Often, no one could have seen it coming. Boundary issues can arise in ways that therapists may not initially predict or even recognize. But, in too many cases therapists behaved in ways that seem completely out of touch with the impact their decisions and actions had on those with whom they had a professional relationship.
Legal suits and the cost of defending licensing board complaints cause professional liability insurance rates to rise, thus harming all therapists. Sadly, the stigma and the stress endured by the therapist if found guilty can be debilitating Warren and Douglas, Among the most significant changes in the ethics codes of professional organizations are those related to the drawing of boundaries between therapists and their clients.
Over the last couple of decades we have witnessed a relaxation of rigid restrictions. The reasoning for this has included the recognition that boundary crossing cannot be totally avoided, some belonging under certain circumstances may even be helpful to the client or at least cause them no harm , and sometimes boundary crossings are mandated Barnett, a. On the surface, the loosening of restrictions also feels more protective of therapists, allowing for leeway as to how therapists and their clients interact.
At the same time, however, additional burdens are placed on therapists because the rules are no longer firm. What the therapist may deem as an acceptable, even helpful, boundary crossing may be experienced as inappropriate or harmful by the client, as will be discussed further. Our main goal for this course is to make a strong case for vigilance and ongoing self-awareness when making decisions about boundary crossing with clients.
The police came to your client's home this morning to arrest her year-old son for assault. She is extremely distraught. And what if your next client is in the waiting room now? Should you ask if she would mind dropping you off on the way home?
A new client has rheumatoid arthritis and struggles to unbutton her heavy coat. Do you rush over to help her? The small town in which you practice has suffered an economic decline. A client asks if he can pay you for psychotherapy services by doing your yard work, as he does landscaping on the side. Your yard requires extensive maintenance, so should you accept?
Your client starts bringing fancy coffee and croissants to every session. Is this an innocent pleasure? Case adapted from Pope and Keith-Spiegel, You realize that you have disclosed a great deal about your personal life over several sessions.
Should you pull back? You want to sell your car, and have a sign on it out in the parking lot and another on your bulletin board in your therapy office waiting area. Your client decides to purchase it from you. You assure the client that it is in excellent condition and a good buy. Should you go through with a deal? The client you have treated for depression over the last six months tells you that she plans to visit her sibling who lives across the country in a few weeks.
With the exception of boundary violations that clearly violate any standard of care, ethics codes cannot possibly give specific guidance when it comes to mandating appropriate ways to socially interact with counseling and psychotherapy clients across all possible situations. Many boundary crossings can involve no ethical transgressions and even prove beneficial to the client. However, as we will illustrate, remaining vigilant regarding our own needs and vulnerabilities as well as those of our clients is fundamental to ethical practice.
As for our examples, not everything turned out well in the actual cases upon which they are based. The distraught mother scenario illustrates a double boundary crossing. To offer the client extra time seems a kind gesture but runs counter to the therapeutic agreement.
In the future, this actual client felt entitled to extra time and resented not getting it. In the meantime, clients-in-waiting have an agreed upon appointment obligation altered.
One can feel sympathy for the distraught mother, but the matter does not qualify as an emergency. In fact, the mother might more appropriately focus on other actions e. Yet at other times, offering extra time would be prudent, such as in a true emergency situation.
The client who was asked for a favor turned into a bit of a fiasco. The client asked if they could stop on the way home and have dinner together. The therapist refused politely, noting he had to get home to his family.
But now the client, who later became a stalker, knew where he lived. This was a fairly new client with some issues that should have signaled caution on the part of the therapist. His myopic focus on his own convenience ended up costing him dearly.
Regarding the client struggling with her winter coat, what seems like an obvious helpful gesture requires brief reflection. This seemingly helpful act involves physical contact, and not all clients will feel comfortable with that. Some may even feel it as intrusiveness. Asking before acting is essential. The client who brought coffee and sweets to the 10 a.
She began to focus less on her own issues and more on that therapist as someone with whom she could have a relationship with outside of the office. The therapist finally picked up on what was going on and attempted, unsuccessfully, to pull the relationship back to the business of therapy.
The client experienced the request to cease bringing coffee and sweets as both an insult and a rejection. She never returned to therapy. Although this case did not result in an ethics complaint, the therapist felt guilty over failing to better perceive how meeting his own needs for what seemed like an innocent pleasure caused pain for a client he liked.
The economically strapped landscaper provides a more complicated case, and we will have more to say about bartering later. However, in such cases, taking someone up on what seems like a good match can turn into an ordeal. Ultimately, the client successfully sued the therapist for exploitation.
Unfortunately, the therapist became defensive and told the client that the client must have caused the damage. The therapeutic alliance evaporated, and the client successfully sued the therapist in small claims court. Finally, certifying the need for an emotional support animal, as opposed to a trained service animal e. Crossing them has many potential effects.
The work of mental health professionals is conducive to permeable role boundaries because so much of it occurs in the context of establishing emotionally meaningful relationships, very often regarding intimate matters that the client has not spoken of to anyone else.
Yet, mental health professionals continue to hold differing perceptions of role mingling. These perceptions range from conscious efforts to sustain objectivity by actively avoiding any interaction or discourse outside of therapeutic issues to loose policies whereby the distinction between therapist and best buddy almost evaporates. However, even those who would stretch roles into other domains would condemn conspicuous exploitation of clients. Some mental health professionals decry the concept of professional boundaries, asserting that they promote psychotherapy as a mechanical technique rather than relating to clients as unique human beings.
Instead, acting as a fully human therapist provides the most constructive way to enhance personal connectedness and honesty in therapeutic relationships Hedges, and may actually improve professional judgment Tomm, Those critical of setting firm professional boundaries further assert that role overlaps become inevitable and that attempting to control them by invoking authority e.
The answer, they say, involves educating both clients and therapists about unavoidable breaks and disruptions in boundaries and to ensure that therapists understand that exploitation is always unethical, regardless of boundary issues. As the scenarios at the onset of this course reveal, however, exploitation is not the only harmful result of boundary crossings.
We believe that the therapist retains ultimate responsibility for keeping the process focused. We see no reason why maintaining professional boundaries needs to diminish a therapist's warmth, empathy, and compassion. The correct task is to match therapy style and technique to a given client's needs Bennett et al. Furthermore, we believe that lax professional boundaries can act as a precursor to exploitation, confusion, and loss of professional objectivity.
Conflicts, which are more likely to arise when boundaries blur, compromise the disinterest as opposed to lack of interest prerequisite for sound professional judgment. As Borys contended, clear and consistent boundaries provide a structured arena, and this may constitute a curative factor in itself. In short, the therapy relationship should remain a safe sanctuary Barnett, that allows clients to focus on themselves and their needs while receiving clear, clean feedback and guidance.
Frank discussions about boundaries with clients during the initial informed consent phase is also recommended. Cultural traditions, geography e. The ethics code of the American Psychological Association APA, offers a clear definition of multiple role relationships. Multiple role relationships occur when a therapist already has a professional role with a person and: Is also in another role with the same person, or Is also in a relationship with someone closely associated with or related to the person with whom the therapist has the professional relationship, or Makes promises to enter into another relationship in the future with the person or a person closely associated with or related to the person.
To qualify for the definition of multiple role relationship then, the initial relationship typically requires an established connectedness between the parties. The primary role relationship is usually with an ongoing therapy, counseling client, student, or supervisee.
Limited or inconsequential contacts that grow out of chance encounters would not normally fall under the definition or cause for any ethical concerns. Multiple role relationships may occur via action, as when a therapist hires a client as a housekeeper. Or they can take the form of a proposal for the future while therapy remains ongoing, as when a therapist and a client plan to go into business together or agree to start a sexual relationship upon termination of therapy, thus altering the dynamics of the ongoing professional relationship.
Zur has categorized multiple role relationships by types. These categories are illustrated in the cases offered here. Nonsexual consecutive role relationships with ex-clients do not fall under any specific prohibitions in the APA code APA, However, based on post-therapy incidents described in this course, we advise caution even after a natural termination of the professional relationship.
However, not all multiple role relationships with clients are necessarily unethical so long as no exploitation or risk of harm to the client or the professional relationship can be reasonably expected.
We agree that careful consideration should occur prior to softening the boundaries of any professional role, and we also remain unconvinced that accurate outcome predictions involve a simple exercise in judgment. If that were so, therapists would have the lowest divorce rate of any professional group! Alas, no evidence of such foresight exists.