• Definitions
• Overview of the Standards for Professional Boundaries
• Standard 1 Foster Therapeutic Relationships
• Standard 2 Assume Full Responsibility
• Standard 3 Anticipate, Identify and Manage Vulnerabilities
• Standard 4 Be Aware of Changes in the Therapeutic Relationship
• Standard 5 Self-Monitor and Reflect
• Standard 6 Understand that Client Consent is Never a Defense
• Standard 7 Address and Manage Boundary Violations
• Standard 8 Avoid Providing Service to Family, Partners or People You Know Personally
• Standard 9 Avoid Non-Professional Relationships with Current Clients
• Standard 10 Avoid Personal Relationships with Former Clients
• Standard 11 Maintain Professional Boundaries with Students and Subordinates
• Practice Examples

The purpose of this document is to ensure that occupational therapists (OTs) in Ontario are aware of the minimum expectations for maintaining professional boundaries.

OTs have a relationship of trust with their clients. Due to the OT’s position of authority and professional knowledge related to the client’s health status, vulnerability, unique circumstances and personal history, the client-therapist relationship has a power imbalance in favour of the OT. Power is also associated with the OT’s ability to influence a client’s access to care or services. A client’s desire to improve his or her health results in trust being established much more quickly and completely than might occur otherwise. If the OT uses this position of power or takes advantage of client’s vulnerability, it is an abuse of power, whether done consciously or unconsciously.

This Standard outlines the expectations of conduct in the OT-client relationship that specifically relate to the preservation of appropriate boundaries between OT and client. OTs are advised to consult the Code of Ethics (2011), Guide to the Code of Ethics (2012), Standards for the Prevention of Sexual Abuse (2013), Standards for the Prevention and Management of Conflict of Interest (2012) and Conscious Decision-Making in Occupational Therapy (2012) for additional guidance on College expectations for professional client-therapist relationships.

OTs are required to use their professional judgement to prevent boundary issues from arising and to establish and manage boundaries in a wide variety of circumstances. OTs should undertake active and ongoing self-monitoring in therapeutic interactions or interpersonal relationships with clients to ensure appropriate boundaries are maintained.

OTs are responsible for anticipating boundary issues that exist with their client, as well as setting and managing boundaries relating to personal dignity, privacy, control and professional detachment to ensure that the trust a client has placed in the OT is not betrayed. In identifying and setting boundaries, OTs need to work to ensure that client goals will be reached and their words and actions will not be misinterpreted by the client. In order to maintain healthy, trusting professional relationships, OTs must ensure their own competence, integrity and dependability with respect to identifying risk for potential boundary violations by establishing and maintaining appropriate professional boundaries on an ongoing basis, and managing violations should they occur.

The effective maintenance of boundaries between the client and the OT is a continuous process. Boundary violations do not always occur at a single point in time. They can be the cumulative outcome of boundary crossings over a period of time. A boundary crossing may be a subtle event in which the professional either initiates or allows the client conduct in which there may be a temporary excursion across appropriate professional lines. A single boundary crossing may constitute a professional impropriety without immediate harm to the client.

A boundary crossing or a series of boundary crossings may lead to a boundary violation. A boundary violation is an overt change in the nature of the client/professional relationship from professional to personal. A client/professional relationship that moves to a personal relationship constitutes a boundary violation, which ultimately may subject the client to harm.

The topic of professional boundaries applies to many issues such as sexual relations, financial dealings, social interactions, conflicts of interest, differences in values, and breaches of confidentiality. Boundaries differ from circumstance to circumstance and require more than just management by the OT when they occur. Anticipation and ongoing self-monitoring is a means of preventing the development of boundary issues.

An arm around the shoulder or a hug may mean very different things to a grieving client, an elderly client, a young child or a single professional. Refusal of a gift may be appropriate as a general rule, but in some cultures it can be viewed as an insult. Boundary issues involve the OT’s anticipation of, and respect for, the diversity of beliefs, values and interests possessed by clients. These issues also call for reflective insight into intended and unintended interpretations of interpersonal relationships, words, or gestures during interactions with clients.

The onus is on the OT to recognize issues of power and control, to maintain professional boundaries and to practice in a manner that establishes and preserves the client’s trust. OTs, through client-centred practice, can work to minimize the power differential; however, it should be acknowledged that the power does exist.

The consent of a client is never a defence for a boundary violation.

Attending to the possibility of boundary crossings or violations does not mean that the OT is no longer able to demonstrate care in the therapeutic relationship. This relationship requires a combination of comprehensive care and therapeutic rapport. Indeed, in the context of sexual abuse, the Procedural Code of the Regulated Health Professions Act, 1991 (RHPA) recognizes that while sexual abuse of a client is not permitted, “…touching, behaviour or remarks of a clinical nature appropriate to the service provided…” are integral to the therapeutic relationship. In therapeutic relationships, health professionals must stay alert to inappropriate behaviours during interactions with clients, and to client responses that might compromise the integrity of the therapeutic relationship in the present or the future. The sole responsibility for managing client trust rests with the OT. In appropriately managing client trust, the OT serves to protect the client, further validating that a caring relationship exists.

Given the potential complexities of the client-therapist relationship, OTs are advised to contact the College when they are uncertain about the expectations and/or the application of these Standards in the specific context of their practice setting.

OTs must also be aware that expectations regarding professional boundaries extend beyond the client-therapist relationship. OTs should apply the principles of professional boundaries in all circumstances where they are in a position of power which may occur, for example, when an OT assumes a supervisory relationship over a workplace colleague or student.

• The following Standards describe the minimum expectation for OTs.
• The performance indicators listed below each standard describe specific behaviours that demonstrate the Standard has been met.
• It is not expected that all performance indicators will be evident at all times. It is expected that performance indicators could be demonstrated if requested.
• There may be some situations where the OT determines that a particular performance indicator has less relevance due to client or environmental factors. Such situations may call for the OT to seek further clarification.
• It is expected that OTs will always use their clinical judgement to determine how to best meet client needs in accordance with the Standards of the profession.
• It is expected that OTs will be able to provide reasonable rationale for any variations from the Standard.

College publications contain practice parameters and standards which should be considered by all Ontario OTs in the care of their clients and in the practice of the profession. College publications are developed in consultation with OTs and describe current professional expectations. It is important to note that these College publications may be used by the College or other bodies in determining whether appropriate standards of practice and professional responsibilities have been maintained.

Pursuant to the RHPA, the College is authorized to make regulations in relation to professional practice. The College’s Professional Misconduct Regulation establishes that “contravening, by act or omission, a standard of practice of the profession or failing to maintain a standard of the profession,” constitutes grounds for professional misconduct.

This Standard represents the College’s interpretation and expectations and does not supersede the provisions contained in legislation.

What is a professional boundary?
A boundary is the implicit or explicit demarcation separating the professional relationship with a client from one that is personal.

What is professional boundary crossing?
A boundary is crossed when an OT initiates a behaviour or allows a behaviour to persist in a relationship that compromises, or sets a future course that compromises, the OT’s relationship with his or her client. The potential for boundary crossings relates directly to the client’s position of vulnerability in the therapeutic relationship. When a boundary crossing occurs, the relationship can become unbalanced and destabilized in favour of the OT.

What is a professional boundary violation?
A boundary violation occurs when the nature of the therapeutic relationship moves from professional to personal.

What is Transference? 

Transference is generally defined as the set of expectations, beliefs, and emotional responses that a client brings to the therapist-client relationship. Transference reflects past experiences a client has had with important authority figures such as a parent. Transference involves how those experiences influence the client’s relationship with his or her OT, for example, whether the client likes, idealizes, feels attracted to, or feels irritated or angry towards the OT.

 

What is Countertransference? 

Just as clients transfer attitudes to the therapeutic relationship, OTs themselves may experience countertransference. Countertransference is the emotional reaction of the OT to the client’s attitudes.  Countertransference may take the form of negative feelings that are disruptive to the client-therapist relationship but may also encompass disproportionately positive, idealizing or even eroticized reactions.  Client and therapist expectations, conscious or unconscious, may be influenced by transference and countertransference.

Standard 1.		Foster Therapeutic Relationships
Standard 2.		Assume Full Responsibility
Standard 3.		Anticipate, Identify and Manage Vulnerabilities
Standard 4.		Be Aware of Changes in the Therapeutic Relationship
Standard 5.		Self-Monitor and Reflect
Standard 6.		Understand that Client Consent is Never a Defence
Standard 7.		Address and Manage Boundary Violations
Standard 8.		Avoid Providing Service to Family, Partners or People You Know Personally
Standard 9.		Avoid Non-Professional Relationships with Current Clients
Standard 10.		Avoid Personal Relationships with Former Clients
Standard 11.		Maintain Professional Boundaries with Students and Subordinates

Safe, ethical, and effective occupational therapy service delivery requires an OT to establish a therapeutic relationship with clients. Therapeutic relationships enable a therapist to establish rapport and trust with clients. To maintain appropriate relationships and boundaries with clients, an OT is expected to be sensitive to the power imbalance inherent in the relationship, understand the impact of the client’s and his or her own values and beliefs on practice and demonstrate sensitivity to diversity.

Standard 1

The OT will foster therapeutic relationships with clients in a transparent, ethical, client-centred manner with respect for diversity of beliefs, uniqueness, values and interests.

      Performance Indicators

OTs are expected to assume responsibility for proactively determining the possible risks for boundary violations within the context of their practice. This is what is meant by anticipating what boundaries will be necessary to be established.  At times a boundary crossing will occur that is, an OT may move into behavioural territory that if continued, could lead to a boundary violation. OTs are expected to recognize these boundary crossings that may occur for therapeutic reasons, but, at the same time, to take care to ensure that a temporary boundary crossing does not progress to become a boundary violation.

Standard 2
The OT will assume full responsibility for anticipating, establishing and maintaining appropriate boundaries with clients at all times.

      Performance Indicators

In relation to the topic of professional boundaries, the theory of transference and countertransference is an important consideration. Transference and countertransference are unconscious processes that are inherent aspects of the way we relate to others. Individuals cannot necessarily control the presence of these feelings until they are aware of them. Once aware, individuals can control the attitudes and behaviours they display in response to these feelings and emotions. For example, a therapist may not understand why he or she has a strong like or dislike for a client, but can recognize that it would not be appropriate to convey these feelings to a client or to act on them. It is important that OTs are consciously aware of these feelings and emotions and reflect on what may be the result of transference/countertransference and what response may be warranted to the situation. Conscious awareness will assist OTs to manage these feelings and not act on inappropriate emotions, thereby preventing a possible boundary violation.

Standard 3
The OT will understand the causes and effects of transference and countertransference and will anticipate, identify and manage them as they relate to either conscious or unconscious vulnerabilities in the therapeutic relationship.

      Performance Indicators

OTs develop therapeutic relationships with their clients and these relationships are influenced by factors within either the client’s or the therapist’s environment. There can be changes in circumstances of the client or the OT that may create an increased risk of boundary crossings and violations. OTs should be alert to changes in their relationships with clients that may signal a change or create an increased risk of boundary issues and manage these changes effectively.

Standard 4
The OT will be aware of changes in a therapeutic relationship that might raise boundary issues that were not previously present.

      Performance Indicators

In accordance with the Essential Competencies of Practice for OTs in Canada, OTs are expected to engage in reflection and evaluation and to integrate findings from these processes into practice. Actively engaging in reflective practice enables OTs to be consciously aware of any changes to the nature of interactions with clients or warning signs that might indicate an actual or potential boundary crossing or violation. OTs should consider whether any of their actions exceed the limits of what is professionally required or appropriate and proactively manage any boundary issues.

Standard 5
The OT will actively self-monitor and reflect on his or her actions in, and responses to, the therapeutic relationship.

      Performance Indicators

OTs are expected to establish and maintain the therapeutic relationship. Given the inherent power imbalance in the client-therapist relationship and the vulnerability of many occupational therapy clients, OTs are accountable for, and have a duty to maintain, professional boundaries. An OT’s accountability to maintain the therapeutic relationship does not change in relation to the willingness, desire or consent of a client to participate in a boundary crossing or violation.

Standard 6
The OT will assume full responsibility for anticipating, establishing and maintaining appropriate boundaries with clients at all times.

      Performance Indicators

As autonomous health professionals, OTs are expected to demonstrate sound professional judgement and clinical reasoning in decision-making and to accept responsibility for their actions and decisions. Should an OT identify that a boundary violation has occurred the OT is required to take the necessary actions to appropriately manage the violation. Depending on the nature of the violation, actions may include, but are not limited to, discontinuation of service or a mandatory report to the College.

Standard 7
The OT will address and manage a boundary violation should it occur.

      Performance Indicators

OTs engage in many different personal and professional roles and relationships in their day-to-day lives. The nature of appropriate boundaries established for personal and professional relationships varies significantly. Preventing professional boundary violations may not be possible where the established boundaries of a pre-existing personal relationship with a potential client exceed that of a therapeutic relationship. Simultaneously engaging in a dual personal and professional relationship with a client increases the risk of professional boundary violations and conflicts of interest and creates challenges for establishing clear expectations for occupational therapy service delivery.

Standard 8
The OT will avoid providing occupational therapy services to his or her family member or partner, or to individuals they know personally where professional boundaries may not be sustainable.

      Performance Indicators

OTs are in a position of authority over their clients. This authority or power imbalance arises from the knowledge OTs have regarding the clients’ health status, the client’s dependence on the professional knowledge, skill and judgement of the OT, and the decision-making authority of the OT regarding treatment plans. This power imbalance places the client in a vulnerable position in the therapeutic relationship. OTs are expected to be aware of this inherent imbalance and ensure that professional boundaries are maintained to protect the best interests of the client and keep the client safe. Professional boundaries cannot be appropriately maintained if a non-professional relationship is established.

Standard 9
The OT will avoid non-professional relationships with current clients.

      Performance Indicators

OTs must apply professional judgement when considering the appropriateness of a entering into a personal relationship with a former client. Reflecting on the nature of the therapeutic relationship and the occupational therapy service delivery is essential. For example, an OT may have briefly interacted with a former client on a single occasion or been intensively involved with a former client over several years. In determining whether a relationship with a former client is appropriate, an OT must consider how much influence the previous therapeutic relationship had on the client, whether there is any remaining dependence on the therapist and whether a reasonable amount of time has passed since the therapeutic relationship ended. College Standards discourage personal relationships with former clients unless the OT is confident that all ethical considerations have been appropriately addressed and client best interest and safety is not jeopardized. In some circumstances, it is not appropriate to develop a personal relationship with a former client at any time, for example, following a significant course of psychotherapy with a client.

Standard 10
The OT will avoid personal relationships with former clients, unless it can be reasonably established that sufficient time has passed since the professional relationship ended and the OT can demonstrate that the client is no longer dependent on the OT.

      Performance Indicators

OTs form associations with many professionals and non-professionals in the course of practice. Professional boundaries are also required with those with whom the OT works. OTs have a position of power over students and subordinates. This should be recognized by the therapist to prevent abuse or misuse of this power. Professional boundaries may also be required with some colleagues to prevent situations of conflict of interest. OTs are expected to reflect on their relationships with their students, subordinates and colleagues to ensure their position of power does not lead to misuse or abuse, client care is not compromised, and situations of conflict of interest are prevented.

Standard 11
The OT will apply the principles set out in this Standard to relationships with students and subordinates.

      Performance Indicators

    Example One

An OT works in a long term-care facility and is planning to attend the facility’s barbeque, meant for clients and their families, to support the clients and help during the barbeque. The OT does not have a babysitter to watch her children on the day of the event. The OT is exploring the option of bringing her children to the barbeque. Considering the performance indicators from the Standards for Professional Boundaries, what should the therapist consider prior to deciding to bring her children to the event?

Discussion:

According to the College Standards for Professional Boundaries, “An OT will foster therapeutic relationships with his or her clients in a transparent, ethical, client-centered manner with respect for diversity of beliefs, uniqueness, values and interests.” In this scenario, the OT should consider performance indicator 1.4, “An OT will recognize his/her own personal needs and values as they impact on the professional-client relationship due to the authority vested in the therapist”, and 1.5, “Identify the appropriate boundaries of therapeutic relationships with clients”. The therapist is crossing professional boundaries when mixing personal and professional obligations. The barbeque is meant to benefit the clients, and the therapist is expected to identify her own personal gain or benefit that would result from bringing her children to the barbeque. In this case, the therapist would experience personal gain from sharing her personal experiences about her children with the clients and by eliminating the financial burden and stress of obtaining a babysitter for that day. The OT should also consider performance indicator 5.2, “An OT will avoid inappropriate disclosure of his/her own personal information or emotional concerns to the client”. The OT is expected to avoid inappropriate disclosure of his/her own personal information with the clients.

In addition, Standard 9, “The OT will avoid non-professional relationships with current clients” applies to this situation as bringing one’s children to a barbeque that requires a professional relationship to be maintained with clients, may lead to a boundary violation. When a therapist invites family members to a client-focused event, that therapist blurs the lines between personal and professional relationships. Clients may perceive the existence of a personal relationship The OT may initiate the perception of a personal relationship by clients that sets a future course that compromises their professional relationship, and eventually leads to a boundary violation where the nature of the therapeutic relationship moves from being professional to also personal.

Example Two

An OT works for an auto insurance company where he provides assessment reports to clients and the insurance adjuster. During one of his assessments for a client who was involved in a motor vehicle accident, he was engaged in a conversation about hockey with the client. During this conversation, the therapist expressed regret at his inability to obtain hockey tickets due to other financial priorities. Following the OT’s submission of the assessment report to both the client and the insurance adjustor, the client sends hockey tickets to the therapist with a thank you letter expressing his appreciation for the thorough assessment. What must the OT consider in order to meet the Standards in relation to maintaining professional boundaries?

Discussion:

According to the Standards for Professional Boundaries, “The OT will assume full responsibility for anticipating, establishing and maintaining appropriate boundaries with clients at all times.” An OT in this case would be expected to identify any possible risks whereby boundaries could be breached or perceived to be breached. Performance indicator 2.4(a) states that “An OT will demonstrate that practices and procedures have been established in his or her practice regarding attempts to solicit, encouragement of, or receipt/exchange of gift giving by clients”. Whether or not the gift was sent before or after the assessment report was submitted by the therapist to both client and insurance adjustor, this situation presents a conflict of interest. The OT should refuse the gift as per College Standards as the gift may be an attempt to influence care the client receives, especially in this context where an insurance adjustor is involved.

There is always a risk that communication or actions by a professional could be misinterpreted. In this case, the conversation about hockey inadvertently solicits hockey tickets from the client. Setting appropriate boundaries and using clear, professional communication is especially important with clients. While establishing rapport with clients is a natural process for OTs, therapists need to pay extra attention to the messages they may consciously or unconsciously send when they communicate with clients.

In rare instances, the refusal of a gift will offend the client and harm the therapeutic relationship, e.g., cultural beliefs of the client are affected. Consider a client who offers a therapist a small gift during a home visit as a gesture of appreciation. The client may be from a culture where offering gifts is the only way to secure health care. In situations like this, prior to accepting the gift, the OT would refer to agency policies, ensure that he/she has not solicited the gift in any manner, consider the capacity of the client, and if the gift is a method to ensure personal gain or benefit on behalf of the client. If the therapist decides to accept the gift after all considerations, then he/she should convey that such gestures are not necessary, and that the best offering is knowing whether or not the client is satisfied with the care that is being provided.

OTs can manage these situations by setting clear policies about accepting gifts from clients, and convey these policies to clients either when gifts are offered, or in their organization’s communication materials as a proactive measure. Some people may feel personally rejected when a professional rejects their gifts. The refusal of a gift can always include an expression of appreciation for the thought of the gift, and explanation that the refusal of the gift is for the best interest of the therapist-client relationship.

For additional examples and practice scenarios refer to the PREP Module entitled Professional Boundaries: Defining the Lines (2010).

Legislative References:

Regulated Health Professions Act, 1991 and Schedule 2, the Health Professions Procedural Code.

Professional Misconduct Regulation, 2007 made under the Occupational Therapy Act, 1991

College References:

College of Occupational Therapists of Ontario (2010). PREP Module: Professional Boundaries – Defining the Lines. Toronto, ON.

College of Occupational Therapists of Ontario (2011). Code of Ethics. Toronto, ON.

College of Occupational Therapists of Ontario (2012). Guide to the Code of Ethics. Toronto, ON
.
College of Occupational Therapists of Ontario (2012). Conscious Decision-Making in Occupational Therapy Practice. Toronto, ON.

College of Occupational Therapists of Ontario (2012). Standards for the Prevention and Management of Conflict of Interest. Toronto, ON.

College of Occupational Therapists of Ontario (2013) Standards for the Prevention of Sexual Abuse. Toronto, ON.

Other References:

Kaplan H.I., & Sadock, B.J. (1998) Synopsis of psychiatry – Behaviour sciences/clinical Psychiatry (8th ed.) (pp. 6-8).. Baltimore: Williams & Wilkins. 6-8.

Townsend, E.A. & Polatajko, H.J. (2007). Enabling occupation II: Advancing an occupational therapy vision for health, well-being & justice through occupation. Canadian Association of OTs.