Client Self-determination Research Articles

Withstanding "Friendly Fire": A Frontline Reply to O'Hare

I feel the need to respond to Thomas O'Hare's article, Court-Ordered versus Voluntary Clients: Problem Differences and Readiness for Change (July 1996, pp. 417-422). is not his research that prompts my reply but the misleading statements about court-mandated clients and the pessimistic tone of his positions. O'Hare reported that court-ordered treatment undermine the effectiveness and morale of social workers, do little to improve the lot of the offender, and promise unachievable benefits to the general public (p. 418). He decried offender rehabilitation as an that does not deliver. He stopped short of making this a factual claim - a good thing, as it is seriously misleading and if taken as fact is erroneous. I felt a strong sense of deja vu when I read this statement; in 1974 Martinson sent shock waves through the criminal justice field by reporting offender rehabilitation was a failure with the now infamous line nothing works. Martinson (1979) later recanted, and Canadian researcher Gendreau (1996) listed scores of published literature reviews on offender treatment outcomes that attest to the success and potency of work with this population. All are readily accessible. As a practitioner who serves court-mandated clients, I experienced several of O'Hare's statements much like friendly fire that falls on frontline troops from an unwitting rear echelon. O'Hare spoke of the social work profession providing court-mandated interventions: We may be unintentionally participating in a system that at best provides a more humane diversion from punishment or at worst colludes with an oppressive social (p. 421). How sad and reductive it would be if field workers chose to accept this acrid view. To be fair, O'Hare's pessimism is a matter of course after he allowed the first premise that offender rehabilitation is a do-little enterprise. O'Hare attempts to throw stones at a field that has always had to wrestle with conflict. He does so by invoking the NASW Code of Ethics (NASW, 1993), which, he cited, enjoins practitioners to foster maximum self-determination (p. 421). Why does he single out one area when all practitioners face this issue regardless of the population they serve? Let us face a hard fact: Anyone who works in a change agent must take a position along a continuum of threat to client self-determination. Pincus and Minahan (1973) spoke of this threat: It is impossible to structure a change which is totally free of manipulation or imposition of values. . . . [The social worker] is confronted with a value dilemma that is built into the social worker's role (p. 43). O'Hare picks up stones where glass houses abound. Much can be found in how the author chose to excerpt the ethical principal of client self-determination. He may have been self-serving when he chose not to circumscribe the full text of the Code, which includes the words make every effort to foster maximum self-determination. A pity he chose to bypass the very words that assist field in allowing advancement in the face of treatment issues with court-mandated clients. This ethic calls for a professional with reflection and examination. does not call for perfection. He warned that social work risks participating in a muddled enterprise (p. 421), and I get a feeling O'Hare is attempting a call for expulsion, or practice cleansing, because my field lacks the clinical clarity (read purity) of work with more voluntary clients. …

Unjust Freedom: The Ethics of Client Self-Determination in Runaway Youth Shelters

Client self-determination has been called “the most confounding and professionally debilitating concept of all the intellectual principles under-girding social work” (Rothman, 1989). Identifying the appropriate parameters of client self-determination is a particularly acute problem for social workers employed by runaway and homeless youth shelters where minors are making adult decisions free from parental guidance. We examine the ethical dimensions of practice with minor clients in runaway shelters by arguing that a conflict exists between the liberty-based principle of self-determination and the justice-based notion of client competency. We analyze the conflict by using minimal distributive justice as the organizing principle of social work practice. We conclude that client self-determination in runaway shelters should be restricted and that presuming client competence violates the basic value tenets of the profession.

Correction

In the article “Client Self-Determination and Professional Intervention: Striking a Balance” by Jack Rothman et al. (July 1996, Vol. 41, No. 4, pp. 396–405), a coauthor's name was misspelled. The correct name is Mary Anne Patterson, not Paterson.

Client Self-Determination and Professional Intervention: Striking a Balance

Social workers find themselves caught in the cross fire between two imperatives: (1) outcome-oriented and competency-based practice requisites and (2) the principle of client self-determination. In this context, the authors hypothesize that social workers use a wide range of gradations along a continuum of practice directiveness. Furthermore, there is ethical justification for this diverse role repertoire. Directiveness modalities are influenced by specific conditional factors that guide practitioner behavior. A study is described that empirically explores and amplifies these hypotheses.

Social Work and End-of-Life Decisions: Self-Determination and the Common Good

Client self-determination is the key element of NASW's policy statement about social work intervention in end-of-life decisions. However, both self-determination and the common good must be respected in social work practice and policy regarding end-of-life decisions. This article discusses self-determination in end-of-life decision making, ethical decision making and the NASW Code of Ethics, and professional ethics based on a balanced view of both self-determination and the common good. Recommendations for professional practice and social policy are offered.

Use of involuntary outpatient commitment in community care of the seriously and persistently mentally ill patient.

Involuntary outpatient commitment (IOC) in some form has been adopted by all states as an alternative to hospital commitment. Regulations for IOC vary among the states. Although some studies have shown that IOC reduces hospital admission rates, research findings have not clearly determined the effectiveness of IOC or the type of concurrent care measures indicated. The limited community care available for IOC patients, the legalities, and the ethical issues surrounding the restriction of a client's autonomy and self-determination are rarely addressed. Nurses need to be prepared to advocate for patients who may be at risk for violation of their basic rights. More research is needed to validate the effectiveness of IOC and to determine when IOC is justified to support an individualized treatment program.

Searching for Solutions to Alcohol and Other Drug Abuse during Pregnancy: Ethics, Values, and Constitutional Principles

Recent efforts to develop legal mechanisms to detect prenatal substance abuse and force pregnant women into drug-free conditions have precipitated ethical struggles for social workers. This article reviews relevant social work values and ethical issues, particularly the need to balance obligations to promote client self-determination, privacy, and access to chosen services with professional values that support coercive intervention to aid vulnerable people and to protect life. The constitutional principles that most affect coercive interventions--due process and equal protection--are reviewed. Recommendations are offered to guide ethical and legal social work for case interventions and policy development.

Patient Rights and Dying

Every year 2 million people in America--80 percent of them in hospitals, hospices, or nursing homes. Two-thirds of these deaths result from chronic illnesses such as cancer or heart disease, and approximately 70 percent occur only after decision is made to forgo life-sustaining treatment. Social workers face no greater humanitarian challenge than assisting these individuals, their loved ones, and their healers in making decisions about dying. to die has emerged amid an almost unprecedented array of obstacles. Because the doctor-patient relationship is inherently unequal, the construction of policy and regulations affect each quite differently. application of rights is complicated by ethical questions, the shared nature of family decision making, the lack of clarity regarding who is responsible, and the decision of whether (or when) to withhold or take more active role in ending life. Dying has been policy arena driven by technological advances; by competitive business advantages for providers and producers of medical products; by commitments underwritten by significant public expenditures; and by questions about the competency of the patient, the extent of the medical condition, and the types of or assistance sought. Policy outcomes at any given time are the product of struggle, a mediated resultant that emerges when the forces of activism overwhelm the forces of restraint, forcing mediators to act (Hoefler with Kamoie, 1994, p. xiii). Similar to other polycentric, controversial issues of the past 50 years, the courts have been the leaders on the right to die, whereas legislatures have done their best to avoid it. Although the focal point of attention is family circumstances, range of social, cultural, political, religious, medical, and scientific forces has mediated the policy-making process. These forces have mostly kept death off the policy agenda, while constraining and shaping its eventual emergence (Hoefler with Kamoie, 1994). In the United States, policies regarding the right to and how one chooses to are largely ceded to the states, but policy innovations are diffused among the state courts and legislatures in an often unpredictable fashion. Although the Supreme Court has set few parameters, state courts have taken the most initiatives by interpreting individual cases, and state legislatures have responded by clarifying intention even more definitively and reluctantly. Policy implementation by administrative bodies, including the management of public health care expenditures, muddies the picture further, whereas social activism occasionally creates sufficient momentum to overcome some of these restraining factors. results are disjointed, divergent right-to-die policies from one jurisdiction to another. NASW Code of Ethics (National Association of Social Workers, 1994) places significant value on the principle of client self-determination. Legal frameworks for the protection of the patient's right to make health care decisions, including the right to refuse treatment, are generally found in the philosophical principle of patient autonomy. Constitutionally, this guarantee is derived from the right to privacy and the right to due process under the Fourteenth Amendment, right originally established in 1914 in ruling by Judge Benjamin Cardozo that every competent adult has the right to determine what should or should not happen to his or her body (Sloan, 1988). Years later, this right to self-determination in medical was extended to the right to refuse in the case of Nancy Cruzan. A 25-year-old Missouri woman when she was injured in car accident in 1983, Ms. Cruzan remained comatose, fed by feeding tube, for eight years while her parents repeatedly requested that it be removed on the grounds that she would not have wished to have her life prolonged in this way. In concurring opinion in the Cruzan case, Justice Sandra Day O'Connor wrote, The liberty guaranteed by the Due Process Clause must protect, if it protects anything, an individual's deeply personal decision to reject medical treatment (Gisleson, 1991, p. …

The ethics of assisted suicide.

The ethics of assisted suicide and the wisdom of changing public policy to support assisted suicide are considered from the perspective of the social work profession. The traditional social work value of client self-determination is reviewed and discussed, and tensions in this ideal and conflicts with another primary social work value--client well-being--are identified. The primacy of the client's well-being sometimes, in the professional judgment of the social worker, overrides a client's stated wish. This article finds assisted suicide unethical: Studies indicate that the judgment of most suicidal people is impaired as a result of depression or other mental illness. Truly "rational suicide" may exist but is probably quite rare compared to the overwhelming majority of suicides. In addition, assisted suicide may lead to increased rates of suicide in the general population, especially among young people, because of the contagion phenomenon and the destigmatization of suicide.

Consumer-Centered Social Work Practice: Restoring Client Self-determination

One of the highest traditional social work values is the maximization of client self-determination. In actual practice it is a difficult ethic to uphold, especially in this time of budget cuts and overwhelming caseloads. This article examines an orientation toward practice that places consumers at the center of decision making and control. The author examines current trends in the consumer movement, including advances among the aging, disabled, and mental health client populations. A comparison of medical-rehabilitation and independent living paradigms is presented to demonstrate fundamental philosophical differences. The author introduces suggestions to enhance participation by consumers for direct service workers, administrators and supervisors, and social work educators.

Contradictions in case management: client-centered theory and directive practice with frail elderly.

New long-term care legislation and managed care legitimate case management for gatekeeping and advocacy for frail elderly. Qualitative in-depth interviews with case managers who are social workers and nurses were used to address the question: To what extent is client-centered theory reflected in case management practice? Differences between reported client-centered theory and directive practice were identified by five themes: (a) client wishes versus system constraints; (b) the paradox of working to keep clients home versus the perceived inevitability of nursing home placement; (c) client centeredness versus the case manager's care plan; (d) client self-determination versus strategies of persuasion; (e) informing the client about case management versus the reality of practice. Ethical implications, competing demands, and environmental constraints are discussed. Suggestions are made to better integrate client-centered theory with directive practice.

The Professional Is Political

I understood from teachers in those segregated schools that work of any teacher committed to full self realization of students was necessarily and fundamentally radical, that ideas were not neutral, that to teach in a way that liberates, that expands consciousness, that awakens, is to challenge domination at its very core. bell hooks, 1989, p. 50 For almost two decades, has been enthusiastically embraced as a highly valued goal of social work practice. Sparked by publication of Barbara Solomon's (1976) Black Empowerment: Work in Oppressed Communities, empowerment became primary stated objective in practice with disadvantaged and oppressed groups. social work literature was replete with articles extolling of clients through social work practice. In fact, has been assumed to be a part of most practice. As we have embraced this ideal, it may be that we have not really examined dilemmas that emerge and choices to be made when a profession adopts as a mission. It may be that exists more in our professional discourse than in actual practice. There are many forces--institutional, economic, political, ideological, and historical--that continue to be obstacles to achievement of a truly empowering practice. dilemmas implicit in a profession's commitment to client are not new. These dilemmas have challenged profession, although perhaps in different words, since we attempted to separate ourselves from our early beginnings rooted in moral superiority, noblesse oblige, and social control. profession attempted that separation by adopting value of client self-determination, precursor to empowerment. Self-determination was defined as clients' right to make their own choices, to define their own destiny. But for many, self-determination was a hollow promise sharply limited by lack of access to resources, to opportunity, to power. Self-determination, colored by American individualism, was too often simply right to be left alone. Social workers' ability to put principle of self-determination into practice ... is affected and determined by level of exploitation, oppression, and lack of available opportunities that clients confront (Freedberg, 1989, p. 34). These limitations challenged social workers to turn to social action, to advocacy, and eventually to client so that inequalities could be addressed, opportunities made available, and client self-determination realized. language of has added new dimensions to self-determination. It envisions a more vigorous, more active stance. It implies that people have not only right to self-determination, but also right to power, ability, and authority to achieve self-determination. The ability to act in behalf of oneself is a function of factors such as critical consciousness, sense of entitlement, knowledge, resources, competency, skills, and self respect (Staples, 1990, p. 33). In discourse on empowerment, we have primarily focused on oppression, marginalization, deprivation, and disempowerment of clients by large social forces, by society, by the system. We have rarely examined power dynamics as they exist in worker-client relationship (Pinderhughes, 1989). We have been less ready to own that we, as professionals, are part of the system and to examine implications of our position of power. We have been reluctant to speculate that perhaps if our clients are to truly become empowered, we must learn to shed some power (Hoffman, 1985). Sources of Power Perhaps average social worker, constrained by resource limitations, policies, time, knowledge, and skill deficits, does not experience herself or himself as powerful, but in worker-client relationship, in our accustomed models of professional practice, power belongs to us. …

Classification and Correlates of Ethical Dilemmas in Hospital Social Work

The authors used categories based on the NASW Code of Ethics to code hospital social workers' descriptions of ethical dilemmas according to the specific principles in conflict. They also developed codes to identify discharge destination and medical care issues involved in the ethical dilemma. Most ethical dilemmas were found to involve conflicts between client self-determination and client best interest. Ethical dilemmas were more likely when patient mental status was impaired and when decision making was problematic. Ethical dilemmas were related to delayed discharge, in-hospital mortality, and less-than-adequate postdischarge care. The study enhances understanding of ethical dilemmas and advances a methodology for studying their occurrence and consequences.

A model of advocacy for promoting client self-determination in psychosocial rehabilitation.

A model of advocacy for promoting client self-determination in psychosocial rehabilitation.

Client Self-Determination: Untangling the Knot

Client self-determination may be the most confounding concept in the intellectual underpinnings of social work. While self-determination is accorded utmost esteem in the profession, its meaning and application are clouded. A number of existing justifications for self-determination concepts are outlined. However, serious questions have been raised concerning the primacy and efficacy of the self-determination principle from a number of sources. This critique covers four general areas: limitations in client capacity to make choices, external restraints that inhibit choice, other values that may have primacy, and other professional considerations that influence practice behavior. An alternative conceptual perspective is proposed.

Social Work Practice with Homeless Mentally III People: Engaging the Client

The engagement phase in practice with homeless mentally ill clients is central to work with this vulnerable population. In this article, the author develops an empowerment-oriented approach to the tasks of engagement. Specific engagement strategies include making a clear offer of service and providing voluntary services that meet clients' perceived needs. The author's thesis that homeless mentally ill individuals can be helped most effectively if their control over the helping process is maximized suggests practice strategies that encourage clients to participate fully in identifying needs, determining goals, and setting the terms of the helping process. Involving clients in program planning further promotes client self-determination and autonomy. Recent studies of programs for homeless mentally ill people suggest that empowerment-oriented approaches have been highly effective in engaging clients in the service relationship.

Facing Reduced Decision-Making Capacity in Health Care: Methods for Maintaining Client Self-Determination

Facing Reduced Decision-Making Capacity in Health Care: Methods for Maintaining Client Self-Determination

Ethical Issues in Occupational Social Work:

Social work practice in work settings, particularly employee assistance programs has experienced substantial growth over the past decade. With this growth comes a number of practice issues related to the professional conduct of social workers in work based social programs and the impact these programs have on public social services. Other relevant issues are client self-determination and degree of confidentiality. This paper clarifies these issues and also identifies potential policy and economic implications for social work practitioners and the profession.

Psychotherapy and the clinical social worker.

Social work's long and historical involvement in psychotherapy has resulted in many significant contributions to practice such as the use of time, family and group therapy, the development of innovative settings and practices, and skill in using action communication. In addition, social workers have developed expertise in working with many that others have considered unsuitable for psychotherapy. Differences between psychiatric social work and the present more commonly used term, clinical social work, are related to issues of identity and autonomy, and essential practices and values that differentiate the clinical social worker from other professionals. These are a preference for the term client rather than patient, an emphasis upon person-in-situation, and a valued belief in client self-determination. However, special educational preparation is needed for the practice of psychotherapy which is considered a specialty within social work.

Professional maturity or independence?

This paper discusses the thesis that nurse-midwifery will grow and flourish in a climate of economic constraint and competition if every nurse-midwife assumes both the responsibilities and privileges of professional maturity. This maturity is based on the concept of interdependence in relationships with clients, physicians, and nurses, and other nurse-midwives. These relationships are also built upon mutual respect and trust. Concerns for client self-determination at the expense of safety, paternalism/matemalism at the expense of client autonomy, expansion of midwifery practice into medicine, and the extension of professional limits of practice beyond one's level of competence are discussed. The final goal of healthier mothers and babies with access to care for all women requires nurse-midwifery care in cooperation with other health professionals. No one professional group can meet this goal alone.