__________________________________________________ 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)
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