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This final track will examine four areas that require particular attention concerning the setting of constructive and clear boundaries: physical contact, pity, overidentification, and detrimental dependence.
Warmth vs. Professional Qualities.
Ethics - 4 Areas for Setting Constructive Clear Boundaries
Area # 1 - Physical Contact
Because touching is socially not condoned, but can be a very effective means of establishing rapport or showing understanding, the limits to physical contact in the mental health professional and client relationship deservedly have received attention. One of the most basic societal acknowledgments where therapists, in in-patient settings, depart dramatically from accepted social norms of physical contact is found in the legal foundations of informed consent. The legal concept of battery is based on society's deep prohibition against unconsented touching.
As you know, by giving informed consent the patient is saying, in effect, I give you and others involved in my care consent to stroke, rub, poke, or even puncture or cut me, depending on what you are licensed by society to do as a part of your professional procedures. You have experienced this if you have worked in an in-patient unit. If a person on the street attempted such activity with a stranger, he or she would end up in jail.
Obviously, the permission to make physical contact in an in-patient setting already puts the mental health professional and patient relationship into a special category where usual socially acceptable distances are breached on a regular basis. Informed consent is the contractual basis of the professional and patient relationship. Many cultural, social, and personal factors will come together to create a patient's comfort zone regarding physical contact and you naturally are guided by a sensitivity to individual differences.
Some types of physical contact are not deemed acceptable under any conditions, even with the consent of the patient. As you know, by law you cannot make contact with a patient with an intent to harm him or her physically or psychologically. If you do, you will be charged with sexual or other physical abuse. This boundary seems, at first, all too clear, but the following case studies will undoubtedly provoke some added thought on your part.
Sexual Touching and Not-So-Clear Boundaries
The strongest argument against this type of contact is that it betrays the reasonable expectations built into the essence of the client relationship. Patients have a right to receive the best care possible without having to satisfy the professional's needs. Shades of "meeting the professional's needs" have been discussed earlier in this CD set.
Let's look into a not-so-clear boundary area. How does this relate to sexual harassment laws? The importance of the idea that sexual distance must be maintained is being aired today in the notion of "sexual harassment." As you know, the United States Equal Employment Opportunity Commission (EEOC) defines harassment as unwelcome sexual advances, requests for sexual favors, other verbal or physical conduct, and even activity that creates a hostile or unwelcome work environment for the person who feels "harassed." At the heart of the discussion is the degree of distance and quality of exchanges that must be maintained for respect to be expressed.
As you know, in interactions with the client, the therapist who has become enmeshed often develops an emotional connection with, or an emotional availability, to his or her client. This can ultimately lead to client feelings of anger or emotional pain and to a sense of abandonment once the therapy ends. The process of enmeshment may also complicate provision of adequate care at a later time. In an in-patient situation, for example, this can occur if the patient sees the other care team members as not caring sufficiently or as providing inadequate care, in comparison with the therapist who is enmeshed.
In these moments a "self-conscious distance zone" should be created to enable each to gain or regain perspective. Underlying the problems created in these situations are the dynamics of what exactly is detrimental.
Area # 2 - Pity
However, as I'm sure you have experienced, it is not at all unnatural for mental health professionals to become periodically so involved in patient's dilemmas that we take these problems home with us. Almost any mental health professional can recall the time he or she had trouble falling asleep or was moved to tears or laughter by a sudden tragic or joyful announcement touching a client's life. There is, however, as you know, a significant difference between this depth of caring, which stimulates a purely human response, and fruitless or destructive enmeshment. The problem can be illustrated with the following case of a client of mine.
Ethics Case Study: Michael
Craig Hopkins, a health care student in the practicum portion of his education, is also 29 years old. His similarity to Michael Anderson, however, ends there. Craig Hopkins grew up in an upper-middle-class home and served as an officer in the Marines. He has never had close contact with an addict before, but he finds Michael very warm and human during his initial interactions. Michael is admitted to the detoxification unit where he will spend the next week or so. They both chat when Craig has a few minutes, and, over the next few days, Craig arrives at the conclusion that Michael has had more than his share of misfortune.
The next day, when Craig goes into Michael's room, he finds Michael doubled up, writhing in agony. With a trembling voice, Michael tells him that the doctor has not given him anything to take the edge off his withdrawal from alcohol. To Craig's surprise, Michael grabs him by the wrist and pleads, "Please, please, I can't stand this agony. If you will just get me something to drink, just enough to make it over the hump, I swear I'll never touch another drop. If I can't get a little relief, I will kill myself. The doctor is a sadist."
tears himself away and leaves the room. That night, however, he cannot sleep.
He is haunted by the pictures of Michael. Craig sees clearly the beads of sweat that clung to Michael's face as he spoke; he thinks that Michael is clearly all
alone in the world; he is angry at Michael's physician for not making detox a
little easier for Michael.
Craig remembers Michael's pleading eyes the day before and is overcome with a desire to make a sharp retort to the nurse's statements. He goes instead to Michael's room and slips a half pint of whiskey into the drawer of the bedside stand and makes enough noise so that Michael stirs from his tortured sleep and sees what he is doing. He is not sure why he does this, but he quickly turns and leaves.
What do you think about Craig's conduct? He has reached the point where he is responding impulsively rather than with genuine caring because the situation is so painful to him. Such a feeling exceeds sympathy and is more closely related to pity. Because pity distorts the objective perspective necessary to resolve the real problem, he ceases to be of help. In fact, he may include himself among the patient's many problems.
As you know, the boundary of pity can be communicated to the patient in one meeting as well as over a period of time. Facial expression can instantly convey one's feelings. Quick nervous movements, coupled with a sudden departure, are sometimes correctly interpreted as expressions of pity. The desire not to talk about the patient's problem, and trite comments such as, "It'll be fine, I'm sure," can also be interpreted to mean "Poor, poor you."
you are well aware, you cannot solve this type of problem arising from pity simply
by enmeshing yourself more deeply into the patient's personal life. Of course,
your pity is in response to a real need of a client or patient. I am sure that
you have found like I, what is called for is sympathetic acknowledgment of the
person's dilemma. However, at the same time you need to establish clarity that
your professional role sets boundaries on what you will be able to do to intervene
constructively in his or her plight.
The patient may so remind you of someone else that the patient becomes that person, or you may have had an experience so similar to the patient's that you believe your experiences to be identical. In all three instances such a reaction is called Overidentification and is another variety of enmeshment. Because elsewhere we have discussed dynamics present in stereotyping and countertransference, we will now concentrate our discussion on the third type of situation.
At first, it seems counterintuitive that having had similar experiences may actually hinder the effectiveness of health professional and patient interaction at times. Everyone has had the experience of beginning to relate a traumatic, or exciting, event only to have the other person interrupt with, "Oh! I know exactly what you mean!" and then go on to describe his or her own story. As you know, one feels cheated at such times, thinking, "No, that's not what I meant, but you are more interested in telling me about yourself than in listening to me!" The way such overidentification works within the mental health professions can be illustrated with a client of mine named l Grace.
Ethics Case Study: Grace
The embarrassed mother replied, "Well, since you asked, I'll give you a direct answer. I don't feel this way, but some of the mothers think that you don't understand their children's difficulties because every time they start to tell you something about their children, you immediately interrupt with an experience that your child had."
In short, overidentification leads to the boundary challenge of an "I-know-how-you-feel" reaction that can be helpful or can convince your client of the complete opposite. The therapist who is astute enough to discern that he or she may be overidentifying will also be able to see that attempts to become close to the patient by pointing out superficial similarities between their experiences are being interpreted by the patient as the therapist's desire to talk about his or her own problem.
As mentioned earlier, overidentification is very basic boundary, but perhaps one you need to reevaluate concerning clients you are currently treating. You should not be falsely led to believe that a closeness has been established. A technique to establish a clear boundary here is to maintain greater distance until the uniqueness of your client emerges.
Area # 4 - Detrimental
We identify some signs that affection, a positive component of the relationship, has spilled over into enmeshment and make some general suggestions about what can be done to rectify the situation to set a clear boundary. Obviously, affection is more likely to develop in situations where an ongoing relationship exists. One example of how a problematic dynamic of setting clear boundaries can arise is illustrated in a client I treated -- Jason, a paraplegic.
Ethics Case Study: Jason
day he tearfully tells Morgan, a health professions student who has been treating
him, that he is depressed and desperately lonely. Up to this point, their interaction
has been full of banter and they have felt quite comfortable with each other.
Morgan does not divulge to the rest of the staff Jason's expression of depression
and loneliness, but that night on the way home, she stops by his room to see him.
As you can well see, Jason's reaction indicates that he feels she has betrayed their relationship and rejected him. He has now reached the point where leaving her to go to his own home will mean relinquishing an immediate enjoyment and, perhaps, someone he thought was a friend. Morgan, who acted in good faith on her feelings of warmth and affection for Jason, has thus unwittingly fostered detrimental, rather than constructive, dependence. Her subsequent attempts to explain her sudden withdrawal may have profound, lasting effects on Jason. Instead of being a friend and confidant, as he had hoped, she will become just another of a long line of rejections he has experienced. He has relied on her more than she had intended or was able to manage.
For you to assess the warning signs of detrimental dependence, periodic reexamination of your own motives and conduct, or colleague's assessment of your relationship, can help, too. To maintain appropriate professional distance and clear boundaries, a rule of thumb as you know is, temper your warmth and affection with awareness that the other person's needs and wishes may exceed or differ from your own. A clear boundary checking technique I use is periodic reflection regarding the conduct I am observing from my client.
- Stone, M. PhD, Boundary Violations between Therapist and Patient. Psychiatric Annals, 1999, 670-7.
With that in mind, now that we have explored numerous areas of setting ethical boundaries with clients on these two CDs, is there one area that stands out in your mind as a possible red flag for you? Think of the boundaries you are setting regarding your : Attitudes; Personal Needs; Defense Mechanisms; Security vs. Growth; Setting Boundaries with Tempo; Nonverbal Communication; Acceptance that leads to Expectation; Self-Determination; Friendship versus Partnership; Counter Transference; Judgments; Focus; Partialization; Advice Giving; Promises; Confrontation; Manipulation; and Referrals.
If you feel you are in danger of violating an ethical boundary with a client or are currently violating a boundary, how can you change the situation? If you feel you cannot change the situation, what would be an appropriate referral?
In conclusion, the purpose of this course has been to assist you in increasing your self awareness regarding setting ethical boundaries with clients. As I stated at the beginning, you get out of this content what you put into it. I challenged you to remold, reshape, and reexamine the information presented to find the piece of information that will be of value to you for current or future reference.
It is our hope that this learning experience will prove to be a valuable one for you and you received information that enhances your professional skills,
is Brian Clark. I'll talk to you again in another home study course. Thank you.
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