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Ethics and Boundaries Back to Course Index

 

 

 

 

Ethics and Boundaries 

  

 

 

Boundaries are the framework within which the counseling relationship occurs.  Boundaries keep the relationship professional.  They set the parameters within which the client remains safe and the treatment can be effective.  They also help to protect the clinician both emotionally and legally.

Having a strong ethical compass it critical to being a good counselor.  Are your boundaries consistent?  Do they waiver based on how you feel about the client or the situation?  Do they establish healthy relationships, enabling the client to experience personal growth?

Professional issues typically include personal disclosure, limits regarding the use of touch, the tone of the professional relationship both in treatment and with the chance meeting in public, fee setting, projected length of sessions, the limits of the relationship and ultimately end “all things ethical”. 

The primary concern in establishing and managing boundaries with each individual client must be the best interests of the client. Except for behaviors of a sexual nature or obvious conflict of interest activities, boundary considerations often are not clear-cut matters of right and wrong. Rather, they are dependent upon many factors and require careful thinking through of all the issues, always keeping in mind the best interests of the client.

Many questions arise when navigating the counseling relationship.  Should a counselor date a former client?  If they can date, how long should they wait after counseling has been terminated to have a relationship?  Should the counselor terminate counseling if they begin to privately become interested in the client?  Should a therapist accept a client’s gift? 

The relationship outside of counseling, the acceptance of gifts, and the recognition of a previous or current client in public are examples of areas that could pose problems for both the therapist and the client.

Boundary issues also involve counselors and supervisors, both during academic years and post graduation on into the work force, as well as colleague situations.  Should my aunt, as a licensed professional, be able to supervise my practicum as an intern?  If my husband is a psychologist speaking for an association offering continuing education should I be able to earn contact hours if I attend?

Most state boards and all national associations have bi-laws and regulations concerning the relationships between a counselor and a client, as well as a supervisor and a counselor.  It is good counsel to make yourself aware of the regulations and then to steer clear of any inappropriate situations.  It is also a best practice to make your clients aware of the general boundaries and why they exist such as, “please understand to protect your privacy, if I see you in public I will not acknowledge you in any way.  This is not intended to offend you, but only to protect you.  This way the client will not feel slighted should the event occur. 

In this course will explore the dynamics and potential danger zones for the counseling relationship and in the mental health field. This text will explore.

 

  •         Key Concepts Regarding Dual Relationships with Clients
  •         Physical Contact and Sexual Relationships with Clients
  •         Self Disclosure
  •         Sound Decision Making and Managing Boundaries Set
  •         Emotional and Dependency Needs
  •         Professional Distance
  •         Therapeutic Styles
  •         Dynamics Which Make Therapy a Potential Setting for Boundary Violations and    Exploitation

 

Dual Relationships with Clients

 In most friendships or marriages the relationship bears some resemblance to a seesaw.  I tell you my thoughts and in turn you tell me your thoughts.  You know my faults and I learn yours.  There is a give and take of information that creates a balance.  A therapist/client relationship is not balanced.  By the nature of the relationship, one person is telling intimate details, feelings and fears and the other is not.  This intimate knowledge creates power that has to be handled professionally.  

A dual relationship exists when a therapist serves in the capacity of both therapist and at least one other role with the same client. Most commonly the second relationship is social, financial, or professional and may be concurrent or subsequent to the therapeutic relationship. The American Psychological Association reports research citing that dilemmas arising from “blurred, dual, or conflicting relationships” were the second most frequent ethical dilemma noted.  Dual relationships can also be a major basis for licensing disciplinary actions and ethics complaints against mental health professionals. 

The Code of Ethics for the American Counseling Association (ACA) strongly advises avoidance of harmful dual relationships whenever possible:

Counselors are aware of their influential positions with respect to clients, and they avoid exploiting the trust and dependency of clients. Counselors make every effort to avoid dual relationships with clients that could impair professional judgment or increase the risk of harm to clients. When a dual relationship cannot be avoided, counselors take appropriate professional precautions such as informed consent, consultation, supervision, and documentation to ensure that judgment is not impaired and no exploitation occurs. (ACA, 1995, Standard A. 6.a.)

 

The ethics code for the American Psychological Association states that multiple relationships may be unavoidable and recommends that therapists remain aware of the pimgres-1otentially harmful consequences. They recommend refraining from multiple relationships if harm may occur.

 

The ethics codes of the American Association of Marriage and Family Therapists, National Association of Social Workers, and the American Association of Pastoral Counselors recommend avoidance of multiple relationships that exploit or harm clients. All of the above codes strictly prohibit sexual activity between therapist and client. All but the AAPT code warns against superior/subordinate dual relationships such as when a therapist has an administrative, supervisory, or evaluative role with a client.

 

A window into any relationship is only as clear as the participant’s insight.  Most people see things from their point of view.  Is it wise, with one participant in a more powerful position to enter into multiple types of relationships with someone? 

 

Therapists can and should be concerned about any behavior on their part that may interfere with their ability to maintain a professional and therapeutic relationship with their clients. When roles get blurred as when the therapist and patient become personal friends, business partners, or become involved sexually it often becomes impossible for the therapist to maintain professional objectivity. Dual relationships can erode and distort the professional nature of the therapeutic relationship. They may create conflicts of interest that compromise professional judgment or create situations where the therapist is engaged in meeting his or her own social, financial, or personal needs, rather than putting the welfare of the client foremost. Dual relationships can affect the current and future benefits of therapy.

Some of the most clear cut dual and boundary problems are therapists engaging in business ventures with patients or having sexual relationships with patients or former patients.  It is clearly unethical and in most states, therapists who have sexual relationships with clients violate the law, as well as ethical standards. But these overt situations are not the only type of dual relationships.  Friendships, dating a client’s brother, or even being neighbors are also potentially hazardous situations. 

The reality of potentially overlapping relationships and the effects of overlapping relationships make for a complicated decision making process.  To determine if a relationship outside of the therapeutic realm is hazardous a professional must explore several areas. 

 

Circumstantial roles, those that occur by pure coincidence, such as running into a client at their sales job in the mall, are difficult to avoid.  They are bound to occur and this potential and how it is to be handled should be discussed in advance.  As noted earlier:  “If I see you in public, please do not be offended, but I will not approach or acknowledge you in any way to protect your confidentiality.” 

 

Shifts in professional roles include difficulties that arise when a teacher or supervisor counsels a student. There is a clear potential for difficulty with this type of dual relationship.  Personal and professional role conflicts include sexual or romantic, social, and peer-like relationships.   These personal and professional situations are fraught with danger. 

 

Some professionals use their own comfort level to gauge whether they could successfully manage the overlapping relationship. The type and severity of the clients’ presenting problems is also used as an indicator when deciding to enter a dual relationship. Therapists are more likely to enter a dual relationship if the client is seeking problem solving and would likely avoid a dual relationship with a client if they suspected a complex issue such as a personality disorder. Other therapists involve prospective clients in the decision-making process to decide if the benefits of entering into a dual relationship outweigh the risk. Keith Brownlee (1996) expresses that “Pivotal to any decision making based on the codes, are the two central principles, impaired objectivity, and risk of exploitation.

 

When a dual relationship exists it is important to minimize the risks by engaging in ongoing consultation, setting clear expectations and boundaries, informed consent, documentation. 

 

Physical Contact and Sexual Relationships with Clients

 

The achievement of trust is possible in a therapeutic relationship because there is no fear of losing “self” in establishing a connection with a therapist.  Most clients come to the situation with a vulnerable self.   Intimacy for these individuals can easily lead to abuse if those with whom they relate prove untrustworthy. 

 

Many therapeutic styles involve the healing touch.  Hugging a client when they enter the office, holding their hand through difficult sessions or placing a hand on their shoulder when they are crying can all be ways of expressing interest and concern.  They can connect and solidify the helping relationship.  They can also be abused, misunderstood and damaging.  This issue forces counselors to examine the heart of the therapeutic process: the counseling relationship.

 

It is doubtful that most therapists set out to exploit their clients.  When a counseling relationship turns into a romantic relationship the professional will often say, I can’t help whom I fell in love with.  This type of violation is more of a process than a single event.  Yet when professionals deny or remain unaware of their personal significance, power, or authority they will begin the process of boundary violation. Any time a professional exploits a relationship to meet personal needs rather than the needs of the client, even if not consciously done, the boundaries have been crossed and the professional is responsible.

 

There is clear consensus among the professional associations that concurrent sexual and professional relationships are unethical and in many states also illegal. Many of the associations agree that a sexual relationship cannot later be converted into a therapeutic relationship.

 

Ethical codes vary in their requirements about the length of time that must pass for another “significantly different” relationship, especially a sexual one, to be permissible (Herlihy & Corey, 1992). Although most codes prohibit the counselor from having a sexual relationship with a current client, variation occurs in the prohibition of such a relationship with former clients and the length of time that must pass for such a relationship to be permissible (American Counseling Association, 1995; National Association of Alcoholism and Drug Abuse Counselors, 1995).

 

All the major professional associations agree that sexual contact less than two years after termination of the professional relationship is unethical. If a sexual relationship occurs after a two-year interval, the burden rests with the therapist to demonstrate that there has been no exploitation. Considerations include: amount of time that has passed since termination; nature and duration of therapy; circumstances surrounding termination; client’s personal history; client’s mental status; and any statements or actions by the therapist suggesting a romantic relationship after terminating the professional relationship.

There is disagreement among practitioners about whether a sexual relationship initiated after termination is ever ethical. Some maintain that “once a client, always a client.” The transference elements of the therapeutic relationship persist forever, and therefore, many professionals consider romantic relationships with former clients unethical.

 

After having various standards for a number of years, the American Psychiatric Association went from a “nearly never OK” standard to an absolute “never OK” standard. 

 

The National Association of Social Workers code prohibits sex with former clients in section 1.09, but states that if a social worker claims an exception, the full burden is on them to demonstrate “…that the former client has not been exploited, coerced, or manipulated, intentionally or unintentionally.” The codes also ban sexual contact with clients’ relatives or close personal friends where there is a potential to harm the client, but it is not clear whether this extends to a former clients’ relatives and friends.

 

The American Association for Marriage & Family Therapy has forbidden sex for 2 years after termination. This applies to either spouse or any family member who is seen in even a single session of marital or family therapy.

 

The American. Association for Pastoral Counseling has a prohibition of no sex for two years following termination of the counseling.

 

The American Psychological Association created an absolute prohibition for two years following termination of therapy. Even in relationships which begin after 2 years the psychologist has the burden of showing there has been no exploitation, in light of “relevant factors, including (1) the amount of time that has passed since therapy terminated, (2) the nature and duration of the therapy, (3) the circumstances of the termination, (4) the patient’s or client’s personal history, (5) the patient’s or client’s current mental status, (6) the likelihood of adverse impact on the patient or client and others, and (7) any statements or actions made by the therapist during the course of therapy suggesting or inviting the possibility of a post termination sexual or romantic relationship with the patient or client.”. A few standards are provided for terminating: unless precluded by the client’s conduct, “…the psychologist discusses the patient’s or client’s views and needs, provides appropriate pre-termination counseling, suggests alternative service providers as appropriate, and takes other reasonable steps to facilitate transfer of responsibility to another provider if the patient or client needs one immediately.

 

The above-mentioned associations are not meant to be finite standards.  It is recommended that each professional explore their association’s codes.  State licensure laws or certification laws in each state may also include codes of conduct, which define the post-termination relationship with a former client or patient. Most codes adopt the ethical standards of the major national professional organization for that profession. However, in some states such as Florida, the standards may be more stringent. For example, the Board of Licensure of Psychologists in Florida has a rule that for the purpose of evaluating a case of therapist-client sex, the therapeutic relationship “…is deemed to exist in perpetuity.” This was the first “never OK” rule.

 

Although sexual relationships are clearly defined there are many other forms of physical contact that many professionals utilize in their therapeutic modalities.  Professionals have argued that the increased sensitivity to physical contact with clients inhibits counseling.  In Neuro Linguistic Programming, anchoring is done by applying gentle pressure to a part of the client’s body, such as the top of the knee.  Reaching out to touch someone on the hand is a common gesture showing concern and support.  It is difficult and sad to think an innocent gesture of support could be misunderstood or potentially hazardous. 

 

Transference and counter transference can lead to harmful situations.  Intense friendships which confuse the counseling or make the client unnecessarily dependent on the helper can be very damaging to a client.  Even romantic “game playing” can be quite distracting and harmful. Even without overt sexual contact, boundary breakdowns can lead to damages similar to those seen when the relationship becomes sexual (Schoener et. al., 1989, pp. 133-147; Simon, 1991) These damages can include:

 

  •         The failure to render needed therapy — undermining what good work may have been done;
  •         Failure to refer for other services — the psychotherapist “hanging on” to the client and trying to provide for all of his or her needs;
  •         Creation of unhealthy dependency which is difficult to resolve;
  •         Confusing the client about what is therapy and what is personal;
  •         Breach of trust — client distrusting professionals as a result of the corruption of the therapy;
  •         In some instances, interference in family relationships, friendships, etc.
  •         Anger, loss of self-esteem, depression, and other psychological distress.

 

To Prevent and Avoid Sexual Misconduct: 

 

1. Respect cultural differences and be aware of the sensitivities of individual clients.

2. Do not use gestures, tone of voice, expressions, or any other behaviors which clients may interpret as seductive, sexually demeaning, or as sexually abusive.

3. Do not make sexualized comments about a client’s body or clothing.

4. Do not make sexualized or sexually demeaning comments to a client.

5. Do not criticize a client’s sexual preference.

6. Do not ask details of sexual history or sexual likes/dislikes unless directly related to the purpose of the consultation.

7. Do not request a date with a client.

8. Do not engage in inappropriate ‘affectionate’ behavior with a client such as hugging or kissing. Do offer appropriate supportive contact when warranted.

9. Do not engage in any contact that is sexual, from touching to intercourse.

10. Do not talk about your own sexual preferences, fantasies, problems, activities or performance.

11. Learn to detect and deflect seductive clients and to control the therapeutic setting.

12. Maintain good records that reflect any intimate questions of a sexual nature and document any and all comments or concerns made by a client relative to alleged sexual abuse, and any other unusual incident that may occur during the course of, or after an appointment.

 

 

Self-Disclosure 

 

How much of themselves, if anything, should effective counselors reveal to clients? Does self-disclosure by the therapist help the therapeutic process or interfere with clients’ needs? Self-Disclosure to some degree is an almost universal behavior for counselors to use with the clients.  Up to 70% of therapists have used some degree of self-disclosure in their practice. 

 

Even therapists who are uncomfortable with the idea of talking about themselves during sessions often believe that it is impossible for a therapist to be completely anonymous to their clients. After all, everything the psychologist says or does is revealing in some way to the patient. Further, an over-emphasis on this can be troubling or even damaging to the client. The client may begin to feel self-conscious about his or her own revelations or feel judged or disliked by the therapist.

 

A research study reported in The Journal of Consulting and Clinical Psychology supports appropriate self-disclosure.  Researchers from the University of Pennsylvania’s Center for Psychotherapy Research studied clients and therapists-in-training who had randomly been asked to make revelations about themselves during the course of therapy or not. The study authors found that the clients whose therapists were willing to talk about themselves or offer opinions felt more secure in the counseling process and liked their therapists better than participants whose therapists were not offering any information about themselves. The therapist’s use of self-disclosure demystifies both the therapist and the client. It allows more of the client’s essence to come out and allows the interaction to become more of a dialogue.

 

In a group setting, group leaders can use self-disclosure, just like other members of the group, to become part of the genuine flow of communication.  They openly share their thoughts and feelings in a thoughtful and accountable manner, respond to others authentically, and acknowledge or refute motives and feelings attributed to them. They can demonstrate respect for the feedback group members offer them.

 

Appropriate Self-disclosure is done for the purpose of helping the client.  Some common situations in which a therapist would be justified in making a self-disclosure include:

 

  •         The disclosure is made for the purposes of the patient not the therapist.
  •         The disclosure is that type that should be made to a patient with a certain type of disorder.  For example, if a patient is suffering from depression, the disclosure that the therapist had suffered from depression in the past might help the patient by giving him insight into the fact that a person suffering from depression can get past it. 

 

Ultimately, the appropriateness of a therapist’s self-disclosure comes down to the question of whether it was made with the patient’s best interests at heart.

 

Excessive therapist self-disclosure, however, is the most common boundary violation.  Although it does not always lead into, it is also a frequent precursor to sexual involvement with clients, as well as a number of other therapeutic mistakes. 

 

Disclosing personal information can seem very natural and as noted can be helpful to the client and the therapeutic process.  It can be done with the intent to show that the client is not alone in their specific situation or to encourage positive behaviors. 

 

Therapist self-disclosure is problematic when it involves:

 

  •         Disclosing current personal needs or problems
  •         Disclosure as a common, rather than rare event, during sessions
  •        Disclosing things not clearly connected to client’s problems or experiences; or not clearly things which would be likely to encourage or support client
  •         Self-disclosure is not only frequent, but uses up more than a few minutes in a session
  •         Self-disclosure occurs despite apparent client confusion or romantization

 

 

Sound Decision Making

 

One of the easiest gauges to use to determine if you are making good boundary decisions is to ask yourself, how would I feel if I woke up tomorrow morning and this was broadcast on the front page of the Newspaper in my hometown?  David, A Therapist in Walnut Cove, Was Supervised During His Practicum For Licensure By His Aunt Who Is Also In The Industry.  If the thought of this headline being read by your colleagues, neighbors, friends and family doesn’t leave you with a confident feeling then it probably is not a secure boundary decision.  Don’t do anything that you would not want to see on the front page of the newspaper. 

 

A second way to explore the relationship is to look for ways that this could jeopardize the counseling and the client.  For example, you are seeing Jessica who is nine years old and very upset over her parents pending divorce.  Her mother has brought her in for regular sessions for 4 months.  On one afternoon, her father comes to pick her up after her session and sparks ignite between the two of you.  It is likely not in the best interest of Jessica for the counselor with whom she has been trusting with her broken family to begin dating her father who is divorcing her mother.  Ask yourself, can I potentially see how this could negatively affect my client?

 

As seen the decision making process is at times set in place by associations and state laws, always should be in agreement with our morals and by who we want to be and be seen as, and many times a gray area that each professional must navigate by how they feel about the situation.  Many professionals feel differently based on the circumstances. An example of this is that some counselors accept gifts from their clients, some do not.

Beyond the specifics set forth in an association code or state licensing law, the counselor is left to navigate the waters.  Ultimately though, make no mistake; it is the counselor’s responsibility to cause no harm to the client.  The counselor is the sound, stable, professional in the scenario.

 

Emotional and Dependency Needs

 

It is crucial for a counselor to maintain good awareness of their own emotional and dependency needs so as to not reverse the therapeutic process for their own gain. 

 

Using excessive self-disclosure, romantic encounters-whether brought to fruition or just perpetuating a clients flirtation out of your own desire to be flattered, or financial dealings that can be seen as an exploitive are in opposition to the true goals of therapy.

It is a very dangerous power position to be in if the therapist cannot see
how he is getting his own needs met by using his position. The use of ongoing supervision can be effective here. 

 

 

Professional Distance

 

To be a successful counselor an individual needs good personal boundaries, as well.  This means allowing clients to be responsible for their own decisions and actions and allowing them to experience the consequences.  Professional distance does not mean that a counselor should be cold and uninvolved, but it is important the client works as hard as the counselor and the client owns the issue.  Burn out in the mental health field is a major issue.  Over involvement on an emotional level can cause therapists to lose their objectivity.  They cannot exercise proper judgment in their dealings with those with whom they are seeking to help.  There are many steps in establishing health professional distance, to explore a few:

 

  •         Allow clients to participate in identifying the goals of treatment.
  •         Identify resources in the community that meet specific needs for the clients so that the client can benefit from several support systems such as community projects and church groups with similar interests.
  •         Help clients to accurately evaluate their options and to see progress-establish benchmarks for measuring growth.
  •         Help clients develop strategies for handling problems outside of and between sessions.

 

 

Therapeutic Styles  


People who grow up in dysfunctional families tend to believe they are not allowed to have personal boundaries. This personal boundary, essentially the line that divides me from you, has been debated for decades by the different treatment modalities.  Freud, although he thought that a therapist should be a blank slate and should refrain from any self-disclosure, was known to take patients on vacation to analyze them.  D. W. Winnicott had patients living with him as part of their treatment. 

 

Research has failed to show that practice style is the major issue in boundary breakdowns.  Some who practice modalities that frown upon self-disclosure end up having sexual relations with their clients and some who use touch techniques never have issues. 

  

 

Dynamics Which Make Psychotherapy a Potential Setting for Boundary Violations and Exploitation        

 

Many clients come into therapy vulnerable, confused and in need.  Without clear boundaries I can’t tell what is your stuff and what is mine.  Maintaining this line is essential to effective work.  However, keeping a clear line between the client and the counselor is not easy. 

 

Some of the reasons for the difficulty include:

  •         Therapy involves a fiduciary relationship with unequal power, especially early in the relationship. The therapist sets all the rules and the therapy is conducted in private so there is little accountability.
  •         Transference
  •         Wishes for nurturing can emerge and be quite powerful
  •         Rescue fantasies — the counter transference trap of doing a better job than someone’s parents or previous therapist/counselor;
  •         Fantasy that love, or sex, are curative in and of themselves
  •         Repression or disavowal of anger at client’s persistent thwarting of your therapeutic efforts
  •         It is a fertile ground for acting out anger at organization, supervisor, etc.
  •         Defense against grief and mourning at termination;
  •         It is an unreal world — the “exception” fantasy
  •         Cultural myth that the “right woman” can fix the most disordered man

 

 

Supervisory Oversight imgres-12

Some areas which require self-awareness and watchfulness by ones’ supervisors or consultants include:

  • Obvious therapist distress or upset
  • Therapeutic drift — shifting style and approach to a given client
  • Lack of goals and reflection on progress in therapy
  • Therapy which exceeds normal length for a client of that type in the particular therapist’s practice.
  • Exceeding areas of competence, reluctance or unwillingness to refer for other types of therapy, assessment, etc.
  • Unwise techniques:

o        Routine hugs

o        Face to face, intimate hugs

o        Excessive touch

o        Sessions in non-traditional setting when this isn’t necessary

o        Adult clients on lap

o        Routine or common socializing with clients

o        Excessive self-disclosure by therapist

o        Direct intervention in client’s life

o        Attraction

o        Over-identification with client

o        Uniquely similar family dynamics

o        Divorce or loss in therapist’s life

o        Identity disturbance in therapist


Summation

 

Public opinion and courts have lead the way.  Therapists can and have been sued for malpractice when their treatment lead to harming their patients and one of the most common causes of malpractice is therapists having sexual relations with patients and former patients.

 

Nowadays, virtually every professional discipline has ethical codes, which cover boundary issues and most expressly prohibit sexual relations with patients.   

 

In order to establish a helping relationship the individual in need must relinquish some level of control to create trust.  The client or patient’s trust rests on the assumption that the professional will operate within the context of the client’s need.   When the client expects this and projects an aura of sanctity onto the professional, the client’s vulnerability becomes a key factor in the relationship.   This is the reason that a client (adult or teen, male or female) is not considered morally and legally culpable if an illicit relationship develops between the two.  It remains incumbent upon the professional to set the limits of the relationship.

 

The key to dealing with these issues?  Know who you are; know your strengths and weaknesses; and commit to use your strengths (power) in service to others.  Find ways outside of the therapeutic process of having your personal needs for intimacy met appropriately.  No spouse or best friend can meet all your needs but perhaps a cluster of persons with whom you share a reciprocal relationship can.  No one seeking your help in a professional role should be meeting your needs for receiving care.

 

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