1. Boundaries in clinical psychology

Question 1

How is the professional relationship different from other relationships?

Answer 1

1. Payment –fiduciary financial relationship
2. Absence of physical contact
3. Time limits
4. Confidentiality
5. Don’t give gifts
6. Avoidance of multiple relationships
7. Asymmetry of self-disclosure
8. Specific location

Question 2

What should be taken into account when accepting a gift?

Answer 2

1. How much the gift cost
2. Whether the person can afford it
3. What it means for the person to give it (e.g., gratitude, or romantic gesture)
4. Timing of a gift –if not at Christmas or end of treatment, then not really appropriate; and they should not know your birthday

Question 3

What should you do if you are given something?

Answer 3

Check policy of the organisation – some hospitals share all gifts between colleagues. Private practice hard –presents are wrapped.

Question 4

How can the integrity of a psych be compromised by accepting gifts?

Answer 4

If lavish present, then integrity may be compromised; e.g. client pays for holiday, then asks for medical note.

Question 5

What should a therapist provide?

Answer 5

A safe structure to allow for warmth, empathy and spontaneity.

Question 6

If you suspect child abuse, what then?

Answer 6

Mandatory reporting of child abuse.

Question 7

Can children of 14-15 ask for confidentiality?

Answer 7

Grey area. They can ask for confidentiality if deemed competent.

Question 8

What’s the risk involved in giving patient a lift?

Answer 8

Conversation could get personal –outside of the therapeutic zone.

Question 9

What’s the danger of disclosing to patients?

Answer 9

This may create intimacy between client and therapist.

Question 10

How you can ensure clients don’t learn stuff about you?

Answer 10

• Tell your secretary not to give out information.

- If computer is getting repaired, take info off first.

Question 11

What’s the difference between a boundary crossing and a boundary violation?

Answer 11

Crossing –intended to advance therapy constructively, but may be a departure from accepted practice. Are inevitable in a long-term clinical relationship.

Violation –may be harmful or exploitative. Not in interests of client.

Question 12

Why is flexibility important?

Answer 12

To accommodate individual differences in patients and clinicians.

Question 13

What is the gender split in sexual boundary crossings?

Answer 13

Males –1-12%

Females –0-3.1%

Question 14

What are the four types of clinicians who cross sexual boundaries?

Answer 14

1. Psychotic disorder.
   - Very rare.
2. Predatory psychopathy and paraphilia.
   - Antisocial or narcissistic PD
   - Patients are ‘easy targets’
   - Almost always male
3. Lovesickness
   - Infatuated with patient
   - Mistakes own needs for patient’s
   - Mainly female
4. Masochistic surrender
   - Allows patients to control them
   - Unable to set limits

Question 15

Why is crossing sexual boundaries wrong? Three things

Answer 15

1. Abuse of power –therapist is being paid to help with patient’s psychological problems.
2. Exploitation –therapist’s needs are placed above patient’s needs
3. Failure to provide services contracted to provide.

Question 16

What are the APS Guidelines for sexual relations with a client?

Answer 16

• Not with client or anyone closely related to client, for two years after termination of therapy.
• If after two years must explore with a senior therapist the possibility that former client may be vulnerable; encourage client to seek independent counselling on the matter.
• Not accept as client former sexual partner.

Question 17

What are the pros and cons of the two-year rule? 2 of each

Answer 17

CONS

• Permanent ban is an infringement of rights (freedom of association)
• If they get married, exploitation is hard to prove

PROS

• Transference is immediately re-established upon reunion between patient and therapist
• If possibility for sexual/romantic relationship exists, then therapy is contaminated.

Question 18

Why is supervision useful?

Answer 18

• to monitor boundary violations
• reassure that feeling attraction is not uncommon or shameful
• help recognise harm caused if therapist were to act upon attraction

Question 19

What are 7 common boundary issues?

Answer 19

1. Special fee arrangements (low or free)
2. Extending time beyond what was initially agreed
3. A small gift. Large gift.
4. Self-disclosure
5. Socialising with the patient
6. Calling each other by first name
7. Non-sexual physical contact

Question 20

Describe the ‘slippery slope’ or ‘road much travelled’ (Simon, 1995)

Answer 20

• The ‘slippery slope’ or the ‘road much travelled’ (from Simon, 1995)
• Therapists’ neutrality is eroded in ‘little’ ways
• Therapist and patient address each other by first names • Therapy sessions become less clinical and more social
• Patient is treated as ‘special’ or confidant
• Therapist self-disclosures occur, usually about current personal problems and sexual fantasies about the patient
• Therapist begins touching patient, progressing to hugs and embraces
• Therapist gains control over patient, usually by manipulating the transference and by negligent prescribing of medication
• Extra-therapeutic contacts occur
• Therapy sessions are rescheduled for the end of the day
• Therapy sessions become extended in time
• Therapist stops billing the patient
• Therapist and patient have drinks/dinner after sessions; dating begins
• Therapist–patient sex begins

Question 21

What confidentiality issues are there with teenagers?

Answer 21

Grey area for competence. Should discuss with them beforehand whether they give you permission to discuss things with their parents if asked.

Question 22

In what cases should you document?

Answer 22

1. If a patient makes you feel uncomfortable.
2. When you consult a superior about something.
3. If there has been a boundary crossing from you or patient.

Question 23

If you are being supervised you should disclose to client that…

Answer 23

You may discuss their case with supervisor, but will not mention identity.