Practice issue:

Newish CM is assigned a new client who had brain injury 6years ago. No previous case management or rehabilitation intervention has been provided whatsoever.

Having received input from CM over the last 2 months, client and his wife are very pleased with support given, which they never dreamt was available.

The couple frequently refer to, or jokingly greet CM, as their hero or guardian angel, thanking her for coming to their rescue, including saving their marriage. They admit they had both been at their wits end since client had injury and consequently lost his job leaving them at home together for long periods, with him requiring additional care from his wife. They are pleased with the services they now receive and state the case manager is the first person who seems to recognise the challenges they have been facing since the injury.

At Christmas to express their thanks they present CM with package containing a small box of chocolates and a Christmas card, which she accepts. A few days later CM finds the unopened Christmas card envelope in her bag, opens it to display it on her desk, and discovers a £100 gift card.

In February client’s wife approaches CM and asks if she can speak privately. Explains that she and client are having marital problems and she wants counselling support to address this. Wife says she has read CM’s CV and is aware that she was previously a couples’ counsellor prior to training as a Mental Health Nurse and then eventually moving into case management. She requests CM provide the counselling as they already both trust her and they are very private individuals who do not feel comfortable opening up to a stranger.

During their next meeting wife again asks to speak privately to highlight increasing urgency of need for counselling. She explains that their marriage is suffering since her husband has become increasingly obsessed with hard core pornography, recently expressing an interest in accessing child pornography. She quips that she suspects he fantasises more about their neighbour’s pretty young daughter, for whom he occasionally babysits, than he does about his own wife, which leaves her feeling undesirable and rejected and she thinks this is affecting their sex life. Finally, she asks that the CM keep this conversation secret due to its sensitive and personal nature.

Case Management Actions:


Communication (clarifying boundaries and managing expectations):

  • When the couple compliment her, CM always acknowledges their appreciation yet additionally points out that what she provides is normal for the service and part of her job.
  • When they give her a Christmas gift, due to the low value, she accepts it so as not to cause offence, yet points out that it was not necessary.
  • After discovering the gift card she returns it explaining that she is unable to accept such a high value gift.
  • When asked if she can provide counselling, CM acknowledges their need for trust in the professional, but explains why, despite her skill set, it would not be appropriate for her to undertake this role, assuring them that she will help the find someone suitable and acceptable to them.
  • When the wife asks her to keep her disclosure secret, CM makes it clear that she cannot promise to keep any conversation off the record.


  • CM receives regular monthly supervision from a more experienced CM.
  • Initially she reports enjoying working with this couple as they are so appreciative and straightforward.
  • On receiving the gift of chocolate CM reports this to her supervisor and formally declares it to her HR team.
  • On later discovering the gift card, she again informs her supervisor, expressing mixed feelings of being appreciated for doing a good job, and concern about the high value of the gift. Seeks advice.
  • After the wife’s disclosure and request to maintain confidentiality, CM immediately seeks additional supervision, feeling out of her depth regarding the potential (implied/alleged) safeguarding risk, combined with the complexity of the wife’s desire to keep her suspicions and concerns secret. CM is uncomfortable having this information and is unsure as to the best next steps. Together they created a suitable plan of action and agree the best approach to respond to the risks.

Skills used:


6a Supervision – Knowing one’s own limitations and identifying when supervision is needed to support clinical practice


6b Consent, Capacity and Confidentiality – Understanding and managing issues associated with human rights


6c Boundaries – Setting clear guidelines to separate personal and professional responsibilities according to one’s own professional code of conduct


6d Personal development – Continuing professional development in brain injury case management


Positive indicators demonstrated:

  • receives regular and appropriate supervision
  • maintains objective perspective
  • considers increased range of options
  • has increased knowledge and confidence
  • shares relevant details to inform others
  • is able to maintain perspective to guide case forwards
  • follows best practice


Bear traps avoided:

  • Case Manager not seeing the need for supervision
  • Case Manager being flattered by the appreciation of the client and his wife and not recognising the potential risk to managing expectations or boundaries
  • Case Manager not being clear about professional obligations and boundaries leading client to overly rely on CM, consider them as a friend rather than a professional, and compromise safety and integrity by agreeing to requests





Duty of Care


Personal Attributes





BABICM Code of Ethics and Conduct in Case Management Practice



Practice reflections:


Not all issues are apparent at initial assessment and more difficulties are discovered over time as trust in the CM/Client relationship develops.


Although it is lovely to be appreciated, the Case Manager needs to be responsible for managing expectations and maintaining professional boundaries.


With this complex client group, even clients who appear relatively straightforward can turn out to be surprising, unpredictable or challenging.


Individual case managers are not expected to always know what to do. It is a strength to recognise when you feel out of your depth or lacking in knowledge, and supervision is an essential forum in which to reflect, test, enquire and seek advice.