Background
At some point in every occupational therapist’s career, the issue of a professional boundary crossing with a client will come up.
A boundary crossing occurs when an occupational therapist (OT) or client initiates a behaviour that compromises the OT’s professional relationship with their client. The potential for boundary crossings relates directly to the power imbalance in the therapeutic relationship. Clients are in a position of vulnerability because they place trust in the OT’s knowledge and expertise and will defer to an OT’s judgement.
A boundary violation occurs when the nature of the therapeutic relationship moves from professional to personal. It is important to understand that a boundary may be crossed without it being violated.
Boundary crossings may be small to start, but if not managed effectively, they can affect an OT’s ability to provide safe and ethical service and lead to a boundary violation.
- Savanna (OT) works in an outpatient hand therapy program. She has been working with her client Dale who suffered a hand injury in a work-related accident. Dale made significant progress over the course of his therapy, and gave Savanna a thank you card to show appreciation. He signed the card by hand to demonstrate the improvements in hand function. Savanna thought this was a nice gesture and accepted the card graciously. A week later, client Dale sends an elaborate bouquet of flowers to her at the clinic.
- Kramer (OT) is providing virtual support to Jordan, who has ADHD and has challenges keeping up with his university course work. Kramer typically uses text messaging only to set up appointments with clients. However, Jordan was struggling during a stressful exam period, so Kramer started texting strategies and reassurance to Jordan, thinking he was being responsive. He wanted to be timely by answering Jordan whenever he reached out even if it was in the evening or on the weekend. Kramer becomes increasingly absorbed in client Jordan’s case and finds himself sharing personal tips and prioritizing his appointments.
Considerations
In managing professional boundaries, occupational therapists must:
- Follow the Standard for Professional Boundaries and the Prevention of Sexual Abuse, 2023 and maintain professional boundaries with clients at all times.
- Understand the power imbalance that exists in a therapeutic relationship and recognize when the therapeutic relationship begins to shift.
- Be self-aware of their own life circumstances that can contribute to a lapse in professional judgement including actions that take advantage of the power imbalance with a client. For example, an OT who is going through a relationship breakdown may be more susceptible to boundary crossings that involve exchanging personal information and compliments.
- Be aware that boundary crossings can be subtle and can lead towards a boundary violation.
- Know that the responsibility is always on the OT to maintain boundaries, even if the client initiates the behavior and indicates a desire to have a personal relationship.
In managing professional boundaries, occupational therapists must:
- Prevent sexual abuse, which is defined in the Health Professions Procedural Code, being Schedule 2 to the Regulated Health Professions Act, 1991 (RHPA) (https://www.ontario.ca/laws/statute/91r18) as:
- Sexual intercourse or other forms of physical sexual relations between the member and the patient,
- Touching, of a sexual nature, of the patient by the member, or
- Behaviour or remarks of a sexual nature by the member towards the patient.
“Sexual nature” does not include touching, behaviour or remarks of a clinical nature appropriate to the service provided.
Reflective Questions
Occupational therapists should ask themselves:
- Am I giving or accepting gifts/favours from my client?
- Am I sharing personal information with my client? This can include sharing personal aspects of your life during virtual sessions or on social media.
- Am I engaging in a dual role, for example acting as an occupational therapist and acting as a friend?
- Am I using communication methods that appear less formal or may get misinterpreted, such as text messaging?
- Am I behaving or communicating in a way that can confuse the client as to my professional role as an occupational therapist?
- Am I touching or communicating with my client in any way that may be misunderstood as sexual in nature?
- Am I clear in the consent process when I need to touch my client for clinical purposes?
- Am I spending an increasing amount of time thinking about a particular client?
- Am I favouring a certain client or find myself “going the extra mile” for them?
- Am I paying more attention to my appearance if I know I am seeing a particular client?
- Am I thinking about going into business with a client or those who support them?
- Am I working outside of established practice processes? For example, working with or responding to clients outside of clinical sessions or my established work hours?
- Am I experiencing any life stressors that could be impacting my ability to carry out services? For example, divorce or break up, death of a family member, illness, burnout, feelings of loneliness or isolation, etc.
- How would my actions be perceived by my employer or colleagues?
Discussion
What should you do if you are concerned that you may be at risk of crossing professional boundaries?
- Take timely steps to re-establish and maintain boundaries by being clear about your role and obligations. Remain neutral and professional, keeping the client’s interest as the priority. Some examples include:
- Respectfully declining a gift
- Apologizing for the oversharing of personal information
- Discontinuing any activities outside of your role as an occupational therapist and typical workplace practices
- Explain clearly what clients can expect in your work practices moving forward
- Determine if boundaries can be re-established and your professional objectivity can be maintained to provide care
- Implement working hours and provide information about after-hours services and resources
- Establish the discharge plan early and communicate it regularly
- If professional objectivity cannot be maintained, client care should be discontinued and transferred to another occupational therapist or health care provider.
- Document the situation in the clinical record.
- If personal feelings have developed between the OT and client, client care should be discontinued immediately and transferred to another OT or health care provider. Avoid further contact with the client as the power imbalance remains even after services are discontinued.
- Consider if there are personal factors that are influencing your ability to keep clear boundaries, for example, relational stress, mental or physical health, compassion fatigue, etc. Look into supports for your own wellness.
- Discuss the situation with a colleague or trusted advisor. Be mindful of maintaining client confidentiality and seek supports for safe practice.
Outcome
- Savanna (OT)
By gifting an expensive bouquet of flowers, the client initiated a boundary-crossing. This type of personal gift may be a sign that the client sees the relationship as more than just professional and may expect special treatment or reciprocity of that relationship in return. The therapeutic relationship can be compromised if the OT does not stop and re-establish professional boundaries.
Refer to the Standard for the Prevention and Management of Conflicts of Interest, 2023.
3.1 “Know that the inappropriate exchange of gifts, money, services, or hospitality can exploit client relationships and is considered a boundary violation.”
Savanna re-establishes boundaries by explaining that elaborate gifts to clinic staff are not appropriate. She reiterates her role as an OT, the purpose of the occupational therapy service and her obligation to prioritize the client’s health care needs. Savanna reflects in hindsight on whether she could have communicated her role more clearly when the client first gave her the thank you card. To help manage potential issues in the future, she speaks to her employer about developing a clinic policy about accepting gifts from clients.
Had Savanna not re-established boundaries, this situation may have progressed towards a personal relationship which is a boundary violation. The responsibility is always on the OT to manage boundary crossings even if it is the client who initiates the behaviour or indicates a desire to have a personal relationship. The OT has the responsibility to maintain boundaries whether it is a current or previous client. The RHPA states that a client remains a client 1 year post-discharge, regardless of the practice context.
Refer to the Standard for Professional Boundaries and the Prevention of Sexual Abuse, 2023
1.5 “Never form intimate, personal, or romantic relationships with previous clients who were especially vulnerable, no matter how much time has passed since the client-therapist relationship ended.”
4.5 “Never form intimate, personal, or romantic relationships with previous clients or their relatives and support people unless the following four conditions are met:
- At least one year has passed since therapeutic services were last provided or since the client was discharged from the occupational therapist’s care and
- The occupational therapist can demonstrate that any previous power imbalance no longer exists and
- The person involved is not dependent on the occupational therapist and
- No future client-therapist relationship is ever resumed”
The RHPA sets out the penalties for health professionals, including occupational therapists, who are found guilty of sexually abusing a client. This includes losing their license to practice among other consequences. Details are outlined in the appendix of the Standard.
- Kramer (OT)
After discussing this client with a colleague, Kramer realizes that he has crossed professional boundaries. He reflects on his own emotional responses and recognizes that he was developing a personal connection to the client. Providing preferential treatment beyond typical working hours and communicating personal information via text messaging can confuse the client as to Kramer’s role as the OT. Kramer apologizes to the client and attempts to re-establish boundaries by clarifying his role and responsibilities and setting limits to communication. Upon further reflection, Kramer does not feel he can maintain objectivity moving forward and decides that it would be in the best interest of the client to transfer care to another OT.
Refer to the Standard for Professional Boundaries and the Prevention of Sexual Abuse, 2023
2.3 “Maintain professionalism by limiting excessive sharing of personal or private information, and consider how communication is being interpreted.”
2.4 “Avoid creating situations where dependencies develop between clients and the occupational therapist.”
3.5 “Be aware of and reflect on any feelings that are developing toward clients and could result in boundary violations (for example, the desire to form intimate connections or the internalization of a client’s grief).”
Conclusion
Boundary crossings may be initiated by a client or an OT with unintended consequences. If not recognized and dealt with, boundary crossings can easily result in a boundary violation.
Occupational therapists are in a position of trust and power in the therapeutic relationship and have the responsibility to always maintain professional boundaries with their clients. Continuous reflective practice and paying vigilant attention to the various signs are key to preventing and effectively managing boundary crossings.