Case Management Corner: Close Ties In Rural Communities Can Mean Ethical Complexities
By Kelly Bilodeau
Licensed clinical social workers working in rural areas quickly learn how tightly winding country roads can bind everyone together.
“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,” said Kalie Wolfinger, manager of clinical services at Phoenix Medical Management, Inc.
Unlike urban settings, where it’s relatively easy to maintain clearly defined professional boundaries, rural social workers often struggle to do the same, particularly when they take on multiple roles in the same community.
“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,” she said.
These intersecting relationships often create ethical tensions that traditional professional frameworks weren’t designed to address and suggested solutions are often impractical or unworkable.
“Licensing boards sometimes recommend documenting every incidental encounter or role overlap but in a small town, how feasible is that?” Wolfinger asked. “Should every unexpected hallway greeting or school pickup interaction become a clinical note?”
Navigating a crisis
These shortfalls can leave social workers flying blind in moments of crisis, a fact that was brought into sharp relief for Wolfinger during one late-night tragedy. At the time, Wolfinger was working as an inpatient therapist at her local hospital, while also seeing private practice therapy clients part-time to meet the requirements for her LCSW.
A child arrived at the emergency department in critical condition. “Resuscitation efforts were underway, and it was becoming increasingly clear that the injuries sustained were not survivable,” Wolfinger recalled. Then she heard the name and realized it was a patient’s child.
“Time slowed, and everything around me faded into the background as I realized the gravity of what I was facing,” she said. “There was no guidance from the Arizona Board of Behavioral Health for this specific kind of moment.”
The first ethical dilemma was whether to retrieve the family’s contact information from her private practice records because the hospital didn’t have it.
“I remember thinking, if I don’t contact this parent now, they may miss the last moments of their child’s life,” Wolfinger said. “So, I made the decision. I logged in, found the number, and called.” The challenges didn’t end there. Should she help the patient navigate the crisis? Should she continue to be the client’s therapist after that day? “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,” Wolfinger said.
Ultimately, when given the choice, the patient asked Wolfinger to continue their therapeutic relationship because of their shared history and reluctance to start over with someone new. But that decision raised even more questions.
“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,” Wolfinger said. “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.”
Ethics codes versus rural reality
The experience underscored why rigid professional ethics guidelines often fall short in rural care.
“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,” Wolfinger said.
Certain situations in rural clinical practice simply require greater flexibility.
“This includes weighing professional guidelines alongside community context, urgency, and the clinical necessity of maintaining relational continuity, especially in trauma care,” she said.
Wolfinger argues that it’s time to develop new frameworks that uphold ethical client-centered care while allowing for informed, flexible decision-making in critical moments, like the one she experienced. “The ethical boundary between roles, emergency clinician and therapist, was crossed and not by my actions, but by the circumstances,” she said. “And yet, the situation demanded immediate decisions. The most ethical choice wasn’t obvious. It was urgent.”
The most responsible response sometimes requires setting aside textbook solutions in favor of humanity.
“The most ethical course of action, in this case, was not rigid adherence to policy,” Wolfinger said. “It was a compassionate, competent, trauma-informed response that honored the dignity of both the client and the clinician.”
Case Management Corner is your go-to source for insightful discussions on relevant topics in case management. Through an engaging interview-style format, our team members share their expertise, experiences, and best practices to keep you informed and empowered. Whether you're looking for industry updates, practical strategies, or real-world perspectives, we bring you valuable conversations designed to enhance your knowledge and support your professional growth. Stay tuned for expert insights straight from the field! Kelly Bilodeau has been a longtime writer for HCPro’s Case Management Monthly.