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.