Psychoanalytic - EDs

  • Doc File 125.50KByte



Most people print off a copy of the post test and circle the answers as they read through the materials. Then, you can log in, go to "My Account" and under "Courses I Need to Take" click on the blue "Enter Answers" button.

After completing the post test, you can print your certificate.

Boundaries in Mental Health Treatment

Introduction

Case Vignette

Carolyn is a 34-year-old woman with a history of sexual abuse and dissociative behaviors. She had been in treatment with Jackie O’Brien for 10 years. Jackie terminated treatment with Carolyn because she considered Carolyn to be too dependent. Carolyn has been seeing Nina Black for the past year. Nina is working with Carolyn on the abuse issues, with the primary goal of empowering Carolyn to manage her own symptoms. She has encouraged Nina to learn grounding skills. This goal has been derailed due to Carolyn’s continued contact with Jackie, who will answer Carolyn’s phone calls at all times, including at night and during treatment sessions with other clients. Recently Carolyn had a flashback and instead of attempting any grounding, she called Jackie for reassurance. Nina is frustrated, and Carolyn is angry. She sees Nina as “mean” and feels she is trying to separate her from Jackie.

As the vignette above illustrates, the ability to establish and maintain therapeutic boundaries is an important competency for mental health professionals. “Boundaries” delineate the personal and the professional roles and the differences that characterize interpersonal encounters between the client and the mental health professional (Sarkar, 2004). Boundaries are essential to client and therapist safety. Although setting and maintaining professional boundaries seems on the surface to be a simple process, in actual practice, it can be very difficult. Our professional relationships with our clients exist for their benefit. A useful question to ask ourselves is “Whose needs are being met in this relationship, my client’s or my own?” Ironically, familiarity and trust, basic tenets of effective psychotherapy, as well as the pull to help the client, are what often lead to boundary breaches (Gabbard, 2008b).

Obtaining accurate statistics on the extent of boundary violations is difficult. Frequently only more serious violations are reported, and minor, less physical, forms of violation are not. Even sexual boundary violations are likely underreported due to shame and guilt on the part of the client. In a 15-year study of malpractice claims against psychologists, Pope (2003) cites sexual violations as the most frequently made allegation. Self-report studies of health care professionals suggest a prevalence range of 1–10% (Sakar, 2004).

It is important for practitioners to be aware of issues related to boundaries, of the importance of a strong therapeutic frame, as well as common pitfalls the practitioner can experience.

After finishing this course, the participant will be able to:

• demonstrate familiarity with what often leads to boundary breaches.

• demonstrate familiarity with the most frequently made allegations of ethics

violations.

• demonstrate familiarity with conflicts of interest.

• Demonstrate familiarity with components of informed consent including HIPAA

• demonstrate familiarity with examples of multiple relationships.

• demonstrate familiarity with important areas to consider regarding

boundaries.

Defining Boundaries

Although the term “boundary” is not found in formal ethical codes, it is a key term to understand with regard to professional ethics. A simple metaphor is to think of a boundary as similar to a fence around one’s yard. As the fence marks the parameters of someone’s property, boundaries mark the parameters of a therapeutic relationship. According to Everett and Gallop (2001) “boundaries define the helping pathway — for both clients and professionals — and as such are integral to professional effectiveness (p. 229). Other authors have pointed to professional boundaries as the tool that allows therapists and clients to explore issues in a safe and neutral environment (Guthriel & Gabbard, 1993; Simon, 1999). The most important feature of a therapeutic boundary is that the focus of the relationship is on the welfare of the patient and not the treatment professional (Bennet et. al., 2006).

Boundary concerns include behaviors that span a broad range in terms of frequency and harmfulness. Some authors make a distinction between boundary violations and boundary crossings (Guthriel & Gabbard, 1993). The National Council of State Boards of Nursing defines boundary crossings as “a decision to deviate from an established boundary for a therapeutic purpose. These are brief excursions across boundaries with a return to the established limits of a professional relationship” (Peternelj-Taylor, 2003). Guthriel and Gabbard (1998) also utilize the term boundary crossing, which they define as an activity that moves the clinician from a strictly objective position with their clients. A boundary violation, on the other hand, is a harmful boundary crossing. Although boundary crossings may be minor, and there may be therapeutic usefulness of these actions, boundary crossings can have the potential of progressing to a boundary violation. In addition, it is often difficult to assess what actions could cause harm to the client, or know in all cases how a client may interpret a boundary crossing. For instance, one client may construe a small gift as a token of the work done in therapy, while another could interpret it as a therapist’s attempt to move the relationship to a more social level.

The list below provides examples of potential boundary crossings and boundary violations. Mental health professionals should discuss therapeutic boundaries early in the relationship, such as during the informed consent process. In this way boundaries are clearer. Additionally it is important to assess whether a boundary that may be acceptable for some clients may not be appropriate for others. Bennet et. al. (2006) provide the caution that otherwise benign boundary crossings may problematic for patients with “high-risk factors” such as personality disorders. In the example seen in the introduction, it may be perfectly acceptable to allow phone calls between sessions, especially for emergency situations. The fictional therapist Jackie, however, did not consider that the client’s history of sexual abuse may color her perception of the meaning of these phone calls, or that they may interfere with her former client’s current therapeutic goals.

Some examples of boundary crossings include:

• Taking phone calls between sessions (if not agreed upon)

• Small gifts (giving and accepting)

• Special fee arrangements or bartering

• Allowing patients to run a large balance

• Excessive therapist self-disclosure/disclosure of personal information

• Extending time beyond what was initially agreed

• Lengthy sessions, especially last session

• Saying “yes” rather than “no”

• Making special allowances for patient

• Nonemergency meetings outside the office

Examples of boundary violations include:

• Avoidable dual or multiple relationships

• Sexual relationships

Therapists seeking consultation on such cases often begin the request with "I don't usually do this with my patients, but in this case. ..." (Norris et. al., 2004)

An important consideration in terms of what causes harm to the client is not the behavior itself or even the intentions of the treatment professional but the meaning of the behavior to the client (Sarkar, 2004). Both clients and therapists enter the relationship with ideas about what constitutes care and being cared for. A strong therapeutic frame ensures that when these ideas are unconsciously triggered, they do not cause harm to the client.

In contrast boundary violations are behaviors that always result in harm to the client. Sexual relationships with clients are the most severe forms of boundary violations. Sexual boundary violations are often preceded by less extreme boundary crossings. These may include behaviors such as excessive self-disclosure by the therapist, dual roles, or touching/frequent hugs. This will be discussed in more detail later in these materials.

Why Do Boundary Violations/Crossings Occur?

Boundary violations may occur due to a number of factors related to the therapist or the client and how the conscious and unconscious mechanisms of each come together in the therapeutic relationship. As such, it is impossible to identify all the potential factors that could lead to a boundary problem. There have been some attempts, however, to explain this phenomenon. Sarkar (2004) feels that a key factor in why boundary violations occur is that treating professionals have both personal and professional identities. He states “The duty of physicians is to address the patient’s unconscious or pre-conscious desires to know not just their professional, but also their personal identity. Their personal identity may aid the formation and maintenance of their professional identity, but it is for them and them alone to be aware of the distinction between the two identities and to preserve it, at least within the therapeutic frame.”

Pilette et. al., (1995) propose a similar framework for explaining why boundary problems occur. These theorists state that the two most common problems that may lead to wearing away of therapeutic boundaries are: 1) inability to differentiate the professional relationship from the social relationship and 2) attempting to have personal needs met through the therapist-client relationship. Although the maintenance of therapeutic boundaries is within the auspices of the treating professional, there are factors that sometimes complicate this task.

One of these factors concerns the treatment environment. In some cases professionals working in a hospital or another residential facility may interact with clients in different ways, such as sharing meals or recreational activities. These may feel more “intimate” to both the client and the treating professional. Clients may come to see the therapist in other roles, such as friend, parent, or sexual object (Peternelj-Taylor, 2008). In addition these treatment environments may contain more challenging clients, such as those with personality disorders, whose presentation may be exaggerated by the anxieties of a hospital setting and the restricted freedom of these settings (Nield-Anderson et. al., 1999). Nield-Anderson (1999) and her fellow authors state that such clients may use manipulation (a word which they divorce from its negative connotation) to satisfy unmet needs for trust, security, and control. They urge treating professionals to be aware of things such as instant intimacy (disclosing information “never told to anyone else”), excessive neediness, and soliciting of personal information. These authors also note the presence of sexually provocative behaviors, such as use excessive flattery, flirting or touching. They recommend that the clinician clarify his or her role as a professional, redirect behaviors, and document these behaviors. Above all, the professional must also remember that the needs of the client are what should drive the therapeutic relationship.

Another concern that may lead to boundary issues is a clinician’s attempt to satisfy personal needs in their relationships with clients. This can be seen in many areas, including personal therapist factors, therapist difficulties with limit-setting, use of touch, caretaking/rescuing, and therapist self-disclosure. Each will be briefly discussed.

Personal Life of the Therapist. Norris et. al.(2003) have identified a number of therapist factors that have been found to precede boundary violations such as sexual misconduct. The first is midlife and late-life crises in therapists' development including difficulty establishing a practice, an excessive need to please patients, and balancing the demands of family and professional life. Other crises such aging, career disappointment, or marital conflict can also result in increased vulnerability to boundary issues. They also identify transitions including retirement, job loss, or job change. Finally therapists' illness appears to increase their vulnerability to boundary crossings such as turning to a patient for support.

Therapist Difficulties with Limit Setting. 
Some patients press for boundary breaches for a variety of psychological reasons. A common barrier to limit setting is the therapist's countertransference conflicts about aggression or when the prospect of the patient's expected distress, discomfort, or frustration at being told "no" is unbearable to the therapist. When caught in such conflicts, therapists with issues around limit-setting may feel that they cannot refuse patients' requests to violate a boundary (Norris et. al., 2004).

Touch. One concern connected to satisfaction of personal needs is the therapeutic use of touch. This is something that is not specifically mentioned in formal ethical codes, and research on the usefulness/harmfulness of touch has been mixed. There may be many reasons that touch is appropriate in a therapeutic relationship, such as helping clients to accept appropriate non-sexual touch. Some questions that may be helpful to consider:

How can I tell when touching will be helpful or not? Consider: incest or abuse victims, cultural differences

Is touching for the client or my own benefit?

Do I have to hold myself back from expressing affection of compassion in a physical way?

What if my touch is misinterpreted by clients?

If I feel sexually drawn to certain clients, is it dangerous to express physical affection?

Am I reaching out too soon to comfort clients due to my own sense of discomfort with clients’ pain?

Caretaking. An additional concern related to satisfaction of the therapist’s personal needs concerns caretaking. Many authors (e.g., Gabbard, 1996, Peternelj-Taylor, 2008) mention the pull of helping a client to have a rich, full life outside of therapy. This is actually a common transference enactment. Caretaking, however, can take the form of the therapist imagining what it may be like to establish a relationship outside of the treatment setting. Again, it is important that treating professionals can separate personal from professional and also have good self-care strategies and supports. This is particularly important given the potential problems with caretaker burnout.

Another issue with regard to caretaking is that excessive caretaking may limit client self-determination. The NASW code of ethics, for example, states that promoting client self-determination is a core ethical responsibility to clients: “Social workers respect and promote the right of clients to selfdetermination and assist clients in their efforts to identify and clarify their goals.”

Therapist Self-Disclosure. Lastly, some treating professionals have a need to be liked or approved of, and if they are unaware of this, it could take precedence over the needs of the client. One area in which this is seen is that of therapist self-disclosure (Peternelj-Taylor, 2008). This has been somewhat of a controversial topic. Some theoretical orientations, for example, feminist therapy, advocate the use of self-disclosure as a therapeutic medium to reduce the inherent power differential between client and therapist and to increase therapeutic connection. The Feminist Therapy code of ethics explicitly states: “A feminist therapist discloses information to the client that facilitates the therapeutic process, including information communicated to others. The therapist is responsible for using self-disclosure only with purpose and discretion and in the interest of the client.” This view is echoed by Beutler (1978), who states: “the degree of therapist disclosure precipitates a similar degree of disclosure in patients.” Strong and Clairborn (1982) disagree. They state: “therapist disclosure to encourage patient disclosure does not seem like a good use of therapist power unless some specific disclosure is needed.” Other theoretical orientations advocate a more neutral therapeutic stance, suggesting that some degree of disclosure is inevitable, and that therapists disclose indirectly anyway.

In looking at this issue, there seem to be both positive and negative aspects of self-disclosure. One concern about therapist self-disclosure is that it is often the final boundary excursion before sexual relations, although self-disclosure does not in itself lead inevitably to that outcome (Norris et. al., 2004)

Therapist self-disclosure can be positive, however. It can be used to deepen a client’s disclosures or provide modeling. What is important is that self-disclosure be planned, and be used in conjunction with a therapeutic goal. Such disclosures must be for the benefit of the patient and not for the benefit of the therapist. Even with careful planning, however, there may be some problems inherent in therapist self-disclosure. Consider the following case vignette, for example.

Case Vignette

Mary is a lesbian patient who has been seeing Dr. Liz Grady for two months. Dr. Grady is an openly lesbian therapist, and has found that this has helped her to connect with gay and lesbian clients. One of Mary’s primary issues has been her inability to establish a healthy relationship. She tells Dr. Grady that she generally meets potential partners in bars and that many of these women do not have the maturity she is seeking. Dr. Grady empathizes with Mary, and suggests that she may wish to check out a lesbian support and social group that she herself has found helpful. Mary is uncertain what she should do. Will Dr. Grady be at these meetings? Does she want to be friends with her? Mary responds by canceling her next therapy session.

In the above vignette, Dr. Grady’s degree of self-disclosure may be completely appropriate, but there are certainly aspects that some clinicians, particularly those clinicians that subscribe to less disclosure, may find concerning. Additionally, if Liz does in fact attend the same support group as Mary, this would be a dual relationship. Dual relationships often bring up similar concerns as Mary’s, and canceling sessions or premature termination of therapy may result.

One issue involving therapist self-disclosure and boundary crossings/violation is the idea that demanding patients may at times insist that the therapist disclose personal information. It is important not to succumb to self-disclosure if it is clear that a client is demanding it to test the boundaries.

Another concern within the realm of therapist self-disclosure involves therapists sharing personal problems with patients. This may be done under the guise of connection or showing that they have struggled with similar issues as clients. A clear rule of thumb is that therapists should not share current problems and make a patient into the therapist. There are other times when sharing past problems, especially with the intention of providing hope, is appropriate. Even with the latter it is important to remember that such disclosures may still result in complex dynamics.

Case Vignette

Dawn is a 23-year-old woman struggling with bulimia. She seeks the help of Karina Jewell, a counselor specializing in treating eating disorders. During one session Dawn expresses profound hopelessness that she will ever recover. Karina reassures her, stating that she herself has had bulimia and that recovery is possible. Dawn is comforted by the disclosure and feels more hopeful.

Challenging Patient Populations/Patient Factors

In looking at the issue of boundary violations and crossings, it is also helpful to consider client characteristics. There are a number of patient factors that have been seen in instances of boundary crossings and boundary violations. Norris et. al. (2003) lists the following factors exacerbating patient vulnerability:

• Enmeshment. Intensely enmeshed, symbiotic relatedness may increase a patient’s lack of ability to recognize boundary crossings. Patients with enmeshment issues may view a therapist as “protective” even when this is inaccurate.

• Retraumatization. For those patients with a history of childhood trauma boundary violations and the familiarity of the victim role may keep a client in a therapeutic relationship in which boundary issues are occurring.

• Shame and self-blame. Patients involved in boundary violations or sexual misconduct often struggle with self-blame.

• Dependency. Dependency issues may mask boundary issues. It may be especially challenging to identify therapist overinvolvement (see initial case vignette).

Personality Disorders

Boundary violations occur more often within more challenging populations, such as with patients with personality disorders. A personality disorder is defined as an "enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment." According to Merkell (2004) possible indicators of a personality disorder, regardless of the specific type, are a stronger emotional reaction to the patient than warranted, whether positive or negative; negative reactions such as discomfort, reluctance, or dislike; or patient characteristics such as demandingness, aggression, or hypochondriasis. Other characteristics include demands for help that outweigh the perceived seriousness of the situation or making special requests for treatment beyond the routine. Being overly compliant, passive, or submissive may also suggest personality disorder. These patient characteristics increase the likelihood that boundary crossings could occur.

Smith (1995) states that the first step in caring for the difficult patient is to acknowledge negative feelings. It is important to recognize how therapist vulnerabilities, such as the need to feel useful, the need to be liked, or the need for order and control, may be present with these patients. Setting realistic therapeutic goals and limits is important as is therapist self-care.

Case Vignette

Dr. Patel is a psychologist that specializes in working with patients with Borderline Personality Disorder. She loves the work, recognizing both the challenges and rewards. Dr. Patel is especially vigilant to setting limits in her first therapy session, specifying how she handles issues such as phone calls between sessions, payment arrangements, therapist accessibility, patient self-harm, etc. In her recent work, she has found that providing a written explanation of these issues, signed by therapist and client (with a copy to the client) is most helpful. Should issues arise, such as clients self-injuring between sessions and pointing to therapist unavailability as the “reason,” Dr. Patel calmly refers to the agreement, and reviews her expectations for use of healthier coping skills.

Informed Consent

In looking at boundary issues it is important for clinicians to lay the proper foundation that allows for appropriate therapeutic boundaries. One way to do so is to provide informed consent. All of our ethical codes stress the need for informed consent. The NASW code of ethics, for example, states: “Social workers should provide services to clients only in the context of a professional relationship based, when appropriate, on valid informed consent.”

Informed consent is a legal and ethical procedure to ensure that a patient or client knows all of the risks and costs involved in mental health treatment. Informed consent is also “a process of communication and clarification” (Pope & Vasquez, 2007). At its heart, informed consent involves clarifying why clients are seeking treatment, what their expectations of the therapy process are, and their thoughts about what treatment will entail. The clinician also needs to discuss these factors with the client. As a result, mental health professionals are often able to refine their own understanding of the clients’ presenting problems.

It is important to provide informed consent as early as possible in the therapeutic relationship, ideally in the first session. The elements of informed consents include informing the client of the nature of the treatment, possible alternative treatments, and the potential risks and benefits of the treatment. In addition, it is important to inform clients at the outset of treatment about exceptions to confidentiality, fee arrangements, limits to services because of the requirements of a thirdparty payer, clients’ right to refuse or withdraw consent, recordkeeping requirements, and the time frame covered by the consent. In order for informed consent to be considered valid, the client must be competent and the consent should be given voluntarily, and clients should have an opportunity to ask questions. It is important to use clear and understandable language in discussing informed consent.

Obtaining informed consent is a collaborative process that respects the client and informs the client about central aspects of the therapeutic relationship and obtains from the client consent to proceed. Through the process of becoming informed, the client receives information on which to base a considered decision; and the psychologist ensures that the decision to proceed with treatment and is not the product of coercion. In addition many of the areas covered later in this material, and that can lead to boundary crossings, such as changes in fee arrangements, bartering, etc. can be made very clear from the outset, reducing the potential for boundary issues.

Case Vignette

Anna is a 36-year-old morbidly obese female. Anna has been obese most

of her life, and has consulted with a surgeon regarding gastric bypass surgery.

He asks Anna to have a series of tests, including a psychological evaluation. Anna seeks the services of Dr. Clemmens, who performs this evaluation. Dr. Clemmens diagnoses Anna with binge eating disorder, but notes that Anna’s history and a myriad of medical issues may eventually make gastric bypass surgery a viable option. Dr. Clemmens recommends that Anna seek counseling for the binging. She contacts Dr. Sarah Jeffers, a clinical psychologist with 15 years of experience in treating eating disorders. In her initial session with Dr. Jeffers, Anna explains why she is seeking treatment for her binging. Anna clearly states that her ultimate objective is to have gastric bypass surgery. She also provides Dr. Jeffers with Dr. Clemmens phone number, and signs a written consent that allows Dr. Jeffers to obtain a copy of her psychological evaluation. Dr. Jeffers and Anna meet for nine months. Both agree that Anna has made good progress on her binging, but recognize that her weight has not

changed. Anna asks when Dr. Jeffers believes that she will be ready to continue

with the surgery process. Dr. Jeffers replies that she does not believe in gastric

bypass and surgery and would not be willing to support her in this and will not

provide Anna with a letter for her surgeon.

In this case, Anna was clear about her need for treatment and her ultimate goal of having a gastric bypass procedure, setting clear boundaries around her goals for treatment. Dr. Clemmens was not equally clear. She did not disclose any factors that would make the therapeutic match a poor one and did not clarify with the client expectations of therapy.

Fee Arrangements

When looking at the issue of boundaries, it is helpful to be familiar with ethical provisions related to fee arrangements. A discussion of bartering will be provided later in this material. Discussion of fee arrangements should occur at the outset of treatment. The APA ethical code, for example, states: “As early as feasible in a professional or scientific relationship, psychologists and recipients of psychological services reach an agreement specifying compensation and billing arrangements.” In ensuring appropriate boundaries, it is helpful to specify when payment for services is expected. It is also important to accurately represent fees, as well as to anticipate limitations in financing. For example, if insurance plans have session limits or a client is being seen though a short-term option such as an employee assistance plan, and initial treatment planning indicates that further sessions will be required it is important to specify this up front.

Case Vignette

Louise is being seen by in counseling by Jill M., an art therapist in private practice. Jill initially met Louise while she is in a partial hospital program and agreed to see Louise in conjunction with her primary therapist, a social worker. It was clear at the outset of therapy that many of Louise’s problems stemmed from her history of sexual abuse, and that this would be an area that Jill and Louise would address. Jill’s services were not covered by insurance, but she felt that she was clear with Louise that her hourly rate was $135, and that she expected payment monthly. When, after several months Louise could not pay in a timely way, Jill arranged for a running tab. Louise became so behind on her payments that she ran up a sizeable bill. Jill terminated the relationship resulting in a crisis that her primary therapist was left to manage.

Although this case is not presented to imply that therapists must continue to see clients that are delinquent with their bills, it is important to consider the many implications of this case. The NASW ethical code clarifies that social workers in feeforservice settings may terminate services to clients who are not paying an overdue balance if the financial contractual arrangements have been made clear to the client, as was the situation in this vignette. The code, however, does state that the “clinical and other consequences of the current nonpayment have been addressed and discussed with the client,” which did not occur here. In addition, the way that this case was managed resulted in both client crisis and difficulties for a colleague that was co-managing therapy.

HIPAA

Information about informed consent is not complete without a summary of HIPPA. HIPAA stands for the Health Insurance Portability and Accountability Act. Initially HIPAA was a way to protect individuals from unfair insurance practices. In its newest iteration, HIPAA governs the way that therapists who accept insurance payments manager Protected Health Information (PHI). Protected health information is any information about health status, provision of health care, or payment for health care connected to a person.

The HIPAA Privacy Rule creates national standards to protect individuals’ medical records and other personal health information.

One change that has occurred as a result of HIPAA is the need for individual providers that are covered under HIPAA to provide clients with a Notice of Privacy Practices. This document details client rights involving release of information. The Notice of Privacy Practices should be incorporated into the informed consent process, and the provider must obtain a signature showing that the Privacy Notice was received. If for any reason a client refuses to sign the Privacy Notice, a note indicating that the form was offered and that the client refused to sign is sufficient. If the client is a minor, the parent is required to sign the notice of Privacy Practices.

The content of the Privacy Practices notice will vary. In general, this document details routine uses and disclosures of protected health information as well as an individual’s rights and the provider or hospital’s duties with respect to protected health information. The discussion below will describe some issues common to mental health care. It is not intended to provide an exhaustive list of what can be included but some general guidelines.

• Treatment Issues: Many mental health providers disclose PHI to provide, coordinate, or manage health care and any related services. This includes the coordination or management of PHI with a third party. For example, PHI may be provided to a health provider to whom a client has been referred to ensure that the provider has the necessary PHI to diagnose or treat them. Clients must be made aware that such disclosures will occur.

• Payment: PHI is often used to obtain payment for mental health services. This may include speaking to representatives of health insurance plans before it approves or pays for the health care services. Depending on the client’s level of care, more or less PHI may be provided for coverage decisions. Routine requests by insurance companies include information about diagnosis, dates of service, and type of service provided (i.e., individual or family therapy.)

• Exceptions to Confidentiality: This is both and ethical and HIPAA mandate. The Notice of Privacy Practices should include information about instances when providers may need to disclose protected health information and do not specifically need to inform clients about these. These vary by state law, but may include disclosing PHI when there is a threat to self or others or when the professional is ordered to do so by law.

• Sensitive Health Information: This mandate involves how details about psychological information is disseminated, such as removing patient identifiers when able to do so, as well as treatment of particularly sensitive information such as HIV/AIDS information, disability status, alcohol and drug information. The Notice of Privacy Practices must detail steps that are taken to protect this information

• Right of Access: The Notice of Privacy Practices should also describe how patient access to medical records. Providers should include a statement indicating “ownership” of medical records. Clients should be informed of their right to access their medical record and to amend or correct errors in medical records.

Conflicts of Interest

In looking at boundary violations, it is important to consider the area of conflicts of interest, which are subtle, but identifiable boundary crossings. There are important reasons that our major ethical codes provide guidelines related to conflict of interest. This has to do both with establishing client-therapist trust and exercising professional and scientific judgments based on training and experience. Fisher (2003) states that ethical standards related to conflict of interest prohibit mental health professionals from taking on a professional role “when competing professional, personal, financial, legal, or other interests or relationships could reasonably be expected to impair their objectivity, competence, or ability to effectively perform this role.” A simple explanation of this concept is found is standard 1.06 of the NASW ethical code that states that conflicts of interest are things that “interfere with the exercise of professional discretion and impartial judgment.”

Some examples of conflicts of interest include:

• Entering a business relationship with a client or their close relative

• Self-referring to one’s own private practice from a hospital setting

• Providing paid testimony for legal services with an existing therapy client

As the examples above show, although these conflicts of interest may be permissible under some cases, the burden will also fall to the therapist to show that the relationship was an objective one and that professional judgment remained clear.

The NASW ethical code explicitly states: “Social workers should inform clients when a real or potential conflict of interest arises and take reasonable steps to resolve the issue in a manner that makes the clients’ interests primary and protects clients’ interests to the greatest extent possible. In some cases, protecting clients’ interests may require termination of the professional relationship with proper referral of the client.”

Another area that can create a conflict of interest are those relationships involving more than one client or party. It is important in these situations that therapists clarify the nature of the relationship in a direct fashion. Standard 1.069(d) of the NASW code says” “When social workers provide services to two or more people who have a relationship with each other (for example, couples, family members), social workers should clarify with all parties which individuals will be considered clients and the nature of social workers’ professional obligations to the various individuals who are receiving services. Social workers who anticipate a conflict of interest among the individuals receiving services or who anticipate having to perform in potentially conflicting roles (for example, when a social worker is asked to testify in a child custody dispute or divorce proceedings involving clients) should clarify their role with the parties involved and take appropriate action to minimize any conflict of interest.”

Case Vignette

Joe and Tina have been in couple’s counseling with Regina McHugh, a clinical social worker specializing in couple’s counseling. When it becomes apparent that the issues they have cannot be worked out in counseling, the couple separates. Tina, who is devastated by the end of the marriage remains in treatment with Regina. Unfortunately, the communication issues they have had in the marriage continue, and a nasty custody fight ensues. Tina talks to Regina about the custody problems and asks if she can call Joe. After all, Tina knows them both and would be the best person to intervene. Right?

This is a clear example of a conflict of interest and the boundary issues such a situation can create. Although there is nothing in the ethical code that would prohibit Regina from continuing with Tina, such issues as the one in the case vignette occur all too often. Anticipating these problems and talking about them prior to beginning individual therapy is ideal. Should that not be possible, it is important to manage issues such as this with delicacy and with balance given to the therapeutic versus potential ethical issues.

Exploitive Relationships

This discussion of conflict of interest also points to another area of concern to mental health professionals and which is directly tied to the concept of boundaries: that of exploitive relationships. The idea of exploitive relationships is addressed in APA standard 3.08 which states: “Psychologists do not exploit persons over whom they have supervisory, evaluative, or other authority as clients/patients, students, supervisees, research participants and employees.” Standard 3.08 prohibits psychologists from taking unfair advantage or manipulating others over whom there is an authority-based relationship. These ideas are covered in the ethical codes of other mental health professionals and are often included within standards connected to conflicts of interest.

Examples of exploitative relationships include:

• Encouraging expensive gifts from clients

• Starting to see a client at a lower fee and increasing the fee after a few sessions

• Recommending services that are unnecessary and not affordable to clients

Violations of standard 3.08 often occur in connection with violations of other standards such as those related to multiple relationships, sexual intimacies, etc.

Case Vignette

Cassie has been in treatment with Dr. Brand, a clinical psychologist. She has often discussed her father’s import/export business and her concerns about working for his company. Dr. Brand has often commented on the lovely silk blouses that Cassie wears and mentioned that she would love to own one herself someday. Cassie feels subtly pressured by the comments and brings Dr. Brand an expensive blouse. Dr. Brand thanks her and accepts the gift.

Multiple or Non-Sexual Dual Relationships

Another conflict of interest, and one that merits more in-depth discussion is that of multiple or non-sexual dual relationships. With regard to boundary violations, sexual relationships and non-sexual dual relationships are the most common sources of disciplinary actions, charges filed with state ethics committees and bases of malpractice suits (Bennet et. al., 2006). Sexual relationships are certainly most potentially harmful and will be discussed in the next section, but it is also important to review issues related to multiple/non-sexual dual relationships.

All of our ethical codes have standards regarding dual relationships. Standard 3.05 of the American Psychological Association’s ethical code states (a) a multiple relationship occurs when a psychologist is in a professional role with a person and (1) at the same time in another role with that person, (2) at the same time is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relationship or (3) promises to enter into another relationship in the future with a person or a person closely associated with or related to that person.

Social work, psychology and other mental health professions take pride in the use of self, the person in the process (Mattison, 2000). As positive as this is, it can lend itself to developing secondary relationships. These relationships can include nonsexual and legitimate interactions, many of which are unintentional, yet still have ethical ramifications (Dewane, 2010).

Some examples of multiple relationships include:

• Social relationships

• Bartering

• Being a treating professional and providing court testimony

• Providing both individual and group therapy

Freud (2002), a clinical social worker, has written about the inadequacy of ethical codes in addressing dual relationships. Freud refers to dual relationships as consecutive or concurrent relationships, and argues that the contexts in which dilemmas arise do not easily fit into the guidelines of the code.

Freud agrees that there is a need for clear boundaries for the following three reasons:

1. Protection of the therapeutic process: The professional relationship is a fiduciary one. Even minor boundary transgressions can give a mixed message; a boundary symbolizes limits of a professional transaction.

2. Protection of clients from exploitation: Clients are vulnerable, and therapists are entrusted to protect them from harm.

3. Protection of from liability: Not establishing dual relationships is one way to limit risk of malpractice suits.

However, Freud also asserts that maintaining the rigid power hierarchy of professional-client relationship can be distancing and reduces authenticity. “There may even be instances when purposeful cultivation of dual relationships may be necessary for successful entry, professional legitimacy, and knowledgeable intervention” (p. 486). She also objects to the idea of perpetuity, the belief that once someone is a client, he or she is always a client, meaning that such relationships can never occur, even years after termination

Unavoidable Relationships

There are, of courses, instances in which dual relationships are unavoidable or times when they may not pose a problem. Therapists working in rural areas, small towns, military bases, or American Indian Reservations or those who can provide services to members of a unique ethnic or language group would not be in violation of the dual relationships standard if they took steps to avoid harm (Fisher, 2003). Dual relationships have been found to occur more frequently in rural areas (Brownlee, 1996; Roberts, 1999). Gottlieb (as cited in Brownlee) developed a model for analyzing the appropriateness of a dual relationship in rural settings and this can be applied to the other examples listed above as well. Using the dimensions of power, duration, and termination, the Gottleib’s model recommends that therapists do the following:

• Assess the current and future relationship on the dimensions of power, duration, and termination.

• Determine the extent of role incompatibility.

• Seek consultation.

• Discuss the decision with clients in terms of possible ramifications.

Case Vignette

Monica Torres is a resident of Wellsboro, a small town in rural Pennsylvania. As one of the few therapists in the area, she often works with neighbors that she will have passing contact with. Monica has consulted with colleagues on the issue of dual relationships. She makes it a practice not to work with friends. She discusses with potential clients the fact that she may encounter them in settings outside of the office, and asks how they would like to handle this. She also reviews with patients their comfort level with the fact that they may have common friends and acquaintances.

Non-problematic Dual Relationships

In looking back at the examples of multiple relationships, it is clear that not all dual relationships are problematic. Multiple relationships that would not be expected to cause harm or are not exploitative are not unethical. For example, our ethical guidelines do not prohibit therapists from attending a client’s wedding or funeral, from receiving a small gift at holidays or giving a gift to a client on a special occasion. There is also not a problem with incidental encounters, such as at a school event, a movie theater or religious service. Fisher (2003) recommends that should a therapist feel than an incidental encounter could lead to misperceptions regarding the encounter it is wise to keep a record of the encounter. Fisher provides an example in which a patient with poor reality testing and a romantic transference misperceived two incidental encounters and made an invalid accusation of sexual misconduct against the clinician.

Post-Termination Nonsexual Relationships

There are not specific prohibitions against post-termination nonsexual relationships. However there are standards that forbid terminating a therapy relationship for the purpose of pursuing a social relationship. Standard 1.16 (d) of the NASW Code of Ethics, for example, states: “Social workers should not terminate services to pursue a social, financial, or sexual relationship with a client.”

It is important as well that a post-termination relationship not be promised during the course of therapy, and that the post-termination relationship not be harmful.

Clients in Individual and Group Therapy

In most cases, working with a client concurrently in individual and group therapy does not represent a dual relationship as the therapist is in a treatment role in both relationships. Although not an ethics concern in terms of boundaries, these concurrent roles may be challenging clinically. The therapist must also take care not to reveal information that was provided in individual therapy in the group setting.

Potentially Unethical Multiple Relationships

Some relationships, however, are both avoidable and problematic. Consider the following case:

Case Vignette

Tom is a counselor in recovery and employed in a drug and alcohol treatment facility. Jeff, a newer client with whom he has developed an excellent counseling relationship, approaches Tom. Jeff tells Tom that he has been having trouble finding an AA meeting he feels comfortable attending. He wonders where Tom attends meetings. How should Tom respond to the client?

There are many possible issues with Tom’s disclosure and the possibility of Tom and Jeff attending the same AA meeting. These problems would affect both Tom and Jeff. Pope and Vasquez (1991) discuss the difficulties inherent in dual relationships. On the whole, dual relationships jeopardize professional judgment, clients’ welfare, and the process of therapy. Pope and Vasquez make the following points:

1. Dual relationships erode and distort the professional nature of the therapeutic relationship, which is secured within a reliable set of boundaries upon which both therapist and client depend

2. Dual relationships create conflicts of interest and thus compromise the disinterest necessary for sound professional judgment. Management of transference and countertransference becomes impossible

3. There is unequal footing between therapist and client, making a truly egalitarian relationship impossible

4. The nature of therapy would change

5. This could affect future needs of the client. In particular, the therapist could be compelled (by court order) to provide testimony on the client’s diagnosis, treatment or prognosis

The APA ethical code itself says that a psychologist refrains from entering into the multiple relationship if the relationship could be reasonably expected to impair the psychologist’s objectivity, competence, or effectiveness in performing his or her functions as a psychologist, or other risks exploitation or harm to the person with whom the professional relationship exists. The term “reasonably expected” is used and indicates that violations of this ethical standard are not viewed solely on the basis of whether harm occurred to a patient, but also on the basis of whether other clinicians would expect that being engaged in similar circumstances could lead to harm.

Examples of potentially unethical multiple relationships include:

• Entering into another role

• Relationships with other

• Preexisting personal relationships

Entering Into Another Role

Therapists may have situations in which the opportunity to enter a new relationship emerges with a person with whom they have a professional role. Most of these fall into the category of a classic dual relationship, which could potentially cause harm to the client. For example, a psychologist in a teaching role could not conduct therapy with a student. Should questions arise, it is better to consult with a colleague prior to entering into such a relationship.

Relationships With Others

Clinicians may also have situations in which a person closely connected with someone they know personally or professionally seeks to enter a relationship with the therapist. One of the more challenging examples of this is client referrals. For example, a client may refer a friend to their therapist for treatment. Although these situations need to be handled on a case-by-case basis, these relationships generally put the therapist at risk of a dual relationship because they may impair the therapist’s ability to make objective judgments and jeopardize the effectiveness of treatment.

Case Vignette

Dr. Lucas received a phone call from Diana, the 26-year-old daughter of a man that Dr. Lucas had successfully treated for a driving phobia. Dr. Lucas had terminated with this patient about 5 years previously. Diana explained that she had had poor experiences with prior therapists and that Dr. Lucas had been highly recommended. After working with Diana for several sessions, Dr. Lucas began to rethink his naïveté in taking on Diana as a patient, especially as she began to express strongly negative feelings about her father and commented that she knew Dr. Lucas would understand her feelings.

Pre-existing Personal Relationships

Therapists may also be asked by people they know to treat them in some way, such as to see them as a therapy client, to provide advice, or to conduct testing. These relationships are generally unethical due to impaired therapist objectivity.

Bartering

Although bartering is addressed separately in many of the ethical codes it is closely connected to the issue of multiple relationships. Standard 1.18 of the APA Ethical Code states “ Psychologists ordinarily refrain from accepting goods, services, or other nonmonetary remuneration from patients or clients in return for psychological services because such arrangements create inherent potential for conflicts, exploitation, and distortion of the professional relationship. A psychologist may participate in bartering only if (1) it is not clinically contraindicated, and (2) the relationship is not exploitative.”

The NASW ethical code also has provisions that address payment for services. The code clarifies that social workers should set fees that are fees are fair, reasonable, and commensurate with the services performed. Consideration should be given to clients’ ability to pay. Setting appropriate fees can limit the need for measures such as bartering. In addition the code discusses bartering in a comprehensive statement. The code states: “Social workers should avoid accepting goods or services from clients as payment for professional services. Bartering arrangements, particularly involving services, create the potential for conflicts of interest, exploitation, and inappropriate boundaries in social workers’ relationships with clients. Social workers should explore and may participate in bartering only in very limited circumstances when it can be demonstrated that such arrangements are an accepted practice among professionals in the local community, considered to be essential for the provision of services, negotiated without coercion, and entered into at the client’s initiative and with the client’s informed consent. Social workers who accept goods or services from clients as payment for professional services assume the full burden of demonstrating that this arrangement will not be detrimental to the client or the professional relationship.”

Bennet et. al. (2006) note that many mental health professionals barter on occasion, and that it is not explicitly contraindicated and in fact may be beneficial. They suggest judicious and cautious use of bartering, however. They also state that it is important to agree upon in advance the value of what is being bartered in order to reduce the possibility of unfairness or misunderstandings. It is also important to look at whether the bartering is exploitive or could create an unanticipated dual relationship. Consider the following example:

Case Vignette

Aimee has been working with Jean Harris, MSW, at her home office for the past 8 months. Recently Aimee’s insurance benefits have run out, but she is unable to afford self-pay sessions. She is not willing to look for another clinician. After Aimee accrues a large balance, and knowing that Aimee needs continued treatment, Jean suggests that Aimee clean her house (both the family areas and office) in exchange for therapy sessions. Although Aimee is initially fine with the arrangement, she begins to become uncomfortable with the arrangement, feeling that she now knows too much about Jean and her family.

Although Jean’s suggestion of this bartering arrangement was meant in a helpful way, Jean did not think through the implications and what knowledge of her personal life would mean to Aimee. It was also not helpful that Aimee was allowed to accrue such a large balance. If bartering were the only option, an arrangement of a less personal nature would have been more helpful.

Sexual Relationships

Case Vignette

Lori is an attractive 35-year-old woman. Lori had seen Dr. Les Williams in treatment for three months. She had been in therapy previously, and feels that she has worked through many of the issues related to her history of childhood sexual abuse. Lately, Les has noticed that Lori has been wearing more provocative clothing to session, and feels that there has been a definite sexual pull. When Lori makes it known that she has an interest in pursuing a more intimate relationship with Les, he suggests that she seek treatment elsewhere, and refers her to a female therapist specializing in trauma treatment. Two and a half years later, Les and Lori encounter each other in a social setting. When Lori again makes her interest known, Les invites her to dinner the next evening.

As the case above illustrates there are many issues involved in the boundary established for mental health professionals that prohibits sexual relationships between clients and therapists. Most professional codes have mandates that refer specifically to sexual intimacies between clients and therapists and many states have laws pertaining to this as well. Standard 4.05 of the APA Ethical Code, for example, states: “Psychologists do not engage in sexual intimacies with current patients or clients.” Standard 1.09 of the NASW Code of Ethics states: “Social workers should under no circumstances engage in sexual activities or sexual contact with current clients, whether such contact is consensual or forced.”

Despite these injunctions, sexual misconduct is one of the major causes for malpractice actions against counselors. The overall definition of sexual intimacies is broad and includes a range of sexual behaviors, including intercourse, kissing, masturbation and verbal invitations to engage in sexual activities. As with other boundary issues, the ethical obligation to refrain from sexual relationships rests exclusively with the clinician. A client’s “voluntary” participation or interest does not enable such relationships (Fisher, 2003). In addition to ethical mandates precluding sexual relationships between clients and therapists, there are those that prohibit sexual intimacies with relatives or significant others of current clients/patients and those pertaining to sexual relationships with former clients.

Like nonsexual dual relationships, sexual intimacies exploit the power differential between client and therapist and limit the provider’s ability to be objective. Sexual relationships between clinicians and clients may also exacerbate symptoms, especially for those with personality disorders or more severe psychological illnesses.

Estimates of sexual relationships between therapists and clients place these in the area of .9-3.6 percent for male therapists and .2-.5 percent for female therapists. The most important predictor of whether a client will become sexually involved with a therapist is prior sexual involvement on the part of the therapist (Pope & Vasquez, 1991). Interestingly there is also evidence that sexual attraction to clients is a common occurrence with 82 percent of therapists reporting that this has occurred for them at some point in their career (Pope & Vasquez, 1991).

Sexual misconduct with a client is usually a progressive process. Simon (1995) calls this “the road much traveled” or the “slippery slope.” He provides the following example of the steps that may precede a therapist-client sexual relationship. Simon states that the sexual relationship begins when the clinicians’ neutrality is eroded in small ways, therapy sessions may then become less clinical and more social, the client is treated as “special” or as confidante and clinician self-disclosures occur. The clinician begins touching client, progressing to hugs and embraces and may manipulate the transference. Extra-therapeutic contacts occur and/or therapy sessions are rescheduled for the end of the day and therapy sessions become extended in time. The clinician may then stop billing the client. The relationship usually culminates when dating begins; the clinician and client have drinks/dinner after sessions and clinician–client sex begins. These examples serve as a reminder of the importance of a strong therapeutic frame.

With regard to mandates pertaining to sexual intimacies with former therapy clients, the APA ethical code states that psychologists “do not engage in sexual intimacies with former clients/patients for at least two years after cessation or termination of therapy (10.08). The rationale behind this is that post therapy relationships could potentially deprive clients from seeking future services with their clinician and could compromise the credibility of court testimony or reports. There is also the risk to the client of exploitation. Although the ethical code specifies a two-year timeframe, there are several additional caveats. The therapist must demonstrate that there has been no exploitation in light of the following factors:

1. The amount of time that has passed since termination

2. The nature, duration and intensity of therapy. For example was the client seen weekly? What were the presenting issues?

3. The circumstances of termination. Were sexual feelings part of the reason for the termination

4. The client’s history. These include the presence of childhood trauma and personality disorders

5. The client’s current mental status

6. The likelihood of adverse impact

7. Any statements/action made during the course of therapy promising the possibility of a future intimate relationship

The NASW code of ethics also looks at the boundary issue of sexual contact with former clients. It states” “Social workers should not engage in sexual activities or sexual contact with former clients because of the potential for harm to the client. If social workers engage in conduct contrary to this prohibition or claim that an exception to this prohibition is warranted because of extraordinary circumstances, it is social workers—not their clients—who assume the full burden of demonstrating that the former client has not been exploited, coerced, or manipulated, intentionally or unintentionally.” There is the burden placed on the social worker to prove that the relationship is not exploitive or harmful.

In the vignette presented at the beginning of thus section, Les’s agreement to pursue any type of relationships would be considered unethical due to the client’s history of childhood sexual abuse as well as the circumstances surrounding the termination. Les would be hard pressed to prove that the relationship was not harmful.

Sexual Relationships With Client’s Family Members

Ethical provisions regarding sexual relationships also extend to client’s family members. The NASW Code of Ethics states: “Social workers should not engage in sexual activities or sexual contact with clients’ relatives or other individuals with whom clients maintain a close personal relationship when there is a risk of exploitation or potential harm to the client. Sexual activity or sexual contact with clients’ relatives or other individuals with whom clients maintain a personal relationship has the potential to be harmful to the client and may make it difficult for the social worker and client to maintain appropriate professional boundaries. Social workers—not their clients, their clients’ relatives, or other individuals with whom the client maintains a personal relationship—assume the full burden for setting clear, appropriate, and culturally sensitive boundaries.”

Case Vignette

Kim Golden, LSW, is a social worker working in a hospital setting. She worked with the Carlson family while 15-year-old Jenna was hospitalized. During the hospitalization, Kim became close to many members Jenna’s family, including her father, Rick, who is a widower. Kim is not surprised to receive a phone call Rick, asking her on a date. As Jenna has been discharged from the hospital, Kim does not hesitate to say “yes.”

This case brings up a number of potential concerns. Although Jenna is no longer a patient under her care, it is unclear whether the relationship with Rick could result in potential harm to her. It may also be the case the Jenna would need to be hospitalized at some point in the future and Kim’s connection to the family would make hospitalization where she is employed problematic. Kim should probably rethink her response to Rick.

Therapy with Former Sexual Partners

The ethical standards of our professions also look at the issue of providing therapy to former sexual partners. The NASW Code of Ethics states: “Social workers should not provide clinical services to individuals with whom they have had a prior sexual relationship. Providing clinical services to a former sexual partner has the potential to be harmful to the individual and is likely to make it difficult for the social worker and individual to maintain appropriate professional boundaries.” The APA Ethical code states: “Psychologists do not accept as therapy clients/patients persons with whom they have engaged in sexual intimacies.” Again, the reason that the ethical standards prohibit these type of relationships is that the therapist would have a difficult time maintaining objectivity if conducting treatment with someone with whom they have had an intimate connection.

Third-Party Requests for Services

Another boundary-related issue concerns third-party requests for services. Standard 3.07 of the APA ethical code states: “When psychologists agree to provide services to a person or entity at the request of a third party, psychologists attempt to clarify at the outset of the service the nature of the relationship with all individuals or organizations involved. This clarification includes the role of the psychologist (e.g., therapist, consultant, diagnostician, or expert witness), an identification of who is the client, the probable uses of the services provided or the information obtained, and the fact that there may be limits to confidentiality.” Standard 1.03(c) of the NASW Ethical Code has a similar provision.

Examples of third-party requests for services include:

• Conducting assessments (educational, employment)

• Providing court testimony

• Consulting with schools and outside agencies

In these cases therapists must explain to both the third party and those individuals who will receive services the nature of the relationship the therapist will have with all parties involved. Clarifying up front the boundary issues involved in third party relationships, there is less room for either therapist or client confusion. It also decreases the potential for harm to the client.

Consequences to the Patient of Boundary Violations

It is well established that boundary violations, especially those of a sexual nature, harm the patient. Simon (1995) describes the types of harm that may occur. In addition to direct causation such as relapse or worsening of symptoms there are more indirect consequences such as loss of trust and damage to self-esteem.

• Disengagement from services

• Depression

• Emotional turmoil

• Cognitive distortion

• Shame, fear or rage

• Guilt and self-blame

• Isolation and emptiness

• Identity confusion

• Emotional lability

• Mistrust of authority

• Self-harm behaviors

Clearly these negative aspects of boundary violations are an important consideration. Although most are related to more severe boundary crossings, the vignettes contained in this module illustrate that they may occur when the therapeutic frame allows for any confusion with regard to boundary issues.

Consequences to the Therapist of Boundary Violations

In addition to consequences to clients, boundary violations effect therapists as well. Fry (2008) describes the following consequences to therapists:

• Less personal time with family and friends

• Less job satisfaction

• Co-worker frustrations

• Burnout

• Compassion fatigue

Fry also lists “extreme” consequences of boundary violations:

• Loss of job

• Loss of license

• Loss of professional identity

• Loss of peers

• Loss of professional relationships

Prevention of Boundary Crossings and Violations

Given the discussion of boundary issues it is important to determine how to prevent unplanned/non-therapeutic boundary crossings and boundary violations. There are a number of ways to support this challenge. Peternelj-Taylor (2008) feels that one of the most important factors is taking a proactive, rather than reactive approach to boundaries. She describes three important areas to consider: education, self-awareness and monitoring, and peer debriefing/consultation. Gabbard (2008b) describes a similar approach.

Education. Norris et. al. (2003) point out that many graduate programs are moving away from psychodynamically-oriented approaches that stress transference and countertransference issues. Understanding of these key paradigms is essential in understanding boundary issues. Even if not taught in this language it is important to train newer therapists about common reactions to clients, especially those with more challenging dynamics. Boundary issues must also be a component of graduate programs and ongoing continuing education. Although it is sometimes difficult to appreciate the reality and sometimes the challenge of setting and maintaining good therapeutic boundaries until one a practicing professional, education through mediums such as case vignettes and discussion with practicing professionals is beneficial.

Supervision. Supervision is essential for early-career therapists. It is also an opportunity to process many client issues, including boundary concerns with an objective, non-judgmental party.

Self-Awareness and monitoring. Professionals need to be aware that boundary crossings do occur. Awareness that this is the case, coupled with vigilance about this fact is very helpful. Many of the therapeutic tools professionals learn in graduate programs, such as awareness of transference and countertransference mechanisms are also beneficial (e.g., “special patient” enactments, caretaking, etc.). Feelings, including sexual feelings, hostile feelings, and boredom are all responses to patients that therapists experience within the process of treatment., and recognizing that these are normal but must be managed is important. In addition there are have been a number of formal assessment tools developed that relate to therapist-client boundaries (for example Epstein & Simon, 1990). It is important to be aware of progressive actions that may lead to boundary violations, such as subtle breaks in the therapeutic frame. While such tools are useful, the question “Is this intervention made for the benefit of the therapist or for the client?” is the simplest tool.

Peer debriefing. Peer debriefing is at its heart, another name for consultation. Talking about concerns with a colleague, rather than holding in thoughts and feelings, is crucial to the prevention of boundary issues. Gabbard (2008b) describes what he terms the “Lone Ranger” problem, that is that many psychotherapists remain isolated when dealing with clinical problems. Group supervision and supervision for early career mental health professionals should also take into account the need for focus on boundary issues.

Summary

The ability to establish and maintain therapeutic boundaries is critical for mental health professionals. Boundaries are essential to client and therapist safety. There are many difficulties to establishing and maintaining therapeutic boundaries, and certain client (e.g., personality factors) and therapist characteristics (e.g., the pull to caretaker/rescue) make setting boundaries even for critical but more challenging. Our professional relationships with our clients exist for their benefit. A useful question to ask ourselves is “Whose needs are being met in this relationship, my client’s or my own?” In addition education, self-awareness and monitoring and peer consultation are important tools.

References

Bennett, B., Bricklin, P., Harris, E., Knapp, S., Vandecreek, L., & Younggren, J. (2006). Assessing and managing risk in psychological practice: An individualized approach. Rockville, MD: The Trust.

Brownlee, K. (1996). Ethics in community mental health care: The ethics of non-sexual dual relationships: A dilemma for the rural mental health profession. Community Mental Health Journal, 32(5), 497-503.

Dewane, C.J. (2010). Respecting boundaries — the don’ts of dual Relationships. Social Work Today, 10(1),18.

Everett, B. & Gallop, R. (2001) The link between childhood trauma and mental illness. Thousand Oaks, CA: Sage.

Fisher, C.B. (2003). Decoding the ethics code. London: Sage Publications.

Epstein, R.S., & Simon, R.I. (1990). The exploitation index: An early warning indicator of boundary violations in psychotherapy. Bulletin of the Menninger Clinic, 54, 450-456.

Freud, S., & Krug, S. (2002). Beyond the code of ethics, part II: Dual relationships revisited. Families in Society, 83(5), 483-492.

Fry, N.J. (2008). Social work boundaries as an ethical consideration. Downloaded October 25, 2010 from

Gabbard, G.O. (2008a). Boundaries, technique, and self-deception: A discussion of Arnold Goldberg’s “some limits of the boundary concept.” Psychoanalytic Quarterly, 77, 877-881.

Gabbard, G.O. (2008b). Prevention of boundary violations: The role of education, self-monitoring, and consultation. Psychiatric Times, 25.

Gorton G.E. & Samuel S.E. (1996). A national survey of training directors about education for prevention of psychiatrist-patient sexual exploitation. Academic Psychiatry, 20, 92-98.

Guthriel, T.G. & Gabbard, G.O. (1993). The concept of boundaries in clinical practice: Theoretical and risk-management dimensions. American Journal of Psychiatry, 150. 409-414.

Guthriel, T.G. & Gabbard, G.O. (1998). Misuses and misunderstandings of boundary theory in clinical and regulatory settings. American Journal of Psychiatry, 155. 409-414.

Hasenfeld, Y. (1987). Power in social work practice. The Social Services Review, 61(3), 469-483.

Kagle J.D., & Giebelhausen P.N. (1994). Dual relationships and professional boundaries. Social Work, 39(2), 213-220.

Mattison, M. (2000). Ethical decision-making: The person in the process. Social Work, 45(3).

Merkell, L. (2004). Managing the difficult patient and boundary issues. Downloaded October 27, 2010 from

Mittendorf, S.H., & Schroeder, J. (2005). Boundaries in social work: The ethical dilemma of social worker-client sexual relationships. Journal of Social Work Value and ethics. Downloaded October 25, 2010 from

Norris, D.M., Gutheil, T.G., & Strasburger, L.H. (2003). This couldn't happen to me: boundary problems and sexual Misconduct in the psychotherapy relationship. Psychiatric Services, 54, 517-522.

Nield-Anderson, L., Minarik, P., Dilworth, J., Jones, J., Nash, P., O’Donnell, K., & Steinmiller, E. (1999). Responding to difficult patients. American Journal of Nursing, 99(12), 26-30.

Patterson, C.H. Therapist Self-Disclosure. Downloaded October 27, 2010 from

Peternelj-Taylor, C.A. (2008). Exploring boundaries in the nurse-client relationship: Professional roles and responsibilities. Perspectives in Psychiatric Care.

Pilette, P.C., Berck, C.B. & Archer, L.C. (1995). Therapeutic management of helping boundaries. Journal of Psychosocial Nursing and Mental Health Services, 33(1), 40-47.

Pope, K.S. & Vasquez, M. (1991). Ethics in psychotherapy and counseling. San Francisco, CA: Jossey-.Bass

Reamer, F.G. (2003). Boundary issues in social work: Managing dual relationships. Social Work.

Roberts, L. W., Battaglia, J., & Epstein, R. S. (1999). Frontier ethics: Mental health care needs and ethical dilemmas in rural communities. Psychiatric Services, 50(4), 497-503.

Royal College of Psychiatrists (2002). Vulnerable clients, vulnerable doctors: Good practice in our clinical relationships (Council Report CR101). London: Royal College of Psychiatrists.

Sarkar, S.P. (2004). Boundary violation and sexual exploitation in psychiatry and psychotherapy: a review. Advances in Psychiatric Treatment, 10, 312-320

Simon, R.I. (1999). Therapist-client sex: From boundary violations to sexual misconduct. Psychiatric Clinics of North America, 22. 31-47.

Wysocker, A. (2000). Legal and ethical considerations: Sexual misconduct. Journal of the American Psychiatric Association, 6, 131-132.

................
................

Online Preview   Download