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 • • • • • • • 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 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.