boundary structure in ethical practiceIn order to be mindful about deviations (boundary crossings) in the therapist/client relationship, there needs to be some general boundary structure from which to deviate.

I’ve drawn the following list of general guidelines for ethical practice from the literature and from my own experience.

If you are new to practice, you may find they are helpful as a starting point for your own thinking. If you are an experienced clinician, I offer them only as a list of reminders of considerations for how you conduct your practice.

Basic Guidelines

Read and understand your profession’s code of ethics: Your license depends on adhering to that code. Whether you are just starting out or have been in practice for years, it’s a good idea to periodically review what your professional organization considers an ethical foundation for clinical work.

Be clear about your theory and practice from the start: It’s crucial to make it clear to your clients from the outset how you go about treatment, especially if it involves touch or any kind of alternative treatment from talk therapy. Summarize your techniques and obtain a clear consent for treatment.

Keep to the schedule: By establishing clear, predictable rules around the beginning and ending times of therapy sessions, our clients can make decisions about what to bring up and when. If they want to discuss something fully, they know to bring it up at the beginning of the hour.

If they want to alert us to a new and perhaps scary issue without going into it, they know they can open it up just as we’re about to close the door, understanding that we’ll get back to it next time.

Have a stated policy about between-session contact: When we make it clear under what circumstances we will and won’t accept phone calls, emails, texts, etc., we prevent, or at least minimize, feelings of abandonment or rejection if we don’t respond immediately. (Yes, there will always be people who test it but the rule gives us a place to start the next conversation).

Clarify the use of your website, FaceBook and other social media. These days, many people are in the habit of spontaneously using social media as a means of communication. Make it clear that you will not use social media as an extension of treatment. Short posts and responses are too easily misunderstood.

Make it a policy not to post “likes” or to respond to texts from clients unless it’s about something very concrete (like confirmation of an appointment).

Be purposeful when you decide to meet out of the office. Record the clinical decision and the client’s permission to proceed in your records. Generally therapy needs to stay in the office for the purpose of confidentiality.

But it can be a legitimate part of treating social phobia, for example, to accompany a client in a walk to town to practice in vivo what has been discussed in the office.

It can be therapeutic, not social, to have lunch with the parents and an anorexic teen to observe their interaction and perhaps to coach everyone about how to detoxify mealtimes.

And there are times it is therapeutic to make a house call or hospital visit. Just be sure that you do what you can to ensure there is no confusion about the purpose of your visit.

Refuse invitations to get into therapy issues outside of the therapy hour. Our clients count on us to keep the relationship clear when perhaps they can’t. One of the challenges of working in a small town like mine is that I often run into clients just going about my own life.

It’s sometimes tempting for clients to want to fill me in about progress (or lack) in the grocery store aisle or on the bleachers at a kids’ game. It’s up to me to politely and kindly refuse and invite them to bring it to the next session or to schedule an additional session if they feel they need it.

Stay out of dual relationships: This is more difficult to do in a small town. It’s not at all unusual to find myself in the same organization, volunteering at the same event, or needing the services of the client or a client’s relative when they have the only such services in town. (I’ll never forget a time when my supervisor refused to talk to me about a case because the client was the photographer for her daughter’s wedding.)

None the less, it’s essential to avoid those dual relationships as much as we can. If it’s impossible, it’s important to keep the therapeutic relationship clear by refusing to talk about therapeutic issues anywhere but in the therapy session.

Be cautious about attending milestone events. There are clients who will ask you to attend their wedding, their graduation or a funeral. It may be important to bear witness or to provide some support. As with other out of office visits, be purposeful and clear about what the client expects and how you intend to participate. Be prepared for the inevitable question “and how do you know so-and-so” that another attendee will ask in an attempt to make conversation.

Be scrupulous about avoiding any behavior that could be interpreted as sexual. We can’t guard against everyone’s interpretations but we can do our best to be clear. If someone suggests that there’s a sexual tone to the relationship or makes a flirtatious remark, have an immediate clarifying conversation.

Get regular supervision: Regardless of how ethical, unbiased and careful you believe yourself to be, therapists are only human. We all make mistakes. We all blunder into conversations or situations we wish we hadn’t.

You can both minimize the mistake-making and obtain valuable help when you blunder by participating in regular supervision. If you aren’t provided supervision by your employer, purchase it.
Doing ethical work by maintaining appropriate boundaries is a continuous process.

It requires us to think carefully about how we conduct every session with every client regardless of how experienced, how well-regarded, or how busy we may be. Our clients deserve no less from us.

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