Seeing the Forest Seeing the Forest and the Trees: and the Trees:

Professional Professional Boundaries and Boundaries and

EthicsEthics

Troy McLean, MSW, LCSWTroy McLean, MSW, LCSW

Staff Development Director Staff Development Director

Boundaries Boundaries

Personal Personal RelationshipsRelationships Social RelationshipSocial Relationship Unlimited TimeframeUnlimited Timeframe Share informationShare information No feeNo fee No legal need for No legal need for

ConfidentialityConfidentiality Informality with Informality with

settings and settings and environment environment

Social Norms may be Social Norms may be looseloose

Equal Power Equal Power

Professional Professional RelationshipRelationship No Social Relationship, No Social Relationship,

Contracted Relationship, Contracted Relationship, do not hire individual to do not hire individual to meet personal needsmeet personal needs

Time LimitedTime Limited Information is about or Information is about or

for the consumerfor the consumer Fee for serviceFee for service Confidentiality a mustConfidentiality a must Respect PrivacyRespect Privacy No flexibility with social No flexibility with social

norms ( Example: No norms ( Example: No sexual relationship)sexual relationship)

Unequal power and Unequal power and authorityauthority

Three Types of Three Types of Boundaries Boundaries

Intimacy – A question of distanceIntimacy – A question of distance Responsibility – What our Responsibility – What our

responsibility isresponsibility is Limits – What we are willing to doLimits – What we are willing to do

(Alan Konell, Partnership Tools, 2001)(Alan Konell, Partnership Tools, 2001)

BoundariesBoundaries

Boundary Violation

Limits

Responsibilities

Boundary Issues relate to Violations and Exploitation

Treatment involves a fiduciary relationship with unequal power. The fiduciary has a duty not to be in a situation where personal interests and fiduciary duty conflict. A fiduciary cannot have a conflict of interest. Fiduciaries must conduct themselves at a level higher than the lay population.

Boundary ViolationBoundary Violation

Violations of intimacy:Violations of intimacy: occur when a occur when a physical or emotional boundary is physical or emotional boundary is breached:breached:

1. inappropriate personal questions.1. inappropriate personal questions.2. inappropriate touching.2. inappropriate touching.3. attempting to control how another 3. attempting to control how another thinks, believes, or feels.thinks, believes, or feels.

DangersDangers The failure to render needed treatment or services -- The failure to render needed treatment or services --

undermining what good work may have been done. undermining what good work may have been done. Failure to refer for other services -- the worker "hanging on" Failure to refer for other services -- the worker "hanging on"

to the individual and trying to provide for all of his or her to the individual and trying to provide for all of his or her needs. needs.

Creation of unhealthy dependency which is difficult to Creation of unhealthy dependency which is difficult to resolve.resolve.

Confusing the individual about what is treatment and what Confusing the individual about what is treatment and what is personal. is personal.

Breach of trust -- individual distrusting professionals as a Breach of trust -- individual distrusting professionals as a result of the corruption of the treatment. result of the corruption of the treatment.

In some instances, interference in family relationships, In some instances, interference in family relationships, friendships, etc.friendships, etc.

Anger, loss of self esteem, depression, and other Anger, loss of self esteem, depression, and other psychological distress. psychological distress.

(Schoener et. al., 1989, pp. 133-147; Simon, 1991): (Schoener et. al., 1989, pp. 133-147; Simon, 1991):

Problematic Self Problematic Self DisclosureDisclosure

Disclosing current personal needs or problems.Disclosing current personal needs or problems. Disclosure as common, rather than rare event, during Disclosure as common, rather than rare event, during

sessions.sessions. Disclosing things not clearly connected to client's problems Disclosing things not clearly connected to client's problems

or experiences; or not clearly things which would be likely to or experiences; or not clearly things which would be likely to encourage or support individual.encourage or support individual.

Self-disclosure not only frequent, but uses up more than a Self-disclosure not only frequent, but uses up more than a few minutes in a sessionfew minutes in a session

Self-disclosure occurs despite apparent individual confusion Self-disclosure occurs despite apparent individual confusion or romanticization. or romanticization.

(Gary Richard Schoener, 1998) (Gary Richard Schoener, 1998)

  

 

Self AwarenessSelf Awareness Obvious worker distress or upsetObvious worker distress or upset Therapeutic drift -- shifting style and approach to Therapeutic drift -- shifting style and approach to

a given individuala given individual Lack of goals and reflection on progress in Lack of goals and reflection on progress in

treatmenttreatment Treatment which exceeds normal length for an Treatment which exceeds normal length for an

individual of that type in the particular worker's individual of that type in the particular worker's practice.practice.

Exceeding areas of competence, reluctance or Exceeding areas of competence, reluctance or unwillingness to refer for other types of treatment, unwillingness to refer for other types of treatment, assessment, etc. assessment, etc.

Becoming enmeshed in individual's life -- treating Becoming enmeshed in individual's life -- treating close friends or family membersclose friends or family members

Self Awareness Cont’Self Awareness Cont’ Unwise techniques:Unwise techniques:

Routine hugsRoutine hugs Face to face, intimate hugsFace to face, intimate hugs Excessive touchExcessive touch Sessions in non-traditional setting when this Sessions in non-traditional setting when this

isn't necessaryisn't necessary Adult individual’s on lapAdult individual’s on lap Routine or common socializing with clientsRoutine or common socializing with clients Excessive self-disclosure by workerExcessive self-disclosure by worker Direct intervention in the individual's lifeDirect intervention in the individual's life

Self Awareness Cont’ Self Awareness Cont’

Unique vulnerabilities:Unique vulnerabilities: AttractionAttraction Over-identification with individualOver-identification with individual Uniquely similar family dynamicsUniquely similar family dynamics Divorce or loss in worker's lifeDivorce or loss in worker's life Identity disturbance in workerIdentity disturbance in worker

(Gary Richard Schoener, 1998) (Gary Richard Schoener, 1998)

  

NASW Code of EthicsNASW Code of Ethics

1.02 Self-Determination1.02 Self-Determination Social workers respect and promote the Social workers respect and promote the

right of clients to self-determination and right of clients to self-determination and assist clients in their efforts to identify and assist clients in their efforts to identify and clarify their goals. Social workers may clarify their goals. Social workers may limit clients' right to self-determination limit clients' right to self-determination when, in the social workers' professional when, in the social workers' professional judgment, clients' actions or potential judgment, clients' actions or potential actions pose a serious, foreseeable, and actions pose a serious, foreseeable, and imminent risk to themselves or others.imminent risk to themselves or others.

NASW code of Ethics NASW code of Ethics Cont’Cont’

1.03 Informed Consent 1.03 Informed Consent (a) Social workers should provide services to (a) Social workers should provide services to

clients only in the context of a professional clients only in the context of a professional relationship based, when appropriate, on valid relationship based, when appropriate, on valid informed consent. Social workers should use informed consent. Social workers should use clear and understandable language to inform clear and understandable language to inform clients of the purpose of the services, risks clients of the purpose of the services, risks related to the services, limits to services related to the services, limits to services because of the requirements of a third-party because of the requirements of a third-party payer, relevant costs, reasonable alternatives, payer, relevant costs, reasonable alternatives, clients' right to refuse or withdraw consent, clients' right to refuse or withdraw consent, and the time frame covered by the consent. and the time frame covered by the consent. Social workers should provide clients with an Social workers should provide clients with an opportunity to ask questions.opportunity to ask questions.

NASW Code of Ethics NASW Code of Ethics Cont’Cont’

1.04 Competence1.04 Competence (a) Social workers should provide (a) Social workers should provide

services and represent themselves services and represent themselves as competent only within the as competent only within the boundaries of their education, boundaries of their education, training, license, certification, training, license, certification, consultation received, supervised consultation received, supervised experience, or other relevant experience, or other relevant professional experience.professional experience.

NASW Code of Ethics NASW Code of Ethics Cont’Cont’ 1.06 Conflicts of Interest1.06 Conflicts of Interest

(a) Social workers should be alert to and avoid conflicts of interest that interfere (a) Social workers should be alert to and avoid conflicts of interest that interfere with the exercise of professional discretion and impartial judgment. Social workers with the exercise of professional discretion and impartial judgment. Social workers should inform clients when a real or potential conflict of interest arises and take should inform clients when a real or potential conflict of interest arises and take reasonable steps to resolve the issue in a manner that makes the clients' interests reasonable steps to resolve the issue in a manner that makes the clients' interests primary and protects clients' interests to the greatest extent possible. In some primary and protects clients' interests to the greatest extent possible. In some cases, protecting clients' interests may require termination of the professional cases, protecting clients' interests may require termination of the professional relationship with proper referral of the client.relationship with proper referral of the client.

(b) Social workers should not take unfair advantage of any professional relationship (b) Social workers should not take unfair advantage of any professional relationship or or exploit others to further their personal, religious, political, or business interests. exploit others to further their personal, religious, political, or business interests.

(c) (c) Social workers should not engage in dual or multiple relationships with clients or former clients in which there is a risk of exploitation or potential harm to the client. In instances when dual or multiple relationships are unavoidable, social . In instances when dual or multiple relationships are unavoidable, social workers should take steps to protect clients and are responsible for setting clear, workers should take steps to protect clients and are responsible for setting clear, appropriate, and culturally sensitive boundaries. (Dual or multiple relationships appropriate, and culturally sensitive boundaries. (Dual or multiple relationships occur when social workers relate to clients in more than one relationship, whether occur when social workers relate to clients in more than one relationship, whether professional, social, or business. Dual or multiple relationships can occur professional, social, or business. Dual or multiple relationships can occur simultaneously or consecutively.)simultaneously or consecutively.)

(d) When social workers provide services to two or more people who have a (d) When social workers provide services to two or more people who have a relationship with each other (for example, couples, family members), social relationship with each other (for example, couples, family members), social workers should clarify with all parties which individuals will be considered clients workers should clarify with all parties which individuals will be considered clients and the nature of social workers' professional obligations to the various individuals and the nature of social workers' professional obligations to the various individuals who are receiving services. Social workers who anticipate a conflict of interest who are receiving services. Social workers who anticipate a conflict of interest among the individuals receiving services or who anticipate having to perform in among the individuals receiving services or who anticipate having to perform in potentially conflicting roles (for example, when a social worker is asked to testify in potentially conflicting roles (for example, when a social worker is asked to testify in a child custody dispute or divorce proceedings involving clients) should clarify their a child custody dispute or divorce proceedings involving clients) should clarify their role with the parties involved and take appropriate action to minimize any conflict role with the parties involved and take appropriate action to minimize any conflict of interest.of interest.

NASW Code of Ethics NASW Code of Ethics Cont’Cont’ 1.10 Physical Contact1.10 Physical Contact

Social workers should not engage in physical contact with clients when there is a possibility of psychological harm to the client as a result of the contact (such as (such as cradling or caressing clients). Social workers who cradling or caressing clients). Social workers who engage in appropriate physical contact with clients are engage in appropriate physical contact with clients are responsible for setting clear, appropriate, and culturally responsible for setting clear, appropriate, and culturally sensitive boundaries that govern such physical contact.sensitive boundaries that govern such physical contact.

1.11 Sexual Harassment1.11 Sexual Harassment Social workers should not sexually harass clients. Sexual

harassment includes sexual advances, sexual solicitation, requests for sexual favors, and other verbal or physical conduct of a sexual nature. .

1.12 Derogatory Language1.12 Derogatory Language Social workers should not use derogatory language in

their written or verbal communications to or about clients. Social workers should use accurate and respectful language in all communications to and about clients..

Therapist Therapist ResponsibilitiesResponsibilities Provide treatment once Provide treatment once

individual consents. individual consents. Provide treatment in the Provide treatment in the

"least restrictive" setting. "least restrictive" setting. Do not force any type of Do not force any type of

treatment on a individual. treatment on a individual. Render some form of Render some form of

"traditional" type of "traditional" type of treatment. treatment.

Prepare a treatment plan and Prepare a treatment plan and discuss it with the individual. discuss it with the individual.

Obtain a signed informed Obtain a signed informed consent for treatment. consent for treatment.

Discuss the cost of therapy at Discuss the cost of therapy at the first session. the first session.

Discuss the policy on late Discuss the policy on late cancellations or no shows. cancellations or no shows.

Review the limits of Review the limits of confidentiality with all confidentiality with all individuals. individuals.

Provide adequate care. Provide adequate care. Engage in continuing Engage in continuing

education. education. Protect life. Protect life. Discuss the status of one¹s Discuss the status of one¹s

license if applicable. license if applicable. Utilize supervision. Utilize supervision. Follow all state and federal Follow all state and federal

laws. laws. Respect a client¹s privacy. Respect a client¹s privacy. Maintain a client¹s Maintain a client¹s

confidentiality. Is accountable confidentiality. Is accountable for one¹s actions. for one¹s actions.

Does cooperate with an Ethics Does cooperate with an Ethics Committee or Licensing Board Committee or Licensing Board investigation. investigation.

Does not defame others. Does not defame others. Assist with third part Assist with third part

collections/reimbursements. collections/reimbursements.

Therapist Therapist Responsibilities Cont’Responsibilities Cont’ Obtain authorization before Obtain authorization before

audio or video recording. audio or video recording. Notify the individual whenever Notify the individual whenever

using a cellular phone. using a cellular phone. Consult with a colleague when Consult with a colleague when

needed or requested by the needed or requested by the individual. individual.

Refer a individual to another Refer a individual to another worker when necessary or worker when necessary or when requested by the worker. when requested by the worker.

Focus on termination issues in Focus on termination issues in final phase of treatment. final phase of treatment.

Permit the individual to Permit the individual to discontinue therapy at any discontinue therapy at any time. time.

Never abandon a individual. Never abandon a individual. Do Not end treatment Do Not end treatment

abruptly. Do not misuse abruptly. Do not misuse therapeutic power. therapeutic power.

Does not engage in dual Does not engage in dual relationshipsrelationships

Do not prolong treatment Do not prolong treatment beyond that which is beyond that which is appropriate. appropriate.

Keep accurate and up-to-date Keep accurate and up-to-date records. records.

Permit access to records as Permit access to records as mandated by law. mandated by law.

Send copy of records to another Send copy of records to another provider when authorized in provider when authorized in writing. writing.

Claim privileged communication Claim privileged communication for the individual. for the individual.

Protect the confidentiality of Protect the confidentiality of records. records.

Keep records as required by Keep records as required by law. law.

Destroy obsolete files and Destroy obsolete files and materials. materials.

Doe not engage in dual Doe not engage in dual relationships. relationships.

(Joyce Parker, PhD, A Psychotherapist Responsibilities; (Joyce Parker, PhD, A Psychotherapist Responsibilities; 2000)2000)

General Practice Guidelines General Practice Guidelines with Individualwith Individual

NeverNever take an individual take an individual served home with youserved home with you

Do not run personal Do not run personal errands /personal business errands /personal business with individual/familywith individual/family

Do not work with two Do not work with two individuals at the same individuals at the same time. Double billing is time. Double billing is illegal and had illegal and had confidentiality concernsconfidentiality concerns

Do not impose your Do not impose your religion religion

Do not transport siblings Do not transport siblings or individuals friendsor individuals friends

Discuss individuals even Discuss individuals even professionals only on a professionals only on a need to know basis and be need to know basis and be sure to get consentsure to get consent

Do see individual regularly Do see individual regularly as contracted as contracted

Do not purchase items from Do not purchase items from individual/family or have individual/family or have them purchase anything them purchase anything from youfrom you

Never work with individual Never work with individual or family when under the or family when under the influence of alcohol of influence of alcohol of substancessubstances

Do not keep individual Do not keep individual overnight, or baby-sitovernight, or baby-sit

Do take your consent to Do take your consent to transport with you and keep transport with you and keep it safe and confidentialit safe and confidential

Inform individual and family Inform individual and family if you are going to be late or if you are going to be late or will have to cancel (should will have to cancel (should be rare)be rare)

Support for Prudent Support for Prudent Practice Practice

Individual Clinical SupervisionIndividual Clinical Supervision Group SupervisionGroup Supervision Treatment TeamTreatment Team ConsultationConsultation Ask Quality ManagementAsk Quality Management

Support for Prudent Support for Prudent Practice Cont’Practice Cont’

Inner VoiceInner Voice: If you think that an : If you think that an intervention or behavior is something intervention or behavior is something it would be best you did not disclose it would be best you did not disclose then it is a good indication you may be then it is a good indication you may be dealing with a boundary violation dealing with a boundary violation

Support development of natural Support development of natural supports, friends and community to supports, friends and community to get the individual’s limit boundaries get the individual’s limit boundaries and particularly intimacy boundaries and particularly intimacy boundaries needs metneeds met

Q&AQ&A