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 clientRights of client are respected & honoredCounselor 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 helper-client 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 sessiontime of sessionpersonal disclosurelimits regarding the use of touchthe general tone of the professional relationshipfee 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 higherThere 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 BASIC MORAL PRINCIPLES OF OF

ETHICAL DECISION MAKINGETHICAL DECISION MAKINGAutonomy: 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 PRACTICELEVELS OF ETHICAL PRACTICEMandatory 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 dilemma2. Identify the potential issues involved3. Review the relevant ethics codes4. Know the applicable laws and regulations5. Obtain consultation6. Consider possible and probable courses of

action7. Enumerate the consequences of various

decisions8. 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 outsetSecure informed consent of clientsDiscuss both potential risks and benefits of counselingConsult with other professionals to resolve any

dilemmasSeek supervision when neededDocument in clinical case notesExamine your own motivationsRefer 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 SocializingTherapists 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 clientsCounselors’ own needs may be enmeshed with those of their clients to the point that objectivity is lostCounselors 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

supervisorsMinimize unique financial arrangementsIf bartering is used, it is better to exchange

goods rather than servicesBoth 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 hoursseeing clients only in “appropriate professional locations” where helping relationship is to be performedonly 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 GIFTSQuestions 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 processRights of the client are respected & honoredHelper is always respectful of & conscious of need to guard privacy of clientHelper does not take advantage of & recognizes extent of “vulnerability” of client in situation

10 QUESTIONS TO ASK IN 10 QUESTIONS TO ASK IN DETERMINING BOUNDARY DETERMINING BOUNDARY

ISSUES WITH CLIENTSISSUES WITH CLIENTS1. 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 10 QUESTIONS TO ASK IN DETERMINING BOUNDARY DETERMINING BOUNDARY

ISSUES WITH CLIENTS 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 & familyBe observant of behavior of other helpers in the field & call them on it, if they appear to be overstepping their boundaries with clientsAlways act in best interest of clients & familiesMost 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 learnedAnswer these questions as we goSelect the correct answer for each questionShare 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. Actions that are not appropriate in client care

B. Whatever the client feels is appropriateC. Whatever the helper feels is appropriateD. 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. PowerB. AngerC. Poor servicesD. 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. The client is not happy with his or her careB. The helper hugs the clientC. The helper asks for a change of assignmentD. 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 clientB. Asks the client if she would like to buy some

“Mary Kay Cosmetics”C. Is attracted to the clientD. 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. TrueB. False

ANSWER QUESTION #5

B. False

QUESTION #6

The first person to realize there is a boundary violation is:

A. The clientB. The helper who is committing the boundary

violationC. A co-worker or the supervisor of the helperD. 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. TrueB. 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. TrueB. False

ANSWER QUESTION #8

B. False

QUESTION #9Albert 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 JoB.Give Maggie Jo the name of another Mary Kay distributor in the communityC.Tell Maggie Jo that she cannot sell product to her but can sell it to her relatives or friendsD.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?

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/

eliminatecaretakerbehaviors.html Letting Go of the Uncontrollables and Unchangeables http://www.coping.us/toolsforhandlingcontrol/

letgouncontrollablesunchangeables.html Accepting Powerlessness http://www.coping.us/toolsforhandlingcontrol/

acceptingpowerlessness.html Developing Detachment

http://www.coping.us/toolsforhandlingcontrol/developingdetachment.html

Establishing Healthy Boundaries http://www.coping.us/growingdown/healthyboundaries.html