Professional Boundaries

Posted on October 03, 2018 by BRUCE KRAMER, One of Thousands of Life Coaches on Noomii.

One of the many challenges that have faced the United States is the creation, regulation, and control of its professions, Starr (1982), (Chapter 1). In particular the development of American medicine and healthcare has evolved and spun into a vast changing and multi- faceted industry. Along with our advances in modern technology, and many scientific breakthroughs, the perceived need and value of healthcare is well represented by the amount of money spent by us in the pursuit of health and wellness, and by the number of people, specialists and professions that make up the industries that are involved in serving our physical, mental, emotional, and spiritual needs. Along with the opening of the 1970s there came for us a declaration and new perception of a “crisis” in health care, Starr (1982), (Chapter 6). Medicine suffered a stunning loss of confidence with public attention focusing and questioning its economic costs, its focus; its moral and ethical problems. This is well stated by Marilyn R. Peterson (1992),
“For centuries, the conduct of society’s most trusted servants was deemed above reproach. Physicians, attorneys, clerics, and teachers were assumed to be paragons of wisdom, morality, and excellence. Today such blind faith is fast disappearing from the landscape”, (1).
Out of this new questioning and assessing rose many new developments in health care along with the rebirth of a new industry of complimentary/ alternative/ integrative medicine. The many well established and existing American professional societies such as lawyers, social workers, psychologists, religious leaders, teachers, and nurses started a controversial self-questioning of their professional-client relationships. Their challenge coming from freshly educated American consumers, who thanks to their involvement in the last world war were eligible for the higher educational benefits of the GI bill. More educated consumers wanted a voice in their health care choices. Consumers were by the 1990s spending billions of dollars for health care outside of the traditional allopathic network and in many cases were not telling their physicians. Consumers were voluntarily and in substantial numbers choosing massage, acupuncture, natural herbs, homeopathy, and other forms of natural healing methods to address their health problems.
It was not until the 1990s that a critical mass of literature began to emerge on boundary issues and became an explicit topic of conversation amongst human service professionals, Reamer (2001) (Chapter 1). I will explore in this short paper some of the new and emerging concepts and definitions of this emerging field of boundary violations in professional-client relationships and I will explore why at this time in our history that there is a great need for every professional to become educated in this field or face great personal loss.
Professional misconduct can be looked at as a professional’s misdeed or harm to his or her client. Ethical issues relating to professional boundaries are greatly challenging and problematic (Congress (1996); Jayaratne, Croxton, and Mattison (1997); Kagle and Giebelhausen, (1994), Reamer in press; Strom-Gottfried (1999); Frederic Reamer (2001) in his book Tangled Relationships says that, “ briefly, boundary issues arise when human service professionals encounter actual or potential conflicts between their professional duties and their social, sexual, religious, or business relationships (St. Germaine 1993, 1996)” (1). Many boundary issues are problematic and or unethical, though some are not. “Boundary issues occur when practitioners face potential conflicts of interest stemming from what has become known as dual or multiple relationships”, Reamer (2001). According to Kagle and Giebelhausen (1994), “A professional enters into a dual relationship whenever he or she assumes a second role with a client, becoming social worker and friend, employer, teacher, business associate, family member or sex partner” (213). Historically human service professionals have not had well-defined guidelines regarding professional boundaries and it is only fairly recently that guidelines are being explored and published in various writings. Regulations relating to these guidelines are being adopted by different state licensing boards around the country. Reamer, in his book Tangled Relationships, distinguishes between boundary crossings and boundary violations, where he says that some boundary crossing may be helpful to colleagues and clients, though most are not. Peterson, in her book At Personal Risk, thinks that boundary violations involve a process of disconnection between the practitioner and the client that occurs within the context of the professional relationship. This process involves a reversal of roles, a secret, a double blind, and an indulgence of professional privilege; which results in the damage to the client. She also believes that many professionals mistakenly feel that they are not at any risk of creating boundary violations, where in fact many excellent healthcare professionals are guilty of and unaware of boundary violations occurring in their work.
Why is there so much excitement about all of this? In an article published in 1993 called Advising Patient-Victims of Sexual Misconduct by Mental Health Professionals by Carl E. Ameringer and S. Michael Plaut, the authors state that in the State of Maryland from January 1, 1989, to June 30, 1992, there were 382 cases of all kinds referred by Maryland’s health licensing boards to the office of the Attorney general for prosecution. Eleven percent of these total cases or 43 prosecutions, contained allegations of sexual misconduct by licensees. Seventy-five percent of these cases were from the mental health boards. The writers think that this represents only the tip of the iceberg. In view of some various studies it is indicated that “between four and thirty percent of all therapists actually engage in sexual contact with their clients,” and the degree of under reporting is significant, L. Jorgenson, R. Randles, & L. Strasburger, The Furor Over Psychotherapisy-Patient Sexual Contact, New Solutions To An Old Problem, 32 Wm.& Mary L. Rev. 645, 658. This is in spite of the fact that beginning with Hippocratic oath centuries ago, all major helping professionals have prohibited sexual relationships with clients. Sexual contact is only one of many forms of boundary violations.
In an article published in April 2000, Acupuncture Today, Shawn Steel, MA, JD, who at that time was the Chairman, Acupuncture Board of California Enforcement Committee, defines the impact of this problem, as it relates to the new human service industry of acupuncture in the State of California, in his article Legal Issues.
“Given the geometric increase of acupuncture in California, there has also been a corresponding growth of consumer complaints and discipline cases for the California Acupuncture Board. The board licenses more acupuncturists than anywhere in the Western hemisphere; the 7,021 current licensed acupuncturists make up about one third of the acupuncturists in the United States. Nearly two-thirds of the board’s 1 million budget is spent on disciplining acupuncturists. Some $600,000 is spent on state investigators who carefully investigate complaints; $400,000 of that sum is spent on the California Attorney General. Since the acupuncture board was established in 1972, hundreds of licenses have been revoked’’…
A licensed therapist or professional has a fiduciary duty to his clients because of his or her special expertise. “The term fiduciary relationship is not widely used outside of the legal profession. Nevertheless, most people who offer medical, mental health, and legal services can readily understand what is implied by that term- – that is, it refers to a special relationship in which one person accepts the trust and confidence of another to act in the latter’s best interest,” Feldman-Summers (1989). The client is seen in a position of vulnerability, low self-esteem, or high dependency in the professional relationship. The fiduciary therapist or professional is always in the position of power, and must overcome the temptation to seek personal gratification from the therapeutic situation. Legally in most states, in sexual matters, the client is never seen as a consenting adult in any way in this fiduciary relationship as a result of this power dynamic. It also is true in several health and non-health professions that time and absence of contact does not change this fiduciary definition of relationship forbidding other relationships and it also includes significant others of the client that the practitioner is forbidden to interact with.
“The literature offers diverse theories about the causes of, and factors associated with practitioner sexual misconduct,” Reamer (2001). Simon (1999) argues, for example that “ boundary violations are a function of the nature of the client (the clients clinical issues), the type of treatment, the status of the therapeutic alliance (whether it is strong or weak, functional or dysfunctional), and the personality of the therapist combined with his or her training and experience.” Reamer (2001), “from a psychodynamic perspective a clinician violates a clients boundaries because of the therapists difficulty in handling countertransference phenomenia- – that is, the therapist transference reaction toward the client (countertransference involves unconsciously feeling toward a client the same feeling the clinician originally had toward someone else).” Simon (1999) asserts that one common countertransference trap occurs when:
The therapist subconsciously over identifies with a patient who he or she tries to rescue. The therapist is usually struggling with conflicts or has experienced traumatic life events that are also observable in the patient. The patient is treated like a favorite child, with increasing exceptions made to the maintenance of treatment boundaries. As the therapist becomes more deeply immersed in the patient’s life, the patient’s demands become greater on the therapist. Eventually the therapist abrogates the role of therapist and enters into a personal sexual relationship with the patient. Although the therapist becomes aware of increasingly boundary violations, he or she feels “powerless” to restore the treatment situation.
Pope (1994) says that sexually exploited patients are put in risk for serious and lasting harm, and that therapist-patient sex is comparable to incest and rape in regards to dynamics, uses of power, lack of freely given consent, characteristics of perpetrators, and consequences for victim/survivors, (Appendix A).
Psychiatrist Glen Gabbard (1989a) notes below important aspects of this view of the incestuous nature of patient- therapist sex.
The problem of incest has lurched into public awareness over the last decade or so… In parallel with this increased interest has been a growing awareness of another form of incest—sexual exploitation of patients… by professionals. The victims of this form of professional incest have placed their trust in a person whom they assume will place their interest above his or her own by the very nature of the professional relationship. When this trust is betrayed, the impact is often as damaging as familial incest.
…Incest victims and those who have been sexually exploited by professionals have remarkably similar symptoms: shame, intense guilt associated with a feeling that they were somehow responsible for their victimization, feelings of isolation and enforced silence, poor self-esteem, suicidal and/or self-destructive behavior, and denial. Reactions of friends and family—disbelief, discounting, and embarrassment—are also similar in both groups. (p. xi)
Through the unique nature of the human services practitioner-client relationship the client seeks to bring about personal changes that he or she cannot accomplish on their own. The therapy is an exercise of power between the client and human services practitioner forming an alliance for the client’s behalf and benefit. Powerful forces of transference and countertransferance create a tendency to act out rather then to resolve the personal changes that the client has hoped for his or her highest good. In order to create effective functioning of the therapeutic alliance, there must be maintenance of treatment structure and boundaries, Wm. & Mary L. Rev., (1991), (645).
According to Stuart W. Twemlow and Glen O. Gabbard,, (1989), in their article, The Lovesick Therapist, sexually abusing health service practitioners fall into three broad categories: the psychotic, the antisocial, and the lovesick. The psychotic involves a very small subset of all of the offenders. The number of abusing therapists with antisocial features is considerably larger and these people are ruthless, without remorse or empathy for their victims, and the most frankly exploitive. The lovesick category is more broad and composed of neurotics and assorted personality disorders. In a survey by Gartrell et.al, 65 percent of the offenders stated that they had been in love with their patients, and 92 percent believed that the patients were in love with them. 55 percent of a sample of 20 therapists who had been sexually involved with their clients described a total attraction to the client on all levels. They define lovesickness as having the following basic phenomenological features: emotional dependence felt by both the therapist and client for each other; intrusive thinking, meaning that neither the therapist or client can stop thinking about each other, physical sensations like walking on air or “heart in the throat”; a sense of incompleteness without each other; social proscription, defined as the impossibility of the situation allowing them to be together. All of these features create an altered state of consciousness, or drugged like feeling that leads to extraordinary risk taking on the part of the therapist and eventually impaired judgment causing a violation of the client’s boundaries.
According to Shirley Feldman-Summers, (1989), in her article Sexual Contact in Fiduciary Relationships, cases in which clients have developed a strong attraction toward their health provider often involves clients with low self-esteem and high dependency that can be attributed to a history of abuse. Some clients use compliance in the relationship to avoid conflict. Many clients through the phenomenon of transference, where the practitioner represents a past power figure that they desperately want to have love them, are made extremely vulnerable. It is also very common for many clients to develop strong feelings of love or adoration towards their therapist, due to the intimate nature of their ongoing therapeutic process, causing them to experience an extreme state of vulnerability.
In Marilyn Peterson’s book, At Personal Risk (1992), she defines the power differential in the professional-client relationship as follows:
As clients we are vulnerable because of needs that we cannot take care of ourselves. Professionals because of their training and expertise are better equipped to meet these needs. The potential for boundary violations derives from the space that exits between the knowledgeable professional and the vulnerable client. The inequality between us, the power differential, creates the need for protection. Boundaries define formally and informally how professionals are to exercise their power inside the relationship. When professionals maintain these limits, the power differential presents no problems. However, when professionals abuse the privilege of their power, they violate the boundary that protects the space and place us in jeopardy.
Professionals are greatly at risk due to their tendencies to minimize their impact on their clients by negating in their minds and attitudes the magnitude of their power. By their not being totally clear on who they are they are more easily able to inappropriately shift the boundaries with their clients. In addition, the practitioner can be so self involved with their own professional processes and their personal desire to serve the client that they loose sight of, or they are blind to the particular individual sensitivities of a client and step on the client’s boundaries without realizing their indiscretion.
It is in my opinion that we are only in the very beginning stages of this process of understanding boundary violations in professional-client relationships. It is acknowledged by many of the writers in this field of ethics that professional schools are just beginning to offer some educational programs for their students. There seems from all indications that this is a particularly acute problem for male professionals due to the majority of sexual complaints involving woman client’s allegations against mostly male professionals, Ameringer and Plaut (1993). We live in a society where the strongly promoted forces for increased empowerment for woman have been very evident in the last thirty years. In that same time frame there have been a yearly escalation of formal complaints by woman. In my conversations with informed male health care providers from several different professions there is expressed a great anxiety and concern about their encountering female client’s with undiagnosed personality disorders and a negative transference reaction, who regardless of any precautions that the professional might take could, they confess, have access to involving them in a very expensive and unsympathetic hearing process with their state boards and possibly ruin their careers and reputation. I was not surprised on a stopover at the Denver airport to find video cameras in a massage establishment. The massage therapist explained that the owner had put them in two years ago and had successfully ended the countless allegation complaints that once plagued their business. #Top tips on managing professional boundaries in social work, #MeToo, #Managing Professional and Nurse–Patient Relationship, #FOAMed, #mhealth, #hcsm, #MedEd, #HealthTalk, #4patients, #Hitsm