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].
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