Professional Boundaries in Mental Health Care _ _________________________________________________
that gifts given during therapy (where possible) remain part of therapy (i.e., they stay in the room and are available for future sessions) [58]. When considering whether to discuss the gift as part of therapy, the counselor should evaluate pertinent factors, such as the client’s time in therapy, the context and frequency of gifts, and client dynamics. While not all gifts warrant full discussion (e.g., those given to show appreciation or of modest financial value), some, such as repeated or expensive gifts, do. Although counselors should be careful not to make too much of a gift, especially those that clients at least initially see as being given simply as a way to say thank you, such conversations may enable both members of the dyad to attain greater insight into the gift’s intention and meaning and thereby prove helpful to the continued therapy work [59]. Gifts can range from physical objects, to symbols or gestures. As stated, consider 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 [4; 5; 7]. If there are con- cerns about any of these factors, it may be best to explore the intent of the gift in session. If a gift is deemed inappropriate, the counselor is advised to decline to accept it. In these cases, counselors should express appreciation for the thought and gesture, explain why they are unable to accept the gift, return it with kindness, and note the encounter in the client’s record. Professionals who work with children have unique challenges regarding gifts. Rejecting a child’s gift or trying to explain a “no-gift policy” can cause the child to feel confused or rejected; children do not have the same levels of cognition and under- standing that adults have. For play counselors, potential com- promises include incorporating the gift into the other materials and toys in the playroom or directly sharing the gift with the child [59]. An important factor affecting the decision to accept a gift is the kind of gift presented by the child. Artwork or something created by the child is an extension of the child and therefore can be viewed as an extension of emotional giving. Accepting non-purchased items (e.g., a flower picked by a child or a child’s drawing) would be acceptable in most cases [60]. Clients with personality disorders present unique challenges regarding the issue of gifts. Generally, these clients exhibit manipulation, poor boundaries, and fixed or rigid patterns of relating, and gift giving can be a feature of the clinical pic- ture for such clients. Accepting a gift from such a client may reinforce patterns of manipulative or self-debasing behaviors that are symptomatic of the problematic levels of functioning. In such instances, counselors should discern which course of action is truly in the client’s best interests [55]. Often, a small token may be given or received at the termina- tion of therapy for a long-term client. A touchstone that has meaning for the client, such as a meditation CD, book, or greeting card, is appropriate. As with all gifts, the gift and the context in which the gift was given or received should be noted in the client’s record, along with your own intent and how you think the client perceived the gift.
TECHNOLOGY AND DISTANCE THERAPY We live in a rapidly changing world, especially where technol- ogy is concerned. In the past, therapy was offered only through in-person interaction in an office setting. Then, gradually, some professionals began to offer telephone sessions. Today, counseling is offered through video conferencing and online message boards, and paper client records are being replaced with electronic records. Competent counseling includes maintaining the knowledge and skills required to understand and properly use treatment tools, including technology, while adhering to the ethical code of one’s profession. The APA has created guidelines to address the developing area of psychologic service provision commonly known as telepsychology [61]. The APA defines telepsychology as the “provision of psychological services using telecommunication technologies. Telecommunication technologies include, but are not limited to, telephone, mobile devices, interactive vid- eoconferencing, email, chat, text, and Internet (e.g., self-help websites, blogs, and social media)” [61]. The APA guidelines are informed by its ethics code and record-keeping guidelines as well as its guidelines on multicultural training, research, and practice. The guidelines allow that telecommunication technol- ogies may either augment traditional in-person services or be used as stand-alone services. The guidelines also acknowledge that telepsychology involves “consideration of legal require- ments, ethical standards, telecommunication technologies, intra- and interagency policies, and other external constraints, as well as the demands of the particular professional context” [61]. When one set of considerations may suggest a different course of action than another, the professional should balance them appropriately, with the aid of the guidelines [61]. The complete guidelines are available online at https://www.apa. org/practice/guidelines/telepsychology. The 2014 ACA Code of Ethics also addresses distance counsel- ing, technology, and social media. It states [4]: Counselors understand that the profession of coun- seling may no longer be limited to in-person, face- to-face interactions. Counselors actively attempt to understand the evolving nature of the profession with regard to distance counseling, technology, and social media and how such resources may be used to better serve their clients. Counselors strive to become knowledgeable about these resources. Counselors understand the additional concerns related to the use of distance counseling, technol- ogy, and social media and make every attempt to protect confidentiality and meet any legal and ethi- cal requirements for the use of such resources. The ACA code also addresses legal considerations, informed consent and disclosure, confidentiality, security, and multicul- tural and disability considerations as they relate to technology.
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