.

They were behind in taxes, owed the local convenience store several hundred dollars, and were being threatened by the power company to have their power shut off. The family did have a prepaid cellular phone and appeared to keep this service paid. The family also owned two working vehicles.

During an intake with the parents, the worker asked what changes the parents would like to see in the boys. The response focused on behavior and on the boys “getting a job” to help with expenses. The parents felt the boys were old enough to take on jobs, and the income would allow the boys to buy their own clothes and contribute some toward family expenses. A plan for improving school attendance and improving behavior was briefly addressed, but the worker said they would discuss these issues with the boys during a follow-up meeting.

Prior to the next meeting, the worker took the parents’ ideas and quickly began identifying job options for the boys. Prior to the follow-up meeting, the boys were provided job experiences. No explanation was provided for the boys, other than their parents had suggested they get a job. Within a few days, both had quit their jobs and negative behaviors had escalated. The boys were threatening their parents with physical violence and were not coming home at night. School attendance had decreased even more.

“Involvement” Boundaries: This next example focused on parents’ assessment of their children. The interventions put in place failed to involve the young boys in the planning phase. The result was a lack of empowerment for the boys to assume responsibility for their actions and personal changes. Their feelings were expressed clearly in a follow-up meeting.

They expressed frustration that the parents contributed no income and wondered why they, the boys, should pay for bills accrued by their parents. They also asked why the parents hadn’t been included in the goal of employment. The boys had responded to the situation by defying their parents with more extreme behaviors. The initial assessment did not include the appropriate people or an accurate account of the total perceived needs in the home.

D. “Willful Disobedience”
One last scenario involves a middle school boy who has struggled a great deal with attendance issues and also academic failure. He has only one identified friend, has been the target of peer harassment, has a history of legal involvement, and has few advocates in the school system. Several meetings had been held with the young man and his parents.

Meetings included teachers, the principal, the school nurse, the school social worker, probation officer, and the area social services social worker. The young man was offered new clothing, the opportunity to shower at school, the opportunity to participate in a peer advocacy program and many opportunities for after school tutoring. However, even with interventions throughout the year, the boy was suspended several times for various reasons. Finally, the young man was expelled from school for the final quarter due to an act of willful disobedience.

On this occasion, he refused to change his shirt that featured a marijuana leaf on it. The staff of the school deemed this shirt inappropriate, and a decision was made that he could not remain in school without changing the shirt. The young man appeared nonresponsive to the expulsion. A 14-year-old boy was out of school with no options for acquiring an education.

The Boundary of “Investment”: In the final example, an accurate assessment was never made to determine the boy’s investment in school and what might help him invest in school. An accurate assessment should have included a discussion about what the boy wanted to gain from school and what it would take to make school a better place. The team assumed all the interventions listed would help, but the boy never invested in any of them.

Summary and Conclusions
All four situations have one very important concept in common. All four lead to an intervention process that enables the client to continue in a situation without making any personal investment in change.

1. The service providers assume responsibility for fixing the problems, and the result is that the problems continue even after the interventions.

2. Accurate assessments never occurred.

3. The assessments were made without including the clients in the process of intervention or change.

4. Inaccurate assessments prohibit empowerment from occurring, and this leads to the enabling of clients by the service provider.

I continue to struggle in many situations as I attempt to make accurate assessments of needed interventions. Through my own mistakes, observations of my co-workers’ successes and failures, and through reevaluation of many cases, I make fewer mistakes now than I used to. It is still very hard to admit failure when you’ve spent many hours, many dollars, and devoted a great deal of emotional energy to a plan that was based on an inaccurate assessment.

Therapists who are new to practice have a great deal of energy and often fall easy prey to this whole phenomena of enabling. I would encourage any mental health professional, old or new, to ask the question and set a boundary, “Is the client I serve invested in this intervention enough to carry it through in my absence?”

If the answer is, ”No,” please proceed with caution. I would encourage the practitioner to reassess the situation and make sure the problem is accurately defined from the client’s perspective. It will improve the likelihood of success for the client as they will feel empowered, and the worker will not carry the load. Empowerment is perhaps one of the most powerful practicing concepts in being effective as a social worker. Good luck in assessing for opportunities to empower.

- Daniels, Jill L. (2005). Employed by Healthcare Training Institute to research and write the article Setting the Boundary between Empowerment and Enabling.
Bio - Jill Daniels, LSCSW, Salina, Kansas, Jill has experience in residential youth care, community mental health, special education, general public education, and a group worker in a wilderness treatment program.

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Personal Reflection Exercise Explanation
The Goal of this Home Study Course is to create a learning experience that enhances your clinical skills. We encourage you to discuss the Personal Reflection Journaling Activities, found at the end of each Section, with your colleagues. Thus, you are provided with an opportunity for a Group Discussion experience. Case Study examples might include: family background, socio-economic status, education, occupation, social/emotional issues, legal/financial issues, death/dying/health, home management, parenting, etc. as you deem appropriate. A Case Study is to be approximately 300 words in length. However, since the content of these “Personal Reflection” Journaling Exercises is intended for your future reference, they may contain confidential information and are to be applied as a “work in progress.” You will not be required to provide us with these Journaling Activities.

Personal Reflection Exercise #1
The preceding section contained information on setting boundaries between empowerment and enabling. Write three case study examples regarding how you might use the content of this section of the Manual in your practice.

NOTE: sentences and phrases are in bold type, in each Section of this Manual, for the purpose of highlighting key ideas for easy reference.

Update
Empowering Local Research Ethics Review
of Antibacterial Mass Administration Research

 Sewankambo, N. K., & Kutyabami, P. (2022). Empowering local research ethics review of antibacterial mass administration research. Infectious diseases of poverty, 11(1), 103.

Peer-Reviewed Journal Article References:
Roberge, V., & Boudrias, J.-S. (2021). The moderating role of employees’ psychological strain in the empowering leadership—Proactive performance relationship. International Journal of Stress Management, 28(3), 186–196.

Russinova, Z., Gidugu, V., Bloch, P., Restrepo-Toro, M., & Rogers, E. S. (2018). Empowering individuals with psychiatric disabilities to work: Results of a randomized trial. Psychiatric Rehabilitation Journal, 41(3), 196–207.

Wallis, H., Bamberg, S., Schulte, M., & Matthies, E. (2021). Empowering people to act for a better life for all: Psychology’s contributions to a social science for sustainability. European Psychologist, 26(3), 184–194.

Record the letter of the correct answer the Ethics CE Test.

QUESTION 9
How does enabling differ from empowering? To select and enter your answer go to Ethics CE Test.