Boundary Management for Social Work Practice

SW 606 / Pugh

Framing Boundaries:

I. Ethics From & For Practice

Focus on the actual practice environment and the professional/therapeutic relationship. This is where most mistakes are made.

Boundary Issues in Social

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Definitions:

The Boundary: the grey area between helpful, professional, role-defined behavior, and those behaviors that are detrimental to the client(s), the provider, the profession, and other agency staff. A fluctuating safe space3 Boundaries are regions that separate social systems; they are comprised of spoken and unspoken rules that clients and providers observe about the physical and emotional limits of their relationship.4,5 Significantly influenced by cultural norms and standards.
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Definitions, cont.

Boundaries are a central concept of identity, pertaining to the implicit rules that determine how people are expected to relate to one another in a given culture. Healthy social functioning largely entails clear, consistent, culturally appropriate boundaries. Dysfunctional social behavior is seen when boundaries are inappropriate or not consistently clear.6
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Definitions, cont.

Boundary Setting: The behavior by the professional to prevent boundary errors and violations, to prevent inappropriate behavior by the client, to prevent errors in treatment, conflicts in care, staff stress, and workplace violence. In addition to preventing problems, boundary setting also supports therapeutic intervention, and personal growth and change through modeling.
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Definitions, cont.

Regardless of the setting, it is the professionals responsibility to maintain healthy boundaries.7

Boundary Setting does not mean a rigidly imposed distance between the professional and the client, but a collaborative, mutually acknowledged and negotiated element of the therapeutic relationship. Authenticity and empathy are part of this "safe connection."21
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Definitions, cont.

Boundary Violations: The area of behavior outside of culturally and professionally defined roles, regulations, expectations, ethical obligations, and the standard of care. Boundary Error: an oopsy. Often results from an attempted crossing, often becomes a violation (runaway train) Maintaining more than one relationship with a client is a boundary violation.
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Definitions, cont.

Boundary Crossing: Crossings by trained professionals can be helpful in a therapeutic setting. Crossings are a difficult skill to master and should only be attempted by those with sufficient training, education and experience, and even then should be avoided. Boundary crossings are NOT a necessary skill or element for effective practice.

Definitions, cont.

Boundary violations are harmful, even if they were attempted crossings. The harm involved in boundary crossings lies in their effects (as interpreted by the client and/or client system), and you are accountable for all actions, intentional or otherwise, that are detrimental to clients. 21

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The Elephant in the Room

Just by starting with definitions, you are all likely thinking about your own experiences:

Reviewing your own recent behavior, and perhaps becoming a bit defensive. This is part of the defense mechanisms found in the literature (and repeatedly demonstrated in these seminars).

They typically sound like this:

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Defense Mechanism Responses:

I want to say that

it was the clients fault. If they hadnt been so __________, this wouldnt have happened. you just dont understand. This kind of work/situation is so special/ complex that this is not a boundary violation, its allowed/expected. it really isnt that big a deal. Nothing bad happened and it wont make a difference in my work/relationship with the client. I meant well. My intentions were good.

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Why are Boundaries Necessary?

To protect clients from harm. The client-provider relationship is NOT a primary relationship. It is a professional relationship with a limited focus on specific personal areas of the clients life for which they have come to us for help. This limited relationship contrasts with the broad primary relationships most people treasure, such as family, significant others, and long-term friendships. Problems occur because may clients misunderstand friendliness and informality during their contacts with providers.8
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The Power Differential

Social workers do not like to acknowledge the fact that the professional relationship involves power.23 This inequality is where the danger lies.21

This can be minimized by including discussions of power and boundaries as part of the therapeutic process. The goal is an authentic, collaborative, and clearly mutually defined relationship with a specific and time-limited therapeutic objective.
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Other Reasons for Boundaries:

To ensure consistent, high-quality care. To support the therapeutic environment. Clinical work is a more complex process that other interventions with especially difficult boundary issues and challenges.5

Clients need us to model and demonstrate9

The NASW COE is a contract with the profession about your ethical obligations. When used consistently, boundaries are great for dealing with difficult clients.
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Difficult Clients

Personality Disorders:

There are 11 different types listed in the DSM-IV, each a little different depending on the dominant trait of the disorder. In general, they are characterized by deeply ingrained and maladaptive patterns of relating to others, impulsive and unpredictable behavior that is often self-destructive, lack of control over anger, intense mood shifts, identity disturbance and inconsistent self-concept, manipulation of others for short-term gain, and chronic feelings of boredom and emptiness.5,10
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Case Studies

Small group discussion of the case studies

What would you do?

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Examples of Boundary Violations:

A.

Intimate gestures: giving or receiving gifts, favors, notes, cards; non-work-related content during phone calls or emails; any calls, emails, or mail outside of work. -physical contact -suggestive behavior/language -sexual relationships with others through the client -sexual relationship with the client -special treatment of any kind
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Examples, cont.
B.

C.

Emotional or Dependent Gestures: -self-disclosure (giving out personal information) -affectionate communications -friendship, community contact -special treatment of any kind. Personal Gains: -monetary gain; business or financial relationships; barter of goods or services, trading or swapping personal property; advice and/or services; favors, gifts, meals; conflict of interest; Altruism
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Examples, cont.
D.

Accidental / Unavoidable: -geographic proximity -cultural, social, ethnic communities -professional encounters -social encounters (community/family)

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Special Notes on Self-Disclosure

Good intentions are misinterpreted by clients Self-disclosure draws us into a new relationship, distorting the original therapeutic alliance and compromising effectiveness11 Most frequent violation found in cases that led to a sexual relationship12,13,14 Used as evidence of alleged misconduct15

Interestingly, in some research it has been found that clients themselves are worried about boundaries, especially inappropriate provider self-disclosure!22
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Why We Violate Boundaries:

Ethical Mistakes: 1. Situational error / Crossings (oopsy 1) 2. Naivet (oopsy 2) B. Deliberate Ethical Decisions (just the wrong one): -situational error; misinformation; insufficient information; insufficient training, practice, supervision; acting outside your roles/responsibilities; inaction c. Gross Misconduct. (not an oopsy)
A.
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Sources of Provider

7 Errors

Personal, financial or medical life crises Idealization of a special client and an inability to set limits with them Denial of the possibility of boundary problems

It wont happen to me

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A Natural History of Boundary Violations16

1. Gradual erosions of neutrality on both sides 2. Violations begin in the empty spaces 3. More socialization of time 4. Disclosure about other clients (the special relationship begins 5. Self-disclosure begins 6. Physical contact begins 7. Professional has more control in the relationship 8. Client becomes more dependent upon relationship 9. External contacts occur 10. Extra time is added to visits 11. Extra time is added to the visit day 12. Visits without appointments or needs 13. Dating potential 14. Sexual potential
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Other Elements of Natural

17 History

It starts with very small mistakes that are missed or uncorrected

It is the small mistakes, if unaddressed, that lead to larger consequences

At the moment of the mistake, many professionals report a vague sense of discomfort or gut feeling (clinical instinct?)

It may be difficult to identify the source or reason for this feeling in some circumstances In others, it can be pretty clear why we feel unease
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Initial Response to

17 Violations

A threat to our sense of a Competent Self A decision to direct our energy in response:

Toward Critical Self-Examination Toward Self-Protection

Defense Against Condemnation by self and others

Blame the client Cite extenuating circumstances Minimize consequences Cite Good Intentions

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Consequences of Violations:

For Clients:

Access to other clients information (HIPAA) Jealousy, anger, escalating behavior, confusion, mistrust, poor self-esteem, guilt and self-blame, substance abuse, anxiety, depression, rejection, isolation, abandonment, suicide. Legal Consequences (Civil Law/Preponderance)

For Providers:

The mere appearance of impropriety. Legal Standard of Care: What an ordinary, reasonable and prudent professional with the same or similar training would have done under the same or similar circumstances.
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Legal Consequences, cont.

The Substantive Standard of Care:

That the behavior of the professional is the most substantially practiced by most people, in most cases, and most settings.
The last line of defense for questionable behavior, typically used only for the most complex ethical dilemmas where there are few, if any, existing standards.

The Procedural Standard of Care:

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Provider Consequences, cont.

Undermines all therapeutic interventions Theft, harassment, stalking Formal complaints Disciplinary action Physical or sexual assault Homicide

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Maintaining

Client in perpetuity legal standard Discuss and set boundaries at the beginning Maintain your neutrality Encourage client independence Protect every clients confidentiality Interact verbally with appropriate physical space Minimize physical contact Avoid self-disclosure Provide a consistent, private and professional setting at all times
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1,7,10,18,19,20 Boundaries:

Maintaining Boundaries II

Continually monitor and manage issues Label (verbally and with signage) and define areas, boundaries Defer and refer (shift authority up) Seek consultation and supervision Document Everything Verbal contracting Written contracts (care agreements) Refer out when necessary Take a leave of absence or reduce hours
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A Description of a Social Worker

She had that contradictory mix of concern and distance that separates social workers from us mere mortals. Dan Savage (1999). The Kid (p.21)
(An adoption story)

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Response

17 Options

(for when you make a mistake)

ADMIT IT (NO RECRIMINATIONS)

To yourself To a consultant (colleague, supervisor) To the client (you are allowed to be human)
Why did you give yourself permission to ignore your clinical instinct (gut feeling)? Emphasize your role in this (not easy to do).
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Analyze your role, motivations, reasons18

Analyze the sequence of events (minutia)

The End

Question: How many elephants are there?

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