Boundary Issues and Supervision
Lately, I have been asked to present numerous times on boundary violations by alcohol and drug abuse counselors. State ethics boards are reviewing cases involving counselors selling cocaine to patients, fraud in billing, changing diagnoses to allow payment for services and sexual violations with patients, among other accusations. We have been teaching classes on ethics for decades. Why, then, do we continue to have what seems to be an increasing number of claims against counselors? What are we not teaching? What needs to be done?
The following article addresses what, in my opinion, are the reasons why boundary violations seem to be escalating. First, we still are not providing adequate, quality clinical supervision to all counselors, especially "old timers." One myth we hold is that counselors with many years of experience "wouldn't do something like that." We also believe that education on the dos and don'ts of counseling and ethics is sufficient. We have failed to help counselors think through their behaviors prior to a violation occurring.
A boundary is a real or understood line in what is acceptable counselor behavior, what falls within their scope of practice and competency. A boundary crossing is a benign deviation from the standards of care that is done so in a way that is not harmful or exploitive to the client and advances therapy. An example of this is reaching out to catch a client who trips on your desk on the way out of a counseling session or picking up a client in your car and transporting him to a safe place when you see the client standing on the street corner in a snow blizzard, with no means of transport. Karl Menninger's classic axiom holds true in a boundary crossing: "When in doubt, be human." A boundary violation is a significant deviation from standards of care that likely is harmful or exploitive of the patient.
Where is the line between a boundary crossing and violation? Here are some clues:
- Is it a repetitive pattern for the counselor?
- To what extent is the behavior out of context or the culture in which counseling is provided? Or outside of the normal therapeutic frame?
- Time, place, purpose and intent are key indicators of a potential violation (sessions lasting longer for certain clients, sessions held after hours, contact between sessions, out of office contact, inappropriate self-disclosure).
- Therapy is adrift or repetitive.
- The client becomes a friend (we are to be friendly in therapy but not a friend).
- There are discrepancies between the counselor's behavior and the clinical record.
- The patient is treated as "special."
- Sexual fantasies about clients. It has been reported that 29 percent of counselors have very frequent sexual fantasies about clients; 26 percent have frequent sexual fantasies; and 46 percent on rare occasions.
Key areas of risk are: breaches of confidentiality; sexual misconduct between the counselor and the client (the #1 complaint heard by state ethics boards against clinicians); conflicts of interest; fraudulent or discrepant records; abrupt termination/abandonment of the client; and counselor impairment. (Why is it that substance abuse counseling may be one of the few professions that, in most states, does not have an "impaired professional" organization to assist troubled or impaired clinicians?) Negligent interventions are also an area of concern: high risk experiential techniques performed by inadequately or poorly trained clinicians.
What happens for clinicians that they think a boundary violation is appropriate? Some counselors have magical thinking, a rescue complex, believing they are the only one who can help a client. Some want to be admired and idolized by patients. Some use clients to work out their own life issues. Some need to be needed. But, most often, the problem is we have an "exception fantasy," the belief that "I'm different. I don't need to abide by that code."
There are unique concerns also for certain clients: those with a history of trauma or abuse; needy and highly dependent individuals; and manipulative clients who want to set a quid pro quo between themselves and the counselor ("I will disclose this if you disclose something about yourself"). Another area of creeping concern for clinical supervision ought to be the new frontiers of technology: email exchanges with clients, social networking sites, information available through the Internet and websites.
The following are risk management approaches for clinical supervisors to reduce the potential for boundary violations:
- Monitor performance through direct observation of the clinician. Quality clinical supervision is essential.
- Minimize the degree of contact between counselor and client by defining clearly the limits of counseling.
- Ask "cui bono," who benefits from this action? Is this in the client's interests? Does it enhance or detract from the therapeutic alliance?
- Is it documented?
- Watch for the warning signs of boundary crossings and violations.
- Help the counselor to identify the issues, conflicting values, duties, the impact on various stakeholders and possible alternative courses of action.
- Examine with the counselor the reasons for/against a particular action, including what is in the client's best interest, the ethical standards and agency policy and procedures
- Be clear, it is always the counselor's responsibility (not the client's) to set the boundary. And we do not blame the client if a boundary violation occurs. Boundary testing can lead to a boundary violation. On the other hand, boundary testing is an important part of counselor growth
It is important to broaden the question of boundary violations from a simple "don't ever do that." That's a simplistic, legalistic approach. Instead, we need to acknowledge there are times when there is intentional breaking of confidentiality, such as, duty to warn, mandated reporting, supervision and case management discussion, in billing, and misconduct by fellow clinicians. Other axioms are also important: touch should never be initiated by the counselor and we do nothing in the privacy of our office that we would feel uncomfortable doing in public. To feel attraction to a client is not unethical. It is unethical not to address these feelings and others in clinical supervision. Successful self-disclosure should lead to a lessening of the client's symptom distress and strengthen the therapeutic alliance. It is important to remember that more counselor self-disclosure does not necessarily lead to an in¬crease in client self-disclosure.
Finally, one of our little secrets is also the transference and counter-transference that can occur between the supervisor and their supervisees. This is another article in and of itself and unfortunately is rarely ever discussed in the literature.
My hope for this article is that counselors and supervisors can establish a safe, trusting environment wherein boundary issues can be discussed, before the clinician goes over the ethical slippery cliff.
See pg 12 for information on David's upcoming 30hr Clinical Supervision Certification webinar prenented by the Institute of chemical Dependency Studies (ICDS).
For further information, the reader is referred to Gutheil and Brodsky's Preventing Boundary Violations in Clinical Practice, 2008. Reprinted with permission from counselor magazine