Chapter 8 – Boundary Issues

boundary
conceptualized as a frame or membrane around the therapeutic dyad that defines a set of roles for the participants in the therapeutic relationship; a limit that promotes integrity; helps to create a safe place that is unambiguous, consistent, and reliable
dual or multiple relationships
occur when professionals take on two or more roles simultaneously or sequentially with a help seeker; ACA standard – counselor-client nonprofessional relationships with clients, former clients, their romantic partners, or their family members should be avoided, except when the interaction is potentially beneficial to the client
three factors in assessing risk of harm in nonprofessioal relationship with clients
1) incompatible expectations (the greater the incompatibility, the greater the risk of harm); 2) divergent responsibilities (the greater the divergence associated with dual roles, the greater the potential for divided loyalties and loss of objectivity); 3) power differential (the greater the difference of power, the greater the potential for exploitation of the individual in the less powerful position)
boundary crossings
behaviors counselors engage in with clients that have a potential for creating a dual relationship but are not in themselves a dual relationship; a departure from a commonly accepted practice that occurs to benefit a client; a boundary is shifted to the meet the needs of a particular client at a particular moment (one counselor’s intended crossing may be another counselor’s perceived violation)
boundary violation
a serious breach that causes harm
bartering
exchanging either services or goods for counseling instead of a direct fee for service (examples: redecorating office in exchange for counseling or giving an oil painting instead of money in exchange for counseling)
bartering guidelines in ACA Code of Ethics (counselors may participate in bartering only if three criterea are met
1) the relationship is not exploitive or harmful and does not place the counselor in an unfair advantage; 2) the client requests it; 3) such arrangements are an accepted practice among professionals in the community
Business or financial relationships with clients
91% of surveryed counselors believe it is unethical to go into business with a current client; 54% believe it is unethical with a former client
Accepting gifts from clients
Over 88% of counselors viewed it as unethical to accept a gift from a client over the amount of $25
self-disclosure
87% of counselors deemed self-disclosing as ethical behavior, however, inappropriate counselor self disclosure (current stressors, personal fantasies or dreams, social or financial circumstances) more than any other kind of boundary violation is likely to precede counselor-client sexual intimacy
assessment of self-disclosure
Self-disclosure should be for the client’s benefit; self-disclosures are considered unethical when they are used to meet the counselor’s own needs for intimacy or understanding. Ask yourself two questions: 1) Does this particular disclosure represent a significant departure from my usual practice? 2) If so, why the change?
physical contact with client
Reassuring touch or a gentle hug can be facilitative, however, risks are invading personal space or the touch being considered a sexual advance. 87% of surveyed counselors judged it unethical to kiss a client, 33% rated it unethical to hug a client, and 84% thought it was acceptable to console a client through touch such as placing a hand on his or her shoulder; a legal risk is present and some liability companies discourage touch or might label a client who reports frequent physical touch as to risky to insure.
ethical decision-making for dual relationships
1) Is the potential dual relationship necessary or avoidable; 2) judge whether the benefits of the dual relationship for the client outweigh the risks of harm to the client or vice versa; 3) consider the 3 factors: client’s expectations of counselor in the two roles; divergent responsibilities in the two roles; and power differential; 4) imagine the best possible outcome and the worst possible outcome of crossing a boundary or engaging in a dual relationship; 5) if the counselor deems the risk greater than the benefit, the counselor should decline the dual relationship, refer if necessary, and offer an explanation to the client so the client understands the rationale for not proceeding.
Safeguards when choosing to enter a dual relationship with a client
1) secure the client’s informed consent (discuss benefits and risks of harm); seek ongoing consultation to avoid risks of a possible loss of counselor objectivity; engage in ongoing monitoring of the relationship with client through discussion; document and self-monitor; obtain supervision if consultation is not sufficient such as in cases where risks for dual relationship are high, relationship is complex or the counselor has concerns about his or ability to assess the situation objectively
dynamics of sexual dual relationships
Unaddressed in professional literature until the 1970s but has been an ethical problem that predates the Hippocratic oath; 7% of male counselor and 1.6% of female counselors reported sexual contact with clients in a study where in another study 20% of clients reported engaging in sexual behavior with counselors; the male counselor/female client dyad dominates and 80% of psychologists who reported sexual contact, reported they had been sexually intimate with more than one client
Scenarios or rationalizations used by offending counselors of sexual contact with clients
1) in a reveral of roles, the wants and needs of the counselor became the focus of treatment; 2) counselor claims sexual intimacy with client is valid treatment for sexual or other problems; 3) counselor fails to treat emotional closeness that develops in counseling with professional attention and respect, claiming the dual relationship “just got out of hand”; 4) counselor exploits client’s desire for nonerotic physical contact (need to be held); 5) counselor fails to acknowledge that the therapeutic relationship continues between sessions and outside the office; 6) counselor creats and exloits extreme dependence on part of the client; 7) counselor uses drugs as part of the seduction; and 8) counselor uses threat or intimidation
Profile of offending counselor
(Offending counselors DO NOT fit a single model), however, a professionally isolated male who is experiencing distress or crisis in personal life fitting many characteristics of impaired professionals is a frequent portrait described in scant literature
therapist-patient sex syndrome
reactions similar to those of victims of rape, spouse battering, incest, and posttraumatic stress disorder; deep ambivalence toward the offending counselor being trapped between extreme dependency on and fear of separation from counselor to longing for escape from his power and influence, clients vacillate between wanting to flee and wanting to cling and protect him; clients suffer guilt, increased risk of suicide, deeply angry or supressed rage, clients feel isolated and alone, profound confusion about their sexuality, appropriate roles and inappropriate boundaries; impaired ability to trust; PTSD – difficulties with attention and concentration, reexperiencing of overwhelming emotional reactions when they become involved with a sexual partner, nightmares and flashbacks
Sexual relationships with former clients
NASW forbids social workers from every having a sexual relationship with a former client; ACA is five (5) years post client relationship; APA is two (2) years post client relationship
Safeguards for entering into sexual relationshps with former clients after five years
ACA code states that counselors must demonstrate forethought and document (in written form) whether the interactions or relationship can be viewed as exploitive in some way and/or whether there is still potential to harm the former client
Risk of harm to clients entering into sexual relationships with former counselors.
One study indicated that 80% of clients who had begun sexual relationships with mental health professionals after counseling ended were found to have been harmed
Sexual attraction to clients
70% to 95% of mental health professionals have experienced attraction to at least one client
Strategies for handling sexual attraction
Acknowledge and take steps to deal with such as: 1) consulting with colleagues; 2) carefully considering issues of client welfare; 3) seeking supervision; 4) self-monitoring to ascertain whether you feel particularly needy or vulnerable; 5) care for own needs/seek counseling for yourself if needed; 6) if the client develops an attraction to you, handle with tack and ensure client understands a dating or sexual relationships is never possible