This interactive New York Social Work Ebook contains 12 hours of continuing education. To complete click the Complete Your CE button at the top right of the screen.
NEW YORK Social Work Continuing Education
Elite Learning
Includes Professional Boundary
requirement for license renewal.
12-hour Continuing Education Package $75.00 ELITELEARNING.COM/BOOK Complete this book online with book code: SWNY1224
What’s Inside
Chapter 1: Managing Professional Boundaries (Mandatory)
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[3 CE Hours] This course is intended for healthcare professionals who provide care to clients/patients. The course discusses professional standards and principles for providing safe ethical care, how those standards are reflected in clinical boundaries, common boundary dilemmas faced by clinicians, and how to apply a decision-making model to navigate boundary situations. The course also meets the New York requirement for 3 CEU’s on professional boundaries required for psychologists, social workers, mental health counselors, and marriage and family therapists.
UPDATED REQUIREMENT Identification and Reporting of Child Abuse NEW! Mandated reporters, including those who have previously undergone the current training, must complete the updated training curriculum by April 1, 2025* * New York Child Abuse courses do not count towards CE hours and may only be used to satisfy the New York mandatory training requirements. Find the training by using the QR code or at EliteLearning.com/Social-Work/New-York This course presents an introduction to cultural humility and offers tools for healthcare professionals to use when working with diverse patients in a culturally humble manner. The course highlights the importance of cultural humility and the reasons why it is necessary and outlines a quantifiable set of attitudes that allow healthcare professionals to work effectively within the cultural context of each patient. There is an understanding that cultural humility is an ongoing process and is a prerequisite for cultural competency. THIS COURSE FULFILLS THE REQUIREMENT FOR PROFESSIONAL BOUNDARIES Chapter 2: Suicide Risk in Adults: Assessment and Intervention, 2nd Edition [3 CE Hours] 22 The purpose of this course is to assist clinicians in understanding factors that contribute to suicidal behavior, conducting comprehensive suicide risk assessments, and engaging patients in brief, empirically-supported interventions to reduce risk of death. This course meets an increasing demand of many mental health professionals seeking information about working with suicidal clients and conducting empirically-supported suicide risk assessments. This intermediate-level course is designed for social workers, mental health counselors, marriage and family therapists, educators, community- based program administrators, providers, and psychologists. The course will cover major risk factors, demographics and warning signs for suicidal behavior, as well as provide guidance on clinical risk assessment and options for intervention. Although the information presented here is useful to many mental health providers, no continuing education course can provide all the information that may be required in working with each individual who comes for help. It is therefore important that mental health providers consult knowledgeable colleagues, review the most recent articles and books on the topic of suicide, read and understand the risk-management practices of their agency, and maintain awareness of applicable local and state laws concerning the management and referral of suicidal persons. References and resources for those interested in pursuing further education on this topic are provided at the end of the course. Chapter 3: Professional Ethics and Law [4 CE Hours] 47 In practicing a profession, three interrelated but distinct areas come into play: professional values, ethics, and the law. Although all three areas are related to one another, sometimes they can conflict with one another. Sometimes, also, values can conflict with other values, as can ethics. When ethics conflict, an ethical dilemma results. When professional values conflict with professional ethics, the organized and generally agreed-upon framework of an ethical code is vital. When ethics and the law collide, it may be necessary to consult the relevant professional organization. The American Medical Association, for example, has become involved when the law required that a physician be present at an execution. The AMA code of ethics explicitly forbids physicians from participating in capital punishment (Henry, 2018). This intermediate course is intended to provide healthcare professionals such as social workers with an overview of how professional values, ethics, and the law come into play in mental health practice. Chapter 4: Cultural Humility for All Healthcare Professionals 81 [2 CE Hours]
©2024. All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Colibri Healthcare, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge in the areas covered. It is not meant to provide medical, legal or professional services advice. Colibri Healthcare, LLC recommends that you consult a medical, legal or professional services expert licensed in your state. Colibri Healthcare, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation or circumstances and assumes no liability from reliance on these materials.
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Book Code: SWNY1224
SOCIAL WORK CONTINUING EDUCATION
What are the requirements for license renewal? License Expires Frequently Asked Questions
CE Hours Required
Mandatory Subjects
3 hours in professional boundaries 2 hours of training regarding the identification and reporting of child abuse (one time requirement - mandated reporters are required to complete updated training by April 1, 2025)
36 (12-hours allowed through self-study)
Licenses expire on the licensees birth month in the triennial registration period
COURSE TITLE
HOURS PRICE
COURSE CODE
Chapter 1: Managing Professional Boundaries (Mandatory)
3 $27.00
SWNY03PB
Chapter 2: Suicide Risk in Adults: Assessment and Intervention, 2nd Edition
3 $27.00
SWNY03SR
Chapter 3: Professional Ethics and Law
4 $32.00
SWNY04PE
Chapter 4: Cultural Humility for All Healthcare Professionals
2 $18.00 SWNY02CH 12 $75.00 SWNY1224
Best Value - Save $29.00 - All 12 Hours
How do I complete this course and receive my certificate of completion? See the following page for step-by-step instructions to complete and receive your certificate. Are you a New York board-approved provider? Colibri Healthcare, LLC is an approved New York State Education Department Continuing Education Provider (#SW-0004). Colibri Healthcare, LLC (formerly Elite Professional Education, LLC), Provider Number 1147, is approved as an ACE provider to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Regulatory boards are the final authority on courses accepted for continuing education credit. ACE provider approval period: 5/5/2023 - 5/5/2026. Are my hours reported to the New York board? No, the New York State Education Department’s State Board for Social Work board performs audits at which time proof of continuing education must be provided. Is my information secure? Yes! We use SSL encryption, and we never share your information with third-parties. We are also rated A+ by the National Better Business Bureau. What if I still have questions? What are your business hours? No problem, we have several options for you to choose from! Online at EliteLearning.com/Social-Work you will see our robust FAQ section that answers many of your questions, simply click FAQs at the top of the page, email us at office@elitelearning.com, or call us toll free at 1-866-653-2119, Monday - Friday 9:00 am - 6:00 pm, EST, Saturday 10:00 am - 4:00 pm EST. Important information for licensees: Always check your state’s board website to determine the number of hours required for renewal, mandatory topics (as these are subject to change), and the amount that may be completed through self study. Also, make sure that you notify the board of any changes of address. It is important that your most current address is on file.
Licensing board contact information: NY State Education Department Office of the Professions State Board for Social Work 89 Washington Avenue Albany, New York 12234-1000
518-474-3817, Press 1 then ext. 450 518-486-2981 (fax) swbd@nysed.gov
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Book Code: SWNY1224
SOCIAL WORK CONTINUING EDUCATION
Chapter 1: Managing Professional Boundaries (Mandatory) 3 CE Hours
Release Date: October 9, 2023 Expiration Date: October 9, 2027 Upon successful completion of this course, continuing education hours will be awarded as follows: ● Social Workers and Psychologists: 3 Hours ● Professional Counselors: 3 Hours
A reading-based asynchronous distance course. Colibri Healthcare, LLC, Provider 1147, is approved as an ACE provider to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Regulatory boards are the final authority on courses accepted for continuing education credit. ACE provider approval period: 5/5/2023 - 5/5/2026. Social workers completing this course receive 3 ethics continuing education credit(s). Author Denise K. Gross, Psy.D. is a Florida Licensed Psychologist specializing in clinical neuropsychology and medical
and medical students. Most recently she has provided neuropsychological services to military veterans in a memory evaluation clinic and has been actively involved in the training of psychology doctoral interns. Denise K. Gross, Psy.D. has no significant financial or other conflicts of interest pertaining to this course.
psychology. She has been the director of neuropsychology services at acute and post-acute rehabilitation centers, was in private practice for over 23 years, and has provided clinical training and education for psychology How to receive credit ● Read the entire course online or in print. ● Answer the final examination questions at the end of the course. ○ A passing grade of 75% is required. Test questions
● Provide required personal information and payment information.
● Complete the Course Evaluation. ● Print your Certificate of Completion.
link content to learning objectives as a method to enhance individualized learning and material retention.
Disclosures Resolution of conflict of interest
Sponsorship/commercial support and non-endorsement It is the policy of Colibri Healthcare, LLC not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.
Colibri Healthcare, LLC implemented mechanisms prior to the planning and implementation of the continuing education activity, to identify and resolve conflicts of interest for all individuals in a position to control content of the course activity. Disclaimer The information provided in this activity is for continuing education purposes only and is not meant to substitute for the independent medical judgment of a healthcare provider
relative to diagnostic and treatment options of a specific patient’s medical condition.
©2024: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Colibri Healthcare, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge of the areas covered. It is not meant to provide medical, legal, or professional advice. Colibri Healthcare, LLC recommends that you consult a medical, legal, or professional services expert licensed in your state. Colibri Healthcare, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation nor circumstances and assumes no liability from reliance on these materials. Quotes are collected from customer feedback surveys. The models are intended to be representative and not actual customers. Learning outcomes
After completing this course, the learner will be able to: Describe ethical standards and principles in healthcare practice. Identify and differentiate appropriate boundaries from boundary crossings and boundary violations. Implicit in Healthcare Implicit bias significantly affects how healthcare professionals perceive and make treatment decisions, ultimately resulting in disparities in health outcomes. These biases, often unconscious and unintentional, can shape behavior and produce differences in medical care along various lines, including race, ethnicity, gender identity, sexual orientation, age, and socioeconomic status. Healthcare disparities stemming from implicit bias can manifest in several ways. For example, a healthcare
Analyze boundary dilemmas faced in healthcare practice. Apply a model for ethical decision-making to boundary issues that may arise in practice.
provider might unconsciously give less attention to a patient or make assumptions about their medical needs based on race, gender, or age. The unconscious assumptions can lead to delayed or inadequate care, misdiagnoses, or inappropriate treatments, all of which can adversely impact health outcomes. Addressing implicit bias in healthcare is crucial for achieving equity in medical treatment. Strategies to combat these biases involve education and awareness programs for healthcare professionals.
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These programs help individuals recognize and acknowledge their biases, fostering a more empathetic and unbiased approach to patient care. Additionally, implementing policies and procedures prioritizing equitable treatment for all patients can play a pivotal role in reducing
healthcare disparities. Ultimately, confronting implicit bias in healthcare is essential to creating a more just and equitable healthcare system where everyone receives fair and equal treatment regardless of their background or characteristics.
INTRODUCTION
Healthcare professionals are required to provide ethical care to their patients and clients. Knowledge of a profession’s ethical standards and the boundary of acceptable professional conduct is crucial to the provision of ethical care. This course provides the healthcare professional with a general overview of ethical standards and principles, how
those standards are reflected in boundaries and boundary- setting, common boundary dilemmas faced in therapy, and how to apply a decision-making model when faced with those boundary dilemmas as is required by most healthcare professional organizations.
PROFESSIONAL CODES OF ETHICS
Healthcare professionals have an obligation to provide safe and effective care to those they serve. Levine and Courtois (2021) list five principles that are the cornerstone of professional behavior: 1. Altruism—The welfare of the client comes first. 2. Accountability—Healthcare professionals are accountable to the client and to the profession. 3. Excellence—Use interventions based on knowledge and expertise. 4. Felt duty—Help others and serve the client. 5. Respect—Show respect for clients, colleagues, students, trainees, and employees. To this end, all healthcare disciplines have established their own codes of ethical conduct to serve as guidelines for the safe and ethical treatment of clients. The understanding of these professional standards is the responsibility of each healthcare provider. The National Association of Social Workers (NASW) Code of Ethics (2021) states that “Professional ethics are at the core of social work. The Code offers a set of values, principles, and standards to guide decision making and conduct when ethical issues arise.” (Purpose section). The American Psychological Association’s Ethical Principles of Psychologists and Code of Conduct (2017) further adds that their code of principles and standards “Applies to activities across a variety of contexts, such as in-person, postal, telephone, internet, and other electronic transmissions” (Introduction section). The American Counseling Association (ACA) Code of Ethics (2014), the National Board for Certified Counselors (NBCC) Code of Ethics (2023), and the American Association for Marriage and Family Therapy (AAMFT) Code of Ethics (2015) define the ethical obligations and practice of professional counselors for the protection of the public. A core tenant of all ethics codes are professional boundaries. Boundaries help to form the framework of ethical treatment. They provide the foundation for defining the roles of the participants in the therapeutic process, and they define the parameters, or correct limits of behavior, in the relationship. They may include details of role, time, place, money, gifts, self-disclosure, physical contact, and the limits of privacy and confidentiality and mandated reporting. They help to determine the distinction between interactions that would be considered appropriate within the therapeutic relationship with those that would be considered inappropriate and/or harmful. Boundary guidelines may also be used to evaluate professional conduct in disciplinary hearings. While extreme boundaries such as the prohibition of sexual contact with a client may seem clear, it is the more subtle and common day-to-day boundary questions that cause the most confusion for healthcare providers and clients. The concept of boundaries is a general one, yet questions of boundaries in the course of client care are specific to that particular client and therapist, at that
particular time in therapy, and for a particular reason. Decisions about whether to cross or expand a boundary can only be made with full knowledge in the context of professional ethics and behavior. The ethical standards and guidelines for healthcare professions are written in general terms so that they can apply to the varied roles professionals take on. They are not exhaustive, and just because conduct is not specifically addressed by a particular standard does not mean that the conduct is necessarily ethical or unethical. Each organization’s code of ethics addresses the core values, principles, and beliefs of that profession, outlining the standards to which the provider is held and to which their behavior can be judged as a way of protecting the trust and safety of the client. The majority of professionals are conscientious individuals who are committed to providing quality care. As such, they have often internalized ethical principles and concepts, and these guide their professional behavior without them even having to stop and consider whether a decision is ethical. Professionals tend to turn to the standards for guidance when situations are less clear cut. Knowledge about ethics and boundaries is an ongoing process since ethical decisions and the context in which they occur are ever changing. Situations are further complicated by the fact that some ethical situations and decisions also involve legal issues. All healthcare providers are required to follow the laws regulating their profession as well as the ethical principles guiding their professional behavior. When an ethical decision is clearly addressed and is consistent in both law and ethical standards, no dilemma exists, and the provider has a clear path for their decision. However, it is quite common for there to be conflict between law and ethical codes or for the particular situation to be only vaguely addressed by law, ethics code, or both. The APA Code (2017) states that “If psychologists’ ethical responsibilities conflict with law, regulations, or other governing legal authority, psychologists clarify the nature of the conflict, make known their commitment to the Ethics Code, and take reasonable steps to resolve the conflict consistent with the General Principles and Ethical Standards of the Ethics Code” (Standard 1.01). The NASW Code (2021) states that “Social workers’ ethical obligations may conflict with agency policies or relevant laws or regulations. When such conflicts occur, social workers must make a reasonable effort to resolve the conflict in a manner that is consistent with the values, principles, and standards expressed in this code.” (Introduction). The ACA Code (2014) adds that “If the conflict cannot be resolved… counselors, acting in the best interest of the client, may adhere to the requirements of the law, regulations, and/or other governing legal authority” (Standard 1.1.c).
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An understanding of the ethical standards for one’s profession, coupled with the laws and regulations governing that profession, provides sound guidance when faced with ethical situations. While each profession has developed their own set of ethical standards, the underlying values which are central Beneficence At its core, beneficence is the responsibility and duty of the clinician to help their client overcome life’s challenges to achieve a state of well-being. Through respectful, carefully thought-out interventions, healthcare providers work toward helping the client achieve the best possible outcome while minimizing harm. Beneficence is the duty of the clinician to act in ways that improve the well-being of the client. This principle is addressed in professional ethics codes by the following: ● APA (2017)—Psychologists strive to help their client achieve a state of emotional well-being (Principle A). ● NASW (2021)—Social workers understand that relationships between and among people are a vehicle to change, and they seek to strengthen relationships in an effort to promote, restore, maintain, and enhance the well-being of individuals, social groups, and communities (Value: Importance of Human Relationships). Nonmaleficence Nonmaleficence is the principle by which the clinician strives to do no harm. The clinician will not cause intentional harm to clients, and they will avoid behaviors that may place their clients at risk of harm. Harm is broadly defined and can include emotional, physical, and/or psychological harm. It requires the healthcare provider to carefully consider risks and benefits when making decisions that affect the care of the client. ● APA (2017)—Psychologists strive to do no harm and attempt to resolve conflicts in a way that minimizes harm (Principle A). ● NASW (2021)—Social workers use their knowledge, values, and skills to help people in need, and they Integrity/Fidelity Clinical Consideration : The concept of “do no harm” may seem straightforward, for example yelling at or hitting a client is clearly unacceptable. However, there may be situations where acts of potential harm must be weighed against what is best for the client. Consider, as an example, the client who you feel would benefit from a psychotropic medication evaluation. Does the potential for harm from side effects of a medication outweigh the potential benefit of the medication to the client’s mental health? Clinicians establish relationships of trust with their clients; they remain aware of their responsibility to clients and society as a whole; they uphold standards of conduct; they promote honesty; and they do not intentionally misrepresent information. ● APA (2017)—Clinicians aspire to work to the ethical standards of the profession, they accept responsibility for their own behavior, and they work to serve the best interests of their client (Principle B). ● NASW (2021)—Social workers are continually aware of the profession’s mission, values, ethical principles, and ethical standards and practice in a manner consistent with them (Value: Integrity).
to those professions are remarkably similar. Principles of beneficence, nonmaleficence, integrity/fidelity, and autonomy/justice span the ethics codes of the professions and are meant to describe the ideals all professionals should aspire to.
● ACA (2014)—Counselors work for the good of the individual and society by promoting mental health and well-being, enhancing development throughout the life span. They work to help the client foster control over the direction of their life (Introduction). ● AAMFT (2015)—Marriage and family therapists participate in activities which contribute to a better community and society (Preamble). Clinical Consideration : A client with a diagnosis of adjustment-related depression has been seen for eight sessions of cognitive behavioral therapy and has shown little to no improvement in mood and behavior. Recommending another form of treatment since this method is not working is a form of beneficence. ● NBCC (2023)—Counselors strive to enhance the social and mental well-being of their clients while supporting the overall wphysical health of each client (Core Values). elevate service to others above their own self-interest. They continually work to increase their professional knowledge and skills and apply them in practice (Value: Service, Competence). ● ACA (2014)—Counselors act to avoid harming their clients (Client Welfare). ● AAMFT (2015)—Competence is essential to the well- being of clients and their communities (Professional Competence & Integrity). ● NBCC (2023)—Counselors seek to minimize undue harm and take particular care of those who are vulnerable or in anguish (Core Values). ● ACA (2014)—Counselors honor commitments, keep promises, and fulfill their responsibility of trust in the professional relationship. They deal truthfully with their clients (Professional Responsibility). ● AAMFT (2015)—Marriage and family therapists do not exploit the trust of clients. They maintain high standards of professional competence and integrity (Professional Competence and Integrity). ● NBCC (2023)—Counselors seek to listen to others with intention and respond with respect (Counseling Relationships). Clinical Consideration : Issues of justice are not uncommon with access to services. Clinicians serve as advocates for their clients to ensure fair access to treatment. Consider: 1. The client with depression who you have been seeing, whose health insurance will not authorize more psychotherapy sessions. 2. The client with substance abuse who wants rehab but has no financial resources. Ethical professional guidelines instruct providers to work to the best of their ability to help their client access needed services.
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Autonomy/Justice Clinical Consideration : Keeping appointments, starting on time, and remaining attentive in the therapy session are basic examples of fidelity, as is maintaining confidentiality to foster trust. Clinicians have a responsibility to be fair and impartial and to treat people equally. They respect the dignity and worth of clients and respect individual, cultural, and role differences. They work to ensure that all clients have access to resources and services. ● APA (2017)—Clinicians have a responsibility to be fair and impartial and to treat people equally. They remain aware of their personal potential biases and boundaries of competence. They respect the rights of individuals to privacy, confidentiality, and self-determination (Principles D, E). ● NASW (2021)—Social workers challenge social injustice and pursue social change focused primarily on issues of poverty, unemployment, and discrimination, and they seek to promote sensitivity to oppression. They treat each person in a caring and respectful manner, and they stay aware of individual differences and cultural and ethnic diversity (Value: Social Justice). ● ACA (2014)—Counselors work to help the client foster control over the direction of their life. They treat individuals equitably and foster fairness and equality (Client Welfare). ● AAMFT (2015)—Marriage and family therapists provide services to persons without discrimination. They foster diversity, equity, and excellence in clinical practice (Responsibilities to Clients). ● NBCC (2023)—Counselors strive to be sensitive to differences in attitudes and culture. They provide The concept of boundaries in the therapeutic relationship has received increasing attention over the years and is addressed in most of the laws, regulations, and ethics codes of the various professions. However, these tend to focus on the more extreme violations with less attention being paid to the subtle and less obvious boundary issues that can cause difficulty for clinicians. Boundaries in professional relationships have been defined in many ways. According to the American Psychological Association, (APA 2023) boundary issues are “Ethical issues relating to the proper limits of a professional relationship between a provider of services and his or her patient or client, such that the trust and vulnerability of the latter are not abused.” Essentially, boundaries are the line between professional and personal. The fundamental purpose of boundaries in therapy is to create and maintain clear expectations for the client in order to provide the client protection from harm. When boundaries are not respected, there is risk of the therapist starting to work in their own best interest, which could lead to exploitation or harm to their client. Despite the importance of boundary knowledge, Chen and colleagues (2018) point out that education about boundaries in training and education programs tends to take on an abstract, theoretical quality and does not address the day-to-day dilemmas that most practitioners face. The terms “boundary crossings” and “boundary violations” are often used interchangeably, but the literature strives to separate the terms. Boundary crossings refers to any deviation from traditional practice which are harmless to the client and may also at times be therapeutic (Appel, 2023). It refers to situations where a boundary is crossed in order to meet therapeutic goals, and it does not harm the client or damage the therapeutic relationship. Boundary crossings
services to all of those in need, utilize available resources, and advocate for the expansion of resources in underserved communities. They avoid discrimination, oppression, or any form of social injustice (Core Values). Barnett (2019) emphasizes that familiarity with one’s professional ethics codes is necessary but not sufficient for ensuring ethical practice. Ethics codes are by design general guidelines and cannot address every possible ethical dilemma or challenge. Some aspects provide clear and specific behavioral guidance, while many of the standards are broad and vague. It then becomes difficult at times to navigate real-life dilemmas within the boundaries of the codes. Barnett suggests that ethics codes represent the minimum standards for ethical behavior, the ethical floor, and that providers should instead focus on aspirational standards: Focus on doing your best at all times for the benefit of the client and others. He reviews the core principles that transcend all disciplines and also adds self-care as an essential obligation. He argues that without appropriately attending to therapist functioning and well-being, over time the therapist’s ability to effectively implement the core principles becomes jeopardized. Self-Assessment Quiz Question #1 Which ethical principle states that a clinician has a responsibility to be fair, impartial, and treat people equally? a. Beneficence are not uncommon in day-to-day practice. The following are examples of common boundary crossings: ● Limited self-disclosure by the therapist to help establish rapport or normalize the client’s behavior. ● Extending the length of a session one time for a client in distress. ● Taking nonemergency phone calls between sessions. ● Accepting a minor gift from a client. ● Running into a client at the store or a public gathering. ● Temporarily reducing the session fee for a client who just lost their job. All of these situations deviate from traditional practice but are not necessarily harmful to the client. Not all boundary crossings lead to boundary violations, and some boundary flexibility allows for a response to an individual client’s needs at that time. A boundary violation is a more serious infraction. It is a deviation from practice which is harmful or exploitative of the client (Appel, 2023). A boundary violation moves the therapist out of the professional role; it tends to benefit the clinician more than the client; there is risk of harm to the client; it is often exploitative; and it violates professional ethical standards. When a boundary violation has occurred, the professional has engaged in a cognitive decision- making process that allowed a potentially harmful behavior to occur. This is not necessarily intentionally malicious behavior; it could have occurred from the professional being selfish, uninformed, or impaired. Nonetheless, the potential for causing harm to the client is great. Some potential consequences for the client can include the client prematurely terminating services, emotional distress, feelings of shame or anger, guilt or self-blame, confusion,
b. Nonmaleficence c. Integrity/fidelity d. Autonomy/justice THE CONCEPT OF BOUNDARIES
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● Boundaries help the clinician separate themself from their client by drawing a distinction between the clinician’s personal issues and those of the client. ● Boundaries fostered a sense of confidence and competence on the part of the counselor. They provided a framework within which therapy decisions were made, reducing therapist anxiety about competence. ● Boundaries helped reduce anxiety or fear surrounding judgment by others through client or professional colleague complaints. It is apparent that in order to provide ethical care to clients, it is crucial for the clinician to understand the definition of boundaries. They must recognize boundary situations, differentiate a boundary crossing from a boundary violation, and have a knowledge base for evaluating and navigating those situations. Corey and Corey (2021) list several signs that the counselor must pay attention to as they may be early warning signs that therapist objectivity may be an issue and a boundary crossing may occur: ● The counselor finds themself going out of their way to be helpful to the client, to the extent that the client becomes more dependent. ● The counselor is experiencing negative feelings toward the client, for example, they feel relieved when the client cancels a session. ● The client reminds the therapist of someone significant in their life, and the counselor feels a sense of familial comfort with them. ● The counselor feels attraction toward the client. ● The counselor self-identifies with the client, perceiving some of their own traits and qualities in the client. Self-Assessment Quiz Question #2 Examples of boundary crossings include all of the following except: a. Extending the session one time b. Having a sexually provocative conversation with the client c. Accepting a small, inexpensive gift from the client d. Running into the client at church
or mistrust. Consider the following boundary violations and how they may impact the client and therapist: ● Engaging in a sexually provocative conversation with the client ● Discussing a client’s confidential information with a group of friends at a social party ● Extensive therapist self-disclosure about the therapist’s past abuse history ● The therapist pressuring the client to babysit the therapist’s child Professionals tend to believe that they instinctively know where a professional boundary lies. However, the professional’s understanding of a boundary may be very different from the client’s understanding. A good number of licensing board complaints relate to client-perceived boundary issues; however, it is difficult to ascertain the actual frequency of boundary crossings or violations. Magiste (2020) examined the prevalence of ethics violation complaints to state social work licensing boards from 1985 through 2013. This review of literature found that the actual occurrence of professional ethics violations was low, at a rate of 0.05% of the total licensed population over 28 years of data. Although failure to comply with continuing education audit requirements was the largest group of violations, this was followed closely by nonsexual boundary violations, specifically, engaging in dual relationships. Blundell and colleagues (2022) explored how counselors understand and experience boundaries in their practice. All participants understood that professional boundaries were important for offering protection and safety to the client. They also understood that those boundaries also provided safety to the clinician since the power imbalance in therapy is not always toward the therapist. There are times where it shifts to the client, for example, when the client holds a position of power or authority in the community (e.g., court judge, police officer). Respondents in the study specifically noted that: ● Professional boundaries help the clinician protect themselves from the demands of their work. For example, boundaries related to session length and office hours help prevent professional burn out.
ESTABLISHING BOUNDARIES IN THERAPY
Healthcare services are value-laden professions in which the clinician brings their own personal values, beliefs, and viewpoints to the session. These have the potential to cloud ethical decision making. Recognizing one’s own viewpoints does not eliminate ethical bias but may at least help to mitigate their impact on ethical decision making. All professional ethics codes remind providers that they should not let their personal issues interfere with their professional judgement or jeopardize their responsibility to work in the best interests of their clients. The NBCC Code of Ethics (2015), for example, specifically states that counselors avoid imposing their personal values on those who receive their professional services (Principle 17). Establishing clear boundaries at the onset of therapy helps to create a set of ground rules which guide the course of therapy. This serves to build a sense of trust and safety for the client in the therapeutic environment. While therapists tend to keep their code of ethics in mind when establishing boundaries in therapy, they may not have direct and explicit conversations with their clients about those boundaries. That discussion is crucial, however, to avoid any confusion or misunderstanding during the course of therapy. An explicit discussion about boundaries, roles, and responsibilities at the start of therapy can help prevent or
resolve problems later. Celestine (2021) reviews six areas related to boundaries to be mindful of when entering into a therapeutic relationship with a client. 1. Use contracts and informed consent. This should include discussion about the risks and benefits of therapy and the expected timeline. Use of a standardized set of intake materials outlining expectations is recommended, with the client receiving a copy for their information. The therapist may consider setting up a boundary management plan with the client which states what will happen if boundaries are crossed. This sets up guidelines not only for the client but for the therapist as well if a boundary crossing is considered. 2. Discuss time. Explicitly establish expectations about session time limits, punctuality, and consequences of repeated tardiness or no shows. Discuss the boundaries around your time for answering client extra-session contacts such as phone calls. Consider whether constant availability may foster unhealthy client dependency or prevent them from solving problems independently. For example, other than crisis situations, phone calls may be confined to administrative issues. 3. Be mindful of self-disclosure. Therapists should reflect on any underlying motives for therapist self-disclosure and
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consider the risk of undermining the client’s perception of therapist professionalism or competence. Thoughtful consideration of self-disclosure as a potential boundary crossing is crucial. 4. Remain conscious of personal feelings. Be aware of how you feel about spending time with the client. Feelings of excitement, dread, attraction, or dislike may all impact the therapist’s effectiveness and lead to boundary challenges. 5. Reflect on feelings about touch. Attitudes about nonsexual touch and its implications may need to be addressed. Take cues from the client. For example, if the client is grieving and distressed and you’re considering consoling with a hug, ask for the client’s consent first. 6. Boundaries on gift giving. Some therapists have been taught that giving or receiving gifts is never acceptable while others are more flexible on the practice under certain circumstances. Consider the motivation underlying the gift, discuss the boundary directly with the client, and clearly document the gift and the conversation in client notes. Once boundaries are established and agreed upon by the practitioner and the client, a framework for the therapy relationship has been established. These boundaries, however, are not meant to be overly rigid or inflexible. Ethics codes recognize that boundary crossings may be unavoidable or at times even helpful to the client. The codes emphasize that counselors should use discretion when considering a boundary crossing to ensure that precautions are in place to safeguard client welfare. For example, The ACA Code of Ethics (2014) states that if a boundary is extended, the counselor takes precautions to ensure that judgement is not impaired, and no harm occurs (Standard A.6.b). Extending or crossing boundaries in therapy requires careful thought on the part of the clinician. Psychological ethicist Ken Pope in Pope and Keith-Spiegel (2008) discuss nine guidelines which are still widely referenced and should be considered when making decisions involving boundary crossings and whether they are likely to be helpful or harmful to the client. 1. Imagine the best and worst possible outcome from both crossing the boundary and not crossing the boundary. Does the boundary crossing involve risk of negative consequences or risk of serious harm to the client in the Dual or multiple relationships have been a primary area of focus when discussing boundary issues. These describe situations in which the counselor has another relationship with a current or former client outside of the therapy one. There is a secondary relationship between the clinician and the client in addition to the therapy one. Providing therapy to a client’s relative or friend, socializing with a client, or loaning money to a client are examples. Multiple relationships also occur when the therapist takes on more than one role with a person, for example, counselor and supervisor or counselor and business partner. There is an inherent power differential in these relationships that creates the potential for harm or exploitation. The dual relationship could impair the counselor’s judgment or objectivity, and the client could misunderstand the nature of the relationship. While all multiple relationships are boundary crossings, they are not necessarily boundary violations. As previously discussed, Magiste (2020) reported that a survey spanning 28 years of ethics complaints for a profession found that, although continuing education
short or long term? If harm is a possibility, are there ways to address it? 2. Consider any available research regarding the boundary crossing. 3. Consider guidance offered by professional guidelines, ethics codes, legislation, case law, and other resources. 4. Have at least one colleague that you can trust to give honest feedback about boundary crossing issues with whom you can consult if needed. 5. Pay attention to any uneasy feelings, doubts, or confusion on the clinician’s part and try to identify what is causing them. They note that many of the therapists they consulted with had felt uncomfortable prior to the boundary crossing but ignored it. 6. As part of the informed consent discussion when starting therapy, describe to the client how you work and exactly what type of therapy you do. If the client appears uncomfortable, explore further and if warranted refer to a colleague who may be better suited for the client. 7. Refer to a colleague any client that you feel incompetent to treat or that you do not feel you could work effectively with. 8. Pay attention to informed consent for any planned or obvious boundary crossing. 9. Keep notes on any planned boundary crossing describing why, in your clinical judgment, you feel the boundary crossing is necessary and will be helpful to the client. Finally, Levine and Courtois (2021) point out that not all boundary crossings are planned. When a provider does something outside of the established boundaries, when they make a mistake or break a parameter, it should be brought to the client’s attention and discussed. Sometimes a simple apology is all that is needed, but the feelings and response of the client should be elicited and appreciated. This can repair the relationship and foster trust and understanding.
Clinical Consideration : It is clear that to cross or not to cross a boundary at any particular time in therapy requires careful thought and consideration by the therapist. The therapist must take into consideration the client’s history, culture, values, and diagnosis. Any crossing that is considered should be part of a well- constructed and clearly defined treatment plan that is for the benefit of the client. It should be discussed in full with the client and should be clearly documented in the client’s chart. BOUNDARY CROSSING: NONSEXUAL DUAL OR MULTIPLE RELATIONSHIPS
audit requirements compromised the largest number of complaints, this was followed closely by complaints related to the nonsexual boundary issue of engaging in a dual relationship. It is no surprise, then, that all of the ethics codes specifically address the issue of dual or multiple relationships in the course of the therapeutic relationship and may also define the type of relationship that is cautioned against. ● ACA (2014) states that counselors avoid extending the boundary of the therapy relationship to include other roles (Standard A.6.b). Prohibited non-counseling relationships include engaging in counseling with persons with whom they have had a previous sexual or romantic relationship or with friends or family members, as it could impair objectivity. Personal virtual relationships with current clients are also prohibited (Standard A.5). ● NASW (2011) notes that dual relationships occur when the social worker relates to the client in more than one way, whether professional, social, or business and these
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Book Code: SWNY1224
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relationships can occur simultaneously or consecutively. They 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. If a multiple relationship is unavoidable, the social worker takes steps to protect the client and is responsible for setting clear, appropriate, and culturally sensitive boundaries (Standard 1.06). ● AAMFT (2015) states that multiple relationships include but are not limited to business or close personal relationships with a client or the clients’ immediate family. Therapists make every effort to avoid multiple relationships that could impair professional judgement or increase the risk of exploitation (Standard 1.3). ● NBCC (2023) states that counselors should avoid counseling relationships with individuals with whom they have another relationship with such as a community connection, friendship, or work relationship. They strive to avoid multiple relationships with clients except in cases where it is culturally appropriate or therapeutically relevant. If an unforeseen multiple relationship happens, the counselor is to discuss the potential effects with the client and make attempts to resolve the situation, which may include termination of the therapy relationship and referral to another provider (Standard 22). They should not enter into a non-counseling relationship with a former client for at least 5 years after the last professional contact (Standard 23). ● APA (2017) does not specifically define persons but broadly states that a multiple relationship occurs when the clinician “Is in a professional role with a person and at the same time is in another role with the same person,” “At the same time is in a relationship with a person closely associated with or related to” the client or “Promises to enter into another relationship in the future” with the client or person closely related to the client. Psychologists do not enter into a multiple relationship if it could reasonably be expected to impair the psychologist’s objectivity, competence, or effectiveness or if it otherwise risks exploitation or harm to the client. If the psychologist finds that a potentially harmful multiple relationship has arisen, they take steps to resolve it keeping the best interests of the client in mind (Standard 3.05). As implied in these guidelines, there are many types of relationships which fall under the definition of multiple
relationships. Examples include social, when the therapist and client are also personal friends; professional, when the therapist and client work together in the same organization; business, when the therapist shops at a store owned by the client; community, when the therapist and client attend the same church or community group; or romantic, when the therapist and client are intimately involved. Despite these guidelines advising against multiple relationships, they may not always be avoidable. Small towns, small communities, or limited-in-size groups may make it nearly impossible to avoid having a relationship with a client outside of the therapy room. For example, in a small community the therapist may attend the same church as the client. In a rural area with one physician, the therapist who is a patient of the physician may provide therapy services to the nurse who works at the doctor’s office. Brownlee and colleagues (2019) surveyed rural social work practitioners and found that 90% of the therapists felt that dual relationships in rural communities are inevitable and common. Szumer and Arnold (2023) note that in rural environments it is inevitable that the healthcare provider’s personal relationships will cross over with their professional relationships either with the client or with persons close to the client. They argue that these encounters are just that— encounters—and are not ongoing involved relationships. They suggest the term “overlapping” relationship rather than dual or multiple relationships to differentiate them. They recommend that the provider reflect on whether the overlapping relationship is harmful to the client in any way, whether it could damage the therapeutic relationship in any way, whether any professional codes or regulations are applicable to the situation, and whether new boundaries need to be put in place to protect the client and the therapy relationship, including potential referral to another provider. The overlapping relationship should be discussed with the client and documented in the chart. These situations highlight that not all encounters outside of the therapy office constitute an ongoing, involved relationship. The central question in any dual or multiple relationship situation to consider is whose needs are being met, the client’s or the therapist’s. Brownlee and colleagues (2019) note that any time a dual relationship has occurred, the therapist should self-reflect and consider the specific circumstances surrounding the boundary crossing, including frequency and intent.
BOUNDARY CROSSING: GIFTING
A boundary crossing situation that is seemingly benign and that is frequently faced by the clinician is the giving and/ or accepting of gifts to or from a current client. Appropriate gift-giving is a boundary crossing that may potentially enhance the therapeutic relationship. Inappropriate gift giving moves into the realm of a boundary violation. Gift-giving is a nearly universal way of showing gratitude, appreciation, respect, and caring toward others. It is not uncommon for clients to offer gifts to providers, especially around traditional holiday times or at the conclusion of treatment. Many providers also choose to give a small gift or token to their client at various times. Any exchange of a gift must be considered in terms of appropriateness due to type of gift, value of the gift, timing in treatment, intent of the gift-giver, and perception by the recipient of the gift’s purpose. How gifts are given or received in the context of a therapeutic relationship requires careful consideration as this seemingly benign act of a boundary crossing may have a significant impact on the provider, client, or both. Gifting is typically viewed as a boundary crossing and, as such, is addressed directly or indirectly by the ethics
codes of many professions. For those fields where the code of ethics does not specifically address the issue of gifts, ethical considerations can be inferred. For example, the APA Ethical Principles (2017) and the NASW Code of Ethics (2021) do not directly discuss gifts but are clear about prohibiting exploitation of the client, they have several sections addressing the issue of multiple relationships, and they also state that the provider must, above all, strive to do no harm. The ACA Code of Ethics (2014) is more specific and states counselors must take into account the monetary value of the gift, the client’s motivation for giving it, and the counselor’s motivation for wanting to accept it. The AAMFT Code of Ethics (2015) states that therapists must consider the potential effects that receiving or giving gifts may have on clients and the efficacy of the therapeutic relationship. The NBCC Code of Ethics (2023) is even more specific by stating “Counselors shall not accept gifts from clients except in cases when it is culturally appropriate or therapeutically relevant. Counselors shall consider the value of the gift and the effect on the therapeutic relationship, and acceptance of a gift shall be documented in the client’s
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Book Code: SWNY1224
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