This interactive New York Social Work Ebook contains 12 hours of continuing education. To complete click the Complete Your CE button at the top right of the screen.
NEW,
Live CE Available! See Inside
NEW YORK Social Work Continuing Education
Elite Learning
12 Hours for $72.00 with book package Get this book FREE With Premium Passport Membership Your Social Work CE or
Elite courses are rated 4.8/5 stars
ELITELEARNING.COM/BOOK Complete this book online with book code:
SWNY1225
What’s Inside
PROFESSIONAL BOUNDARIES IN MENTAL HEALTH CARE (MANDATORY)
1
[3 CE hours] Without proper boundaries and awareness, mental health professionals become vulnerable to burnout and vicarious traumatization. This can result in a risk of therapeutic effectiveness, loss of trust with clients, and possible ethical crossings or violations. This course supports professionals practicing competence, while utilizing self-care and boundaries to minimize burnout while practicing compassion for the clients that they serve. THIS COURSE FULFILLS THE REQUIREMENT FOR PROFESSIONAL BOUNDARIES 17 [9 CE hours] With the development of the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, text revision (DSM-5-TR), professionals who work with people who have mental health diagnoses will be responsible for learning and understanding the changes that have taken place in the new diagnostic manual. The transition from using the previous edition of DSM-5 to the new DSM-5-TR presents a challenge for any clinician. Given the extent of the changes that have occurred for DSM- 5, reading through DSM-5-TR and piecing together these changes should be done thoroughly. This course provides clinicians with the most up-to-date information on DSM-5-TR, relative to the previous edition, DSM-5, including diagnostic criteria needed to assess the presence of various disorders. This course will not only present newly classified disorders and identify those that have been removed or reclassified but will also illuminate any changes to diagnostic criteria for disorders in the previous manual and continue to be defined as disorders in DSM-5-TR. The course will cover the development process used by the DSM-5-TR task force in deciding the diagnostic system’s new structure and removing the multiaxial system. Alternative diagnostic systems proposed in place of DSM-5-TR will also be described. A CLINICIAN’S GUIDE TO THE DSM-5-TR
FINAL EXAM ANSWER SHEET
44
©2025: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Colibri Healthcare, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge in the areas covered. It is not meant to provide medical, legal or professional services advice. Colibri Healthcare, LLC recommends that you consult a medical, legal or professional services expert licensed in your state. Colibri Healthcare, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation or circumstances and assumes no liability from reliance on these materials.
i
SOCIAL WORK CONTINUING EDUCATION
Frequently Asked Questions
What are the requirements for license renewal? Licenses Expire CE Credit Hours
Mandatory Subjects
36 (12-hours allowed through self-study) NEW: You can now satisfy your live requirements with unlimited access to LIVE WEBINARS, now available with Premium Passport Membership. See inside cover for details.
3 hours in professional boundaries 2 hours of training regarding the identification and reporting of child abuse (one time requirement - mandated reporters were required to complete updated training by April 1, 2025)
Licenses expire on the licensees birth month in the triennial registration period
How much will it cost?
Enter the code that corresponds to the online course listed below.
Course Title
Hours Price Course Code
Professional Boundaries in Mental Health Care
3
$18.00
SWNY03MH
A Clinician's Guide to the DSM-5-TR
9
$54.00
SWNY09DS
All 12 Hours
12
$72.00
How do I complete this course and receive my certificate of completion? See the following page for step-by-step instructions on how to complete and receive your certificate. Are you a New York board-approved provider? As a Jointly Accredited Organization, NetCE is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. Regulatory boards are the final authority on courses accepted for continuing education credit. NetCE is recognized by the New York State Education Department’s State Board for Social Work as an approved provider of continuing education for licensed social workers #SW-0033. Are my hours reported to the New York board? No. The board performs random audits at which time proof of continuing education must be provided. What information do I need to provide for course completion and certificate issuance? Please provide your license number on the test sheet to receive course credit. Your state may require additional information such as date of birth and/or last 4 of Social Security number; please provide these, if applicable. Is my information secure? Yes! We use SSL encryption, and we never share your information with third parties. We are also rated A+ by the National Better Business Bureau.
What if I still have questions? What are your business hours?
No problem, we have several options for you to choose from! Online at EliteLearning.com/Social-Work you will see our robust FAQ section that answers many of your questions. Simply click FAQs at the top of the page, email us at office@elitelearning.com, or call us toll-free at 866-653-2119, Monday - Friday 9:00 am - 6:00 pm and Saturday 10:00 am - 4:00 pm EST. Important information for licensees Always check your state’s board website to determine the number of hours required for renewal, mandatory topics (as these are subject to change), and the amount that may be completed through home study. Also, make sure that you notify the board of any changes of address. It is important that your most current address is on file. Disclosures Resolution of conflict of interest Colibri Healthcare, LLC implemented mechanisms prior to the planning and implementation of the continuing education activity, to identify and resolve conflicts of interest for all individuals in a
position to control content of the course activity. Sponsorship/commercial support and non-endorsement
It is the policy of Colibri Healthcare, LLC not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners. Licensing board contact information: NY State Education Department Office of the Professions State Board for Social Work 89 Washington Avenue Albany, New York 12234-1000 518-474-3817, Press 1 then ext. 450
518-486-2981 (fax) swbd@nysed.gov
ii
SOCIAL WORK CONTINUING EDUCATION
How To Complete This Book For Credit
Please read these instructions before proceeding.
• Go to EliteLearning.com/Book and enter the code that corresponds to the course below, then click GO . Each course will need to be completed individually, and the specified course price will apply. • Proceed to your exam. If you already have an account, sign in with your username and password. If you do not have an account, you’ll be able to create one now. • Follow the online instructions to complete your exam and finalize your purchase. Upon completion, you’ll receive access to your completion certificate. ONLINE FASTEST AND EASIEST!
Enter book code
SWNY1225
GO
Complete your CE
Course Title
Hours Price Course Code
ENTIRE PROGRAM (All 12 Hours)
12 $72
SWNY1225
Professional Boundaries in Mental Health Care
3
$18 SWNY03MH
A Clinician’s Guide to the DSM-5-TR
9
$54 SWNY09DS
Complete the answer sheet and evaluation found in the back of this book. Include your payment information and email address. Mail to: Elite Learning, PO Box 997432, Sacramento, CA 95899 BY MAIL Mailed completions will be processed within 2 business days of receipt, and certificates emailed to the address provided. Submissions without a valid email address will be mailed to the postal address provided.
iii
SOCIAL WORK CONTINUING EDUCATION
__________________________________________________ Professional Boundaries in Mental Health Care
SWNY03MH — 3 CE HOURS
R elease D ate : 11/01/23
E xpiration D ate : 10/31/26
Professional Boundaries in Mental Health Care
Audience This course is designed for social workers, counselors, and marriage and family therapists in all practice settings. Course Objective The purpose of this course is to educate mental health profes- sionals on how to provide compassionate and competent care within the boundaries of appropriate practice. Learning Objectives Upon completion of this course, you should be able to: 1. Define professional competence. 2. Outline components of the therapeutic relationship. 3. Define empathy and describe the difference between empathy and sympathy. 4. Define transference and countertransference and discuss their implications for the mental health profes- sional. 5. Identify the functions of professional boundaries in the therapeutic relationship and multiple relation- ships. 6. Discuss the guidance on giving and receiving gifts provided by professional ethics codes. 7. Discuss the legal and ethical considerations of provid- ing distance therapy. Faculty Lisa Hutchison, LMHC , has more than 15 years of experi- ence providing individual and group counseling with adults. She specifically focuses on teaching assertiveness, stress man- agement, and boundary setting for empathic helpers. Ms. Hutchison graduated from the University of Massachusetts, Boston, with a Master’s degree in education for mental health counseling. Faculty Disclosure Contributing faculty, Lisa Hutchison, LMHC, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned. Division Planners Alice Yick Flanagan, PhD, MSW James Trent, PhD Senior Director of Development and Academic Affairs Sarah Campbell
Division Planners/Director Disclosure The division planners and director have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned. Accreditations & Approvals As a Jointly Accredited Organization, NetCE is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. Regulatory boards are the final authority on courses accepted for continuing education credit. NetCE is recognized by the New York State Education Department’s State Board for Social Work as an approved provider of continuing education for licensed social workers #SW-0033. This course is considered self-study, as defined by the New York State Board for Social Work. Materials that are included in this course may include interventions and modalities that are beyond the authorized practice of licensed master social work and licensed clinical social work in New York. As a licensed professional, you are responsible for reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of practice for an LMSW and LCSW. A licensee who practices beyond the authorized scope of practice could be charged with unprofessional con- duct under the Education Law and Regents Rules. Designations of Credit Social workers completing this intermediate-to-advanced course receive 3 Ethics continuing education credits. Individual State Behavioral Health Approvals In addition to states that accept ASWB, NetCE is approved as a provider of continuing education by the following state boards: Alabama State Board of Social Work Examiners, Pro- vider #0515; Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health, Provider #50-2405; Illinois Division of Professional Regulation for Social Workers, License #159.001094; Illinois Division of Professional Regula- tion for Licensed Professional and Clinical Counselors, License #197.000185; Illinois Division of Professional Regulation for Marriage and Family Therapists, License #168.000190.
Mention of commercial products does not indicate endorsement.
1
EliteLearning.com/Social-Work
Professional Boundaries in Mental Health Care _ _________________________________________________
About the Sponsor The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare. Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice. Disclosure Statement It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distrib- uting or providing access to this activity to learners.
HOW TO RECEIVE CREDIT • Read the entire course online or in print. • Depending on your state requirements you will be asked to complete: ‒ A mandatory test (a passing score of 75 percent is required). Test questions link content to learning objectives as a method to enhance individualized learning and material retention. • Provide required personal information and payment information. • Complete the mandatory Course Evaluation.
2
EliteLearning.com/Social-Work
__________________________________________________ Professional Boundaries in Mental Health Care
INTRODUCTION Mental health professionals can make a significant, positive impact in the lives of those with whom they work, and the practice of therapy can be highly rewarding and gratifying. However, it can also be emotionally demanding, challenging, and stressful. These professionals are at risk for occupational stress from a variety of sources, including [1]: • The demands of clinical and professional responsibility • The challenges of managing the client/counselor rela- tionship • The role characteristics that make counselors prone to burnout (e.g., high level of involvement) • Vulnerability to vicarious traumatization • The changing standards and business demands of the profession (e.g., increased documentation require- ments, increased intrusion of legal/business concerns into therapeutic practice) • The intersection of personal and professional demands Healthy boundaries are a critical component of self-care. Set- ting boundaries can help counselors manage occupational stressors and maintain the delicate balance between their personal and professional lives. Boundaries also demonstrate competency in clinical practice and help counselors avoid ethical conflicts [2]. Please note, throughout this course the term “counselor” is used to refer to any professional providing mental health and/ or social services to clients, unless otherwise noted. COMPETENCE Professional associations representing the various fields of clinical practice have codes of ethics that provide principles and standards to guide and protect both the mental health professional and the individuals with whom they work. For example, the American Psychological Association (APA), the American Counseling Association (ACA), the National Association of Social Workers (NASW), the National Board of Certified Counselors (NBCC), and the National Certification Commission for Addiction Professionals (NCCAP) each has an ethics code created to identify core values, inform ethical practice, support professional responsibility and accountabil- ity, and ensure competency among its members [3; 4; 5; 6; 7]. Competency is defined as “the extent to which a therapist has the knowledge and skill required to deliver a treatment to the standard needed for it to achieve its expected effects” [8]. It is the scope of the professional’s practice. According to the ethics codes of the APA, the ACA, and the NASW, members are to practice only within their boundaries of competence [3; 4; 5].
THE THERAPEUTIC RELATIONSHIP Many situations that occur in the counseling office are not written about in textbooks or taught in a classroom setting. Counselors learn through hands-on experience, intuition, ongoing supervision, and continuing education. One constant is the therapeutic relationship. Every therapeutic relationship is built on trust and rapport. Counselors teach their clients what a healthy relationship is through the compassionate care and limit setting that occurs within the therapeutic context. Counselors model acceptable behavior in the office so their clients are equipped to emulate and apply that behavior in the outside world. In many cases, counselors are teaching self- regulation to clients who are learning how to control impulses or regulate behavior in order to improve their connection to other people. Bandura has described self-regulation as a self-governing system that is divided into three major subfunctions [9]: • Self-observation: We monitor our performance and observe ourselves and our behavior. This provides us with the information we need to set performance stan- dards and evaluate our progress toward them. • Judgment: We evaluate our performance against our standards, situational circumstances, and valuation of our activities. In the therapeutic setting, the counselor sets the standard of how to interact by setting limits and upholding professional ethics. The client then compares the counselor’s (i.e., “the expert’s”) modeled behavior with what they already have learned about relationship patterns and dynamics (i.e., referential comparisons). • Self-response: If the client perceives that he or she has done well in comparison to the counselor’s standard, the client gives him- or herself a rewarding self-response. The counselor should reinforce this response by deliver- ing positive reinforcement and affirmation for the newly learned behavior. For example, if the client arrives to therapy habitually late and then makes an effort to arrive on time, the counselor can remark, “I notice that you are working hard to arrive on time for session. That is great.” The counselor’s positive reinforcement and acknowledgment can have a positive impact on the cli- ent’s self-satisfaction and self-esteem. According to Rogers, “individuals have within themselves vast resources for self-understanding and for altering their self-concepts, basic attitudes, and self-directed behavior” [10]. To facilitate a growth-promoting climate for the client, the counselor should accept, care for, and prize the client. This is what Rogers refers to as “unconditional positive regard,” and it allows the client to experience whatever immediate feeling is going on (e.g., confusion, resentment, fear, anger, courage)
3
EliteLearning.com/Social-Work
Professional Boundaries in Mental Health Care _ _________________________________________________
EMPATHY There is great power in empathy. It breaks down resistance and allows clients to feel safe and able to explore their feelings and thoughts. It is a potent and positive force for change [10]. Empathy serves our basic desire for connection and emotional joining [12]. Empathy may be defined as the action of under- standing, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts, and experience of another. It is a deeper kind of listening in which the counselor senses accurately the feelings and personal meanings that the client is experiencing and communicates this understanding to the client [10]. Empathy is not parroting back the client’s words or reflecting only the content of those words. It entails capturing the nuances and implications of what the client is saying, and reflecting this back to the client for their consideration using clear, simply connotative language in as few words as possible [13]. Counselors also can show empathy in nonverbal ways to their clients by, for example, looking concerned, being atten- tive, leaning forward, and maintaining eye contact [13]. Empathy is a multi-level process of relating to others. It encom- passes both an emotive experience and a cognitive one. It includes an intellectual component (namely, understanding the cognitive basis for the client’s feelings), and it implies the ability to detach oneself from the client’s feelings in order to maintain objectivity [14]. While engaged in empathic listen- ing, mental health professionals should remain responsive to feedback and alter their perspective or understanding of the client as they acquire more information [14]. Empathy may be summarized by the ability to [15]: • See the world as others see it. • Be nonjudgmental. • Understand another person’s feelings. • Communicate your understanding of that person’s feelings. Empathy should not be confused with sympathy, which may be defined as an affinity, association, or relationship between persons wherein whatever affects one similarly affects the other. Compared with empathy, sympathy is a superficial demonstra- tion of care. With sympathy, you feel sorry for the client; with empathy, you feel the client’s pain. Although a counselor can get caught up in the client’s feelings, he or she should always strive to empathically understand what the client is experienc- ing while maintaining emotional detachment. This potentially provides a broader perspective that extends beyond the cli- ent’s situational distress. Mental health professionals want to employ the best tools in order to affect change in their clients without causing harm, and empathy surpasses sympathy in terms of effectiveness. Research has validated the importance of empathy, unconditional positive regard, and congruence for achieving an effective therapeutic relationship [16].
knowing that the professional accepts it unconditionally [10]. In addition to unconditional positive regard, a growth- promoting therapeutic relationship also includes congruence and empathy. CONGRUENCE Trust is built and sustained over time through consistent limits that are maintained within the sacred space of each therapeutic hour. When a counselor is observed as consistent and congruent, the client notices. Being authentic is part of being compassionate and empathic. Clients know when a counselor’s words and actions do not match. These actions can be overt, such as cutting short the therapeutic time or going over the time allotted. They also can be subtle, as when leaked out and expressed through a stressed vocal tone, facial expression, or other body language indicator (e.g., arms folded across the chest). To the highly aware client, these actions can result in a loss of trust. Nevertheless, counselors are not perfect and can err from time to time. This is why it is important for counselors to be self-aware, acknowledge when their words and actions do not match, and discuss that within the therapeutic relationship. If a client notices one of these cues of incongruence and expresses it to the counselor, it is essential that the counselor listen openly and validate the client’s experience. Any defensiveness on the part of the counselor will decrease relationship trust. Conversely, this admission of human failure can actually build a stronger bond of trust. Clients see that counselors are, like themselves, human and imperfect. This presents an opportu- nity for clients to learn and then model this type of integrity in their own relationships. “Congruence for the therapist means that he (or she) need not always appear in a good light, always understanding, wise, or strong” [10]. It means that the therapist is his or her actual self during encounters with clients. Without façade, he or she openly has the feelings and attitudes that are flowing at the moment [10]. The counselor’s being oneself and expressing oneself openly frees him or her of many encumbrances and artificialities and makes it possible for the client to come in touch with another human being as directly as possible [10]. As discussed, this involves self-observation and self-awareness on the counselor’s part. This does not mean that counselors burden clients with overt expression of all their feelings. Nor does it mean that counselors disclose their total self to clients. It means that the counselor is transparent to the client so that the client can see him or her within the context of the therapeutic relationship [11]. It also means avoiding the temptation to present a façade or hide behind a mask of professionalism, or to assume a confessional-professional attitude. It is not easy to achieve such a reality, as it involves “the difficult task of being acquainted with the flow of experiencing going on within oneself, a flow marked especially by complexity and continuous change” [10].
4
EliteLearning.com/Social-Work
__________________________________________________ Professional Boundaries in Mental Health Care
Compassion-focused therapy is a rapidly growing, evidence- based form of psychotherapy that pursues the alleviation of human suffering through psychological science and engaged action [17]. According to Gilbert, the following are attributes of compassion-focused therapy [18]: • Sensitivity: Responsive to distress and needs; able to recognize and distinguish the feelings and needs of the client. • Sympathy: Being emotionally moved by the feelings and distress of the client. In the therapeutic relationship, the client experiences the counselor as being emotion- ally engaged with their story as opposed to being emo- tionally passive or distant. • Distress tolerance: Able to contain, stay with, and toler- ate complex and high levels of emotion, rather than avoid, fearfully divert from, close down, contradict, invalidate, or deny them. The client experiences the counselor as able to contain her/his own emotions and the client’s emotions. • Empathy: Working to understand the meanings, func- tions, and origins of another person’s inner world so that one can see it from her/his point of view. Empathy takes effort in a way that sympathy does not. • Nonjudgment: Not condemning, criticizing, shaming, or rejecting. It does not mean nonpreference. For exam- ple, nonjudgment is important in Buddhist psychology, which emphasizes experiencing the moment “as it is.” This does not mean an absence of preferences. Empathic Boundaries Counselors strive to achieve empathy with their clients while maintaining boundaries that protect their own energies. Pro- fessionals should ‘‘sense the client’s private world as if it were [their] own, without ever losing the ‘as if’ quality,’’ and while not becoming entangled with their perception of the client [10; 19]. It takes work to maintain a healthy distance emotionally while feeling and intuiting what the client is saying. Too much sympathy, or working with empathy without proper boundaries in the therapeutic relationship, drains the counselor of energy and leads to burnout. In a study of 216 hospice care nurses from 22 hospice facilities across Florida, it was found that trauma, anxiety, life demands, and excessive empathy (leading to blurred professional boundaries) were key determinants of compassion fatigue risk [20]. In other words, there can be too much of a good thing. In order to motivate client change, there should be a limit to the use of empathy in therapy. Empathy is but one tool that a compassionate mental health professional can use to ensure client growth.
TRANSFERENCE AND COUNTERTRANSFERENCE
The term transference was coined by Freud to describe the way that clients “transfer” feelings about important persons in their lives onto their counselor. As Freud said, “a whole series of psychological experiences are revived, not as belonging to the past but applying to the person of the physician at the present moment” [21]. The client’s formative dynamics are recreated in the therapeutic relationship, allowing clients to discover unfounded or outmoded assumptions about others that do not serve them well, potentially leading to lasting positive change [22]. Part of the counselor’s work is to “take” or “accept” the transferences that unfold in the service of understanding the client’s experience and, eventually, offer interpretations that link the here-and-now experience in session to events in the client’s past [23]. The intense, seemingly irrational emotional reaction a client may have toward the counselor should be recognized as resulting from projective identification of the client’s own conflicts and issues. It is important to guard against taking these reactions too personally or acting on the emotions in inappropriate ways [24]. Therapists’ emotional reactions to their patients (countertransference) impact both the treatment process and the outcome of psychotherapy. REFLECTION It also is important to be reflective rather than reactive in words and actions. Use of the mindfulness technique can help counselors to become reflective rather than reactive and can help counselors unhook from any triggering material and maintain appropriate limits and boundaries. Reflection demands a reasonable level of awareness of one’s thoughts and feelings and a sound grasp of whether they deviate from good professional behavior. Reflection includes [25]: • A questioning attitude towards one’s own feelings and motives • The recognition that we all have blind spots • An understanding that staff are affected by clients • An understanding that clients are affected by staff behavior • A recognition that clients often have strong feelings toward staff Clients are more accepting of transference interpretations in an environment of empathy. Transference interpretation is most effective when the road has been paved with a series of empathic, validating, and supportive interventions that create a holding environment for the client [26].
5
EliteLearning.com/Social-Work
Professional Boundaries in Mental Health Care _ _________________________________________________
SELF-AWARENESS Problems arise when the professional lacks awareness or refuses to devote the necessary time to process the personal emotions and thoughts that arise within the therapeutic relationship. Feelings of anger, grief, jealousy, shame, injustice, trauma, and even attraction can, when they touch a wound from the past, trigger reactions within even experienced profession- als. Clients’ experiences can replicate the professional’s past relationships and trigger emotions that have not been worked on or addressed. If this occurs, the professional can, without disrupting the client’s session, make a mental note of the feelings. This allows the professional to attend to the present moment. After the client’s session has ended, the professional can arrange to talk to a colleague or supervisor for processing. If the countertransference continues, it may be necessary for the professional to seek counseling. Self-awareness helps the professional to reflect back to the client’s true emotions. It also is an important component of training, development, and effectiveness [33]. Mental health professionals need to possess certain values, qualities, and sensitivities, and should be open-minded and have an awareness of their comfort levels, values, biases, and prejudices [34]. As stated in the ethics codes of the ACA [4]: Therapists are aware of—and avoid imposing—their own values, attitudes, beliefs, and behaviors. They respect the diversity of clients, trainees, and research participants and seek training in areas in which they are at risk of imposing their values onto clients, especially when their values are inconsistent with the client’s goals. They refrain from initiating an activity when they know or should know that there is a substantial likelihood that their personal prob- lems will prevent them from performing their work- related activities in a competent manner. When they become aware of personal problems that may interfere with their performing work-related duties adequately, they take appropriate measures, such as obtaining professional consultation or assistance and determine whether they should limit, suspend, or terminate their work-related duties. BOUNDARIES AND LIMITS Generally speaking, a boundary indicates where one area ends and another begins. It indicates what is “out of bounds” and acts to constrain, constrict, and limit. In the therapeutic relationship, a boundary delineates the “edge” of appropriate behaviors and helps to rule in and out what is acceptable, although the same behaviors might be acceptable or even desirable in other relationships [35; 36]. Boundaries have important functions in the therapeutic relationship, helping to build trust, empower and protect clients, and protect the professional.
Freud believed transference to be universal, with the possibility of occurring in the counselor as well as the client. He described this “countertransference” as “the unconscious counter reac- tion to the client’s transference, indicative of the therapist’s own unresolved intrapsychic conflicts” [27]. Freud felt that countertransference could interfere with successful treatment [22]. Since the 1950s, the view of countertransference has evolved. It is no longer believed to be an impediment to treat- ment. Instead, it is viewed as providing important information that the professional can use in helping the client [22]. Empathy allows the counselor to experience and thus know what the client is experiencing. Countertransference emerges when the client’s transference reactions touch the counselor in an unresolved area, resulting in conflictual and irrational internal reactions [28]. Good indicators of countertransfer- ence are feelings of irritability, anger, or sadness that seem to arise from nowhere. Countertransference frequently originates in counselors’ unresolved conflicts related to family issues, needs, and values; therapy-specific areas (e.g., termination, performance issues); and cultural issues [29]. When feelings have intensity or when they persist, this is an indicator for future work and healing. The counselor’s work is to bear the client’s transferences and interpret them. When the counselor refuses the transference, there is often a mutual projective identification going on, in which both counselor and client project part of themselves onto the other. Refusal may also mean that one of the coun- selor’s own blind spots has been engaged. As Shapiro explains, “a rough edge of our character has been ‘hooked’ by a bit of what the patient is struggling with, and we act out a bit of countertransference evoked in us by the transference” [30]. In a group therapy setting, family dynamic re-enactments can emerge as transferences. Managing these complex dynamics can raise the counselor’s anxiety and mobilize his or her defenses, compromising a usually thoughtful stance. When counselors experience intense reactions in trauma groups that pull them out of the present moment, they should investigate whether they are responding to traumatic content, personal unresolved issues, or individual or collective transference [31]. Counselors who find themselves ruminating about a previous session’s content, a client’s welfare, or their own issues should talk with a trusted, objective colleague. Countertransference issues for the mental health professional should be resolved apart from the therapeutic environment to avoid burdening and poten- tially harming clients [27]. One study of countertransference found that therapists’ self-reported disengaged feelings over a treatment period adversely impacted the effect of transference work for all patients, but especially for patients with a history of poor, nonmutual, complicated relationships [32].
6
EliteLearning.com/Social-Work
__________________________________________________ Professional Boundaries in Mental Health Care
BUILDING TRUST An inherent power differential exists in the therapeutic relationship between the client, who is placed in a position of vulnerability as she or he seeks help, and the practitioner, who is placed in a position of power because of her or his professional status and expertise [36]. When the client sees the counselor sitting in a chair, with a diploma or licensure on the wall, it can be intimidating. To help mitigate these feelings with the client, it is important to maintain a sense of professionalism while working to build trust and rapport. Part of that professionalism includes setting limits and explaining what they are in the context of therapy. The familiarity, trust, and intensity of the therapeutic relation- ship create a powerful potential for abuse that underscores the need for careful attention to the ethical aspects of profes- sional care [36]. Trust is the cornerstone of the therapeutic relationship, and counselors have the responsibility to respect and safeguard the client’s right to privacy and confidentiality [4]. Clients have expressed what they believe to be essential conditions for the development of trust in the therapeutic relationship. These include that the clinician [37]: • Is perceived as available and accessible • Tries to understand by listening and caring • Behaves in a professional manner (evidenced by attri- butes such as honesty in all interactions) • Maintains confidentiality • Relates to the client as another adult person rather than as an “expert” • Remains calm and does not over-react to the issue under discussion Only when satisfied that the clinician is sufficiently experi- enced, professional, flexible, and empathic can a foundation for therapy be laid. Clients acknowledge that this takes time and that the trustworthiness of the therapeutic relationship may be tested. If the relationship is perceived to be wanting, clients indicate that they would have difficulty continuing it [37]. THE VALUE OF FLEXIBILITY Rigid boundaries can negatively reinforce the power differential that exists between the client and the counselor. Rigid bound- aries may serve the fears and needs of counselors who are new to the profession and/or concerned with the implications of boundary violations. However, rigid boundaries can lead to harm for the client who perceives that the “rules” are more important than his or her welfare. While rigidity and remote- ness on the counselor’s part may help ensure that boundaries are intact, they do not accurately reflect the intended role of boundaries in clinical practice. Boundaries should never imply coldness or aloofness. As stated, clients value flexibility, caring, and understanding. Within conditions that create a climate of safety, flexible boundaries can accommodate individual
differences among clients and counselors and allow them to interact with warmth, empathy, and spontaneity [38]. Firm, intractable boundaries may be a comfort to the helping profes- sional; however, fixed rules cannot capture the complex reality of the therapeutic relationship [36]. EMPOWERING AND PROTECTING THE CLIENT Boundaries and effective limit setting in sessions help to empower and protect clients by teaching and reinforcing the skills they need to become healthy. Boundaries set the parameters and expectations of therapy, so it is important to articulate them in such a way that each client’s understanding of them is clear. Counselors should constantly and actively make judgements about where to draw lines that are in the client’s best interests [39]. Boundaries begin the moment a client enters the room. Indicate which chair is yours and where it is acceptable for the client to sit. Take note of where your seat is in relation to the door should an emergency arise. Be sure to maintain an appropriate amount of space between yourself and the client. Too much space can feel impersonal and too little can feel invasive. Consider the décor of the setting. Clients may become distracted by the counselor’s personal artifacts and family photographs and may place their focus on the counselor rather than on their own therapeutic work. Some clients with poor boundaries may become preoccupied with the counselor’s family, which can become a source of transference. Clients often enter therapy with a history of prior boundary violations (e.g., childhood sexual abuse, domestic violence, inappropriate boundary crossings with another professional) that leave them with persisting feelings and confusion regard- ing roles and boundaries in subsequent intimate relationships [40]. Consequently, they may test the boundaries as children do. The counselor should recognize these boundary dilem- mas and manage them by reiterating the boundaries calmly and clearly [39]. The counselor must also set and maintain boundaries even if the client threatens self-harm or flight from therapy. This can be extremely challenging when faced with a client’s primitively motivated, intense demands. However, counselors should recall that one description of the tasks with clients with primitive tendencies is to resist reinforcing primi- tive strivings and to foster and encourage adult strivings [41]. Winnicott refers to this as a “holding relationship,” wherein the counselor acts as a “container” for the strong emotional storms of the client. The act of holding helps reassure the cli- ent that the clinician is there to help the client retain control and, if necessary, assume control on his or her behalf [42]. Due to the potential issues and challenges that the client brings to therapy (e.g., cognitive deficits, substance abuse/ addictions, memory issues, personality disordered manipula- tions), it is important to maintain a record of instances when the articulated boundaries and limits have been ignored or violated. For example, a client is habitually late, despite know-
7
EliteLearning.com/Social-Work
Professional Boundaries in Mental Health Care _ _________________________________________________
ing that it is unacceptable to arrive more than 10 minutes late to session. The first instance of a late arrival might simply warrant a reminder of the 10-minute limit, whereas repeated instances would require that the limit be enforced. The clini- cian who overidentifies with a client might experience a need to do things for the client rather than help the client learn to do things for him- or herself. While this behavior may appear relatively harmless, it suggests overinvolvement with a client and potential boundary problems [43]. Such behavior inhibits the client’s ability to learn personal responsibility and how to resolve conflict [44]. It also may impede the reflective and inves- tigative character of an effective helping process [45]. Mental health professionals should take reasonable steps to minimize harm to clients where it is foreseeable and unavoidable [3; 4]. They also should facilitate client growth and development in ways that foster the interest and welfare of the client and promote the formation of healthy relationships [4]. PROTECTING THE PROFESSIONAL As stated, professional associations that represent the various fields of clinical practice have codes of ethics that provide principles and standards to guide and protect the professional and the individuals with whom they work [3; 4; 5; 6; 7]. Cli- ent welfare and trust in the helping professions depend on a high level of professional conduct [3; 4]. Professional values, such as managing and maintaining appropriate boundaries, are an important way of living out an ethical commitment [4]. Some situations in therapy are clear with regard to boundaries (e.g., no sexual relationships with clients). Other situations may be not as clear or may be ambiguous (e.g., receiving gifts from clients). When faced with such situations, profession- als should engage in an ethical decision-making process that includes an evaluation of the context of the situation and collaboration with the client to make decisions that promote the client’s growth and development [4]. Supervision and colleague support also may be necessary to reach the best decision. Such a process helps clinicians maintain justice and equity and avoid implications of favoritism in dealing with all of their clients [46]. Professionals who deliver services in nontraditional settings, such as those who have home-based practices, face unique challenges related to boundaries and limit setting. As with office-based therapy, some situations cannot be prepared for and will need to be addressed in the moment. While delivering services in nontraditional settings may benefit some clients, when working in homes or residences, the professional is advised to emphasize informed consent, particularly with regard to therapeutic boundaries. Whenever possible, the impact of crossing boundaries on therapy and on the thera- peutic relationship should be considered ahead of time [47].
BOUNDARY CROSSINGS AND VIOLATIONS
A boundary crossing is a departure from commonly accepted practices that could potentially benefit clients; a boundary violation is a serious breach that results in harm to clients and is therefore unethical [48]. Professional risk factors for boundary violations include [49]: • The professional’s own life crises or illness • A tendency to idealize a “special” client, make excep- tions for the client, or an inability to set limits with the client • Engaging in early boundary incursions and crossings or feeling provoked to do so • Feeling solely responsible for the client’s life • Feeling unable to discuss the case with anyone due to guilt, shame, or the fear of having one’s failings acknowledged • Realization that the client has assumed management of his or her own case Denial about the possibility of boundary problems (i.e., “This couldn’t happen to me”) also plays a significant role in the per- sistence of the problem [49]. Lack of self-care and self-awareness also can leave the mental health professional vulnerable to boundary crossings and/or violations. Whatever the reason the professional has to cross a bound- ary, it is of utmost importance to ensure that it will not harm the client. Each boundary crossing should be taken seriously, weighed carefully in consultation with a supervisor or trusted colleague, well-documented, and evaluated on a case-by-case basis. Intentional crossings should be implemented with two things in mind: the welfare of the client and therapeutic effectiveness. Boundary crossing, like any other intervention, should be part of a well-constructed and clearly articulated treatment plan that takes into consideration the client’s prob- lem, personality, situation, history, and culture as well as the therapeutic setting and context [50]. Boundary crossings with certain clients (e.g., those with borderline personality disorder or acute paranoia) are not usually recommended. Effective therapy with such clients often requires well-defined bound- aries of time and space and a clearly structured therapeutic environment. Dual or multiple relationships, which always entail boundary crossing, impose the same criteria on the professional. Even when such relationships are unplanned and unavoidable, the welfare of the client and clinical effectiveness will always be the paramount concerns [50].
8
EliteLearning.com/Social-Work
__________________________________________________ Professional Boundaries in Mental Health Care
Some counselors may consider a boundary crossing when it provides a better firsthand sense of the broader clinical context of their client, such as visiting the home of a client that is ailing, bedridden, or dying; accompanying a client to a medi- cally critical but dreaded procedure; joining a client/architect on a tour of her latest construction; escorting a client to visit the gravesite of a deceased loved one; or attending a client’s wedding [50]. Many mental health professionals will not cross these boundaries and will insist that therapy occur only in the office. Each professional should operate according to the parameters with which he or she is comfortable. As stated, the best interests of the client, including client confidentiality, and the impact to therapy should be of paramount importance when considering whether to cross a boundary. To be in the best position to make sound decisions regard- ing boundary crossings, mental health professionals should develop an approach that is grounded in ethics; stay abreast of evolving legislation, case law, ethical standards, research, theory, and practice guidelines; consider the relevant con- texts for each client; engage in critical thinking and personal responsibility; and, when a mistake is made or a boundary decision has led to trouble, use all available resources to determine the best course of action to respond to the prob- lem [51]. The risk management strategy also should include discussions with supervisors, colleagues, and the client. Each step should be documented and should include supervisory recommendations and client discussion regarding the benefits versus the risks of such actions. Although minor boundary violations may initially appear innocuous, they may represent the foundation for eventual exploitation of the client. If basic treatment boundaries are violated and the client is harmed, the professional may be sued, charged with ethical violations, and lose his/her license [52]. MULTIPLE RELATIONSHIPS Examples of multiple relationships include being both a cli- ent’s counselor and friend; entering into a teacher/student relationship; becoming sexually involved with a current or former client; bartering services with a client; or being a client’s supervisor. Even when entering into a multiple relationship seems to offer the possibility of a better connection to a cli- ent, it is not recommended. Multiple relationships can cause confusion and a blurring of boundaries and risk exploitation of the client. The issue of multiple relationships is addressed by the codes of ethics of mental health professions. According to the APA’s ethics code [3]: A multiple relationship occurs when a psychologist is in a professional role with a person and (1) at the same time is in another role with the same person, (2) at the same time is in a relationship with a per- son closely associated with or related to the person
with whom the psychologist has the professional relationship, or (3) promises to enter into another relationship in the future with the person or a per- son closely associated with or related to the person. A psychologist refrains from entering into a multi- ple relationship if the multiple relationships could reasonably be expected to impair the psychologist’s objectivity, competence or effectiveness in perform- ing his or her functions as a psychologist, or other- wise risks exploitation or harm to the person with whom the professional relationship exists. The ethics code of the NASW (standard 1.06 Conflicts of Inter- est) defines dual or multiple relationships as occurring “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” [5]. It also states that “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 unavoid- able, social workers should take steps to protect clients and are responsible for setting clear, appropriate, and culturally sensitive boundaries” [5]. The code further states that it is the professional’s responsibility to “be alert to and avoid conflicts of interest that interfere with the exercise of professional dis- cretion and impartial judgment” and that counselors 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” [5]. In some instances, this may require “termination of the professional relationship
with proper referral of the client” [5]. The ACA ethics code states that [4]:
Counselors are prohibited from engaging in coun- seling relationships with friends or family members with whom they have an inability to remain objec- tive. They also are prohibited from engaging in a personal virtual relationship with individuals with whom they have a current counseling relationship (e.g., through social and other media). When a counselor agrees to provide counseling services to two or more persons who have a relationship, the counselor clarifies at the outset which person or per- sons are clients and the nature of the relationships the counselor will have with each involved person. If it becomes apparent that the counselor may be called upon to perform potentially conflicting roles, the counselor will clarify, adjust, or withdraw from roles appropriately. Mental health professionals who practice in small, rural com- munities face special problems in maintaining neutrality, fostering client separateness, protecting confidentiality, and managing past, current, or future personal relationships with clients [53]. Whether the practice is located in a small town
9
EliteLearning.com/Social-Work
Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Page 11 Page 12 Page 13 Page 14 Page 15 Page 16 Page 17 Page 18 Page 19 Page 20 Page 21 Page 22 Page 23 Page 24 Page 25 Page 26 Page 27 Page 28 Page 29 Page 30 Page 31 Page 32 Page 33 Page 34 Page 35 Page 36 Page 37 Page 38 Page 39 Page 40 Page 41 Page 42 Page 43 Page 44 Page 45 Page 46 Page 47 Page 48 Page 49 Page 50Powered by FlippingBook