__________________________________________________ Professional Boundaries in Mental Health Care
(d) Social workers should not provide clinical services to individuals with whom they have had a prior sexual rela- tionship. Providing clinical services to a former sexual partner has the potential to be harmful to the individual and is likely to make it difficult for the social worker and individual to maintain appropriate professional boundar- ies. 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, appro- priate, and culturally sensitive boundaries that govern such physical contact. The safest course of action is to continue to maintain estab- lished boundaries and limits indefinitely after therapy ends. In addition to the noted relevant factors, counselors should keep in mind that the client may return for further treatment. If the counselor has become involved in a business or social relationship with a former client, he or she deprives the cli- ent of the opportunity to return for additional treatment. It is vital to be mindful of the potential to exploit the client’s vulnerability in a post-termination relationship [54]. Mental health professionals who find themselves attracted to a client should seek supervision around this issue. It is normal for feelings to develop in any type of relational context. It is not the feelings of attraction that are the problem, but rather actions taken. Mental health professionals should never act on these feelings, but instead discuss them with a trusted supervisor or colleague, exploring the possibility of counter- transference as well as the potential trigger for the attraction. If the attraction causes intense feelings, it is advisable to seek personal therapy. If the feelings interfere with one’s ability to treat a client, the client should be transferred to another professional, and work with the client terminated. GIFTS It is not unusual during the course of therapy for a client to present a counselor with a token of appreciation or a holiday gift, and receiving gifts from clients is not strictly prohibited by professional ethics codes. Instead, the ethics codes advise professionals to consider a variety of factors when deciding whether to accept a client’s gift. Section A.10.f (Receiving Gifts) of the 2014 ACA Code of Ethics states that [4]: Counselors understand the challenges of accept- ing gifts from clients and recognize that, in some cultures, small gifts are a token of respect and gratitude. When determining whether to accept a gift from clients, counselors take into account the therapeutic relationship, the monetary value of the
gift, the client’s motivation for giving the gift, and the counselor’s motivation for wanting to accept or decline the gift. The National Board for Certified Counselors Code of Ethics: Directive #4 provides similar guidance to its members [6]: National certified counselors (NCCs) shall not accept gifts from clients except in cases when it is culturally appropriate or therapeutically relevant because of the potential confusion that may arise. NCCs shall consider the value of the gift and the effect on the therapeutic relationship when con- templating acceptance. This consideration shall be documented in the client’s record. In the code of ethics of the Association for Addiction Profes- sionals, Principle I-40: The Counseling Relationship states that [7]: Addiction professionals recognize that clients may wish to show appreciation for services by offering gifts. Providers shall take into account the therapeu- tic relationship, the monetary value of the gift, the client’s motivation for giving the gift, and the coun- selor’s motivation for wanting to accept or decline the gift. As noted in these excerpts, the effect on the therapeutic rela- tionship should be a primary consideration when considering whether to accept a gift. Gifts can mean many things and also can fulfill social functions. The counselor’s task is to identify the contextual meaning of the gift and determine when the gift is not merely a gift. To do so, the counselor must draw out from the client information to discern the possibility of a metaphorical or culturally significant meaning for the gift giv- ing [55]. Counselors should consider the client’s motivation for gift-giving as well as the status of the therapeutic relationship. Gifts that may seem intended to manipulate the counselor are probably best refused, whereas rejection of a gift intended to convey a client’s appreciation may harm the relationship [56]. If the counselor is most comfortable with a “no-gift policy,” it is best that the policy be discussed at the beginning of therapy. To wait until a client is presenting a gift to state that it is your policy to decline gifts may harm the client and dam- age the therapeutic relationship. Clear communication, both written and spoken, of the policy with clients as they enter therapy may help avert difficult later interactions around gifts. If clients have an understanding as they begin therapy what the counselor’s approach will be, misunderstandings may be avoided [57]. While restrictive guidelines might be unhelpful, confusion surrounding gifts seems to be exacerbated by a lack of professional discussion about the topic [58]. Many professionals try to keep gifts “alive” throughout client sessions. This often involves putting the gift “on hold” (includ- ing decisions about acceptance and rejection) until the best moment for exploration with the client occurs. This allows
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