by Allan Barsky, JD, MSW, PhD
Photo credit: Pixabay/CDD20
As professional social workers, we have ethical duties to respect our clients’ rights to self-determination, competent service, privacy, and confidentiality (NASW, 2021). But what are our obligations when clients do not show up for services? Consider, for instance, a client who does not attend a scheduled meeting with you. You follow up by calling the client, but the client does not respond. You send a text message using your agency’s secure text messaging program. Once again, the client does not respond. Have you fulfilled all your ethical obligations? What other courses of action should you consider?
Assessing the Situation
To determine the best course of action when a client does not attend a scheduled meeting, it is helpful to assess the situation from the client’s perspective. If you’ve been working with the client for a period of time, you may have a sense of possible reasons for their missed appointment and lack of responsiveness to your outreach. Perhaps the client is depressed and lacks the energy or motivation to respond. Maybe the client is upset over something that occurred in a recent session, for instance, feeling judged or misunderstood by you or feeling pressured to explore issues that the client was not ready to explore. It could be that the client has taken ill or has simply forgotten that they had an appointment. Each of these examples is just a “theory,” a possible explanation for what may be happening. You may not be certain about what is going on with the client, but your theories may present possible starting points for follow-up.
As with many challenging situations, prudent practice suggests consulting with others about the best way to proceed (Barsky, 2023). In this situation, consulting with your supervisor may help you process what has happened with the client and assess why the client may not be responding. It is particularly important for you and your supervisor to assess possible risks. If a client is at significant risk for child abuse or neglect, maltreatment of a vulnerable adult, suicide, homicide, or other harmful behavior, then the need and urgency for follow-up is greater. If the risks are relatively low, then there may not be the urgency for further follow-up, even though some follow-up may be appropriate. One challenge is determining the level of risk without the benefit of direct client communication.
Pre-Empting Problems
We’ve been considering what to do at the point when a client does not attend a scheduled meeting and does not respond to your initial outreach by phone or secure text messages. However, we should also consider what we might have done well before the situation of the “missing client” arose. During intake or early stages of the helping process, it is prudent to ask clients for the name and contact information of a friend or family member to contact in the event of an emergency situation. If the client provides information for you to contact a particular person in case of an emergency, then you may contact this person to help assess how the client is doing and whether additional follow-up may be helpful. When contacting the emergency contact, it is still important to protect the client’s confidentiality as much as possible. For instance, you may need to share that the client has not been attending sessions, but you may limit what you share in terms of personal information that the client has shared with you.
Another preventative measure is asking the client about the best ways to contact them in case of emergency. For instance, does the client agree that you may communicate through voicemail messages on their phone, email messages on their personal email account, or letters sent to their home address? The client may have concerns about family or friends who may have access to such communications, particularly when the client is involved in an abusive relationship. You and the client may also agree that only limited information may be shared through such means, such as a request to contact you but not private information that the client has shared with you. Once again, respecting the client’s right to privacy should be balanced with the need to contact them for follow-up.
A third way to pre-empt problems is to discuss options for termination of services. Let clients know that if they have concerns about your services, they may discuss these concerns with you or your supervisor. Inform them that you are open to referring them to other service providers and that your primary focus is their well-being. You may also provide them with a list of alternate service providers and support systems, so they are empowered to access additional help on their own. Consider, for instance, a client who is struggling with sexuality or gender identity. They may not have disclosed their concerns to you. By providing them with a link to a website that lists community-based resources, they may be able to access a self-help group or professional where they may feel more comfortable sharing their concerns.
Relevant Ethical Duties
Standard 1.01 of the NASW Code of Ethics (2021) states that our primary obligation is to our clients. Accordingly, it may be important to follow up with clients even when they do not initially respond to your outreach. We have a duty to maintain continuity of service and avoid abandoning clients. Although these standards do not explicitly refer to situations in which a client stops attending services and responding to the social worker, prudent practice suggests that social workers should consider whether further follow-up is warranted. As noted earlier, if a client is experiencing distress or other serious risks, we want to ensure their welfare and safety.
Options for Follow-Up
Possible follow-up actions include:
- Re-engaging the client through a telephone call, voice message, secure text message, or email and offering to schedule a new appointment.
- Providing the client with a “termination of services” letter, summarizing the nature of services, identifying ongoing needs or concerns, highlighting their strengths, and offering referrals for other sources of support.
- Contacting the client’s emergency contact to assess whether the client may need additional services and to determine helpful follow-up.
- Reaching out to mental health crisis, child protection services, adult protection services, or emergency response services if there are serious concerns about the client’s mental health or physical safety (e.g., risks of suicide, drug overdose, abduction, abuse, or neglect).
- Conducting a wellness visit at the client’s home (Banks & Rutter, 2022).
Consider where there are additional creative options that could allow you to ensure the client’s safety and welfare, while also honoring the client’s rights to privacy and autonomy (Banks & Rutter, 2022). Your specific choice of follow-up will depend on the particular circumstances and assessed risks. Collaborate with your supervisor to determine the specific purpose of follow-up (e.g., to address a safety concern) and the best course of action, taking the potential benefits and risks of each option into account. In terms of risk management, remember to document the situation, including dates of missed appointments, contact attempts, supervision discussions, and the rationale for selecting a particular option for follow-up.
Addressing the ethical complexities of client disengagement or disappearance requires proactive measures. By using assessment, consultation, and strategic follow-up, we can uphold our ethical commitments to client well-being, self-determination, privacy, and professional integrity.
Questions To Consider
- What are your agency’s policies regarding how to follow up when a client misses an appointment and does not respond to your initial follow-up attempts?
- Have you ever dealt with this type of situation? If so, what were your initial thoughts about why the client missed the appointment? What risks did you consider? What steps did you take, if any, to follow up with the client? What was the outcome of your efforts? What additional steps, if any, might have been helpful?
- What are the risks of legal liability (malpractice) if a client does not attend scheduled services and the social worker does not provide any form of follow-up?
References
Banks, S., & Rutter, N. (2022). Pandemic ethics: Rethinking rights, responsibilities and roles in social work, The British Journal of Social Work, 52(6), 3460–3479. https://doi.org/10.1093/bjsw/bcab253
Barsky, A. E. (2023). Essential ethics for social work practice. Oxford University Press.
National Association of Social Workers (NASW). (2021). Code of ethics. https://www.socialworkers.org/About/Ethics/Code-of-Ethics
Allan Barsky, JD, MSW, PhD, is Professor of Social Work at Florida Atlantic University and author of Social Work Values and Ethics (Oxford University Press).
The views expressed in this article do not necessarily represent the views of any of the organizations to which the author is affiliated, or the views of The New Social Worker magazine or White Hat Communications.