Pp1-5 Professional Boundaries (respect for persons)
Transference and Countertransference
- Both terms can make patient-therapist relationships more complicated than they appear, difficult for RMTs to stay clear-headed and compassionate, and to remain fully present for the patient - Key: understanding the built-in "power differential" between patient and therapist - Role of the Practitioner - gives us special authority (power) in eyes of the patient, but it's not always who we are personally
History of Respect for Persons:
- I8th century philosopher Emmanuel Kant developed idea: respect for persons - Kant believed that humans are unique, unlike any other forms of life, thus worthy of special esteem or regard - Kant believed that man should be treated according to his "humanity", known as Human Dignity -Definition - an inherent aspect of being human, which we share with every other person and it cannot be taken away; an abstract concept What does it mean to treat someone according to their humanity? - Be honest, straightforward - No false build-up or expressing false affection or loyalty to get what you want from someone - Kant: "Always treat people, both the self and others, as ends in themselves and never merely as a means". o Using people as a means to an end, a means to get what you desire is NOT demonstrating Respect for Persons o Treating people as an "end in themselves" means they are valued and respected
Mixing Other Business With Our Practice:
- Leads to confusion of roles, or can be harmful - can cause us to lose patients! E.g. Taking on business associates as patients, trying to involve patients in other kinds of business transactions E.g. Selling supplements to patients - patient has an allergic reaction E.g. Selling product - magnets - patients feel pressured to buy Unethical for RMTs to use relationships with patients to benefit themselves in any way! - Patients are vulnerable - RMT takes advantage - RMT tries to influence/persuade patient to purchase product or engage in business, for their own benefit, not for patient!
What Stays OUT of the Professional Therapeutic Relationship? (Basic Elements of a Therapeutic Relationship)
- RMTs must stay within limits / boundaries of our Scope of Practice - We cross a fine boundary line when we try to comfort, make recommendations, giving too much personal info - Easy to over-stepped this line - RMTs are human, we make mistakes, takes constant action and correction - RMTs must realize when we've crossed that line, then be willing to change our behaviour - RMTs must value and be aware of this line and be tolerant of our own human imperfections, but not too tolerant - we can harm/hurt patients or our practices
Definition of Professional Boundaries
- The physical and emotional limits that are appropriate in the therapeutic setting - Boundaries are not barriers, but limit us as to what to expect and what is appropriate in each situation; keeps us within limits of our training - Society's expectation: the person with the greater power (the professional), will act in the best interests of the patient - Boundaries make us professional and bring respectability and credibility to our work - Boundaries are a natural part of everyone's world - every relationship in our lives has boundaries....name some: ____________________________________
Establishing and maintaining a Therapeutic Relationship:
- In order to keep the Therapeutic Relationship professional, we need to establish professional boundaries - the "how" of maintaining the therapeutic relationship
Counter-transference
- When the therapist projects unto the patient old feelings or attitudes that they had about significant people in their past - RMT allows unresolved feelings / personal issues to influence the relationships with patients and can get in the way of ability to facilitate healing
Definition of "Respect for Persons"?
Human beings have dignity and worth because they are rational agents capable of making their own decisions We demonstrate "Respect for Persons" when: - We maintain the therapeutic relationship - We ensure our patients provide informed consent - We protect our patient's right to privacy and confidentiality
Signs of Counter-transference:
- Treating patients as weak and fragile - trying to protect them from pain or discomfort - that you are the only one that can help your patient - even though we know that some manual techniques can involve some discomfort but that this will subside - RMT has need to re-create a past therapeutic experience - in a way that would have worked for the therapist: must acknowledge patient as a different person in the present, who does not want to be protected by you, but just treated effectively and respectfully - Patient rejection - RMT may project onto a patient a past experience with others in her life who were considered needed and imposed excessive demands on her time and energy: RMT may become distant, create excessive boundaries for fear of patient asking and talking too much - Excessive need for approval, validation, constant re-enforcement - RMT may feel need to please a patient in order to be liked and valued: e.g. if RMT doesn't achieve desired results, may feel discouraged and start to doubt their skills/abilities - will tie in to RMT thinking patient not like, respect, or value them - Desire to develop social relationships with patients - to meet our need for friendship; we are departing from the purpose and goal of the therapeutic relationship -We must ensure this need is met OUTSIDE of the therapeutic relationship: we must focus on the Cl-Th relationship even if the patient expresses a desire to form a friendship with us -we must remain clear and focused in our roles, so we do not enter into a dual relationships with patients: do not merge role of therapist and friend
Going Outside our Scope of Practice:
- When we behave as if we are experts in areas where we have little or no training, or when we exaggerate claims about effectiveness of our treatments E.g. We cannot guarantee massage therapy can: decrease cholesterol levels, cannot tell patients what foods to eat, why they should divorce their spouses..... - Learn to say, "I don't have enough training (or the skills) to help you/your condition. Please let me refer you to a more advanced RMT or another kind of health professional" - As professionals, RMTs must know their limits, and must never disparage other hcps
We must learn to understand our Professional Role
- to be at ease with our roles takes time. 2 Roles with our Patients: 1. A specific role as a certain type of Somatic (body) Practitioner - defined by our training as an RMT, Physiotherapist, Nurse, etc.. 2. A more general role as a Professional - we keep our personal lives, opinions, needs out of our sessions. This can cause confusion, yet we expect to be treated as a professional.
Laws and Professional Codes of Ethics
-....... are sources of defining boundaries and tell RMTs what these limits are This is essential for a) protecting patient's vulnerability, b) fulfilling treatment goals When RMTs go beyond these limits - when we violate ethical standards - we violate professional boundaries E.g. When professionals exploit the therapeutic relationship to meet their own personal needs rather than those of the patient, we violate professional boundaries
Therapeutic Relationships
-Due to patient vulnerability, we must ensure the therapeutic relationship respects and honours their vulnerability and fulfills their health care needs - Sometimes, RMTs can be: unclear, unfocused, not fully present • RMTs can bring issues into the therapeutic relationship that do not belong there, that get in way of serving our patients' needs • cause us to depart from the purpose/goal of the therapeutic relationship • can obstruct the progress of our patients • happens consciously or unconsciously • focus shifts from meeting patient's needs to the therapist's own personal needs • requires WORK and focused INTENT to stay present • doesn't mean needs of therapist do not exist or are not important, but: • therapeutic relationship is WRONG PLACE to have needs of therapist met • thus, RMTs as healthcare professionals must examine what we bring to the therapeutic relationship
transference relationship
-When the patient projects unto the therapist old feelings or attitudes that they had about significant people in their past (often parental figures)
3 Common Ways We Stray Outside Professional Relationship:
1. Bringing in our social and personal needs 2. Going outside our Scope of Practice and expertise 3. Mixing our practices with other businesses Social Needs and Personal Needs: - Most frequent boundary confusion! - Range from harmless to problematic: lapse into chatting during a session - to socializing with patients - to unethically dating a patient - Why is it important to draw boundaries between our social and professional lives? - What is wrong with having casual conversation with a patient? - What is wrong with sharing something personal about ourselves with our patient? - Maybe nothing, but can take advantage of patient vulnerability and/or interfere with patient receiving full benefit of their treatment!
Two Major Categories of Boundary Violations:
1. Gross Violations: Breaches of the professional promise not to engage in sexual contact with patients 2. Dual Relationships: The blending of a professional (therapeutic) relationship with another potentially incompatible relationship (to be discussed in more detail) Sexual activity with patients constitutes Sexual Misconduct: the most serious of all ethical violations******
What should stay OUTSIDE Of the Therapeutic Circle?
1. Medical Advice: - We are NOT medical experts/Medical Doctors - we must be honest and act within the boundaries of what we know - We should not treat medical conditions without properly consulting with patient's MD, Chiro, Naturopath, etc. E.g. Cannot tell a patient to stop wearing ankle brace or to reduce medication. What should we tell the patient in this case? - If we give an opinion, it must be within our Scope of Practice and training; and we must state them carefully E.g. "I've known some people who used vitamin C for colds with very good results" versus: "You should take vitamin C."
What Stays IN the Professional Therapeutic Relationship: (Basic Elements of a Therapeutic Relationship)
1. Patient-Centered Actions and Words: - Our actions and words should be motivated by what is best for patient - We must put aside our personal egos, interests, needs, likes/dislikes - Doesn't mean, "customer is always right", or let patients take advantage of us - Patients have right to ask for what they want - Patients are free to request treatment as long as they are not abusive, destructive or inappropriate - Patients are encouraged to make their needs known: RMTs job is to adjust and meet that need, or explain that their request is not in their best interests, not appropriate, or not within the scope of our practice
What Stays IN the Professional Therapeutic Relationship: (Basic Elements of a Therapeutic Relationship)
2. Confidentiality: - RMTs gain respect as professionals by honouring patients' privacy and confidentiality - RMTs cannot complain, gossip, brag, or in any way discuss what patients said/did during the treatment - or with any other professional without the patient's consent - The CORE of professional relationships - Starts with first phone call (point of contact with RMT) and continues throughout the entire relationship
What should stay OUTSIDE Of the Therapeutic Circle?
2. Psychological Counselling: - Hardest judgement calls to make; easy to fall into this trap - RMTs must be sensitive to and support patients - Yet, it's never appropriate to pry into a patient's private life, unless obtaining info necessary for treatment - Difference between being friendly vs. acting like amateur psychotherapists - Patients will volunteer info about their lives - makes this difficult for us to know how to respond - we can become uncomfortable when patients discuss their personal life - RMTs must remember not to counsel or give advice when we do not have the training! - Even if we have training in psychotherapy, we must look at the reason the patient has come to us: treat painful lower back, sprained ankle, NOT psychological issues - Yet, we are educators, and can deduce that, "muscle tension may be related to stress/anxiety about a problem. Perhaps you've been under stress at work or at home." - Part of our professional role - to provide atmosphere within which patients can relax tight muscles - Some patients unwind by talking, so we can provide a sympathetic ear 3. Spiritual Advice: - Not appropriate to promote ourselves as spiritual advisors, regardless of our own spiritual beliefs and practices E.g. If a patient describes their life as being empty and meaningless, or unsure about their religious belifs - RMTs can paraphrase back to them saying, "Your questions strike me as involving spirituality", or "You sound as if you're thinking a lot about your fundamental beliefs about life". - Reflecting back to patient can help clarify his/her thoughts/ideas, rather than share personal advice
What Stays IN the Professional Therapeutic Relationship: (Basic Elements of a Therapeutic Relationship)
3. Consistency: - What keeps patients coming back - our professional standards are solid and upheld - Consistency keeps us reliable - We must be attentive & professional - keep standing time slots; notification of clinic changes
What Stays IN the Professional Therapeutic Relationship: (Basic Elements of a Therapeutic Relationship)
4. Informed Consent and Right of Refusal: - Patient has a right to understand everything involved in the treatment - Creates a verbal and written contract with patient - RMT must have a patient's educated and informed consent so that there are no surprises - covers all aspects of our training methods, techniques, styles, risks, benefits... - RMT tells patient they can stop treatment at any time and for any reason: right of refusal - Can you see how the Patient's responses ultimately control the session?
What Stays IN the Professional Therapeutic Relationship: (Basic Elements of a Therapeutic Relationship)
5. Our Rights as Professionals: - RMTs must be clear as to what WE expect of our patients - RMTs can decline to treat patients when we do not feel it is in our or their best interests to do so (keeping the Code of Ethics in mind) - abusive or disrespectful patients - E.g. we expect patients to be on time, leave after treatment, give us appropriate notice of cancellation of appointments, to pay the massage fee - [which is NOT the same a verbally abusive patients/abusive behaviour/rude remarks/sexually flirtatious borderline harassment]
MOST COMMON or PROBLEMATIC MANIFESTATION
: development of romantic/sexual feelings towards our patients; sometimes patient and therapist are attracted to each other - as long as we acknowledge and deal with the attraction promptly and cautiously - ***if you are experiencing sexual feelings towards your patient who tells you how wonderful you are, or how incredibly attractive she/he finds you, those feelings have NO PLACE in the therapeutic relationship; remember: you are the keeper of your patient's vulnerability and you have promised the patient AND society that you will protect that vulnerability.
Therapeutic Relationships
By virtue of our "Social Contract" with society, RMTs commit to enter into and participate in a Therapeutic Relationship with patients, which is different from other relationships. Definition of a Therapeutic Relationship? -A relationship which exists between two people; one being a therapist and the other a patient, for the sole and expressed purpose of serving the health and well-being of the patient, ensuring we bring our full presence and commitment to this experience
Dual Relationships
Dual Relationships was the cause of much legal and ethical concern in past several years, especially in the 1980's: merging a professional relationship with a sexual relationship involving a patient. - In Ontario, sexual abuse legislation and adoption of zero tolerance philosophy prohibited dual relationships with a sexual component both by law and ethical standards and norms in code of ethics documents of professional health care providers. (advent of Bill 100) -other forms of dual relationships that are not addressed by the above: can cause risk
Gross & Dual Violations
Gross Violations - fall into three categories: 1. Sexual Intercourse - or other forms of physical sexual relations between therapist & patient 2. Sexual Touching - any touching of a sexual nature of patient by therapist 3. Sexual Behavior / Remarks - by therapist directed towards a patient Dual Relationships - can take many forms, such as: - Therapist and Teacher - Bartering for Goods and Services - Providing therapy for relatives and friends - Socializing outside of treatment - Being emotionally or sexually intimate with a patient
Examples of Transference:
Mary's boyfriend teases her constantly and she gets very agitated because her father used to tease her about her downfalls and criticize everything she did - now she is easily upset and hurt by anyone who teases her. A patient, Mark, who enjoyed a very warm and nurturing relationship with his mother, projects the love and warmth he experienced with his mother onto his RMT and begins to treat the therapist as though she were his mother. A patient, Marie, may react in a hostile or aggressive manner when feedback is provided by her RMT, even if feedback was asked for - Marie expects her RMT to be everything her mother was not, and will feel especially distressed when her RMT fails to be the mother Marie needed. Examples of Counter-Transference: A patient reminds RMT of his father and RMT projects onto this patient a controlling attitude or a negative disposition because of this reminder. There is a strong emotional charge, either positive or negative towards a patient. RMT is very irritated and upset with the patient for not actively participating in their rehabilitation. A patient who makes an RMT feel exhausted. Feeling disappointment when a patient does not praise your work, or feeling abandoned and rejected when a patient stops making appointments because she feels better The RMT feels annoyed when the patient "pushes his buttons" by making small demands.
Professional Boundaries
The goal of Professional Practice. . . - To serve the health, well-being and best interests of our patients We fulfill this goal. . . - By respecting and protecting our patient's vulnerability Definition of Patient Vulnerability? - A state in which a person is susceptible to injury or harm - All patients are vulnerable, if for no other reason than the fact that they have come seeking help and trust that you will provide it We protect our patient's vulnerability by: - Treating them equally and fairly - Not discriminating against them based on culture, ethnicity, age, mental or physical ability, sexual orientation, religion etc. - can be an obstacle to practising respect for persons - Making our services available and accessible to them
Therapeutic Relationships
To be fully present in the therapeutic relationship, we must be: o Self-aware - of our own needs, areas of conflict, problems, unfinished business, vulnerabilities, financial worries, employment frustrations o Personally Responsible - want to make a living, pursue a career, develop skill sets to be the best we can be and offer patients the best service
We also breach Professional Boundaries when we make the therapeutic relationship about us: there are 2 psychological terms that identify specific issues or behaviours that can interrupt the goal of the therapeutic relationship:
Transference and counter transference
Why are dual relationships ethically wrong
We place our needs/desires as RMTs (financial, social, and emotional) above the patient's well-being. 3 Types of Risks in dual relationships: High Risk - types of dual relationships that have potential for harm to patient - most obvious example: a sexual relationship with a patient - universally prohibited by law and by professional codes of ethics - to sexualize a therapeutic relationship detracts from the goals of that role, regardless of WHO initiated it - penalty is severe as often causes harm to patient: forfeit license Moderate Risk - includes behaviours not directly prohibited by law, but usually highly discouraged in codes of ethics, official policy statements of regulating bodies - examples: friendships with patients; treating relatives, treating friends, merging role of teacher and therapist Low Risk - includes behaviours where risk of harm to patient is unlikely, or judged as less than the 2 above categories - examples: bartering for services, socializing with patients, accepting gratuities - behaviours are discouraged not explicitly prohibited; would not attract serious consequences - RMT may be exposed to drawbacks: socially (tarnished reputation), politically, psychologically (harm a patient, remorse about making 'bad' decision) Unlikely Risk - no foreseeable harm likely - examples: any behaviour not in above categories, but which could merge roles: attending funeral of patient's father; attending performance by invitation of patient, accepting a gift from a patient - no legal prohibitions to discourage this type of group behaviour; CMTO allows for individual discretion
Why We Bring Our Social Needs Into Our Professional Lives:
a) Need for Social Interaction: - Most common complaint from patients: therapists who talk too much! - Should be relaxing for patient, yet therapist demands attention - Patients are too polite/too influenced by the power imbalance to say anything - Patients will be polite, but may complain to friends, or NOT COME BACK! b) Need for Friends: - May be on "friendly terms" with patients, but are they really like our friends? - Do friends come and see us, take off their clothes and describe all aches and pains to you? - Difference: friends - listen, put up with our flaws, forgive us, and DO NOT PAY US!! - As soon as friend/other becomes patient - PATIENT ROLE COMES FIRST during the treatment - The more unclear the division between the social and professional, more likely we can do/say something that interferes with having a healing, professional relationship - When we focus on ourselves, when we ask them to listen to us and take care of us, we cheat our patients c) Need for Romance and Excitement: - Of course we can be attracted to our patients and vice versa! - Socializing with patients....what message does this send? - We may not intentionally flirt, but: patient may think we are! - still unethical - Seek outside advice/counselling, or discontinue working with a patient we may be strongly attracted to - Small town, small communities - may be difficult to avoid social interactions with patients (more detail in Dual Relationships)
