Clinical Social Work Journal

https://doi.org/10.1007/s10615-022-00859-7

ORIGINAL PAPER

When the Client is a Struggling Clinical Social Worker: Ethical

Challenges
Frederic G. Reamer1 

Accepted: 19 November 2022

© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2022

Abstract
Some clinical social workers encounter personal struggles and seek counseling services from other clinical social workers.
These complex clinical relationships sometimes produce challenging ethical issues, particularly when treating social workers
are concerned that their clients, who are also professional colleagues, may be impaired or have engaged in ethical misconduct.
This article identifies challenging ethical issues and dilemmas that can arise when clinical social workers treat clinical
social workers; reviews pertinent ethical standards; and discusses practical risk management protocols designed to protect
clients, treatment providers, and employers. The author focuses especially on ethical issues related to consent-to-treatment
agreements; release of information; confidentiality and its exceptions; management of social worker impairment; practitioner
self-care; documentation; and boundary issues.

Keywords  Confidentiality · Documentation · Ethics · Impairment · Informed consent

Some clinical social workers encounter personal struggles
and seek counseling services from other clinical social
workers. Clinical social workers are not immune to the range
of challenges that people generally face in life, including
depression, anxiety, family and relationship conflict, trauma,
career and workplace issues, and substance use disorders and
other addictions, among others. Clinical social workers who
seek counseling services sometimes prefer to obtain them
from other clinical social workers because they appreciate
social workers’ unique professional training, perspective,
values, and approach to helping.
Unfortunately, there are no published estimates of the
percentage of clinical social workers who seek therapy.
Further, there are few reliable estimates of the percentage
of social workers who manifest significant symptoms
of impairment and burnout that lead to licensing board
complaints and sanctions (Magiste, 2020). The best available
data indicate that among the most common violations
addressed by licensing boards are those that concern
boundary and dual relationship issues and evidence of
practice falling below expected standards of care (Barsky
* Frederic G. Reamer
freamer@ric.edu
1
School of Social Work, Rhode Island College, Providence,
RI, USA
et  al., 2021; Boland-Prom, 2009; Boland-Prom et  al.,
2015; Magiste, 2020; Reamer, 2015). In a compelling
study of 6112 licensed social workers in thirteen states,
Straussner et al. (2018) found that over 40% of practitioners
reported experiencing mental health problems before their
social work careers, and almost 52% indicated that they
experienced mental health problems over the course of their
social work careers, with 28% currently experiencing such
problems.
Prominent social work codes of ethics require
practitioners to seek assistance to address personal struggles.
Both the NASW Code of Ethics (2021a, standards 4.05[a],
4.05[b]) and the Clinical Social Work Association Code of
Ethics (2016, standard II.4.e) state that social workers should
not allow their own personal problems or psychosocial
distress to interfere with their ability to practice and should
seek assistance when warranted. These ethics standards
implore these social workers to make necessary adjustments
in their workload, seek consultation and supervision, or
terminate practice, depending on the nature and severity of
the impairment.
Clinical social work services provided to a social
work colleague can be fraught with ethical challenges,
especially related to consent-to-treatment agreements;
release of information; confidentiality and its exceptions;
documentation; boundary issues; and management of social

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worker impairment. These challenges can arise with any
client who is a professional and responsible for the well-
being of others, such as a nurse, physician, dentist, airline
pilot, or bus driver. However, unique ethical challenges arise
when the clinical social worker treats a colleague because
of tailored language in social work ethics standards and
regulatory laws concerning social workers’ special duties
when they have concerns about other social workers. The
purpose of this article is to explore the nature of social
worker impairment, ethical challenges that can arise when
a clinical social worker treats a colleague, and relevant best
practices.
The Nature of Impairment
Clinical social work can be very stressful. On a daily basis
practitioners encounter people whose lives have been
challenged by emotional pain, trauma, loss, addiction,
poor health, poverty, and other life challenges. Many
clinical social workers manage to sustain their dedication
and professionalism. Others, however, find that the steady
stream of work-related stressors and, possibly, personal
stressors, leads to some form of impairment and seriously
compromises the quality of their work. In some instances,
clinical social workers who struggle with impairment issues
seek services from a clinical social work colleague.
In their seminal work on the subject, Lamb and
colleagues (1987) have provided a comprehensive definition
of impairment and incompetence among behavioral health
professionals: “Interference in professional functioning
that is reflected in one or more of the following ways: (a)
an inability and/or unwillingness to acquire and integrate
professional standards into one’s repertoire of professional
behavior; (b) an inability to acquire professional skills
in order to reach an acceptable level of competency; and
(c) an inability to control personal stress, psychological
dysfunction, and/or excessive emotional reactions that
interfere with professional functioning” (p. 598).
Data indicate that impairment among clinical social
workers can result from relentless stress, mental illness
(such as depression, anxiety, bipolar disorder, and
personality disorders), substance use, and other addictions
(Coombs, 2000; Reamer, 2015; Straussner et al., 2018; Zur,
2017). Work-related stress can result from pressures and
frustrations associated with efforts to help overwhelmed
clients, especially when resources are not sufficient. Some
clients do not make the kind of progress clinical social
workers prefer; others engage in behaviors that practitioners
find challenging.
In addition to stress that is directly related to their work,
clinical social workers are also affected by their own illness
or death of family members, marital and relationship
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Clinical Social Work Journal
challenges, financial problems, midlife crises, physical
illness, legal problems, and addiction (Barsky et  al.,
2021; Reamer, 2015). With respect to psychotherapists
in particular, Wood et al. (1985) noted that professionals
encounter special problems from the extension of their
therapeutic role into the nonwork aspects of their lives
(such as relationships with friends and family members),
the absence of reciprocity in relationships with clients
(therapists are “always giving”), the frequently slow and
erratic nature of the therapeutic process, and personal issues
that are raised as a result of their work with clients.
In their classic and insightful discussion, Lamb et al.
(1987) argue that professional education itself can produce
unique forms of stress and impairment, primarily as a result
of the close supervision to which students are typically
subjected, the disruption in their personal lives that is often
caused by the demands of schoolwork and internships, and
the pressures placed on them by their academic programs.
These authors found that the most common sources of
impairment are personality disorders, depression and other
emotional problems, marital problems, and physical illness.
Research suggests that employment-related burnout can
also lead to impairment. Burnout in the human services has
been addressed explicitly since the 1970s (Maslach & Leiter,
2017). Typical symptoms include insomnia, exhaustion,
headaches, apathy, irritability, and depression (Kerulis,
2013). Research on burnout has identified three common
features: emotional exhaustion, depersonalization, and
feeling ineffective (Thompson et al., 2014).
Not surprisingly, burnout has been linked to many
negative outcomes that may come to the attention of
clinical social workers who counsel clinical social workers.
Outcomes may be personal, social, and organizational in
nature. In clinical social work, burnout may lead to poor
quality of services delivered to clients. When clinical social
workers are experiencing high levels of burnout, the clients
they serve may receive substandard care. The clinicians
may not return clients’ telephone calls in a timely fashion,
complete required paperwork carefully and thoroughly,
arrange needed services, or be active participants when
meeting with clients.
Case Examples
Many of the clinical relationships between a treating clinical
social worker (hereafter “clinician”) and a clinical social
worker client (hereafter “client”) proceed much the way any
therapeutic relationship would evolve. Clinicians conduct
comprehensive assessments, identify treatment goals, and
develop treatment plans. However, in some instances the
clinician encounters challenging ethical issues and dilemmas
because of the unique relationship between the clinician
Clinical Social Work Journal
and the client, who happens to be a member of the treating
clinical social worker’s profession.
Here are real-life examples drawn from the author’s
ethics consultations:
• A clinical social worker in independent (private)
practice was contacted by another clinical social
worker who is in recovery from addiction to alcohol.
The clinical social worker who sought services was
employed as a counselor at a local mental health center
providing services to people who have serious and
persistent mental illness. This client explained that she
was going through “a very difficult divorce and child
custody battle” and felt the need for emotional support
and some guidance. Prior to this clinical relationship,
the two social workers did not know or work with each
other.
• During the intake interview, the client disclosed her
recovery status and past struggles with alcohol. The
client explained that her “very positive” experience with
social workers when she received substance use disorders
treatment years earlier led her to switch careers and
attend social work school for her MSW degree.
• During their fifth counseling session, the client shared
that she was feeling clinically depressed and had
relapsed on alcohol. The clinician, who was also a
licensed substance use disorders counselor, conducted
a comprehensive assessment using the Drug Abuse
Screening Test (DAST) and was concerned about the
clinically significant score on this instrument. In addition
to addressing the clinical concerns, the clinician had to
decide how to handle her concerns about the possible
risk the client posed to her work-based clients, including
whether to report this concern to the state social work
licensing board.
• A clinical social worker who worked in a group private
practice was contacted by a local clinical social worker
who sought counseling for, as the potential client
described it during the initial telephone conversation, “a
very sensitive and troubling personal and professional
issue.” During their first session, the client began to
cry and told the clinician that she worries that she is in
“deep trouble.” The client explained that she had become
sexually involved with one of her clients, a man who
recently divorced and who sought counseling to cope
with his loss. The client expressed deep remorse and
shared her concern that this lapse in judgment could end
her career. The client told the clinician that she was eager
to explore the clinical dimensions of her poor judgment.
The client asked the clinician for reassurance that she
would not report the client to the state licensing board.
• A clinical social worker was contacted by a former
classmate from his MSW program. They were in school
together 12 years earlier. For years, the former classmate
has been working as a clinician in two community
mental health centers, serving primarily clients with
co-occurring issues. When she called, the former
classmate explained that she has begun to question
whether to continue working as a clinician and wanted to
schedule “a number of sessions” to explore the relevant
issues and options. The former classmate said, “For the
past year or so, I have been feeling completely drained,
empty, and spent. I used to feel so excited about going
to work; now it feels like a chore. I’m not sure I’m doing
my clients any favors, and I think it may be time for me
to move on. I’d like to work with you to take a deep dive
into all this.”
These case examples highlight key ethics challenges
related to consent-to-treatment agreements; disclosure
decisions; documentation decisions; professional
boundaries; and management of practitioner impairment.
Consent‑to‑Treatment Agreements
Clinical social workers typically have clients sign a consent-
to-treat document that spells out the nature of the social
worker’s services, the social worker’s responsibilities, the
client’s responsibilities, confidentiality policies, fee and
payment policies, insurance reimbursement protocols, and
cancellation policies, among other topics. However, the
consent-to-treat protocol is necessarily different when the
client is a clinical social worker who is struggling with
impairment or who has disclosed unprofessional conduct.
In these instances, clinicians should draft a tailored consent-
to-treat document that sets forth the clinician’s policies
regarding confidentiality and its exceptions, with specific
regard to the client’s impairment and/or ethical misconduct
(Bismark et al., 2016; Haston, 2014). The specific content
of the document will differ depending on whether the client
is voluntary (for example, seeking assistance without state
licensing board involvement or under the auspices of a
professional health program that is voluntary in nature) or
mandated as part of licensing board sanctions or a consent
order. The latter may require inclusion of language related to
disclosure that may not be appropriate with the former. It is
especially important to craft these documents, and manage
decisions about disclosure, in a way that minimizes the
likelihood that they will have a chilling effect on struggling
social workers’ willingness to seek assistance.
Typical agreements and guidelines include several key
elements concerning the clinician’s responsibilities:
13

• Providing oversight, treatment, and assistance for a
potentially compromised social worker.
• Setting forth confidentiality guidelines, including
circumstances that may require the clinician to report
concerns to the state licensing board, the client’s
employer, or others (e.g., when the client’s continued
work in the profession may pose a danger to their clients).
• Monitoring the treatment.
• Developing a monitoring agreement with provisions to
ensure compliance. The monitoring agreement identifies
consequences if the client does not comply with its
conditions.
• Implementing treatment tailored to the client’s needs and
challenges.
A key component of this unique consent-to-treat protocol
is discussion of confidentiality policies and exceptions.
Hypothetically, the clinician may conclude, on the basis
of information obtained during clinical sessions or from
other sources, that the client poses a threat to self or others
(especially individuals served by this client) and that the
clinician is obligated to share these concerns with third
parties (for example, a state licensing board, the client’s
employer). Clinicians who counsel an impaired colleague is
obligated to clearly and fully explain relevant confidentiality
exceptions (see NASW Code of Ethics standard 1.07[e]).
The consent-to-treat protocol also needs to set forth
expectations regarding the client’s compliance with
treatment if the clinician is concerned that the client may
be impaired or needs to address a pressing ethics-related
risk (for example, boundary confusion with a current client).
The agreement should spell out the compliance elements
(for example, regular attendance at counseling sessions, full
disclosure about any impairment or ethics concerns, absence
of evidence of imminent risk of harm to individuals being
served by the client) and the circumstances under which
the clinician may be obligated to terminate counseling and
take steps to protect third parties (for example, the client’s
clients) or the client from self-harm.
Disclosure Decisions
Clinicians who provide counseling services to a colleague
who is struggling with personal issues, manifests
symptoms of impairment, or has engaged in unethical
conduct understand the vital importance of client
confidentiality. It is a maxim in clinical social work that
maintaining confidentiality is essential to development
of a meaningful and trusting clinical relationship. That
said, clinical social workers—including those who are in
the clinical role and those who are clients—understand
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Clinical Social Work Journal
that there are limits to clients’ confidentiality rights, as
established by ethical standards and the law (Barsky et al.,
2021; Reamer, 2015; Straussner et al., 2018).
The NASW Code of Ethics (2021a) includes standards
that explicitly address social workers’ obligations when
they believe a colleague may be impaired or has engaged
in unethical conduct. In both scenarios, as a first step
social workers are expected to share their concerns with
the colleague, when feasible, and when such discussion is
likely to be productive (standards 2.08[a], 2.10[c]). The
code then states that if conferring with the colleague is not
likely to be productive or is not feasible, the social worker
is obligated to disclose the concern about impairment or
unethical conduct with parties who are in a position of
authority (standards 2.08[b], 2.10[d]). The Clinical Social
Work Association’s Code of Ethics includes a comparable
standard (standard IV.e).
State laws may also require social workers to report
concerns about a colleague’s impairment or unethical
conduct. For example, the North Carolina law governing
social workers states “A social worker certified or licensed
under this Chapter who has knowledge of conduct that
would constitute grounds for disciplinary action under this
Chapter, or the Chapter governing the practice of another
licensed healthcare provider, shall report the conduct
to the licensing authority that oversees the healthcare
provider believed to be engaged in misconduct” (North
Carolina Administrative Code, 21 NCAC 63 0.0505).
Some states carve out a mandatory-reporting exception
if the social worker who is impaired is another social
worker’s client, that is, the social worker who has
challenges is in treatment. For example, the Ohio law
governing social workers, counselors, and marriage and
family therapists states:
All licensees, registrants, supervisors and trainees
have a responsibility to report any alleged violations
of this act or rules adopted under it to the counselor,
social worker, and marriage and family therapist
board. Also, if they have knowledge or reason to
suspect that a licensed colleague or other licensee,
who is not a client, is acting in an unethical way
or is incompetent or impaired they shall report
that practitioner to the board. (Ohio Laws and
Administrative Rules, Rule 4757-5-10-A; emphasis
added)
Treatment programs that serve social workers who
have been deemed to be impaired, such as substance
use disorder treatment programs designed for struggling
professionals, have developed commonly adopted
confidentiality guidelines. Ordinarily, these guidelines
state that treatment records are confidential, with
exceptions. Typical exceptions include possible disclosure
Clinical Social Work Journal
to the practitioner’s licensing board or an employer when
there is evidence:
• Of an illness or condition that has directly resulted in
client harm or compromised client safety;
• Of an illness or condition that has resulted in conduct that
violates state or federal law;
• That the social worker poses a danger to herself or others,
or that the social worker may present a significant risk in
their professional practice; and
• That the social worker has failed to comply with the terms
of a treatment and/or monitoring program established by
the licensing board or employer and that, because of that
failure, the social worker presents a danger to herself or
others, or that the social worker presents a significant risk
in their professional practice.
Documentation Challenges
Clinicians who treat colleagues must develop rigorous
documentation protocols to protect clients and themselves
(Sidell, 2015). Clinicians’ records may be subpoenaed if
their clients are involved in legal proceedings. For example, a
clinical social worker who is impaired and sought counseling
from a clinical social worker may sue an employer (a mental
health center) for wrongful termination if the employer
fires the social worker due to this practitioner’s alleged
impairment. In such a case, the lawyer representing the
employer may subpoena the clinician’s records in search of
evidence that the former employee (the client) was impaired.
Thus, clinicians need to decide when to be vague in their
clinical notes and when to be explicit, given who may have
access to the notes as a result of a subpoena or court order.
Clinicians who treat colleagues may wish to be vague in
documentation whenever possible in order to protect the
client. However, there are some instances when, based on
prevailing standards of care, clinicians should not be vague,
especially when there is evidence that the client poses a
threat to self (for example, engaging in suicidal ideation) or
others, especially the client’s clients.
Clinical social workers who treat clinical social
workers can add a layer of protection by following HIPAA
guidelines pertaining specifically to what the law defines
as psychotherapy notes (Herold & Beaver, 2015). HIPAA
defines psychotherapy notes as notes recorded (in any
medium) by a health-care provider who is a mental health
professional documenting or analyzing the contents of
conversation during a private counseling session or a
group, joint, or family counseling session and that are
separated (physically or electronically) from the rest of the
individual’s medical record. Excluded from the definition
of psychotherapy notes are prescriptions for and monitoring
of medication, counseling session start and stop times,
modalities and frequencies of treatment furnished, results
of clinical tests, and any summary of client diagnosis,
functional status, treatment plan, symptoms, prognosis, and
progress to date. Although recording clinical impressions
of a colleague’s impairment or ethical misconduct in
psychotherapy notes, as opposed to the general clinical
record, offers added protection, clinicians should know that
it is still possible for lawyers to subpoena psychotherapy
notes; in principle, a judge can order their disclosure.
Clinical social workers who are employed in substance
use disorders treatment programs or agencies that provide
services to struggling social workers must be familiar
with the implications of the strict federal regulation
Confidentiality of Substance Use Disorder Patient Records
(Title 42 CFR Part 2). Disclosures that are permitted under
HIPAA may not be permitted under Title 42 CFR Part 2.
This regulation broadly protects the confidentiality of the
records of substance use disorder treatment programs—with
respect to the identity, diagnosis, prognosis, or treatment of
any client—maintained in connection with any program or
activity relating to substance use disorder treatment that is
federally assisted. Disclosures are permitted only in a narrow
range of circumstances that are set forth in this detailed
federal regulation.
Boundary Issues
Clinical social workers typically receive extensive education
about the importance of professional boundaries in their
relationships with clients. Rarely, however, does professional
education broach the unique boundary challenges that can
arise when a clinical social worker’s client is a clinical social
worker (Reamer, 2021a). Hypothetically, for example, the
clinician and client may live and work in a rural community
and provide services to different members of the same
family who are their respective clients. It would not be
unusual for the two social workers to consult with each
other about pertinent clinical issues faced by the family
(with their respective clients’ consent). If this scenario
arose, the two social workers would face a complex dual
relationship, where they are in both a clinical social worker-
client relationship and a collegial relationship. Or the two
social workers may encounter each other at a professional
meeting or conference where they have joined the same
discussion group. There are myriad dual relationship
possibilities. Ideally, the two social workers should have a
frank discussion of possible boundary challenges and how
they might handle them to avoid problematic boundary
crossings or a conflict of interest. This is consistent with
language in the NASW Code of Ethics explicitly related to
boundary management (standards 1.06[a], 1.06[c]). The
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Clinical Social Work Association Code of Ethics includes The Louisiana State Board of Social Work Examiners
comparable standards (standards 3.a, 3.g). recognizes that impairments in the functioning
Clinical social workers who provide services to a clinical of persons licensed, credentialed or registered to
social worker should be concerned about two key phenomena practice under the auspices of the Louisiana Social
related to professional boundaries: (1) impropriety and (2) Work Practice Act can affect competent delivery
the appearance of impropriety. Impropriety involves blatant of social work services and impair professional
boundary violations, such as providing psychotherapy judgment. Therefore, in order to safeguard the public
services to a client during the same period of time that the health, safety, and welfare of the people of this state,
two are members of the same peer consultation group that as mandated by R.S. 37:2701, the Louisiana State
occasionally socializes outside of consultation meetings. Board of Social Work Examiners establishes the
This mixing of roles would not be appropriate and could Social Work Impaired Professional Program (La.
compromise the quality of the clinical relationship. Admin. Code tit. 46, § XXV-701). The goal of the
What is more likely, perhaps, is the risk of the appearance Social Work Impaired Professional Program is to
of impropriety. Sometimes even well-meaning gestures provide for public protection through monitoring
by clinical social workers on behalf of clients can be and a remediative course of action applicable to
misinterpreted or misunderstood in ways that comprise the social workers who are physically or mentally
quality of the clinical relationship. Imagine, for example, impaired due to mental illness or addiction to drugs
that a clinician is contacted by her client outside of a or alcohol. Impairments include, but are not limited
therapeutic session for consultation purposes related to an to mental, physical, and addictive disorders or other
individual that the client is serving. The client might make conditions. The program also supports recovery
such a consultation request for understandable reasons, such through preventive measures and allows entrance
as greatly respecting the clinician’s judgment and expertise. into the program before harm occurs” (La. Admin.
However, such extracurricular contact and consultation Code tit. 46, § XXV-703).
would likely have the appearance of impropriety, especially
Virginia, South Dakota, and Indiana have enacted laws
if the client who sought the consultation documents the
specifically intended to protect health care practitioners
consultation in the clinical record and this information is
seeking help with career fatigue and wellness (American
disclosed during legal or other proceedings involving the
Medical Association, 2021). These laws further the goal
client’s client (for example, if the client’s client is involved in
of supporting practitioners to seek assistance to address
a child custody dispute and this social worker’s records are
career fatigue, burnout, and behavioral health concerns
subpoenaed in conjunction with those proceedings).
with confidentiality and civil immunity protections. These
laws enable practitioners, who may avoid seeking help
because of the fear of potential negative repercussions,
Managing Impairment
to get the help they need. In Virginia, for example,
participation in such a program does not trigger the
Clinicians who provide services to colleagues who manifest
requirement that the practitioner be reported to the state
symptoms of impairment can encourage their clients to “self-
licensing board, so long as there is no evidence indicating
report” to their state licensing board. One key advantage
a reasonable probability that a practitioner who is a
of self-reporting is that the reporting social worker may
participant in a rehabilitation program addressing issues
be in a position to negotiate a treatment plan (usually with
related to career fatigue or wellness is not competent to
the assistance of a lawyer who has experience negotiating
continue in practice or is a danger to herself or himself,
with licensing boards) that avoids serious sanctions (such
her or his patients, or the public,
as license suspension or revocation) in the event the board
Over time, health professions have developed guidelines
learns of the impairment from another party (for example, as
and protocols for treatment of impaired professionals in
a result of a licensing board complaint filed by a disgruntled
what is commonly referred to as a professional health
client or a concerned colleague).
program (PHP). It is important for clinical social workers
A number of state licensing boards have developed
who provide services to struggling colleagues to be aware
formal protocols to assist practitioners who voluntarily
of them.
seek assistance. For example, Louisiana law (Title VI, Part
The purpose of a PHP is to guide the rehabilitation
XXV, Chapter 7) provides for treatment of impaired social
of impaired or potentially impaired practitioners who
workers:
are struggling. This involves the early identification,
evaluation, treatment, monitoring, documentation
of adherence, and advocacy, when appropriate, of

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Clinical Social Work Journal

practitioners with potentially impairing illness (es), ideally
prior to functional impairment. PHPs commonly provide
services to both voluntary and licensing board or employer
mandated referrals. Ideally, PHP services would include
the following (Federation of State Medical Boards, n.d.;
Iowa Department of Public Health, 2020).:
• Wellness programs that address practitioner health,
stress management, burnout, and early detection of
at-risk behavior.
• Educational programs on topics, including but not
limited to, the recognition, evaluation, treatment, and
continuing care of impairing conditions.
• Educational resources for the profession, the public,
and licensing boards about the role and function of
PHPs.
religion, sexual orientation, gender, gender identity,
specialty, professional degree, or membership affiliations;
• Treating practitioners’ arrangement for emergency
interventions and evaluations, when necessary and where
possible; and
• Establishment of a health monitoring agreement template
designed to optimize continuing care, practitioner
rehabilitation, and client safety; details of each agreement
should be individualized and subject to change based on
case specifics.
These guidelines are consistent with the spirit of NASW’s
policy on professional impairment (National Association of
Social Workers, 2021b).

Typically, PHPs are expected to report substantive non-

Practitioner Self‑Care and Wellness
adherence with PHP recommendations and monitoring
Social workers who provide services to struggling
agreements and make periodic reports regarding adherence
colleagues should be well versed in the latest research on
based on ongoing documentation to appropriate individuals,
the importance of self-care in the profession. It may be
committees, licensing boards, or organizations on behalf of
important for clinicians to address wellness and self-care
practitioners under PHP monitoring.
issues when they provide services to clients.
The Federation of State Medical Boards—whose key
Self-care in the human service professions includes
functions are comparable to those of the Association of
various elements: physical well-being, psychological
Social Work Boards (ASWB)—has developed guidelines
well-being, spiritual well-being, support, and workplace
that provide a useful template for clinical social workers
changes (Newell & Nelson-Gardell, 2014; Richards
who provide services to struggling colleagues. First, it is
et  al., 2010;  Shanafelt et  al., 2012; Smullens, 2015).
important to distinguish between impairment and illness.
Physical activity—such as exercise, sports, and household
Illness, per se, does not constitute impairment. When
activities—has been shown to decrease symptoms of anxiety
functional impairment exists, it is often the result of an
and depression (Callaghan, 2004; Dishman, 2003; Newell &
illness in need of treatment. Therefore, with appropriate
Nelson-Gardell, 2014). Also, there is evidence that personal
treatment, the issue of impairment may be prevented or
counseling can help mitigate the negative impact of work-
resolved while the diagnosis of illness may remain.
related distress (Norcross, 2005).
Second, programs serving struggling practitioners should
Workplace changes that can promote self-care include
aim to reduce stigma and barriers to treatment. This includes
setting realistic goals with regard to workload and client
allowing treatment to be sought confidentially for impairing
care, actively encouraging the use of well-timed breaks
illness and not requiring this to be reported as part of the
during the workday, and promoting adequate rest and
licensing process.
relaxation (Drolet & McLennan, 2016; Newell & Nelson-
Third, treating practitioners satisfy their ethical duty
Gardell, 2014). It is particularly important for agency
when they have evidence that an impaired colleague has
administrators and supervisors to acknowledge the potential
ceased practicing and is receiving reputable professional
impact of workplace stressors.
services to protect clients. When a clinical social worker
Importantly, in 2021 the NASW Code of Ethics added
treats a social worker whose treatment was mandated by a
language explicitly acknowledging the importance of
licensing board, the relationship between the treating clinical
practitioner self-care. According to the code,
social worker and the board would be characterized by:
Professional self-care is paramount for competent and
• Applicable confidentiality protections; ethical social work practice. Professional demands,
• Mutual understanding of each party’s responsibility to challenging workplace climates, and exposure to
treatment participants and the public; trauma warrant that social workers maintain personal
• No discrimination nor denial of clinical services based and professional health, safety, and integrity. Social
on a practitioner’s race, creed, color, national origin, work organizations, agencies, and educational
institutions are encouraged to promote organizational

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 Clinical Social Work Journal

policies, practices, and materials to support social First, these clinicians should be familiar with protocols for
workers’ self-care. treatment of impaired professionals and those who have
engaged in ethical misconduct. As a foundation, treating
A comparable statement is included in the Clinical Social
clinicians should be familiar with literature on the nature and
Work Association’s Code of Ethics (standard II.4.d).
causes of social workers’ impairment and unethical behavior.
Some struggling social workers satisfy the definition of a
Second, treating clinical social workers should
“wounded healer.” The concept of the wounded healer was
implement state-of-the-art protocols pertaining to
introduced by the Swiss psychoanalyst Carl Jung (1966),
consent-to-treat and management of clients’ confidential
who used the term to refer to helping professionals who
information. They should fully understand when
experience personal challenges that affect their work. This
information should be kept confidential and when it may
construct is based on the Greek myth of the centaur Chiron,
or must be disclosed to protect third parties and clients
who was physically wounded, and by way of overcoming the
who pose a risk to themselves.
pain of his own injuries became a master of the healing arts
Third, clinicians should develop and implement sound
(Reamer, 2021b; Straussner et al., 2018). Jung hypothesized
documentation protocols. Documentation practices should
that the physician who has experienced adversity is better
reflect the very real possibility that clinicians’ clinical
equipped to understand the causes and amelioration of a
records will be subpoenaed or may be disclosed due to
patient’s suffering, but may also experience limitations as a
a court order. Treating clinical social workers should be
result of this personal history. This concept has been applied
very familiar with HIPAA’s special provisions regarding
to a wide range of human service professionals (Reamer,
protection of “psychotherapy notes.” Treating social
2015; Straussner et al., 2018).
workers employed in federally assisted substance use
Some practitioners may find it difficult to seek help for
disorder treatment programs should be cognizant of the
their own problems because they believe that they have
very strict documentation guidelines embedded in federal
infinite power and invulnerability, that they should be able to
regulation Confidentiality of Substance Use Disorder
work out their problems themselves, an acceptable therapist
Patient Records (Title 42 CFR Part 2).
is not available, seeking help from family members or
Further, clinicians must be cognizant of potential
friends is more appropriate, confidential information might
boundary issues that can arise when providing services
be disclosed, proper treatment would require too much effort
to a clinical social worker. Clinical social workers who
and cost, they have a spouse or partner who is unwilling to
provide services to colleagues must be scrupulous in their
participate in treatment, and therapy would not be effective
efforts to avoid problematic dual relationships.
(Coombs, 2000; Reamer, 2015; Straussner et al., 2018).
Finally, to enhance social worker well-being and protect
In some instances, social workers who provide treatment
clients, clinicians should promote client self-care. These
to struggling colleagues may need to engage in “constructive
ambitious efforts should follow well-established protocols
confrontation” (Sonnenstuhl, 1992). Constructive
that address physical, psychological, spiritual, support,
confrontation means that professionals confront colleagues
and workplace issues.
diplomatically with evidence of unsatisfactory work or
More generally, the social work profession should take
concerns about their level of functioning, coach them on how
assertive steps to address challenges faced by struggling
to improve their work or functioning, urge them to access
practitioners. Social work education programs would do
supports and services if they have personal problems, and
well to address practitioner impairment—including causal
emphasize the consequences of continued poor performance.
factors, prevention strategies, and ethical responses—in
their undergraduate and graduate curricula. Organizations
such as the Clinical Social Work Association, National
Recommendations
Association of Social Workers, and Council on Social
Work Education can offer continuing education trainings
Some clinical social workers encounter significant
on this subject to enhance awareness and promote
personal challenges in their lives and, to their credit, seek
prevention. State licensing boards and the Association
counseling from other clinical social workers. These clinical
of Social Work Boards can encourage practitioners to
relationships can produce ethical challenges for treating
enroll in relevant continuing education offerings. Also,
social workers, especially related to consent-to-treatment
these organizations can encourage or sponsor research
agreements; release of information; confidentiality and
designed to document the nature and extent of social
its exceptions; documentation; boundary issues; and
worker impairment and the extent to which struggling
management of social worker impairment. To protect their
social workers seek assistance.
clients and themselves, clinical social workers who provide
Clinical social workers who provide services to struggling
services to struggling colleagues should take several steps.
colleagues must be particularly mindful of potentially

13
Clinical Social Work Journal
complex countertransference issues. This can be especially
challenging when clinicians regard their clients as members
of their professional “family.” Further, clinicians may
experience their own sense of moral distress and injury when
they provide services to a “wounded” colleague (Reamer,
2021b). Knowing that a struggling colleague continues to
work professionally may be troubling. Clinicians may find it
helpful to process these dynamics during peer consultation
discussions.
Conclusion
Clinical social workers are not immune to life’s challenges.
Like all people, clinical social workers sometimes
encounter daunting issues concerning mood, relationships,
trauma, and work, among others. To their credit, these
practitioners sometimes reach out to other clinical social
workers for assistance. Seeking help from a colleague is
the ultimate expression of trust.
Providing services to professional colleagues is
daunting, a task that requires skillful balancing of
complex clinical and ethical concerns. In these instances,
it behooves treating clinical social workers to be especially
mindful of relevant ethical standards and practical steps
they can take to protect clients and themselves.
Funding  There is no funding for this project.
Declarations  ed-​Pract​ition​er-​Progr​am
Conflict of interest  Frederic Reamer declares that there is no conflict
of interest.
Research Involve in Human and Animal Rights  This article does not
contain any studies with human participants or animals performed by
the author.
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Frederic G. Reamer  Ph.D. is professor in the School of Social Work,
Rhode Island College.