Boundary crossings

Report
OKLAHOMA DRUG AND ALCOHOL
PROFESSIONAL COUNSELOR
ASSOCIATION
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN
COUNSELING AND THERAPY:
KNOWING WHERE TO
DRAW THE LINE.
APRIL 4 -5, 2014 -NORMAN, OK
JUDITH K. ADAMS, PH.D., LMFT, LADC
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Boundaries in counseling or therapy define
the therapeutic-fiduciary relationships.
Boundaries define what has been referred to
as the "therapeutic frame."
 (Fiduciary=
faithful, dutiful)
These boundaries distinguish therapy
from social, familial, sexual, business
and many other types of relationships.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Key Points
1. Boundary violations in therapy are
different from boundary crossings.
Boundary violations and boundary crossings may
be seen as a departure from the traditional milieu
of counseling and psychotherapy.
Boundary violations and boundary crossings in
therapy refer to any deviation from traditional,
strict, 'only in the office,' emotionally detached
or distant forms of therapy or deviation from rigid
risk-management protocols.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Crossing vs. violating “boundaries” concerns
issues of:
• Self-disclosure, personal revelation by the counselor
• Incidental encounters with clients in stores, community or sports events, large vs. small church)
• Physical contact with clients, such as handshake,
touch, or hugs
• Giving gifts to or receiving gifts from a client
• Bartering or provided services pro-bono in lieu of
charging: Out-of-office visits, such as home or hospital
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
“Boundaries” concerns refer to issues of
engaging in activities with clients outside the office
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Attending clients’ school plays, weddings, or
graduations
Adventure therapy, ROPES courses
Recreational outings, dances, etc.,
Attending the same recovery meeting as a client
Eating with a client for therapeutic vs. social reasons
E-therapy, electronic media, social networking
Various other forms of “dual” relationships.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Key Points
3. Boundary crossings are not all
inherently unethical.
Ethics code of all major mental health
professional associations (e.g., APA, ApA, NASW,
ACA, NBCC) do not prohibit (non-harmful)
boundary crossings, only (harmful)
boundary violations
Key word Harmful
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Key Points
2. Boundary violations by therapists are harmful
to their clients
Boundary crossings are not harmful and can
even prove to be helpful or therapeutic.
For example, harmful boundary violations occur
typically when therapists are engaged in
exploitative dual relationships, such as sexual
contacts with clients or other exploitative
relationships. This could be also occur in business,
politics, etc.
Key word Exploitative
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Dual or multiple relationships in therapy refers
to any situation where multiple roles exist between a
therapist and a client.
Examples of multiple or dual relationships are when
the client is also a student, friend, family member,
employee or business associate of the therapist. This
discussion refers to non-sexual dual relationships.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Most of these codes state that dual or multiple
relationships should be avoided if they could
reasonably be expected to impair the
therapists’ effectiveness or cause harm to the
client or therapeutic relationship.
Boundary violations occur when therapists cross
the line of decency and violate or exploit their clients.
Harm to the client is the criterion for judgment.
Key concept Impair Effectiveness
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Harmful boundary violations occur
typically when therapists and patients
are engaged in exploitative dual
relationships, such as sexual contacts
with current clients.
Sexual involvement with past clients is
also unethical.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
The boundary violation of becoming sexually
involved with a client is one of the
greatest sources of ethical complaints.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
The rule, contained within the Board of Licensed
Alcohol and Drug Counselors Act says:
A sexual dual relationship is where therapist and
client are also involved in a sexual relationship.
Sexual dual relationships with current clients are
always unethical and often illegal. The time frame
for involvement with past clients varies between
ethics codes.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Rule No 1: if there is a clear
prohibition against a certain boundary
situation,
i.e., do not become sexually intimate
with clients,
then DON’T DO IT!!!!
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Despite the prohibition against sexual involvement with
clients, either current or past, many ethical complaints
are filed every year against alcohol and drug counselors
for sexual involvement with clients.
Obviously, this prohibition needs greater
emphasis.
Sexual involvement with clients is a fundamental
violation of the professional-client relationship that
undermines the therapeutic relationship and creates a
range of psychological wounding to the client.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Do not enter into sexual relations with a
client: it is likely to impair your judgment
and nullify your clinical effectiveness.
You may “trust” the client, but you put your
professional career on the line.
You will be forever held hostage
to the possibility that the client will
report you for an ethical violation
and your life goes down the tubes.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
As a professional counselor, you should:
 Recognize when you have issues with attraction to a client.
 Be aware of the potential for a client being attracted to
you.
 Consider the clinical information, as it may be relevant to
the development of physical attraction, even sexual
exploitation.
 Seek supervision in situations that warrant particular
attention. (Put yourself in “time out.”)
 Be fully aware of the risks which sexual involvement poses.
 Consider the alternative of referring the client, having a
supervisor readily available, or establishing other “buffers”
between you and the client.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Therapist factors increasing risk of engaging in a
harmful, exploitative, and/or sexual relationship with a
client.
 If you are recently divorced, without close friends, or do
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not have adequate social networks.
If you live an isolated life, where work is your primary
social outlet.
If you rely on your clients for too much of your
professional/personal satisfaction.
If you have not resolved personal issues and/or are not
working an effective recovery program.
If you have a ‘personality disorder,’ are focused on
yourself, and/or inclined to rationalize and justify having a
personal relationship with the client.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Sexual relationships are exploitive and harmful.
Certainly, we do not have ethical justification for an
exploitive or sexual dual relationship with clients.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Key Points
4. Some boundaries are drawn around the
therapeutic relationship & include concerns with
time and place of sessions, fees and confidentiality
or privacy.
Boundaries of another sort are drawn
between therapists and clients rather than
around them and include therapists’ self-disclosure,
physical contact (i.e., touch), giving and receiving
gifts, contact/communication outside of the normal
therapy session, and proximity of therapist and
client during sessions.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Many boundary crossings are
not sexual in nature.
A multiple or dual relationship may be
non-sexual but still be exploitative;
they are therefore unethical.
Non-sexual multiple or dual relationships
also may be non-exploitive;
they are therefore ethical.
The Big Question becomes: How do you
know if it’s crossing the line, in a bad way?
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
In real life, the “boundaries” of
boundaries may be fuzzy.
(Isn’t that brilliant?)
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Exploitative business relationships also
constitute boundary violations.
Jim has been charged with a felony crime which could
result in his going to prison. He had been drinking at
the time and hopes that you can do an evaluation and
attest that he was in a blackout, which might be a
defense for him. He tells you that he doesn’t have much
money but he recently started a business and he would
be willing to make you a partner in the business, which
could make you a lot of money.
Would you accept his offer?
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Key Points
5. Boundary crossing often involves clinically
effective interventions, such as self-disclosure, home
visits, non-sexual touch, gifts or bartering, or
therapy-based out-of-office contact.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
A potentially helpful boundary crossing would be:
A female counselor has a female patient, who is
going through menopause and who feels very
unattractive with her appearance: she is concerned
that her husband doesn’t love her any more. The
counselor accompanies the client to another building
in their treatment complex, where the client receives
instruction and guidance on exercise, makeup,
grooming, and her appearance in general.
Is this a boundary crossing or boundary violation?
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Potentially helpful boundary crossings also include
going on a hike with an adolescent client; giving a
non-sexual hug to a grieving client; sending
cards; exchanging appropriate, not too expensive,
gifts; lending a book to a client; attending a
wedding, confirmation, Bar Mitzvah or funeral; or
going to see a client receive a commendation or
perform in a show.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Key Points
6. Boundary crossings can be an integral part of
well formulated treatment plans or evidencebased treatment plans. Certain therapeutic
approaches are more flexible.
It is recommended that the rationale for boundary
crossings be clearly articulated and, when
appropriate, included in the treatment plan.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Residential programs often have staff transport clients
on recreational outings, to doctor’s appointments, or to
local AA meetings. In some instances, staff members
attend the same recovery meetings as clients.
A counselor may be may be requested to see a client in
the jail, in prison, in a hospital, or in a group home.
Other examples are making a home visit, doing a home
assessment to a bed-ridden elderly patient, having
lunch with an anorexic patient, or going for a vigorous
walk with a depressed patient.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Examples of common interactions which may or may
not be within ethical boundaries:
 giving a supportive hug to a grieving client
 lending a CD (book, pamphlet, Big Book) to a client
 sending a card of congratulations, sympathy, or
encouragement
 accepting a small termination gift from a client
 accepting a bartering with a cash-poor client
 assisting a phobic client to schedule and keep a
dreaded but important doctor's appointment
BOUNDARY CROSSINGS & BOUNDARY
VIOLATIONS IN THERAPY
Have you ever visited a client in the hospital, half-way
house (when you treated the client at a different level of
care) at jail, prison, or other location?
Did you consider it problematic to see
the client in that location? Why or why not?
Are you in a job position of making home visits?
What parameters do you consider when making a
home visit?
What risks may be engendered by going to the home
of clients/consumers?
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Some counseling formats may endorse “out of
office” contacts.
Making a home visit, taking a child (or parent and
child) on a shopping trip for school supplies, or
transporting a client to a doctor’s appoints, are
boundary crossings which do
not necessary constitute unethical
dual relationships.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Therapeutically sanctioned or therapy-based
“out-of-office” contact with clients are not likely to
be unethical.
When may it be acceptable and when is it not
acceptable?
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Would the following interventions constitute
unethical dual relationships or boundary crossings?
Bob works with substance abusers who have recently
been released from prison. Moving toward employability
is a part of the major purpose of the program in which
he which he works. He helps program participants sign
up for their G.E.D., goes over the test requirements,
then transports them to the location to take their test.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Would the following interventions constitute
unethical dual relationships or boundary crossings?
Mary works in a sheltered workshop with developmentally
disabled clients, who have very little opportunity to socialize
with other clients. Mary helps arrange a dance and party for
her clients and she attends with them. She even gets out on
the dance floor with the clients. They all enjoy themselves.
A behavioral therapist takes the therapy
outside the office and walks with an
agoraphobic client to an open space,
as part of an in vivo intervention.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Rule No 2. You can worry less if you have
therapeutic justification for the boundary
crossing.
Ask yourself:
Is this interaction documented in your treatment plan?
 Do your clinical notes indicate this was a therapeutic
issue, and you interaction integral to treatment?
 Was the boundary crossing interaction clearly directed at
client stabilization/benefit, symptom-reduction, skill
development, or personal growth?
 Although a deviation from ‘standard” practice, can you
readily assure the client, yourself, and supervisors
that you conducted yourself professionally?

BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Other interactions, perhaps less common, which may arise
and may not be potentially harmful boundary crossings:
 making a hospital, home, or jail visit to a client
 attending a therapy-compatible ceremony for the client
 engaging “in vivo” treatment methods, such as going to
the mall with an patient with agoraphobia
 walking or “activity therapy” with a client
 going to see a shy client perform in a show
 attending a wedding, confirmation, Bar Mitzvah or
funeral for a client or family member of a client
BOUNDARY CROSSINGS & BOUNDARY
VIOLATIONS IN THERAPY
If you live in a small community, trying to avoid all forms of
dual relationship, even non-sexual dual relationships, may
be awkward, inconvenient, or impossible. The car
mechanic, pharmacist, grocery store clerk, Avon lady,
nurse’s aid may be clients.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Counselors and other therapists who work with children
routinely leave the office for walks with them and or
perhaps attend school plays in which they are performing.
Numerous other “treatment justified” contacts with
clients out of the office may occur.
Question: Would you attend a graduation
ceremony for a client? How would you
decide? Where would you sit? Would you
talk to the client? Would the age of the
client or therapeutic issues be factors?
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
EXPLOITIVE VS. NON-EXPLOITATIVE
NON-SEXUAL DUAL RELATIONSHIPS
IN THERAPY
How can you determine if a relationship is crossing the
boundaries from being a therapist to be a peer or friend?
The boundaries of boundaries are sometimes fuzzy.
(Boundaries of boundaries really aren’t boundaries)
We need some guidance on how to decide if we are keeping
the professional relationship or if we are letting our
professionalism be overshadowed by the non-counseling
interaction.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Gottlieb (1993) developed a model for evaluating dual
relationships and for dealing with them. The assumptions
of this model are:
1. The model applies to all professional relationships; i.e.
relationships with students, supervisees, and clients,
regardless of the theoretical orientation.
2. The aspirational goal of avoiding all dual relationships is
unrealistic. Decisions need to be made sensibly,
sensitively, and effectively.
3. All relationships with consumers should be evaluated to
assess potential harm.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
The assumptions of Gottlieb’s (1993) model include:
4. Not all dual relationships are exploitative, per se. Some
are “low risk” and some may actually be beneficial.
Relationships which are harmful should be avoided or
discontinued.
5. The purpose of Gottlieb’s model is to sensitize
practitioners to the relevant issues and make
recommendations for action.
6. The model assumes that the professional’s dilemma
results from “contemplation” of a second relationship, not
when one already exists.
7. The risk must be assessed from the perspective of the
consumer, not the professional. Decisions must be made
on a conservative basis. [Err on the side of caution.]
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Gottlieb’s model considers three dimensions:

Power

Duration (of the Relationship)

Clarity of Termination
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Power refers to the amount of power a counselor has
with/over the other person, which may vary greatly
from situation to situation.
The amount of power the counselor has over the
client increases over time. The counselor has
more power or influence over a client who comes
for several years than one who comes for only one
or two sessions.
The professional relationship continues as
long as the consumer assumes that it does,
regardless of the amount of time elapsed or
contact in the interim.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Low
Little or no personal relationship
or
Persons consider each other peers
(may include elements of influence)
Brief
Single or few contacts over
short period of time
Specific
Relationship is limited by time
Externally imposed or by prior
agreement of parties who are
unlikely to see each other again.
POWER
Mid-Range
High
Clear power differential
present but relationship
is circumscribed
Clear power differential
with profound personal
influence possible
DURATION
Intermediate
Regular contact over a limited
period of time
TERMINATION
Uncertain
Professional function is
completed but further contact
is not ruled out
Long
Continuous or episodic
contact over a long period
of time
Indefinite
No agreement when or if
termination is to take
place
BOUNDARY CROSSINGS & BOUNDARY
VIOLATIONS IN THERAPY
Evaluate current relationship using three dimensions
Relationship falls to the right side
on most or all dimensions
No
Yes
Relationship falls at mid-range
Discontinue relationship:
or to the left on most dimensions
obtain consultation if needed
Yes
Use dimensions to evaluate
contemplating relationship
Contemplated relationship falls
to the right side on most dimensions
No
Contemplated relationship falls
at the mid- range or to the left
Yes
Yes
Discontinue relationship:
obtain consultation if needed
Evaluate in terms of
role incompatibility
No
Relationship may be non-exploitive
Yes
Discontinue relationship:
obtain consultation if needed
Obtain consultation
Discuss above with consumer
as a matter of informed consent
Discontinue
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Consider the following cases, using Gottlieb’s model:
Mr. Harry Potter receives a referral for Ms. Smith, an
attractive young woman, who is facing some legal difficulty
and needs an evaluation. Harry has done similar referrals
of this type, so that he has developed a “protocol” for the
assessment. He agrees to accept the referral, which will
consist of about four to five sessions, including a detailed
clinical interview, administration of several questionnaires
and tests, then completion of his report.
How would this scenario be evaluated, considering the
dimensions of power, duration, and termination?
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Let’s try another hypothetical case:
Billy Bob is an alcohol and drug counselor, who has also
obtained his credentialing for working with mental health
clients. He receives a referral of a lady, whose husband
recently passed away suddenly. Her husband was a
businessman, so the female client didn’t have to work, unless
she wanted to – off and on. She was very dependent on her
husband, who was 21 years older than herself. When Billy
Bob meets her, he finds she is very attractive and “dresses to
the nines.” She is heart-broken, wants to come to counseling
at least once a week, and can afford to come to counseling
indefinitely. She is highly emotional, at times dramatic.
How would this scenario be evaluated, considering the
dimensions of power, duration, and termination?
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Eleanor receives a request for services from a middle-aged
male, who is a few years older than herself. He has been
ordered to attend “anger management counseling,” which is
a specialty of Eleanor’s. She provides an anger management
program, which consists of 10 sessions, each of which is 1.5
hours long. This anger management “course” is expected to
be completed in 3 months, since she allows a little flexibility
for make-up sessions, if the client has a good reason for
missing a session and does not reschedule more than twice.
If she sees additional problems, she can recommend
additional counseling and her recommendation is usually
well respected by the court.
How would this scenario be evaluated, considering the
dimensions of power, duration, and termination?
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Key Points
7. Counselors should consider contextual constraints.
Determining the best course of action may be impacted by
whether that counselor is working in a substance abuse
treatment program, a residential treatment center for
adolescents, a program for eating disorders, or an out-patient
counseling practice.
The course of action should be based on whether the “boundary
crossing” is justified by your treatment protocol.
Going to the cafeteria at an eating disorders
residential program or having an ice cream cone
with an eating disordered client may be justified: g0ing for ice
cream to the local ice cream shop with a
substance abuse client would not be.
BOUNDARY CROSSINGS & BOUNDARY
VIOLATIONS IN THERAPY
 Your agency/office/treatment center may have explicit
policies, developed to help counselors maintain clear
boundaries. For example, the agency may have a policy
that gifts become the property of the agency, rather than
the counselor.
 You must also consider other factors, such as state laws,
cultural factors, community mores and situational factors
come into play. If you are a female counselor working with
male felons, hugging would seem inappropriate.
 The client’s particular history and personality
characteristics are relevant. Physical contact with a
person who has a history of being sexual abused must be
well thought-out.
BOUNDARY CROSSINGS & BOUNDARY
VIOLATIONS IN THERAPY
 The qualities of the therapeutic relationship and
the counselor himself or herself are also of
significance.
 A hug may be appropriate for one client but not
another: one client may have clear boundaries
him/herself, while the other may not have clear
boundaries, due to a history of abuse,
exploitation, poor parenting, or blurred
boundaries in his/her past experience.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Incidental Contact with Clients Outside of
the Office:
Not Treatment Based or Counseling-Related
Boundary crossings are unavoidable, somewhat
expected, and relatively normal in small communities such as rural, military, universities and
interdependent communities.
Totally avoiding all contact with clients or former
clients would possibly result in counselors isolating
themselves, forfeiting community activity, and
treating clients like undesirable or second-class.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Many situations may arise which may be
considered a non-sexual multiple or “dual
relationship,” where a therapeutic role existed or
exists, along with another informal or “social” form
of interaction.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
In some circumstances, interacting with clients
and being known to them from another setting can
be seen as positive, i.e., participating in
community activities.
Even in larger cities, boundary crossings may
occur when providing counseling to persons who
come from a distinct ethnic background, persons
in the deaf community, persons within the gays
and lesbian community, etc.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Discussion Question:
You live in a small town, where there are only a
couple of mental health counselors. You receive a
referral of a client who was married to your cousin.
You know about their marital difficulties, the fact
that the referred client was cheating, prior to their
breaking up. You reluctantly accept the referral.
Then you find out that this client in part-owner of a
business that you frequent and you might see the
client there.
What do you do?
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
 Is
it a “dual relationship” to shop at a store at
which your client works?
 What
if that is the only store where you can
purchase a particular product?
 What
if your client is the only one in your town
who has a specialized service and, unless you
want to drive over 50 miles, you would have to
use the services of your client?
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
You purchase some Girl Scout cookies, then find
out that the girl scout who sold them to you is the
daughter of a former client.
You participate in social events with 40-50 adults
present, among whom is a former client. Is this a
boundary crossing or boundary violation?
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
As with dual relationships, boundary crossings
should be implemented according to the client's
unique needs and the specific situation.
Question: What “unique needs” can you think of
that might affect your decision-making process?
Age, gender, ethnicity, economic status,
psychological makeup?
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Let’s consider another scenario.
Is there a problem for you to attend a
large church where several of your
clients also attend?
Ask yourself:
What level of contact would you have?
Do you have direct contact with the client and if so, to
what extent?
Are there several services, so that you may not even
see or interact with the client?
Would your counseling relationship be compromised?
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Let’s consider yet another of these scenarios.
How would you handle a situation in which
you register for a workshop or class and then
discover that several former clients will also
be attending? Should you withdraw or can
you stay enrolled?
Considerations: what is the class size? How much interaction
is required in the class, i.e., is it lecture, lab, group projects
or group interaction? Will this compromise your
professional position to be in the class with a client or
former client? What is the nature of the class, CPR (not as
much risk) vs. self-exploration (not good)
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Make sure your clinical records document clearly
all consultations, substantiations of your
conclusion, potential risks and benefits of
intervention, theoretical and empirical support of
your conclusion, when available, and the
discussion of these issues with your client.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
 Circumstances present themselves when you may
be inclined to hug a client or to give a reassuring
touch.
 Question: What guidelines do you set for
yourself (or are set for you) with regard to
hugging clients? Where? When? How?
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Therapists who work with different cultures
inevitably join their Native American clients
in some of their sacred rituals, their Latin
clients in weddings, their Catholic clients in
confirmations, or their Jewish clients for
Bar or Bat Mitzvahs. Refusing to do so in
certain settings may cause “irreparable damage” to
the therapeutic alliance,
nullify trust and render
therapy ineffective.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Different cultures have different expectations,
customs and values and therefore judge the
appropriateness of boundary crossings differently.
More communally oriented cultures, such as the
Latino, African American or
Native Americans, are more
likely to expect boundary
crossings, and frown upon
the rigid implementation of
boundaries in therapy.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Key Points
8. Avoiding all dual relationships, including nonsexual dual relationships keeps therapists in
unrealistic and inappropriate power positions,
increasing the likelihood of exploitation.
BOUNDARY CROSSINGS & BOUNDARY
VIOLATIONS IN THERAPY
One source suggests that non-therapeutic outof-office contact be considered based on the
Level of Involvement
 Low-minimal level: When a therapist runs into a
client in the local market or in the theatre parking lot.
 Medium
level: When a client and therapist share
occasional encounters, as attending church services
every week, an occasional PTA meeting, a homeowners’
association meeting four times a year.
 Intense
level: When therapist and client socialize,
work, attend functions or serve on committees together
on a regular basis.
Not all out-of-office encounters are the same.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Question:
Is it a problem for you and a client attending the
same recovery meeting?
Would you be comfortable or uncomfortable?
Would it be harmful to the client?
Does it make any difference if the client is active
client or former client?
Would this compromise your
professional role?
What can you say about the
intensity of that setting?
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
More is known about the types of clients who
may warrant heightened levels of caution and
more strict adherence to boundaries?
In fact, counselors should be aware of a
number of factors that may signal need for
greater caution.
Those factors include client characteristics,
qualities of the setting, characteristics of the
therapeutic setting and interaction, and last
but not least, characteristics of the counselor
or therapist.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Boundaries are defined by several factors in the therapy
context.
The meaning of boundaries and their appropriate
application can only be understood and assessed
within the context of therapy, which consists
of 4 main components:
Client factors
Setting factors
Therapy (modality) factors
Therapeutic relationship factors/Ttherapist
factors
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Client factors that may influence implementation of
boundaries include:
o
Culture and ethnicity (or subculture)
o
History–such as trauma, sexual &/or physical abuse
o
Age, gender,
o
Socio-economic class, i.e., tendency to blur boundaries
o
Presenting problem, mental state; type and severity of
mental disturbances,
o
Personality type and/or personality disorder, sexual
orientation, social support, religious and/or
spiritual beliefs and practices, physical health,
o
Prior experience with therapy and therapists, etc.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Client variables are one consideration
considering a “boundaries” issue.
when
Boundary crossings with certain clients, such as those
with borderline personality disorder, must be
approached with caution. Particular caution ma\may
be warranted with client with extensive sexual abuse
history.
Effective therapy with some clients may require a
clearly structured and well-defined therapeutic
environment.
Caution. Caution. Caution.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Client factors may influence implementation of
boundaries.
For example, you may be more willing to transport a
client of the same gender as yourself.
You may have little concern about taking a 75-year-old
grandmother to a doctor’s appointment, but a great
deal of concern taking an 18-year-old young woman to
that same type of appointment.
Be particularly careful about interaction with clients
(female) with a history of sexual abuse.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Setting factors affecting boundaries include:
 outpatient vs. inpatient; working with a “team”
 solo practice vs. group practice;
 office in medical building vs. private setting vs.
home office;
 free-standing clinic vs. hospital-based clinic;
 privately owned clinic vs. publicly run agency;
 the presence or proximity of a receptionist, staff
or other professionals.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Setting factors also includes
• Locality: Large, metropolitan area vs. small,
rural town vs. Indian reservation;
• Affluent, suburban setting vs. poor
neighborhood vs. university counseling center;
• Major urban setting vs. remote military base,
prison or police department setting.
 Rural areas, small communities, and military
bases may result in “dual relationships,” although
not necessarily unethical.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Therapeutic
factors may also impact the
likelihood of a dual relationship developing.
Therapeutic orientations, such as humanistic,
behavioral, cognitive, behavioral, family systems,
feminist or group therapy are more likely to endorse
boundary crossings as part of effective treatment than
analytically or dynamically oriented therapies.
What is considered a harmful boundary violation
according to one theoretical orientation may be
considered a helpful boundary crossing by another
orientation.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
In general, the more intense the interaction, the more likely
for boundary blurring to take place.
A clinician working in a solo practice is at greater risk that
one working in a group practice;
Maintaining a professional office lends less risk of boundary
blurring while officing in a private setting or home is higher
risk of boundary violations.
The presence of other professionals tends to serve as a
protection, whereas a free-standing clinic may lead to more
vague boundaries. The presence or proximity of a
receptionist, staff or other professionals serves as a
safeguard.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Therapy Factors affecting boundaries include:
Modality:
o
Individual vs. couple vs. family vs. group therapy;
o
Short term vs. long term vs. intermittent long-term therapy;
Intensity:
o
Therapy sessions several times a week vs. once a week, once a month
Client Population: Child, adolescent vs. adult therapy; geriatric therapy.
Theoretical Orientation:
o
Psychoanalysis vs. humanistic vs. group therapy vs. body therapy vs.
eclectic therapy.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Therapeutic relationship factors :
 Quality and nature of therapeutic alliance, i.e., secure,
trusting, tentative, fearful or safe connection.
 Intense and involved vs. neutral or casual relationships;
 Length, i.e., new vs. long-term relationship;
 Period, i.e., beginning of therapy vs. middle of therapy vs.
towards termination;
 Idealized/transferential relationships vs. familiar and more
egalitarian relationships;
 Familiarity and interactivity in the community vs. only in
the office, distanced relationship;
 Presence or absence of overlapping relationships and of
what type, if applicable.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Therapist factors include: Culture, age, gender,
sexual orientation; scope of practice (i.e., training
and experience).
 Age
 Marital or personal relationship status
 Personality variables, i.e., no personality
disorder
 Experience in conducting therapy and managing
therapeutic relationships
 Personal adjustment, healthy recovery
 Integrity and morality
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Therapist factors:
Discussion Question: How would you evaluate
yourself and these factors, i.e., the therapeutic
setting, locality of practice, therapy context,
theoretical orientation, and therapeutic
relationship factors?
Personal examples you are willing to
share?
BOUNDARY CROSSINGS & BOUNDARY
VIOLATIONS IN THERAPY
GUIDELINES FOR NON-SEXUAL DUAL RELATIONSHIPS IN THERAPY: Treatment plans:
1. Develop a clear treatment plan for clinical interventions
which are based on the context of therapy. As indicated
above, the context includes client, therapy, setting and
therapy factors.
Client's personality, culture, diagnosis, gender, etc., are of
the highest importance in determining the Treatment Plan.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
GUIDELINES FOR NON-SEXUAL DUAL
RELATIONSHIPS IN THERAPY:
Treatment plans:
2. Intervene with your clients according to their
needs, as outlined in each of their treatment
plans, and not according to any graduate school
professor's or supervisor's dogma or even your
own beloved theoretical orientation.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
3. Some treatment plans may necessitate dual
relationships however, in other situations dual
relationships should be ruled out. Make sure you know the
difference.
4. If planning on entering a dual relationship you must
take into consideration the welfare of the client,
effectiveness of treatment, avoidance of harm and
exploitation, conflict of interest, and the impairment of
clinical judgment. These are the paramount and
appropriate concerns.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
5. Act with competence and integrity while minimizing risk
by following these guidelines. Do not let fear of lawsuits,
licensing boards or attorneys determine your treatment
plans or clinical inter-entions. Do not let dogmatic
thinking affect your critical thinking.
6. Incorporate dual relationships into your treatment plans
only when they are not likely to impair your
clinical judgment, or create a conflict of interest.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
7. Remember that treatment planning is an essential and
irreplaceable part of your clinical records and your first
line of defense.
8. Consult with clinical, ethical or legal experts in very
complex cases and document the consultations well.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Prior to and during therapy which includes dual
relationships:
9. Study the clinical, ethical, legal and spiritual complexities
and potential ramifications of entering into dual
relationships.
10. Attend to and be aware of your own needs through
personal therapy, consultations with colleagues,
supervision or self-analysis. Awareness of your own
conscious and unconscious needs and biases helps avoid
cluttering the dual relationship.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
11. Before entering into complex dual relationships, consult
with well-informed and non-dogmatic peers, consultants,
and supervisors.
12. When consulting with attorneys, ethics experts and other
non-clinical consultants make sure you use the information
to educate and inform yourself, rather than as clinical
guidelines. Separate knowledge of law and ethics from care,
integrity, decency and above all effectiveness. Remember
you are paid to help and heal, not to protect yourself.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Informed Consent
13. Discuss with your clients the complexity, richness,
potential benefits, drawbacks and likely risks that may arise
due to dual relationships. (Informed Consent)
14. Make sure that your office policies include the risks and
benefits of dual relationships and that they are fully
explained, read and signed by your clients before you
implement them.
15. It is recommended that the rationale for boundary
crossings be clearly articulated and, when appropriate,
included in the treatment plan.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Clinical integrity and effectiveness:
16. Remember you are setting an example. Model civility,
integrity, emotionality, humanity, courage, and, when
appropriate, duality.
17. As a role model, telling your own stories can be an
important part of therapy. Make sure that the stories are
told in order to help the client and not to satisfy your own
needs.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Clinical integrity and effectiveness:
18. Remember that you are being paid to provide help.
At the heart of all ethical guidelines is the mandate that you
act on your clients' behalf and avoid harm. That means you
must do what is helpful, including dual relationships when
appropriate.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
19. Answer clients' basic and legitimate questions about
your values and beliefs, including your thoughts on dual
relationships.
Documentation and Recordkeeping
20. Continue to keep excellent written records throughout
treatment. Keep records of all your clinical interventions,
including dual relationships, additional consultations and
your own and your clients' assessment of treatment and its
progress.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Treatment Evaluation
21. Evaluate and update your approach, attitudes,
treatment plans and above all effectiveness regularly.
22. If you find yourself in a dual relationship which either is
not benefiting the client or is causing distress and harm, or
has unexpectedly brought about conflict of interest, consult
and, if necessary, stop or ease out of the dual relationship in
a way that preserves the client's welfare in the best possible
way.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Key Points No. 8: Evaluate yourself and
boundary crossings
Ask yourself: How can I explain this to my supervisor,
to my ethics board, and to my liability insurance
carrier.
 If an “issue” is raised regarding your behavior, will
you be able to justify it, with the criterion being
“beneficial to the client” or “in the client’s best
interest.
 Check your own ethics code for clarification.
 Consult the literature: review the history of similar
situations.
 See supervision: don’t duck self-reporting.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
12. There is a prevalent but erroneous and
unfounded belief about the 'slippery slope'
that claims that minor boundary crossings
inevitably lead to boundary violations and
sexual relationships.
This somewhat paranoid approach is based on the
'snow ball' effect. It predicts that the giving of a
simple gift likely ends up in a business relationship, a
therapist's self-disclosure becomes an intricate social
relationship, or a non-sexual hug turns into a sexual
relationship.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Summary & Guidelines for Bartering in THERAPY
General Points:
 Barter is the acceptance of services, goods or other nonmonetary remuneration from clients in return for
psychological services.
 Bartering is not inherently unethical, illegal or counterclinical.
 Bartering is common with poor clients who seek or need
therapy but do not have the money to pay for it.
 Bartering for THERAPY is also very common in cultures
and communities where bartering is an accepted norm for
compensation and exchange.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
 Bartering that is likely to benefit clients can be part of a
clinical intervention, negotiated with clients and
articulated in the treatment plan.
 Bartering can be of goods (chicken, furniture, etc.) or
services (automobile repair, plumbing, graphic design,
etc.).
 Some poor agriculture communities may have more
flexible bartering schedules where the arrangement is a
chicken and some fresh produce for each session.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Most analytically oriented therapists, consumer protection
agencies and risk management experts frown upon
bartering. The traditional analysts view bartering as
interfering in transference analysis. Licensing boards,
ethics committees and risk management experts often view
bartering as potentially exploitative and damaging to the
therapeutic work.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Bartering has often been equated, mistakenly, with dual
relationships and boundary violation. While bartering of
services is, indeed, dual relationships, bartering of goods is
generally not.
As with many types of dual relationships, bartering of
services can be clinically beneficial and ethically sound. All
bartering is boundary crossing but not necessary (harmful)
boundary violation.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Bartering has often been equated, mistakenly, with dual
relationships and boundary violation. While bartering of
services is, indeed, dual relationships, bartering of goods is
generally not.
As with many types of dual relationships, bartering of
services can be clinically beneficial and ethically sound. All
bartering is boundary crossing but not necessary (harmful)
boundary violation.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Bartering does not necessarily lead to exploitation, harm or
sex. The slippery slope concept that describes how one
deviation from rigid guidelines inevitably leads to harm and
sex is a fear based, irrational and unproven concept.
Most of those who oppose bartering reluctantly
acknowledge that bartering can be an acceptable practice
with poor people and is a normal and healthy aspect of
certain cultures and communities.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
 Almost all ethical guidelines do not mandate a blanket
avoidance of bartering. All ethical guidelines prohibit
exploitation of clients.
 Bartering arrangements also have tax implications.
Consult your tax preparer and make informed decisions
regarding
your
legal,
civic
and
professional
responsibilities.
 Avoiding all bartering agreements will abandon
thousands, or even millions, of people who are in need of
therapy but do not have the cash to pay for it.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
Clinical and Ethical Considerations with Bartering
In planning on entering into a bartering agreement,
therapists must take into consideration the welfare of the
client, his/her culture, gender, history, condition, wishes,
economic status, type of treatment, avoidance of harm and
exploitation, conflict of interest and the impairment of
clinical judgment. These are the paramount and
appropriate concerns.
Make sure that the client involved in the negotiation fully
understands and consents, in writing, to the agreement.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
 Include the bartering arrangement in the document that
explains the payment agreement, and have the client sign
the appropriate informed consent.
 Make sure that your office policies, when appropriate,
include the risks and benefits of bartering and that they
are fully explained to, read and signed by your clients
before you implement them.
 The bartering arrangement must be well documented in
the clinical notes.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
 Make sure that the bartering agreement is
consistent with and is not in conflict with the
treatment plan.
 It is important to realize that bartering can be
counter-clinical in some situations such as with
borderline clients or those who see themselves
primarily as victims.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
 At the heart of all ethical and clinical guidelines
is the mandate that you act on your client's behalf
and avoid harm. That means you must do what is
helpful, including bartering when appropriate.
 Keep excellent written records throughout
treatment if or when problems and complications
arise with regard to the bartering agreement.
BOUNDARY CROSSINGS &
BOUNDARY VIOLATIONS IN THERAPY
 Evaluate the effectiveness and appropriate-ness of the
bartering arrangement regularly and change it if
necessary through discussion with and, hopefully,
consent from your client.
 If complications, negative feelings or disagreement arise
due to the bartering agreement, discuss it with your
client, get consultations and change it in a way that will
be most helpful to the client and conducive to therapy.

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