Source: CMSA Today
BY , LCSW
In small towns, clinical social workers often find themselves navigating an invisible web of overlapping roles. We are clinicians, neighbors, and community members; ones who carry both our education and our humanity into every interaction. These roles are deeply human, yet they can blur professional boundaries in ways that are ethically complex and emotionally taxing.
Unlike urban settings, where clinicians may serve anonymous populations with clearly defined professional separations, rural social workers often live and work in the same communities they serve. While ethical boundaries are essential, the potential for dual relationships is significantly heightened in rural settings, where personal and professional roles often overlap in ways that are difficult to fully separate. While the Arizona Board of Behavioral Health provides clear ethical standards to help protect both clients and clinicians, applying those standards can sometimes feel more nuanced in rural communities where clinicians are often called to respond in multiple roles, across systems, and in real time.
What also makes boundary navigation uniquely complex for social workers, as compared to other behavioral health professionals such as counselors or psychologists, is the span of roles we are trained and permitted to hold. A social work background equips us not only to offer clinical treatment but also to engage in systemslevel intervention, crisis response, care coordination, case management, and advocacy. This versatility is a strength of our profession, but it also places us in ethically gray spaces more frequently than those whose scopes of practice are narrowly clinical.
For 10 years, I worked as a clinical social worker in the emergency department of a rural Arizona hospital. While the work was emotionally intense and clinically rich, the hours I spent in that acute care setting didn’t count towards licensure under Arizona’s standards. To meet the requirements for my LCSW, I took on a part-time role in a local group private practice, seeing about five to 10 clients a week. Later, I transitioned into a full-time position in inpatient psychiatry while continuing to see clients on the side to complete my clinical hours more efficiently.
Even after transitioning out of the emergency department, I remained on the hospital’s PRN list. Occasionally, I’d pick up a five-hour shift in the evenings, not just for supplemental income, but to stay connected to a skill set I valued and to the hospital team I had spent years building relationships with. It had been over six months since I had picked up a shift when I signed up for one late evening. The shift had been quiet until about an hour before I was scheduled to leave. I sat at my desk listening to EMS’s patch about a traumatic accident. I quickly realized I would not be going home in an hour as I had anticipated. A minor arrived, unaccompanied, in critical condition. Resuscitation efforts were underway, and it was becoming increasingly clear that the injuries sustained were not survivable.
Part of my role in the emergency department had always included locating and contacting family members during life-threatening situations. In this case, I asked a member of the fire department if they had a name. They gave it to me and in an instant, my whole body froze. I recognized the name. The minor was the child of one of my current clients at the private practice.
Time slowed, and everything around me faded into the background as I realized the gravity of what I was facing. There was no guidance from the Arizona Board of Behavioral Health for this specific kind of moment. The ethical boundary between roles, emergency clinician and therapist, had been crossed and not by my actions, but by the circumstances. And yet, the situation demanded immediate decisions. The most ethical choice wasn’t obvious. It was urgent.
I knew I needed to reach the family, but I didn’t have their contact information in the hospital system. The only place I could access it was through the secure electronic health record used at my private practice. I remember thinking, if I don’t contact this parent now, they may miss the last moments of their child’s life. So, I made the decision. I logged in, found the number, and called.
What began as the final hour of a quiet PRN shift became a five-hour stretch of sitting with my client and their family through the unimaginable: navigating life support decisions, medical examiner procedures, and the immediate aftermath of profound loss. Without pause, I stepped from my role as an emergency department social worker into the one I held in our therapeutic relationship. I knew their story, not just from that night, but from the sessions we had shared: the family dynamics, the recent stressors, the weight they had already been carrying before this moment shattered everything.
Later, a new ethical question arose: Should I continue as this client’s therapist? I wondered whether this traumatic overlap in roles would rupture the therapeutic space or shift the power dynamics between us in ways that could undermine the work. Before our next scheduled session, I called and offered space for that conversation. I shared that I would support either decision, whether they preferred to transition to a new clinician or to continue our work together.
Ultimately, the client chose to continue. Their reasoning was simple but powerful: they didn’t want to start over. I had been there, through the phone call, through the hospital, through the most difficult night of their life. Repeating the story to someone new felt like reopening a wound that hadn’t even started to heal.
But continuing in that role also came with a deeper responsibility on my part. To maintain therapeutic objectivity and ensure that I could ethically and effectively support this client’s healing, I recognized that I, too, needed support. In alignment with the NASW Code of Ethics (Sections 1.04 and 4.05), I sought multiple professional consultations with other licensed clinicians and engaged in my own trauma therapy to process the emotional toll of what I had witnessed. These steps weren’t optional. They were essential to maintaining the integrity of the work and ensuring that my presence in the therapeutic space remained grounded, ethical, and client centered.
This situation wasn’t about carelessness or lack of boundaries. It was about navigating the space between ethical clarity and clinical reality. The Arizona Board of Behavioral Health, like most licensing bodies, provides essential guidance on dual relationships, confidentiality, and role integrity. But in moments like this, where crisis and relationship intersect, the ethical path isn’t always obvious. It’s human.
The NASW Code of Ethics recognizes the importance of maintaining professional boundaries and avoiding dual relationships, but also acknowledges that context matters. Section 1.06(c) explicitly states that “social workers should be aware that dual or multiple relationships may increase the risk of harm to clients” and encourages careful evaluation when they are “unavoidable” (NASW, 2021). In this situation, the decision to access my client’s contact information was made not from convenience, but out of clinical urgency with the intent to give a parent the opportunity to be present for their child’s final moments of life. There was no time to wait, consult, or explore alternatives.
This was not a textbook ethical dilemma. It was one grounded in real-world trauma, in a rural setting, within the limits of emergency care infrastructure. The choice wasn’t between right and wrong, but between harm and greater harm. I didn’t step into a dual role to serve my own needs, but to support someone I already had a relationship with, during the most devastating moment of their life.
While I initially wrestled with whether my decision to contact the client’s parent blurred professional boundaries, I kept returning to this: competence in trauma treatment includes the capacity to sustain relational continuity. From a trauma-informed care lens, the therapeutic relationship is not peripheral, but central. According to Courtois & Ford (2012), in Treatment of Complex Trauma, the relationship itself functions as both context and mechanism of healing. For clients impacted by complex trauma, especially those with relational wounds, the clinician’s emotional availability, trustworthiness, and consistency are not optional skills. They are clinical interventions.
This view aligns with trauma-informed principles of care, which prioritize safety, trust, collaboration, and empowerment across all levels of service not only for clients, but within professional decision-making frameworks (SAMHSA, 2014). In that moment of urgency, I acted not out of rigid adherence to protocol, but from a place of clinical discernment: guided by ethics, relational trust, and a deep respect for the humanity of everyone involved. In rural communities, this kind of relational consistency can be profoundly stabilizing particularly when trauma threatens to fracture already-thin support networks.
But when we look at how ethical standards are enforced, nuance is often lost. A review of 2025 Arizona Board of Behavioral Health Examiners meeting minutes shows that many disciplinary actions cite A.R.S. § 32-3251(16)(x) boundary violations and dual relationships, yet provide little contextual detail about setting, urgency, or local limitations. In January, February, and May 2025 alone, multiple clinicians were sanctioned under this statute (Arizona Board of Behavioral Health Examiners, 2025a, 2025b, 2025c). These rules are in place to protect clients but they often fail to reflect the ethical tensions unique to rural practice, where professional roles may inevitably overlap.
One common board recommendation is to refer clients out of the community, frequently via telehealth. Though telehealth may provide a boundary-respecting alternative, it often struggles to meet the relational depth required in trauma work especially in rural settings, where trust is built through in-person presence and community familiarity. For many clients, starting over via screen with a stranger is not healing; it is retraumatizing.
If we want to uphold the spirit of the Code of Ethics and deliver truly client-centered care, we must create ethical frameworks that allow for informed, flexible decision-making. This includes weighing professional guidelines alongside community context, urgency, and the clinical necessity of maintaining relational continuity, especially in trauma care. The most ethical course of action, in this case, was not rigid adherence to policy. It was a compassionate, competent, trauma-informed response that honored the dignity of both the client and the clinician.
This situation was unique in its intensity, but not in its implications. In rural communities, overlapping roles are often part of daily life. Your child may attend school with a client’s child. You may see a client in the grocery store, at church, or on the sidelines of a soccer game. For social workers who develop specialized clinical niches (such as work with first responders, veterans, or educators) the likelihood of these overlaps only increases. In my own case, my years in the emergency department deepened my interest in serving first responders in private practice. But this meant that at times, I found myself providing outpatient therapy to someone I might encounter during a crisis call or hospital consult. Licensing boards sometimes suggest documenting every incidental encounter or role overlap but in a small town, how feasible is that? Should every unexpected hallway greeting or school pickup interaction become a clinical note? The practical reality is that rural clinicians must navigate these intersections thoughtfully, but also sustainably. Ethics in these spaces must be grounded not just in protection, but in presence, transparency, and ongoing reflection.
References
Arizona Board of Behavioral Health Examiners. (2025a, January 10). Meeting minutes. https://www.azbbhe.us
Arizona Board of Behavioral Health Examiners. (2025b, February 14). Meeting minutes. https://www.azbbhe.us
Arizona Board of Behavioral Health Examiners. (2025c, May 9). Meeting minutes. https://www.azbbhe.us
Centers for Disease Control and Prevention. (2022). 6 Guiding Principles to a Trauma Informed Approach Infographic. https://stacks.cdc.gov/view/cdc/138924
Courtois, C. A., & Ford, J. D. (2013). Treatment of complex trauma: A sequenced, relationship-based approach. The Guilford Press.
National Association of Social Workers. (2021). Code of ethics. National Association of Social Workers.
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