OKLAHOMA DRUG AND ALCOHOL PROFESSIONAL COUNSELOR ASSOCIATION

1. OKLAHOMA DRUG AND ALCOHOL PROFESSIONAL COUNSELOR ASSOCIATION B BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN COUNSELING AND THERAPY: Knowing where to draw the line. April 4-5, 2014-norman, ok Judith K. Adams, Ph.D., LMFT, LADC

2. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY Boundaries in counseling or therapy define the therapeutic-fiduciary relationships. Boundaries define what has been referred to as the "therapeutic frame." • (Fiduciary= faithful, dutiful) These boundaries distinguish therapy from social, familial, sexual, business and many other types of relationships.

3. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY Key Points 1. Boundary violations in therapy are different from boundary crossings. Boundary violations and boundary crossingsmay be seen as a departure from the traditional milieu of counseling and psychotherapy. Boundary violations and boundary crossings in therapy refer to any deviation from traditional, strict, 'only in the office,' emotionally detached or distant forms of therapy or deviation from rigid risk-management protocols.

4. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY Crossing vs. violating “boundaries” concerns issues of: • Self-disclosure, personal revelation by the counselor • Incidental encounters with clients in stores, commun-ityor sports events, large vs. small church) • Physical contact with clients, such as handshake, touch, or hugs • Giving gifts to or receiving gifts from a client • Bartering or provided services pro-bono in lieu of charging: Out-of-office visits, such as home or hospital

5. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY “Boundaries” concerns refer to issues of engaging in activities with clients outside the office • Attending clients’ school plays, weddings, or graduations • Adventure therapy, ROPES courses • Recreational outings, dances, etc., • Attending the same recovery meeting as a client • Eating with a client for therapeutic vs. social reasons • E-therapy, electronic media, social networking • Various other forms of “dual” relationships.

6. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY Key Points 3.Boundary crossings are not all inherently unethical. Ethics code of all major mental health professional associations (e.g., APA, ApA, NASW, ACA, NBCC) do not prohibit (non-harmful) boundary crossings, only (harmful) boundary violations Key word Harmful

7. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY Key Points 2. Boundary violationsby therapists are harmful to their clients Boundary crossingsare notharmful and can even prove to be helpful or therapeutic. For example, harmfulboundary violations occur typically when therapists are engaged in exploitative dual relationships, such as sexual contacts with clients or other exploitativerelationships. This could be also occur in business, politics, etc. Key word Exploitative

8. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY Dual or multiple relationshipsin therapy refers to any situation where multiple roles exist between a therapist and a client. Examples of multiple or dual relationships are when the client is also a student, friend, family member, employee or business associate of the therapist. This discussion refers to non-sexual dual relationships.

9. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY Most of these codes state that dual or multiple relationships should be avoided if they could reasonably be expected to impair the therapists’ effectiveness or cause harm to the client or therapeutic relationship. Boundary violations occur when therapists cross the line of decency and violate or exploit their clients. Harm to the client is the criterion for judgment. Key concept Impair Effectiveness

10. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY Harmful boundary violations occur typically when therapists and patients are engaged in exploitative dual relationships, such as sexual contacts with current clients. Sexual involvement with past clients is also unethical.

11. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY The boundary violation of becoming sexually involved with a client is one of the greatest sources of ethical complaints.

12. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY The rule, contained within the Board of Licensed Alcohol and Drug Counselors Act says: A sexual dual relationship is where therapist and client are also involved in a sexual relationship. Sexual dual relationships with current clients are always unethical and often illegal. The time frame for involvement with past clients varies between ethics codes.

13. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY Rule No 1: if there is a clear prohibition against a certain boundary situation, i.e., do not become sexually intimate with clients, then DON’T DO IT!!!!

14. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY Despite the prohibition against sexual involvement with clients, either current or past, many ethical complaints are filed every year against alcohol and drug counselors for sexual involvement with clients. Obviously, this prohibition needs greater emphasis. Sexual involvement with clients is a fundamental violation of the professional-client relationship that undermines the therapeutic relationship and creates a range of psychological wounding to the client.

15. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY Do not enter into sexual relations with a client: it is likely to impair your judgment and nullify your clinical effectiveness. You may “trust” the client, but you put your professional career on the line. You will be forever held hostage to the possibility that the client will report you for an ethical violation and your life goes down the tubes.

16. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY As a professional counselor, you should: • Recognize when you have issues with attraction to a client. • Be aware of the potential for a client being attracted to you. • Consider the clinical information, as it may be relevant to the development of physical attraction, even sexual exploitation. • Seek supervision in situations that warrant particular attention. (Put yourself in “time out.”) • Be fully aware of the risks which sexual involvement poses. • Consider the alternative of referring the client, having a supervisor readily available, or establishing other “buffers” between you and the client.

17. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY Therapist factors increasing risk of engaging in a harmful, exploitative, and/or sexual relationship with a client. • If you are recently divorced, without close friends, or do not have adequate social networks. • If you live an isolated life, where work is your primary social outlet. • If you rely on your clients for too much of your professional/personal satisfaction. • If you have not resolved personal issues and/or are not working an effective recovery program. • If you have a ‘personality disorder,’ are focused on yourself, and/or inclined to rationalize and justify having a personal relationship with the client.

18. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY Sexual relationships are exploitive and harmful. Certainly, we do not have ethical justification for an exploitive or sexual dual relationship with clients.

19. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY Key Points 4. Some boundaries are drawn around the therapeutic relationship& include concerns with time and place of sessions, fees and confidentiality or privacy. Boundaries of another sort are drawn between therapists and clientsrather than around them and include therapists’ self-disclosure, physical contact (i.e., touch), giving and receiving gifts, contact/communication outside of the normal therapy session, and proximity of therapist and client during sessions.

20. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY Many boundary crossings are not sexual in nature. A multiple or dual relationship may be non-sexual but still be exploitative; they are therefore unethical. Non-sexual multiple or dual relationships also may be non-exploitive; they are therefore ethical. The Big Question becomes: How do you know if it’s crossing the line, in a bad way?

21. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY In real life, the “boundaries” of boundaries may be fuzzy. (Isn’t that brilliant?)

22. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY Exploitative business relationships also constitute boundary violations. Jim has been charged with a felony crime which could result in his going to prison. He had been drinking at the time and hopes that you can do an evaluation and attest that he was in a blackout, which might be a defense for him. He tells you that he doesn’t have much money but he recently started a business and he would be willing to make you a partner in the business, which could make you a lot of money. Would you accept his offer?

23. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY Key Points 5. Boundary crossingoften involves clinically effective interventions, such as self-disclosure, home visits, non-sexual touch, gifts or bartering, or therapy-based out-of-office contact.

24. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY A potentially helpful boundary crossing would be: A female counselor has a female patient, who is going through menopause and who feels very unattractive with her appearance: she is concerned that her husband doesn’t love her any more. The counselor accompanies the client to another building in their treatment complex, where the client receives instruction and guidance on exercise, makeup, grooming, and her appearance in general. Is this a boundary crossing or boundary violation?

25. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY Potentially helpful boundary crossings also include going on a hike with an adolescent client; giving a non-sexual hug to a grieving client; sending cards; exchanging appropriate, not too expensive, gifts; lending a book to a client; attending a wedding, confirmation, Bar Mitzvah or funeral; or going to see a client receive a commendation or perform in a show.

26. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY Key Points 6. Boundary crossings can be an integral part of well formulated treatment plans or evidence-based treatment plans. Certain therapeutic approaches are more flexible. It is recommended that the rationale for boundary crossings be clearly articulated and, when appropriate, included in the treatment plan.

27. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY Residential programs often have staff transport clients on recreational outings, to doctor’s appointments, or to local AA meetings. In some instances, staff members attend the same recovery meetings as clients. A counselor may be may be requested to see a client in the jail, in prison, in a hospital, or in a group home. Other examples are making a home visit, doing a home assessment to a bed-ridden elderly patient, having lunch with an anorexic patient, or going for a vigorous walk with a depressed patient.

28. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY Examples of common interactions which may or may not be within ethical boundaries: giving a supportive hug to a grieving client lending a CD (book, pamphlet, Big Book) to a client sending a card of congratulations, sympathy, or encouragement accepting a small termination gift from a client accepting a bartering with a cash-poor client assisting a phobic client to schedule and keep a dreaded but important doctor's appointment

29. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY Have you ever visited a client in the hospital, half-way house (when you treated the client at a different level of care) at jail, prison, or other location? Did you consider it problematic to see the client in that location? Why or why not? Are you in a job position of making home visits? What parameters do you consider when making a home visit? What risks may be engendered by going to the home of clients/consumers?

30. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY Some counseling formats may endorse “out of office” contacts. Making a home visit, taking a child (or parent and child) on a shopping trip for school supplies, or transporting a client to a doctor’s appoints, are boundary crossings which do not necessary constitute unethical dual relationships.

31. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY Therapeutically sanctioned or therapy-based “out-of-office” contact with clients are not likely to be unethical. When may it be acceptable and when is it not acceptable?

32. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY Would the following interventions constitute unethical dual relationships or boundary crossings? Bob works with substance abusers who have recently been released from prison. Moving toward employability is a part of the major purpose of the program in which he which he works. He helps program participants sign up for their G.E.D., goes over the test requirements, then transports them to the location to take their test.

33. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY Would the following interventions constitute unethical dual relationships or boundary crossings? Mary works in a sheltered workshop with developmentally disabled clients, who have very little opportunity to socialize with other clients. Mary helps arrange a dance and party for her clients and she attends with them. She even gets out on the dance floor with the clients. They all enjoy themselves. A behavioral therapist takes the therapy outside the office and walks with an agoraphobic client to an open space, as part of an in vivo intervention.

34. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY Rule No 2. You can worry less if you have therapeutic justification for the boundary crossing. Ask yourself: • Is this interaction documented in your treatment plan? • Do your clinical notes indicate this was a therapeutic issue, and you interaction integral to treatment? • Was the boundary crossing interaction clearly directed at client stabilization/benefit, symptom-reduction, skill development, or personal growth? • Although a deviation from ‘standard” practice, can you readily assure the client, yourself, and supervisors that you conducted yourself professionally?

35. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY Other interactions, perhaps less common, which may arise and may not be potentially harmful boundary crossings: • making a hospital, home, or jail visit to a client • attending a therapy-compatible ceremony for the client • engaging “in vivo” treatment methods, such as going to the mall with an patient with agoraphobia • walking or “activity therapy” with a client • going to see a shy client perform in a show • attending a wedding, confirmation, Bar Mitzvah or funeral for a client or family member of a client

36. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY If you live in a small community, trying to avoid all forms of dual relationship, even non-sexual dual relationships, may be awkward, inconvenient, or impossible. The car mechanic, pharmacist, grocery store clerk, Avon lady, nurse’s aid may be clients.

37. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY Counselors and other therapists who work with children routinely leave the office for walks with them and or perhaps attend school plays in which they are performing. Numerous other “treatment justified” contacts with clients out of the office may occur. Question: Would you attend a graduation ceremony for a client? How would you decide? Where would you sit? Would you talk to the client? Would the age of the client or therapeutic issues be factors?

38. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY EXPLOITIVE VS. NON-EXPLOITATIVE NON-SEXUAL DUAL RELATIONSHIPS IN THERAPY How can you determine if a relationship is crossing the boundaries from being a therapist to be a peer or friend? The boundaries of boundaries are sometimes fuzzy. (Boundaries of boundaries really aren’t boundaries) We need some guidance on how to decide if we are keeping the professional relationship or if we are letting our professionalism be overshadowed by the non-counseling interaction.

39. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY Gottlieb (1993) developed a model for evaluating dual relationships and for dealing with them. The assumptions of this model are: 1. The model applies to all professional relationships; i.e. relationships with students, supervisees, and clients, regardless of the theoretical orientation. 2. The aspirational goal of avoiding all dual relationships isunrealistic. Decisions need to be made sensibly, sensitively, and effectively. 3. All relationships with consumers should be evaluated to assess potential harm.

40. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY The assumptions of Gottlieb’s (1993) model include: 4. Not all dual relationships are exploitative, per se. Some are “low risk” and some may actually be beneficial. Relationships which are harmful should be avoided or discontinued. 5. The purpose of Gottlieb’s model is to sensitize practitioners to the relevant issues and make recommendations for action. 6. The model assumes that the professional’s dilemma results from “contemplation” of a second relationship, not when one already exists. 7. The risk must be assessed from the perspective of the consumer, not the professional. Decisions must be made on a conservative basis. [Err on the side of caution.]

41. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY Gottlieb’s model considers three dimensions: • Power • Duration (of the Relationship) • Clarity of Termination

42. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY Power refers to the amount of power a counselor has with/over the other person, which may vary greatly from situation to situation. The amount of power the counselor has over the client increases over time. The counselor has more power or influence over a client who comes for several years than one who comes for only one or two sessions. The professional relationship continues as long as the consumer assumes that it does, regardless of the amount of time elapsed or contact in the interim.

43. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY POWER LowMid-RangeHigh Little or no personal relationship Clear power differential Clear power differential or present but relationship with profound personal Persons consider each other peers is circumscribed influence possible (may include elements of influence) DURATION BriefIntermediateLong Single or few contacts over Regular contact over a limited Continuous or episodic short period of time period of time contact over a long period of time TERMINATION Specific UncertainIndefinite Relationship is limited by time Professional function is No agreement when or if Externally imposed or by prior completed but further contact termination is to take agreement of parties who are is not ruled out place unlikely to see each other again.

44. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY Evaluate current relationship using three dimensions Relationship falls to the right side on most or all dimensions No Yes Relationship falls at mid-range Discontinue relationship: or to the left on most dimensions obtain consultation if needed Yes Use dimensions to evaluate contemplating relationship Contemplated relationship falls to the right side on most dimensions No Yes Contemplated relationship falls Discontinue relationship: at the mid- range or to the left obtain consultation if needed Yes Evaluate in terms of role incompatibility No Yes Relationship may be non-exploitive Discontinue relationship: obtain consultation if needed Obtain consultation Discuss above with consumer as a matter of informed consent Discontinue

45. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY Consider the following cases, using Gottlieb’s model: Mr. Harry Potter receives a referral for Ms. Smith, an attractive young woman, who is facing some legal difficulty and needs an evaluation. Harry has done similar referrals of this type, so that he has developed a “protocol” for the assessment. He agrees to accept the referral, which will consist of about four to five sessions, including a detailed clinical interview, administration of several questionnaires and tests, then completion of his report. How would this scenario be evaluated, considering the dimensions of power, duration, and termination?

46. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY Let’s try another hypothetical case: Billy Bob is an alcohol and drug counselor, who has also obtained his credentialing for working with mental health clients. He receives a referral of a lady, whose husband recently passed away suddenly. Her husband was a businessman, so the female client didn’t have to work, unless she wanted to – off and on. She was very dependent on her husband, who was 21 years older than herself. When Billy Bob meets her, he finds she is very attractive and “dresses to the nines.” She is heart-broken, wants to come to counseling at least once a week, and can afford to come to counseling indefinitely. She is highly emotional, at times dramatic. How would this scenario be evaluated, considering the dimensions of power, duration, and termination?

47. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY Eleanor receives a request for services from a middle-aged male, who is a few years older than herself. He has been ordered to attend “anger management counseling,” which is a specialty of Eleanor’s. She provides an anger management program, which consists of 10 sessions, each of which is 1.5 hours long. This anger management “course” is expected to be completed in 3 months, since she allows a little flexibility for make-up sessions, if the client has a good reason for missing a session and does not reschedule more than twice. If she sees additional problems,she can recommend additional counseling and her recommendation is usually well respected by the court. How would this scenario be evaluated, considering the dimensions of power, duration, and termination?

48. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY Key Points 7. Counselors should consider contextual constraints. Determining the best course of action may be impacted by whether that counselor is working in a substance abuse treatment program, a residential treatment center for adolescents, a program for eating disorders, or an out-patient counseling practice. The course of action should be based on whether the “boundary crossing” is justified by your treatment protocol. Going to the cafeteria at an eating disorders residential program or having an ice cream cone with an eating disordered client may be justified: g0ing for ice cream to the local ice cream shop with a substance abuse client would not be.

49. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY • Your agency/office/treatment center may have explicit policies, developed to help counselors maintain clear boundaries. For example, the agency may have a policy that gifts become the property of the agency, rather than the counselor. • You must also consider other factors, such as state laws, cultural factors, community mores and situational factors come into play. If you are a female counselor working with male felons, hugging would seem inappropriate. • The client’s particular history and personality characteristics are relevant. Physical contact with a person who has a history of being sexual abused must be well thought-out.

50. BOUNDARY CROSSINGS & BOUNDARY VIOLATIONS IN THERAPY • The qualities of the therapeutic relationship and the counselor himself or herself are also of significance. • A hug may be appropriate for one client but not another: one client may have clear boundaries him/herself, while the other may not have clear boundaries, due to a history of abuse, exploitation, poor parenting, or blurred boundaries in his/her past experience.