Ethics And Boundary Issues in Counseling--CEUs for LPC, LMHC, LCSW

Hi and welcome to Ethics and Boundary Issues brought to you by allce.com today we're going to examine the different types of boundaries, identify common boundary violations, and discover at least three ways to prevent boundary violations. So let's start by talking about the characteristics of professional boundaries. We need to have clearly established limits that allow for safe connections between providers, us and clients. So what does that look like? These clearly established limits? How much do we share? How much self disclosure happens? What are our personal and physical boundaries going to be between clients? The ability to be with the client without becoming the client. The ability to be friendly without being friends. There's a big difference. You can be nice to somebody, you can respect somebody. It doesn't mean you're going to go out for coffee after therapy knowing where those limits stop. You're friendly in the session. You are two people that are working together to solve a problem. But you are not friends. You have a business relationship. You need to have the ability to know where you end and the client begins. So when the client's telling their story, if you have a similar story, not to get enmeshed, making sure to be able to separate your stuff from their stuff, to identify transference when they are projecting onto you versus countertransference when you're seeing things that bring up stuff for you in them. You need to be able to clearly identify what's in the present with that client and what belongs in the client's realm and what belongs with you. And you need to have a clear understanding of the limits and responsibilities of your role as a service provider. Your responsibility is not to mother, it's not. Or father or rescue a patient. Your responsibility is to assist the patient in staying safe. So if there is a situation where there is imminent harm or the risk of imminent harm, we do have the duty to act. However, it is not our obligation to rescue a client constantly from every single little life crisis that happens. We need to empower them to develop a sober support system outside of therapy. We need to encourage them to rely on their own strengths and have faith in their own abilities. We need to understand when we do feel like mothering or nurturing a client, where that's coming from and exactly what that can look like in the context of a professional relationship versus crossing those ethical boundaries. Boundaries are important because they provide role modeling to the client about healthy communication and professional relationships. A lot of our clients, part of their problem has been because prior relationships have had poor boundaries, lots of enmeshment or detachment, lots of violation of their personal boundaries. So if our boundaries are on roller skates, that just models for them that what they've known to date is the norm. And we don't want to do that. We want to model for them what a healthy relationship can look like that respects one another's boundaries. Your client can be upset without you having to be devastated. You can feel compassion for them. You can empathize, but it's different than becoming the client. So we need to role model that it's okay to have physical and emotional boundaries. Boundaries help us avoid that rescuer role. They say, okay here. We need to draw the line and encourage other people to step in. We don't want to encourage clients to become dependent on us where every time the wind changes direction, they're calling us to tell them what to do. We need to help them learn how to figure out what to do so they make the choice on their own. If we're just constantly telling them what to do. It's like the difference between giving a man a fish and teaching him to fish. If we just tell them they solved that one problem in that one particular point in time, but they don't know how to do it again. So we need to educate, empower, and encourage boundaries. Help keep us focused on our responsibilities to the client and the provision of helpful and appropriate services to the client. We're constantly thinking about ethics and boundaries. And what is it that I'm supposed to do in relation to where the client is and wants to go? How can I coach them along the way? How can I encourage them? I'm not going to drag them to the finish line. We want them to run to the finish line themselves, but we need to provide the encouragement along the way and sometimes the tools. We want to help avoid burnout or compassion fatigue by maintaining those boundaries. Again, not becoming the client, it's exhausting when you have a really good session, but you're not the client. So when the client walks out, you can recharge and regroup. It's a fine line, but we have to manage it, we have to negotiate it, and you have to stay ever vigilant, because there are going to be some things that clients talk about that strike a nerve. And you need to know how you deal with those, whether it be your own counseling, somebody who's a colleague that you consult with or debrief with, depending on how serious or severe your issues are, in order to make sure that they don't encroach upon the client's therapy session. Boundaries also help us maintain a healthy, open, communicating and functional team, my boundaries. I know what my job is. When I work in a multidisciplinary team, I don't try to tell the psychiatrist his job. He doesn't try to tell me my job. We provide information to one another. So if the client is telling me they're having unacceptable side effects from the medication and they're monkeying with their own med dosages, sure, I'm going to tell that to the psychiatrist. I'm not going to tell him, well, you need to change her medication to xyz. I am, however, going to inform the psychiatrist of what the patient told me, or better yet, empower the patient to talk with the psychiatrist. A lot of patients have sort of this white coat thing going on. As soon as they see a psychiatrist, it's, yeah, huh, whatever you say. And they won't communicate some of their symptoms and side effects to the psychiatrist the way they will to you, the therapist. We also see our patients on a weekly basis or more often. Psychiatrists often only see the patient on a monthly basis. So we're able to provide useful, vital information about how the medication is impacting the client for the good and for the bad, so that psychiatrist has a bigger picture of what's going on. It's helpful if you write this stuff down. If you're talking to your client and they're giving you information about, it doesn't have to be medication and the psychiatrist. It can be case management, it can be legal representation, it can be whatever else is involved in their multidisciplinary team. If they're saying they're having these issues or things are going really well, make sure to note that. That way, when you meet for a multidisciplinary team meeting, you can share what the client has said is going well versus what's not going well. You can compare notes and see if the story is staying the same between service providers. And if not, then you can look for other issues that the patient may be trying to manipulate. So it helps us maintain healthy, open communication In a multidisciplinary team. It's crucial and it assists us in maintaining our own physical and emotional safety. If we tell clients from the get go what is appropriate behavior, what you will do, what you won't do, it sets the stage so they know what the expectations are, so they know whether it's appropriate to give you a hug or never give you a hug or whatever the case may be. Prevents miscommunications on the part between you and the client. Poor boundaries lead to compassion fatigue. At a certain point, if you are becoming your client in every session, if you are immersing yourself to that degree where you can't back away, your role is not going to be sustainable, especially if you have a large caseload. There's a potential for splitting teams. If you've got poor boundaries and you either align with or detach from your client, you could do the same within the multidisciplinary team. Poor boundaries also lead to the potential that the patient may not be given appropriate services, which could affect their willingness to accept future services. So if you've got poor boundaries, and let's go with what happens more often when we're talking about poor boundaries and ethical violations and you engage in a relationship with your client, they've shown that the effects of having a relationship with a client, especially a sexual relationship, can be similar to that in rape trauma stress disorder. It causes a lot of problems when there's a relationship among two people where there is an inherent power differential. So that happens. The client doesn't receive the services that they probably really needed because your boundaries are gone and you're not objective. They may not ever want to go back to treatment. Or if you don't have good boundaries and it triggers some of your issues, you may provide the client the types of services you would want to receive, not the types of services that he or she wants to receive. Thus, the client doesn't get appropriate services and is jaded towards coming back to counseling. So again, we need to have good boundaries so we can assess what that client needs at that particular time. Poor boundaries may also lead to a client feeling betrayed, abandoned, or poorly served. If you've constantly got your own agenda going on, or you're constantly trying to fit a client into a generalized mold, you have this disorder. So this is what we're going to do to treat you. The client doesn't feel unique, doesn't feel heard, and again, may not come back to counseling or may not benefit from counseling. Poor boundaries also can lead people to act unethically because they want to or need to justify this unethical conduct and these loose boundaries. So they focus on what didn't happen. They focus on the positive. They may make rationalizations, justifications for things that they do in order to fulfill their own needs because they've become enmeshed. The reputation of the company and or the profession may become compromised. If you think about, oh, did you see the news story about that counselor? That did fill in the blank. Then when people think about counseling, because that's fresh in their mind, and it was highly publicized. They think about that unethical counselor. Just like when stories about law enforcement and excessive use of force, it doesn't happen that often. But a lot of us, when we see media stories and media stories about military and law enforcement, think law enforcement, gun, badge, heavy adrenaline junkie, which is not the case. Most of them are great big old teddy bears, as long as you don't pull a gun on them. But I digress. So we need to pay attention to what's real and what is kind of corrupting our perception due to the availability heuristic. But it's also important to remember that even if you are the one and only person in your organization or in your profession that does this bad thing that may come to represent the organization or profession and the service provider and, or the client may be emotionally traumatized and, or put in physical danger because of loose boundaries. Again, this is especially true when it involves dual relationships. Clients can become very hopeless, very angry if they feel like they've been betrayed or they've misunderstood a relationship or maybe they understood it perfectly, which is even worse and the relationship ends. Clients can become very volatile. So common pitfalls are dual relationships when the service provider and client know each other in a personal context from another setting. So if you know somebody from 12 step meetings and they come into your office and they're seeking counseling, that's a dual relationship. You need to evaluate whether there are any other possibilities. Are there other providers? You want to avoid dual relationships at all costs. You really do. And if it's somebody, say in your home group, then you definitely want to try to refer this person to a different provider. If it's the son of a friend of your mother's, the dual relationship, if it is a co worker or a co worker of your spouse, it's a dual relationship. If it is somebody who is a parent of a child that is in your daughter's brownie group door relationship, you know them outside of that room, there is a chance you will run into them outside of that room, there is a chance that the relationship could become destabilized. Does it mean that you have to, that you can't see any of those people? Well, in an ideal world you would refer out. But if you can't avoid the dual relationship because you're in a small community and you're the only provider that deals with that particular disorder or whatever the situation is, you must, must, must make sure you have continuous consultation with another professional. I would suggest consulting your lawyer, the ethics boards, to get their opinions on what, if any other alternatives exist and definitely document a contract with the client identifying the fact that it is a dual relationship and how you will handle those situations. Another common pitfall is values conflicts. The client's choices, history, relationships, feelings, lifestyle and or life circumstances conflict with your values and or knowledge about best practices situations. I've seen this come up in with colleagues. If a patient comes in and is trying to deal with issues related to an abortion she had. If a client is dealing with acceptance of the fact that he or she is gay, lesbian, bisexual, a client who is trying to deal with the fact or who comes into 12 step treatment and firmly asserts I'm an atheist, I don't do 12 step stuff. How do we work with those patients? Can you as an individual be able to be impartial and work with that patient in that patient's reality? Seek consultation. If it's something that you think you're not going to be able to serve the best interest of the client, refer out. Try to have an open discussion with your client at the beginning to make sure that you're going to be able to work together well and discuss how you're going to handle issues if they come up that may cause value conflicts. Playing the hero role is another big pitfall. Needing to save the client. Driving out because you hear that Jim is at the bar drinking and driving out there to tote his happy butt back to detox. Not your role. In theory it's nice, but it is not your role. It could set you up for liability. It creates the expectation in Jim that every time he does something that every time he relapses, you're going to be there to drive him back to detox. It will drain on your every last bit of energy. You need to be able to set boundaries for yourself about when you're on duty and when you are not. How the patients deal with life on life's terms Is there an on call service that you share with other practitioners? Is there a crisis line? What do they do if they're in crisis at 11 o' clock at night? Vicarious trauma is when the service provider experiences trauma symptoms from hearing about the client's experiences. It is hard to hear about some of this stuff day in and day out. I would love to believe that I have heard every possible thing I could ever hear and nothing could shock me. But I learned a long time ago not to say that because every time I think I've heard it all, something else comes up. However, dealing with it, empathizing with that client is tiring. It's hard, and it's very hard to maintain that level of detachment where you can separate yourself and say, this is the client's experience and I am here to support him or her. But it doesn't have to be my experience. Poor teamwork, another pitfall. Now, we've been talking about boundaries in terms of clients, but when you don't have good boundaries in terms of your team, you don't trust that anybody else can do it right? So you do everything. You're going to burn yourself out. If you believe that you can provide better services than anybody else in the building, you need to check that. For some clients, that may be true, but for some clients, they may work better with other therapists. So it's important not to be too confident. It's important to have confidence in your colleagues. And maybe you don't agree with their methods or as long as they're ethical, you want to consider them and say, okay, when I have a client who comes this way who needs this type of therapy or who requests this intervention, it's not my intervention of choice. But if the client believes it will help him or her, I know I can refer to Tom down the hall. So know what the strengths are of everybody in your team. And remember that the client can work best with who they work best with. Sometimes it may be you, but other times they may connect better with other people. It's nothing against you. Which is where a lot of people get caught, is this whole ego thing. They just have more in common or a different type of transference reaction or whatever the case may be. But they connect better with somebody else on the team. There's nothing wrong with that. So in the theme, you might be a boundary violator if you and the client begin referring to each other as friends. We're friends, aren't we? No, we're not. This is a business relationship. It's a doctor patient relationship. We're trying to be equals. I mean, doctors come to see therapists and therapists go to see doctors. It doesn't mean one is less smart or less important than the other one. But there is something of a knowledge or power differential inherent in our profession. If you begin receiving gifts from, from, or giving gifts to a client, you might be a boundary violator. The client has or is asking for your home phone number or other significant personal information. You might be a boundary violator. Let's talk about this for a minute. If I go to your Facebook page and your home phone number and your personal email address are out there for all the public to see. That's just as good as writing it down for the client and handing it to them. Because I can bet you dollars to donuts, and I have no idea where that saying came from, but I can bet you dollars to donuts that they've done their research and they've looked to see if you have a Facebook page, if they want to call you at home. Then there's a strong indication that there's already some boundary problems going on that need to be addressed and a strong likelihood that because of those boundary problems, they have already searched the Internet to find every little last bit of information and photograph that you have on the World Wide web. So another boundary issue. Don't friend clients on Facebook. Make sure anything that you put on Facebook is okay for your clients to know because they're going to everything else. Keep private and have it so only friends can see it or whatever security settings you need to have. So your average client can't just Google you and go, oh, you have three children and they go to such and such elementary school and this is your home phone number and dog's name is Pete. That's not okay information for a client to have. You reveal excessive personal information to a client again, whether you do it in session or you friend them on Facebook and they can see everything from where you were born to when you had your first child. Too much information. Keep that personal information personal. Unfortunately, yes, it does include the stuff on the world Wide Web because if we have it out there for the general public, we know our clients are going to see it. You might be a boundary violator. If you are unable to sleep due to anxiety related to a client's situation, that tells me you're enmeshed with that client. Now every once in a while we get stuck and we ponder. May make it difficult to get to sleep one night. But if you're regularly staying up worried about this client or this situation, you probably need to consult with a colleague and figure out how to resolve it. Because it's clearly crossed over that boundary from being a professional relationship to being something you feel the responsibility to fix or rescue, you might be a boundary violator if discussion regarding work or clients dominates service providers social interactions with friends and family. So if you go to dinner and you're talking to your spouse about oh, let me tell you about my two o', clock, you're a boundary violator. And also some confidentiality and HIPAA stuff in there too. But if all you're thinking about is different ways to Find different interventions to use with your clients. If on Saturdays you're writing treatment plans, you might be a boundary violator. Now that sounds like. I mean, you're working on treatment plans and trying to figure out how to best help your clients. Doesn't that sound awesome? It does until you get burned out. Because all you're doing 24, 7, 365 is work. You need to set boundaries for work and personal. You might be a boundary violator if you offer to provide assistance to a client outside of your role, such as babysitting while they go to the doctor, transportation to and from appointments, to and from your appointments even. You need to be very careful about how you do that and looking into any legal repercussions. Transportation? You wouldn't babysit a patient's children. You just wouldn't. If your facility does offer child care while parents are in group, for example, that is something that the facility is offering. Again, you need to consider any legal ramifications, but it's separate and distinct from you saying, oh, sue, you really need to have a night out. So why don't I watch your kids so you and your husband can go out on a date and talk about the stuff that we discussed in session? Oh, yeah, no. You don't go to a client's house and babysit their children. You don't have them drop their children off at your house. If there is any sort of relationship or service offered other than counseling, you need to see how that fits into your scope of services and make sure it's something you'd be willing to do for any other client, not just this one. You might be a boundary violator if you find yourself venting with a client about other service providers on your team. Don't bad mouth your team. Don't focus on your team. I mean, when you're talking, you're making a referral to Tom down the hall. Again, you may not agree with his methods. You may not really buy into this particular approach to treatment, but it's ethical and it's research based and the client wants to try it. So you want to talk up how good Tom is at doing that, not your concerns and issues with the treatment itself. Making sure the client has informed consent. You know, they know the pros and cons, but Tom is probably going to be the one that goes over the informed consent with them anyway. So just kind of bearing in mind, we don't want to sugarcoat something, but we also don't want to badmouth it. We want to make sure the client has good information about all the choices that they make. So we've talked about all the problems. Let's look at how to create and maintain healthy professional boundaries as early as possible in the relationship. Establish clear agreements with the client regarding your role as service provider. I do this at intake. I let them know what my job is, how I will help them, what my hours of availability are, what to do outside of the hours of availability. We also discuss all the HIPAA and confidentiality limits and we discuss what treatment is going to consist of and what they may or may not want to engage in. When boundary issues or warning signs appear, address these issues with the client quickly. Be sensitive to their feelings, but emphasize the importance of and your commitment to maintaining healthy boundaries. Two prime examples Clients wanting to start giving you hugs, sitting too close to you, physical contact, and clients giving you gifts. These are things that need to be taken on an individual basis, but again, you should address them at the beginning of treatment so they know what is and is not appropriate with regards to those things. And then if the client starts crossing that boundary, you need to have a discussion about what the boundary is, why it's there, and talk about why the client might be crossing that boundary. What is he or she needing or hoping to get? It's important to realize how a client interprets your words and actions when might not match what you are trying to communicate so frequently. Clarify your role in boundaries. You don't want them to think that you're rejecting them if you don't let them hug you. If you tell them that that's not something you're comfortable doing with clients at the beginning, then if it comes up in the middle of treatment, you can say, remember when we first started, we talked about what I'm comfortable with as far as physical contact and I'm not comfortable hugging clients. You can refer back to that. So it's not something you're just like pulling out of thin air going, oh, I don't want to hug you. Discuss again why those boundaries exist. Help the client understand the reason why you don't hug clients or why you do hug clients. If you decide to tell a client something personal about yourself, ensure that the information is related to the client's goals. Too much self disclosure shifts the focus from the client to the service provider and can confuse the client in terms of roles and expectations of the relationship. If you start asking the client for advice or their opinion on things, then the tables are turned and they start getting confused. If you start doing more of the talking during the session than they are then you're dominating and again they start getting confused. So you need to be careful about how much you share, why you're sharing it, is it for your gain or because what you're sharing could benefit the client? Use your supervisor, professional colleagues and or a mental health professional as a sounding board. When you have questions or concerns regarding boundaries, you can also usually contact your local professional association, the aca, the apa, aamft, they have ethics committees that can help you sort through these issues if you want to consult them. It's always good to have a local person professional with whom you can consult on issues like this. You have to have a sounding board. We all have blind spots, so we all need a sounding board so we can get a full picture of what's going on. If you're working with a team of service providers, remember to promote and role model positive open communication and respectful sharing of information. When I was doing my first internship, I had this wonderful supervisor and there were 15 of us on the team and our team meetings, oh my gosh, they went on forever. They were like four or five hour meetings, which I have the attention span of a gnat. So it seemed like a long time. But we all had different backgrounds. Some were social workers, some were therapists, some were just in recovery, some were certified addictions professionals, some were rehab counselors, nurses, doctors. If you want to talk multidisciplinary, we had it, which was great. However, oftentimes when we were talking about a particular case, because we would staff each patient, we would have divergent opinions about what should be done with the client. We all shared our opinions, you know, kind of gave it to the primary therapist who would assimilate it all, take what was useful and leave the rest. None of us got our feelings hurt. None of us condescended to another one saying, oh, that's stupid. We all respected the different points of view. We all respected each other's strengths and tried to focus on those. It's important that you trust that team members are fulfilling their roles as service providers. And you shouldn't do everything and be everything to your client. They need to learn how to reach out and integrate with services. And you're going to burn out if you try to be the psychiatrist, the case manager, the nurse, the therapist, the group leader. You can't do it all. Take care of yourself. You need to get enough sleep, eat well, spend time with friends and family, talking about something other than work, and try to avoid spending a lot of time with friends and family when they're trying to get what I call free counseling. And they're trying to say, well, I've got this problem going on with my son. Well, sounds like you should see a therapist. No, I don't say that, but I try to hedge those conversations early because I don't want to get into a dual relationship. I don't want to give wrong advice because I don't have enough information. So I make referrals of. Well, it sounds like I know somebody who might be perfect to provide you some consultation on that issue. So when you spend time with friends and family, it's doing personal, enjoyable stuff. Recreation, exercise. I know it's a bad word. It is, but a lot of us feel so much better after we do. Doesn't mean you have to spend 30 minutes three times a week in your target training zone. I'd love to hear everybody doing that, but it doesn't mean you have to. It means you need to move your body. Take the dog on a walk, clean the house, do something to move around. Don't just get up, sit in your car, drive to work, walk in the door, sit down, see clients, get up, get in the car, drive home, come home, sit on the couch, watch tv, get up, take a shower, go to bed. There's very little movement there, Very little movement. We need to keep the blood flowing, we need to keep the oxygen moving. Seek supervision as needed and even as not needed. I love going to groups where there's just professionals and we share what's going on. We pick a particular client that we have and present it to the group and get feedback or input. It gives me fresh perspective. That's one of the reasons I used to love teaching at the university, because I would get fresh perspectives and fresh ideas and, well, why are you doing it that way? I don't know. Come to find out. That's a good question. So when you're meeting with other people, they will elicit more questions. They will provide answers you didn't even know you had questions for. But it's wonderful because it stimulates the way we think and it broadens our horizons. Leave work at work to the greatest extent possible. Around our house. I've always had a pretty significant drive from home to work, at least in my opinion. 30 minutes, 40 minutes. So that's my time to decompress. That's my time to go over everything that happened during the day and put it in its happy little boxes or places. So when I get home, hopefully I can start being mommy, wife. All those other roles that I hold don't always do it perfectly, but that's the goal, so I can focus on all areas of my life and I don't get burned out. So in summary, boundaries are not always clear cut. There are going to be those situations where normally you wouldn't do this, but in this particular situation it's in the best interest of the client. It's not in your best interest because you happen to not have a full caseload and you need somebody else. It's in the best interest of the client and there are no other alternatives. Each situation requires thought and consideration of the ethical principles of beneficence, fidelity and non maleficence. Encourage the client to do what's best for them. Be faithful to your client in your promises. If you say you're going to provide treatment, then be on physically and emotionally, be present, keep promises that you make and do what you say you're going to do. And non maleficence means do no harm. If that's what you have to drop down to is you have all these array of choices and the best you can do is do no harm, then do no harm, but above all do no harm. Proper self care prevents the counselor from trying to get his or her needs met in session. If you are feeling respected, loved, cared about, and your self esteem is doing well, you're not going to try to get those needs met in session. If your whole life is going to crap and you're trying to sort of build yourself up in session so you can forget about how your life is going to crap, that's not a good thing. So proper self care and awareness of your limitations. If you can't be there for the client emotionally and physically, then you need to have an alternate plan. And regular consultation or supervision prevents isolation, which can reinforce our rationalizations of unethical behavior. Thank you for attending today and I hope to see you again.