__________________________________________________ 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
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