Laws and Ethics Course > Chapter 5 - Setting and Maintaining Boundaries

Chapter 5: Setting and Maintaining Boundaries

V. Setting and Maintaining Boundaries

Violations of professional boundaries are one of the most common ways that the healthcare practitioner violates ethical and legal regulations.Boundaries can be weakened in any number of ways, from accepting or giving gifts to clients, to having sexual relationships with them.The therapeutic relationship is often an intense sharing of intimate information.The client, dissatisfied with his or her own relationships is vulnerable and may try to fill the gap with you.There are many therapists who have lost their professional standing and many clients who have been severely emotionally damaged as a result of such relationships. it is important that the healthcare practitioner does not engage in behaviors that weaken boundaries, no matter how innocent they may appear.

We all have a desire to be accepted, and there is some level of desire in each of us to be well liked.This is normal and healthy; however, if our desire for acceptance is so great, we create relationships that are damaging to both the client and the health care practitioner, there is a problem.You must always be aware that you are not there to get your own needs met.

The following is a list of some behaviors that weaken boundaries:

  • Physical contact
  • Inappropriate dress
  • Horseplay
  • Divulging too much personal information like your own marriage problems, dating life, use of alcohol, etc.
  • Language
  • Allowing clients to break the client therapist agreement
  • Selling or buying items from clients
  • Seeing each other outside of counseling sessions /socially
  • Dating
  • Extending individual sessions longer than agreed upon
  • Longer term therapy than necessary
  • Flirting
  • Dual relationships: Serving clients you know outside of the therapeutic relationship

Behaviors which strengthen therapeutic boundaries include:

  • Maintaining appropriate space
  • Maintaining appropriate dress
  • Professional consultation
  • Keeping time and number of session to agreed upon amount
  • Setting limits
  • Consistency
  • Role model appropriate behavior
  • No personal favors
  • Reinforcing definition of relationship

The use of appropriate boundaries to enhance therapeutic outcomes

People come to counseling for various reasons: usually as a result of some type of dissatisfaction with themselves, their lives and/or their relationships.It is important for them to have a safe environment to share thoughts feelings and emotions.Clients offer a high level of vulnerability in sharing with therapists intimate personal details of their lives.When the client can feel that there is positive regard and respect for their feelings, and this is maintained through appropriate boundaries, then the relationship becomes a significant part of the therapy itself. If those boundaries are broken, then the client enters an environment that only repeats, but at a more intense level, the issues that are the cause of them coming to therapy.

Levels of self-disclosure play a large part in the therapeutic relationship that can damage or help the relationship depending on the motivation, timing and content of the disclosure.When not sure about what to disclose, it is probably best to follow the rule: less is more.Therapy is not about the therapist.Talking too much about yourself can weaken boundaries and redefine the relationship as something more social than therapeutic.

"Maintain a professional helping relationship. Do not use your client to satisfy the needs that should be satisfied by your friends, spouses, and relatives. A warm, caring relationship with a client does not involve romantic love or sexual involvement." (Mehr, p.297, 1986)

When a client attempts to break down or bend the boundaries the therapist must be prepared to reinforce the relationship in a way that is clear, but not harsh. Experience and consultation are two tools that will help you maintain appropriate boundaries.

Risks of poor boundaries: How did that happen?

Violations of legal and ethical boundaries do not usually occur suddenly.There is usually a process by which boundaries gradually are weakened until the therapist is before a disciplinary review board and asking him or herself, "How did that happen?" Maintaining the highest standards of ethics will keep you and your clients safe from what can turn out to be rather tragic events.

Illustration of How Boundaries may be Weakened

Jeff is a handsome 25 year-old man who is going through a divorce.The separation was initiated by his wife who was seeing a previous boyfriend. He does not have any children and Jeff describes his marriage as having been seemingly happy for them both, and says he still loves his wife. He wants to develop a meaningful relationship with another woman, but is somewhat insecure about going through the dating scene again.

The divorce dealt a major blow to his confidence and his willingness to trust someone to be close.That is the dilemma he presents:On the one hand he is lonely and would like to have a marital relationship again, on the other, he is insecure about initiating such a relationship and fearful what might occur if he does.

The therapist, a Licensed Clinical Social Worker named Anne, is a 32 year-old happily married woman with two children.She has been practicing for five years with a focus on couples therapy and families.She has counseled many individuals in relationships including males and has not had a problem with boundaries or inappropriate behaviors.

Anne notices that Jeff is not bad looking.She expresses empathic concern for his heartbreak and troubles. She feels for Jeff's sadness and he is very distraught.At the end of the first session, she thinks giving him a hug would be the natural thing to do to offer comfort. It is what she would do with a child, or even a woman who seemed to need such comfort.She chooses not to because at the moment she decides it would be a weakening of the boundaries.

In a later session, however, she justifies to herself that it would be okay to give Jeff hugs to comfort him.She finds herself being more aware of her personal appearance on the days that Jeff is scheduled to be seen.They are developing a rapport and Jeff seems to be getting happier as he adjusts to the separation from his wife.In helping Jeff with his insecurity of initiating relationships, Anne role plays as a date partner in phone and date conversations.Jeff thanks Anne for her assistance but states he is still very worried about how things will go on a date.He asks her if they could have a practice date---just out to dinner or lunch. She is hesitant, but agrees as Jeff expresses his need for the help.

The Poor Choices

Throughout this case there are turning points and decisions that Anne makes that either strengthen the therapeutic boundaries, or weaken them.In most decisions Anne is weakening them, in addition to passing over or disregarding the warning signs that she is on a slippery slope to losing her license, her career, and even worse, maybe her family.Anne is being faced with the same type of decisions that nearly every healthcare provider faces. Anne did not intend to begin a dual relationship. She had heretofore been very careful.In this case she gradually made those decisions that created that relationship.

First, Anne found Jeff to be handsome.Depending on Anne's internal response to this, it may or may not be a problem in itself; however, it would at least put up a red flag for her to be careful with her own thoughts, behaviors and emotions and to keep them in check.There are different rules of thought in regards to hugging clients, regardless of their age or gender.In this case, Anne did show some awareness by not hugging him at the first session, but then justified it later.Decisions such as these when justified through the foggy lens of human emotion often end up being poor decisions.

It is next noted that she is becoming more aware of wanting to look attractive to Jeff.Being aware of one's personal appearance would be a positive thing (and one more therapists should pay attention to!), but the fact that she was paying extra attention in regards to how she would look to Jeff was a sure sign that her boundaries and feelings were going beyond the therapeutic relationship. Anne's self-awareness as a therapist should have been a warning bell, but she ignored it.It is doubtful that she was not aware of what she was doing, but she was ignoring the potential consequences.With the proper response, she may have referred Jeff to another therapist, or at least at this point, if she had not from the beginning, sought consultation.

The role playing could have been a positive therapeutic technique, except that Anne had weakened the boundaries to the point where the role play wasn't just a role play, and obviously the practice date was not going to be just practice.Anne has then created a dual relationship under the guise of therapy, and the path, if she continued on it, becomes obviously difficult.

Fortunately, Anne suddenly got a hold of herself, realized what she was doing and where it was leading.She sought consultation and, instead of the practice date,asked Jeff to see her in the office for an appointment.In that appointment, as discussed in her consultation session, she stated to Mark that it was out of the scope of their therapy for her to go on a "practice date" with him, and that she should not have set such an appointment to do so.They discussed the progress that he had made thus far in his counseling and suggested to him that if he still felt a need to see a therapist that she could refer him to another very qualified therapist.

To her credit, Anne eventually stopped the relationship from moving further in the direction it was.It was unfortunate that she let it go as far as it did, having potentially harmed the client, depending on his response to it.This vignette illustrates the need for the provider to have vigilant self-awareness in order to maintain appropriate boundaries.The harm that comes from the failure to do so can be severe.
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Question No.20.Which of the following behaviors weakens professional boundaries?

a. Dual relationships
b. Appropriate dress
c. Limit setting
d. Setting and maintaining time limits of sessions

Question No.21.The violation of professional boundaries:

a. Is okay if you are already friends with the client
b. Is okay if you become personal friends with the client
c. Is one of the more common ways ethical principles are violated
d. May violate codes of ethics but will not result in professional discipline

Question No.22.The tools that will help you maintain appropriate boundaries include:

a. Experience and consultation
b. Dual relationship
c. self-disclosure

Question No.23. Behaviors that can damage or help the therapeutic outcomes, depending on the motivation, timing and content is:

a. Professional consultation
b. self-disclosure
c. Consistency
d. Setting limits
 
Laws and Ethics Course > Chapter 5 - Setting and Maintaining Boundaries
Page Last Modified On: October 10, 2015, 03:51 AM