Seeing the Forest and the Trees: Professional Boundaries and Ethics

1. Seeing the Forest and the Trees: Professional Boundaries and Ethics Troy McLean, MSW, LCSW Staff Development Director

2. Personal Relationships Social Relationship Unlimited Timeframe Share information No fee No legal need for Confidentiality Informality with settings and environment Social Norms may be loose Equal Power Professional Relationship No Social Relationship, Contracted Relationship, do not hire individual to meet personal needs Time Limited Information is about or for the consumer Fee for service Confidentiality a must Respect Privacy No flexibility with social norms ( Example: No sexual relationship) Unequal power and authority Boundaries

3. Three Types of Boundaries • Intimacy – A question of distance • Responsibility – What our responsibility is • Limits – What we are willing to do (Alan Konell, Partnership Tools, 2001)

4. Boundaries

5. 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.

6. Boundary Violation Violations of intimacy: occur when a physical or emotional boundary is breached: 1. inappropriate personal questions.2. inappropriate touching.3. attempting to control how another thinks, believes, or feels.

7. Dangers • The failure to render needed treatment or services -- undermining what good work may have been done. • Failure to refer for other services -- the worker "hanging on" to the individual and trying to provide for all of his or her needs. • Creation of unhealthy dependency which is difficult to resolve. • Confusing the individual about what is treatment and what is personal. • Breach of trust -- individual distrusting professionals as a result of the corruption of the treatment. • In some instances, interference in family relationships, friendships, etc. • Anger, loss of self esteem, depression, and other psychological distress. (Schoener et. al., 1989, pp. 133-147; Simon, 1991):

8. Problematic Self Disclosure • Disclosing current personal needs or problems. • Disclosure as common, rather than rare event, during sessions. • Disclosing things not clearly connected to client's problems or experiences; or not clearly things which would be likely to encourage or support individual. • Self-disclosure not only frequent, but uses up more than a few minutes in a session • Self-disclosure occurs despite apparent individual confusion or romanticization. (Gary Richard Schoener, 1998)

9. Self Awareness • Obvious worker distress or upset • Therapeutic drift -- shifting style and approach to a given individual • Lack of goals and reflection on progress in treatment • Treatment which exceeds normal length for an individual of that type in the particular worker's practice. • Exceeding areas of competence, reluctance or unwillingness to refer for other types of treatment, assessment, etc. • Becoming enmeshed in individual's life -- treating close friends or family members

10. Self Awareness Cont’ • Unwise techniques: • Routine hugs • Face to face, intimate hugs • Excessive touch • Sessions in non-traditional setting when this isn't necessary • Adult individual’s on lap • Routine or common socializing with clients • Excessive self-disclosure by worker • Direct intervention in the individual's life

11. Self Awareness Cont’ Unique vulnerabilities: • Attraction • Over-identification with individual • Uniquely similar family dynamics • Divorce or loss in worker's life • Identity disturbance in worker (Gary Richard Schoener, 1998)

12. NASW Code of Ethics • 1.02 Self-Determination • Social workers respect and promote the right of clients to self-determination and assist clients in their efforts to identify and clarify their goals. Social workers may limit clients' right to self-determination when, in the social workers' professional judgment, clients' actions or potential actions pose a serious, foreseeable, and imminent risk to themselves or others.

13. NASW code of Ethics Cont’ • 1.03 Informed Consent • (a) Social workers should provide services to clients only in the context of a professional relationship based, when appropriate, on valid informed consent. Social workers should use clear and understandable language to inform clients of the purpose of the services, risks related to the services, limits to services because of the requirements of a third-party payer, relevant costs, reasonable alternatives, clients' right to refuse or withdraw consent, and the time frame covered by the consent. Social workers should provide clients with an opportunity to ask questions.

14. NASW Code of Ethics Cont’ • 1.04 Competence • (a) Social workers should provide services and represent themselves as competent only within the boundaries of their education, training, license, certification, consultation received, supervised experience, or other relevant professional experience.

15. NASW Code of Ethics Cont’ • 1.06 Conflicts of Interest • (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 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 primary and protects clients' interests to the greatest extent possible. In some cases, protecting clients' interests may require termination of the professional relationship with proper referral of the client. • (b) Social workers should not take unfair advantage of any professional relationship or exploit others to further their personal, religious, political, or business interests. • (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 workers should take steps to protect clients and are responsible for setting clear, appropriate, and culturally sensitive boundaries. (Dual or multiple relationships occur when social workers relate to clients in more than one relationship, whether professional, social, or business. Dual or multiple relationships can occur simultaneously or consecutively.) • (d) When social workers provide services to two or more people who have a relationship with each other (for example, couples, family members), social workers should clarify with all parties which individuals will be considered clients and the nature of social workers' professional obligations to the various individuals who are receiving services. Social workers who anticipate a conflict of interest 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 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 of interest.

16. NASW Code of Ethics Cont’ • 1.10 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 cradling or caressing clients). Social workers who engage in appropriate physical contact with clients are responsible for setting clear, appropriate, and culturally sensitive boundaries that govern such physical contact. • 1.11 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 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.

17. Provide treatment once individual consents. Provide treatment in the "least restrictive" setting. Do not force any type of treatment on a individual. Render some form of "traditional" type of treatment. Prepare a treatment plan and discuss it with the individual. Obtain a signed informed consent for treatment. Discuss the cost of therapy at the first session. Discuss the policy on late cancellations or no shows. Review the limits of confidentiality with all individuals. Provide adequate care. Engage in continuing education. Protect life. Discuss the status of one¹s license if applicable. Utilize supervision. Follow all state and federal laws. Respect a client¹s privacy. Maintain a client¹s confidentiality. Is accountable for one¹s actions. Does cooperate with an Ethics Committee or Licensing Board investigation. Does not defame others. Assist with third part collections/reimbursements. Therapist Responsibilities

18. Obtain authorization before audio or video recording. Notify the individual whenever using a cellular phone. Consult with a colleague when needed or requested by the individual. Refer a individual to another worker when necessary or when requested by the worker. Focus on termination issues in final phase of treatment. Permit the individual to discontinue therapy at any time. Never abandon a individual. Do Not end treatment abruptly. Do not misuse therapeutic power. Does not engage in dual relationships Do not prolong treatment beyond that which is appropriate. Keep accurate and up-to-date records. Permit access to records as mandated by law. Send copy of records to another provider when authorized in writing. Claim privileged communication for the individual. Protect the confidentiality of records. Keep records as required by law. Destroy obsolete files and materials. Doe not engage in dual relationships. (Joyce Parker, PhD, A Psychotherapist Responsibilities; 2000) Therapist Responsibilities Cont’

19. Never take an individual served home with you Do not run personal errands /personal business with individual/family Do not work with two individuals at the same time. Double billing is illegal and had confidentiality concerns Do not impose your religion Do not transport siblings or individuals friends Discuss individuals even professionals only on a need to know basis and be sure to get consent Do see individual regularly as contracted Do not purchase items from individual/family or have them purchase anything from you Never work with individual or family when under the influence of alcohol of substances Do not keep individual overnight, or baby-sit Do take your consent to transport with you and keep it safe and confidential Inform individual and family if you are going to be late or will have to cancel (should be rare) General Practice Guidelines with Individual

20. Support for Prudent Practice • Individual Clinical Supervision • Group Supervision • Treatment Team • Consultation • Ask Quality Management

21. Support for Prudent Practice Cont’ • Inner Voice: If you think that an intervention or behavior is something it would be best you did not disclose then it is a good indication you may be dealing with a boundary violation • Support development of natural supports, friends and community to get the individual’s limit boundaries and particularly intimacy boundaries needs met

22. Q&A