Transcript Maintaining Healthy Professional Boundaries

UPDATE: LATEST ETHICAL
& BOUNDARY
MAINTENANCE ISSUES
Presented by:
Jim Messina, Ph.D., CCMHC, NCC, DCMHS
Troy University Tampa Bay Site
OBJECTIVES OF
PRESENTATION
1. Identify specific guidelines for best practices for
avoiding breaches of ethical, legal, professional and
moral behaviors in the provision of their clinical
responsibilities
2. Identify common pitfalls or mistakes which contribute to
poor boundary maintenance in the provision of clinical
work in busy clinical settings
3. Identify specific steps which Marriage and Family
Therapists can take to limit their unknowingly breaching
ethical standards, boundaries, or guidelines within their
work as therapists with individuals, couples and families
as well as when providing supervision or consultation
services
WHY BOUNDARIES ARE
IMPORTANT
Boundaries must be set & maintained in the counseling
relationship to insure:

Counselor does “No Harm” to client

Rights of client are respected & honored

Counselor is always respectful of & conscious of need
to guard privacy of client

Counselor does not take advantage of “power
differential” in relationship & recognizes extent of
“vulnerability” of client in counseling relationship.
DO THE SELF-ASSESSMENT
ON PROFESSIONAL
BOUNDARIES
Take self-assessment instrument entitled:
Professional Boundary Self-Assessment
DO THE SELF-ASSESSMENT
ON PROFESSIONAL
BOUNDARIES
Results: If you have answered
 3 or more items with scores of 7 or higher or
 5 or more items with scores of 5 or higher
 There is a strong possibility that you are maintaining
weak boundaries with your clients and or their families
based on your behaviors with them
WHAT ARE HEALTHY
BOUNDARIES?
They are framework within which professional helperclient relationship occurs
They make the relationship professional & safe for client
They set parameters within which helping services are
delivered
They refer to line between self of client & self of
professional helper
WHAT DO HEALTHY
BOUNDARIES INCLUDE?
Healthy Professional Boundaries include:
 length of a session
 time of session
 personal disclosure
 limits regarding the use of touch
 the general tone of the professional relationship
 fee setting (if it is not a pro-bono service)
WHAT MIGHT BE
BLURRING BOUNDARIES?
Are you an addicted fixer or rescuer? Maybe this is
keeping you from maintaining healthy boundaries with
your clients
Take self-assessment instrument entitled: Compulsive
Fixer-Rescuer Self-Assessment
SO ARE YOU A COMPULSIVE
FIXER OR RESCUER?
Results: if on this survey you have answered:
 3 or more items with scores of 7 or higher or
 5 or more items with scores of 5 or higher
 There is a strong possibility that you are maintaining
weak boundaries with your clients and/or their families
because of your being an “addicted fixer” or
“rescuer”
BASIC MORAL PRINCIPLES OF
ETHICAL DECISION MAKING
Autonomy:
 to promote self-determination
Beneficence:
 to do good for others and promote the well-being of clients
Non-maleficence:
 to avoid doing harm
Justice:
 to be fair by giving equally to others and to treat others justly
Fidelity:
 to make realistic commitments and keep these promises
Veracity:
 to be truthful and deal honestly with clients
LEVELS OF ETHICAL PRACTICE
Mandatory Ethics
 level of ethical functioning wherein counselors comply with minimal standards,
acknowledging the basic “musts” and “must nots”
 Example: providing informed consent in professional relationships
Aspirational Ethics
 refer to the highest professional standards of conduct to which counselors can
aspire
 Example: providing services pro bono for those in the community who cannot
afford needed services
Principle Ethics
 focuses on moral issues with the goal of solving a particular dilemma and
establishing a framework to guide future ethical thinking and behavior
 Example: asks “Is this situation unethical?”
Virtue Ethics
 focuses on character traits of the counselor and non-obligatory ideals
 Example: asks “Am I doing what is best for my client?”
STEPS IN MAKING
ETHICAL DECISIONS
In thinking through ethical dilemmas:
1. Identify the problem or dilemma
2. Identify the potential issues involved
3. Review the relevant ethics codes
4. Know the applicable laws and regulations
5. Obtain consultation
6. Consider possible and probable courses of action
7. Enumerate the consequences of various
decisions
8. Choose what appears to be the best course of
action
MINIMIZING RISKS IN MULTIPLE
RELATIONSHIPS
Identify measures aimed at minimizing the risks:
Set healthy boundaries from the outset
Secure informed consent of clients
Discuss both potential risks and benefits of counseling
Consult with other professionals to resolve any dilemmas
Seek supervision when needed
Document in clinical case notes
Examine your own motivations
Refer when necessary
AVOID DUAL RELATIONSHIPS
 One cannot be both “helper” & “friend” or “significant
other” to client due to reality it is too easy to lose
perspective in helping client & client loses perspective as
to helper’s real role in client’s life
 Helper has a “power or authority” role with client even if
helping service in not fee-based service
 Important not to confuse client in creating relationship
where roles become blurred & where expectations &
demands on helper become magnified due to demands
& needs of client who has been befriended & overly
attached to helper
AVOID BECOMING A FRIEND
WITH CLIENTS
 Providing “help” to another in need has visual &
emotional aspect of “friendship” it is important to
maintain the boundary of “no friendship with clients”
 Danger in becoming a friend while serving a client is
emotional vulnerability of client will become
sensitized
 If you should not be able to spend amount of time or
provide amount of services which client expects to
receive from a friend there is situation which is ripe for
conflict, hurt feelings & conceivably exacerbating
needs of client who already was vulnerable & in
need prior to helping relationship being established
AVOID SOCIALIZING WITH
CURRENT OR FORMER CLIENTS
Potential Disadvantages of Socializing
Therapists may not be as challenging as they need to be with
clients they know socially because of a need to be liked and
accepted by the clients
Counselors’ own needs may be enmeshed with those of their
clients to the point that objectivity is lost
Counselors are at greater risk of exploiting clients because of
power differential in therapeutic relationship.
If Counselor develops a friendship with former client, then
client is not eligible to use Counselor’s professional services in
future.
BE CAREFUL IN USE OF
SELF-DISCLOSURE WITH CLIENTS
 When helper reveals very personal information about self
with client which sharing has no real purpose in goals of
meeting the needs of client
 Such self-disclosure take spotlight off of client’s issues &
focuses rather on helper
 Unless a specific therapeutic positive outcome is to be
gained by self-disclosure helpers ought to avoid it
 When helper is ready to disclose one must ask question:
Does self-disclosure serve client’s therapeutic goal? Unless
it can be justified, stay away from self-disclosing to
maintain healthy boundary maintenance with clients
USE CAUTION IN ESTABLISHING A
BARTERING RELATIONSHIP
Evaluate whether it puts you at risk of impaired
professional judgment
Determine value of goods or services in a
collaborative fashion
Determine appropriate length of time for
arrangement
Document arrangement
Consult with experienced colleagues or supervisors
Minimize unique financial arrangements
If bartering is used, it is better to exchange goods
rather than services
Both therapist & client should have a written
agreement for the compensation by bartering
MAINTAIN BUSINESS-LIKE HELPING
SITUATION PROTOCOLS WHILE
PROVIDING HELP TO CLIENTS
This means maintaining a professional relationship which
includes:
 seeing clients only during work hours
 seeing clients only in “appropriate professional
locations” where helping relationship is to be performed
 only taking emergency phone calls from clients on rare
occasion & not make nightly or weekly phone calls
between clients & helper a normal routine
AVOID GIVING OR RECEIVING GIFTS
OF SIGNIFICANT VALUE WITH CLIENTS
 If such gift giving were to transpire, client who gave
gift could expect “special” treatment from helper &
conversely helper could feel “more obligated” to go
outside norms of typical helping protocol to “pay
back” client for client’s generosity in gift given
 To avoid such confusion in future rule would be to just
abide by No Gift Giving Guideline
ACCEPTING GIFTS
Questions to consider in making a decision of whether
or not to accept gifts from clients:
What is the monetary value of the gift?
What are the clinical implications of accepting or
rejecting the gift?
When in the therapy process is the offering of a gift
occurring?
What are the therapist’s motivations for accepting or
rejecting a client’s gift?
What are the cultural implications of offering a gift?
WHAT DRIVES HEALTHY
BOUNDARIES?
Boundaries must be set & maintained in a helping
relationship to insure:
 Helper does “No Harm” to client in helping process
 Rights of the client are respected & honored
 Helper is always respectful of & conscious of need
to guard privacy of client
 Helper does not take advantage of & recognizes
extent of “vulnerability” of client in situation
10 QUESTIONS TO ASK IN
DETERMINING BOUNDARY
ISSUES WITH CLIENTS
1.
Is this in my client’s best interest?
2.
Whose needs are being served?
3.
Will this have an impact on the service I am
delivering?
4.
Should I make a note of my concerns or consult with
a colleague?
5.
How would this be viewed by the client’s family or
significant other?
6.
How would I feel telling a colleague about this?
10 QUESTIONS TO ASK IN
DETERMINING BOUNDARY
ISSUES WITH CLIENTS
7.
Am I treating this client differently (e.g., appointment
length, time of appointments, extent of personal
disclosures)?
8.
Does this client mean something special to me?
9.
Am I taking advantage of the client?
10. Does this action benefit me rather than the client?
11. Am I comfortable in documenting this decision or
behavior in the client file?
12. Does this go against the Standards of Professional
Conduct or the Code of Ethics of my professional
field?
CHALLENGE TO HELPER IN
MAINTAINING BOUNDARIES
Being aware:
 Be self-aware of feelings & behaviors involved in
working with each client & family
 Be observant of behavior of other helpers in the field
& call them on it, if they appear to be overstepping
their boundaries with clients
 Always act in best interest of clients & families
 Most importantly DO NO HARM to your clients
NOW LET’S GET TO
WORK!
In small Groups answer the following questions for each of the
case studies handed out to you.
1. What moral Ethical/Moral Principle has been violated in this
case?
2. What could have been done to avoid the boundary violation
in this case?
3. What steps should the counselor in this case taken to mitigate
the damages which occurred in the violation of boundaries
with the client in this case?
4. What would have been the appropriate decision which the
State Board of Licensing should have taken in this case?
5. What can you learn from this case which will help you in your
future work with clients to avoid a similar circumstance from
occurring?
SO WHAT HAVE YOU
LEARNED
Let’s see what you have learned
Answer these questions as we go
Select the correct answer for each question
Share with your fellow participants as we proceed
through these 10 questions
QUESTION #1
When referring to the relationship between the
client and helper, boundaries are:
A.
B.
C.
D.
Actions that are not appropriate in client care
Whatever the client feels is appropriate
Whatever the helper feels is appropriate
The limits that define the helper-client
relationship
ANSWER QUESTION #1
D. The limits that define the helper-client relationship
QUESTION #2
Boundaries are essential to protect clients from the
helper’s
A.
B.
C.
D.
Power
Anger
Poor services
Lack of knowledge
ANSWER QUESTION #2
A. Power
QUESTION #3
Which is one of the clearest signs that a boundary
violation has occurred in the helper-client
relationship?
A.
B.
C.
D.
The client is not happy with his or her care
The helper hugs the client
The helper asks for a change of assignment
The needs of the helper are being met
ANSWER QUESTION #3
D. The needs of the helper are being met
QUESTION #4
Which of the following is the best example of a
professional business-like boundary violation?
The helper:
A. Shares personal information with the client
B. Asks the client if she would like to buy some
“Mary Kay Cosmetics”
C. Is attracted to the client
D. Attends a party given by the client’s family
ANSWER QUESTION #4
C. Is attracted to the Client
QUESTION #5
Gerald the helper assigned to George, regularly
talks about his personal problems with George.
George is happy to listen to his helper Gerald’s
personal problems and never complains about it.
Since this relationship seems to benefit both parties
it does not appear to be a violation of boundaries.
A. True
B. False
ANSWER QUESTION #5
B. False
QUESTION #6
The first person to realize there is a boundary
violation is:
A. The client
B. The helper who is committing the boundary
violation
C. A co-worker or the supervisor of the helper
D. None of the above
ANSWER QUESTION #6
D. None of the above since the correct answer
would be any of the above
QUESTION #7
If there are things in the helper-client relationship
which the helper would not want to record in the
record of the client then a boundary violation is
likely.
A. True
B. False
ANSWER QUESTION #7
A. True
QUESTION #8
Gill is a 46 year old client who has become very
attracted to his helper Suzette who is 35. Suzette is
equally attracted to Gill. Their personal relationship
began when Gill shared his feelings of attraction to
Suzette and she shared her similar feelings. Since
Gill wants this relationship it is OK for Suzette to allow
it to develop.
A. True
B. False
ANSWER QUESTION #8
B. False
QUESTION #9
Albert is a helper who has been working with
Charles for the past year and it is now time for
Albert to leave this client setting due to Charles no
longer needing the assistance which Albert has to
offer. However on his last visit Albert finds out that
Charles is lacking enough food supplies in his house
to keep he and his family fed for the next week.
Albert’s best response is to:
A. Call Salvation Army to request they drop off food
from their food pantry for Charles and his family
B. Bring groceries to Charles home after he gets off
from work that day
C. Notify the agency for whom Albert works about
Charles’ circumstances
D. Calls Charles’ ex-wife to inform her of Charles
pressing need for groceries in his house to feed
himself and his family
ANSWER QUESTION #9
C. Notify the agency for whom Albert works about
Charles’ circumstances
QUESTION #10
Jackie is a “Mary Kay” distributor in her community and
while working with her client Maggie Jo, Maggie Jo
sees the logo on Jackie’s purse and says: “Oh I love
those products and I sure could use some more…”
Jackie’s best action is to:
A. Request a change of assignment away from
Maggie Jo
B. Give Maggie Jo the name of another Mary Kay
distributor in the community
C. Tell Maggie Jo that she cannot sell product to her
but can sell it to her relatives or friends
D. Sells Maggie Jo the products she needs
ANSWER QUESTION #10
B. Give Maggie Jo the name of another Mary Kay
distributor in the community
SO HOW DID IT GO?
Have you a better idea as to what Maintaining
Professional Boundaries with your clients and their
families is all about?
Can you now identify if you are a compulsive fixer or
rescuer which could impact your maintaining healthy
boundaries with your clients and their families?
Can you now Identify steps you can take to maintain
healthy boundaries in your professional work?
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RESOURCES ON COPING.US TO HELP
YOU WITH PROFESSIONAL
BOUNDARIES
Overcoming the Need to Fix:
http://www.coping.us/toolsforhandlingcontrol/overcomeneedtofix.html
Tempering Idealism:
http://www.coping.us/toolsforhandlingcontrol/temperingidealism.html
Eliminating Caretaker Behaviors:
http://www.coping.us/toolsforhandlingcontrol/eliminatecaretakerbehavi
ors.html
Letting Go of the Uncontrollables and Unchangeables
http://www.coping.us/toolsforhandlingcontrol/letgouncontrollablesunch
angeables.html
Accepting Powerlessness
http://www.coping.us/toolsforhandlingcontrol/acceptingpowerlessness.h
tml
Developing Detachment
http://www.coping.us/toolsforhandlingcontrol/developingdetachment.h
tml
Establishing Healthy Boundaries
http://www.coping.us/growingdown/healthyboundaries.html