PROMOTING QUALITY PRACTICE

Practice Case Study – Maintaining Professional Boundaries

College of Occupational Therapists of Ontario
Winter 2002

Have you ever been uncertain about a request from a client? Managing boundaries in a client-therapist relationship demands constant attention. Imagine yourself in the following scenario:

An OT has had an ongoing therapeutic relationship with a client for the last year. The client has progressed well, nonetheless it is expected that therapy will continue for several more visits. During an OT visit, the client asks if the OT could come to see her perform a solo at her church; she thinks this will be a good way for the OT to see the accomplishments of her therapy.

What would you tell the client? What professional boundary issues does this scenario raise?

Professional Boundaries has been identified by the College as one of the key principles of occupational therapy practice in Ontario. The principle being that it is the therapist’s responsibility to establish and maintain professional boundaries with their clients. This principle is well supported in legislation (Regulated Health Professions Act, 1993), regulation (Professional Misconduct Regulation, 1993) and guidelines (Sexual Abuse Prevention Guidebook, 1996). More importantly perhaps, the public demands it. Client – therapist relationships are built on trust and integrity; any mismanagement of professional boundaries undermines these values and diminishes the professional relationship.

Managing professional boundaries is not a simple task– the boundary is not a clearly marked off territory. Boundaries are behaviours that show respect for individuality, privacy, personal space and time of another and one’s self. There is actually a continuum of behaviours to choose from, dependent on the person and situation. While the appropriate and inappropriate behaviour may be clear at either end, there is an area of practice in the middle that is gray and therefore more challenging to manage. In order to maintain a professional therapeutic relationship, therapists will find the following a useful guide: ensure all decisions and actions serve the client’s best interest, clearly separate and apart from the needs and interests of the therapist. It is also important to remember that the client’s best interest in a therapeutic relationship must be related to the purpose or need for occupational therapy services in the first place.

In the above scenario for example, it is important to consider the intent of the request and true value of attending this event. Does agreement to attend clearly serve the client’s best interest? Would the observations truly provide necessary information? Is it the only way to gather this information? While it may seem an appropriate method to evaluate the therapy, what if the therapist based the decision to attend on a personal interest to see how the client has progressed? In a situation where the therapist is unsure of the therapeutic value of a decision or action, asking a few questions may help. What would need to be recorded in the chart? How does this fit with the intervention plan? Will this be considered work or billable time? How would other therapists view the behaviour? If the answers to these questions suggest there is no clear link to the delivery of clinical services, then the behaviour or action likely isn’t necessary to serve the client’s best interest.

Another way to view this scenario is to consider that the client may see this as an opportunity to establish a friendship with the therapist. In that case, to support the request may seem to be in the client’s interest but actually creates confusion about the boundaries and in the long term does not serve the client well. Friendships are founded on supporting each other’s needs. Therapeutic relationships are not the same. To respond favorably to the above request may not seem unreasonable on its own, but if the client interprets it as a willingness to establish a friendship then she may pursue further activities to strengthen the friendship. Most likely it will reach a point when the client’s desire for friendship leads to requests that the therapist is not comfortable with. It will then be much more challenging to reestablish a therapeutic relationship. The client may also feel betrayed to learn the therapist does not want to be friends. In order to avoid this situation the therapist should maintain clear boundaries at the time of the initial request.

Boundaries are also difficult to manage if the therapist has a dual relationship with a client. In these situations, the ability to clearly define the therapeutic relationship and maintain a focus on the client’s best interest is blurred by the nature of the other relationship. Consider another scenario. A therapist has worked with a client to support their return to work. The client, having reestablished themselves in their job, suggests the therapist use their services. Maybe the client is an accountant, computer technician, interior decorator, or auto mechanic – providing any one of a variety of services that the therapist may need or want to access at some time. Is it appropriate to accept the offer?

The College advises against dual relationships. In these situations the boundaries become blurred and complicated. On one hand the therapist is the expert and in the power position; on the other, the therapist becomes the client. How does your position of power in one situation impact the other? How can you separate out your own needs from the needs of the client? In rare cases where dual relationships are unavoidable (such as rural areas where resources may be limited) then it is wise for the therapist to consider having a colleague help to “monitor” the relationship. From their objective perspective it may be easier to see the where the boundaries lie.

In any situation where therapists find themselves uncertain of the boundaries, it is advisable to rely on the objectivity that others bring to the situation. A therapist’s level of comfort sharing the scenario with someone else is another good guide for judging the appropriateness of the behaviour. If you are not comfortable sharing your actions with others or recording them in the chart, then you may well have crossed the line.