Ethical standards in a practice setting: respecting boundaries in the broadest sense holds the key to humane treatment.
Whether you're a counselor, therapist, psychologist, or psychiatrist, you understand the need to practice according to ethical codes. The word "ethical" undoubtedly means many things to different people. For the purpose of this article, we will define "ethical" in the Hippocratic term of "first, do no harm." In part, doing no harm means to practice in the therapeutic relationship without violating the patient (and family for minors) while helping the patient (and family and yourself) recover to the fullest possible extent. Doing no harm does not mean protecting the patient and/or family from the powerful healing that comes with getting in touch with, expressing, and feeling their feelings--a necessary part of the family recovery process.
Sometimes, lay persons, families, and patients themselves view a therapist supporting a patient in feeling difficult and intense emotions (i.e., rage, shame, sadness, hurt, loneliness) as harmful, or even unethical. The disease of addiction or an eating disorder operates in the service of avoiding feeling emotions. In the service of recovery, we support families in feeling emotions, and deep healing ensues.
Most of us possess an inherent capacity to know the difference between what is useful or constructive (referred to by many people as "right") and what is harmful or destructive (referred to by many people as "wrong"). How do you manage the "gray" areas of those codes in a health care practice setting? As we operate a service-oriented practice, we must constantly be mindful of boundaries in all aspects of treatment for our clients: not only patient-doctor boundaries, but also the boundaries between the therapeutic setting and the outside world--families, referral sources, collaborating treatment providers, insurance companies, etc.
Helping patients build and maintain healthy boundaries through modeling is an important aspect of treatment that results in recovery: knowing what information is important to share, with whom that information needs to be shared, and sharing that information in a manner that fosters recovery rather than in a way that violates a patient's boundaries or separates them from family members, sponsors, or other care providers who may provide support.
We naturally go to the client when we think boundaries, but we must also address the family. Because addiction is a family disease, all members of a family unit are affected--not only by the pain and consequences of an addiction, but also by the treatment and recovery process. Family education, support, each member's own healing, and involvement in recovery programs such as Al-Anon or Families Anonymous play an incredibly strong role in effective treatment.
For us, as the providers, it is critical that we respect those relationships, but also avoid violating the patient's boundaries around confidentiality in the therapeutic relationship. Maintaining this integrity in the therapeutic relationship is an essential aspect of healing for patients seeking recovery from eating disorders, addiction, and other behavioral illnesses. Many of these patients have had experiences where their boundaries (physical, emotional, and/or spiritual) have been violated, discounted, or neglected.
Of course, this respect of the individual's boundaries can lead to frustration at the family level, leading further to possible dissatisfaction with your practice and treatment. At Timberline Knolls, we counter this possible conflict by creating an atmosphere of high-touch customer service, which can be easily replicated at practices large and small. Instead of treating the client alone, treat the family. Invite members to participate in family sessions weekly, and create an environment where the resident, your client, can take the opportunity to share directly, removing you from the ethical challenge of feeling the need to be a "messenger" to inquiring parents, siblings, spouses, or friends.
But what if we are dealing with a client who has disclosed risky, dangerous, or life-threatening behavior? This gray area requires careful consideration of the client's age, the client's awareness level, the type of behavior, and whether the behavior is life-threatening. Would your client be better served if her family knew about the behavior or actions in question? Our initial goal, which meets our ethical responsibility, is to have the patient become aware her behavior is dangerous, then to help her take responsibility for asking for help. The best way we can help our patients do this is by teaching them how, and by supporting them in disclosing the behavior or activity to their family and other supportive people themselves.
This process is facilitated through the therapeutic relationship with the therapist. Patients begin to realize they are not alone, and come to believe that help is available when they share their struggles with a power greater than themselves (a family group, a therapy group, a higher power of their understanding). When practiced over the course of recovery, this belief that help is available becomes a strong faith backed by patients' direct experience that they are not alone and can continue recovery for the rest of their lives with help.
On occasion, the client may fully understand the situation, but is still unwilling to disclose the behavior. This is when you weigh the risks against the benefits and make a difficult judgment call. Remember that confidentiality belongs to our clients, and under only the most severe or threatening circumstances is that to be broken. To help counter the challenge of these situations, it is essential to create an environment that encourages involvement from family and loved ones during treatment. With high-touch customer service for the individual and the family, we can ensure that what boundaries may be present emotionally and mentally are not exacerbated because of isolation or geography.
These physical boundaries should be considered in treating the family as a whole, as well as in your personal interactions with a patient, especially for those of us working in an inpatient or residential setting. Proper boundary management in the client-provider relationship will improve the quality of treatment for your clients, and will maintain a strong ethical foundation despite potentially compromising situations. Physical boundaries refer to more than just respecting a client's body. Avoiding inappropriate physical behavior also includes respecting a client's personal space and belongings--gifts, food, medications, payment for services, mail, etc.
If, in a residential environment, a client and provider were to cross paths outside of the normal treatment setting, what kind of communication would be allowed before it would be considered unethical? And is the outside communication speak-able once back in the usual therapeutic setting? Denying outside contact, asking patients to keep it a secret, and discouraging them from sharing the experience with you and their peers are all ways to keep a patient sick.
Being mindful of where the therapy session is occurring is also important. Talking to an upset client in their room could also lead to confused feelings about the relationship, and could be experienced as a re-enactment of previous trauma by a patient with a history of sexual abuse, for example. These encounters outside the protection of the confidential treatment environment may also conjure feelings of inequality or favoritism when perceived by other clients, creating a service issue for your practice and complicating treatment. Plainly defining acceptable physical boundaries for yourself, but also helping patients discern what's appropriate for them and their loved ones, will help you avoid problematic situations, while also protecting you in cases of a perceived ethical breach.
Policy across the organization
Defining acceptable physical boundaries is also the first step to creating an ethical framework for your treatment organization. This includes working with everyone involved at the practice to define ethics and how to perform respective jobs ethically--this can extend from the cleaning staff to the intake representatives to the medical director. To note, these ethics should include your organization's approach to customer service and the development of healing relationships with customers. It is morally reprehensible not to consider the immediate needs of a desperate mother seeking help for her daughter. A soothing word, a move away from making judgments, and an understanding of her challenges is not only humane, but is also a good first step toward a successful treatment, not to mention good business.
Additionally, by conveying the ethical guidelines to anyone who might come into direct or indirect contact with your clients, you create a system of checks and balances that can ensure clients and families are provided services respectfully and ethically. Your framework should teach employees a method for identifying and handling ethical dilemmas and issues, as well as how to handle them quickly and who to turn to for help. This framework may also serve as a tool in recruiting and hiring, helping you recognize only those individuals who reflect your high standard of ethics for treating the clients and families you value.
The ethical framework should also include a guideline and recommendation for collaboration and referral. At Timberline Knolls, our team includes psychiatrists, psychologists, nurses, social workers, and therapists, all with their own specialties and expertise. In this setting, we have an organizational structure supporting internal collaboration and referral to ensure our clients receive entirely what they need under our supervision. But a single provider practice without the resources of a larger organization must still practice within its scope of expertise and network with other specialists to become familiar and comfortable with valuable referral options. By understanding the scope of our practice and expertise, we can recognize and act when referral and collaboration are needed.
Clinical supervision and peer support are of utmost importance in this regard, as it is only with such support that we can provide care in a manner that fosters a strong patient-therapist attachment. This attachment helps a patient experience a healing, therapeutic relationship without violating boundaries. Many patients have never had such a relationship with an authority figure, and the experience can be life-changing, exquisitely healing, and even life-saving.
An excellent example of a situation needing proper collaboration and referral is the case of a client suffering from co-occurring disorders. When an eating disorder specialist discovers the patient has addiction issues, communication and cooperation with an addiction specialist is key to the treatment equation. At Timberline Knolls, we can expertly treat adolescent and adult females and their families suffering from eating disorders and other addictions, as well as co-occurring disorders, using a 12-Step based treatment model with strong attention to the impact of the disease(s) on the whole family.
Our ethical framework for collaboration and referral ensures patients and families can trust their treatment is confidential, while knowing they have ultimate choice around what information is shared with other family members, other treatment professionals, or other outside sources. It is imperative for therapists to help their clients and family to understand clearly the importance and relevance to recovery of any information that is shared with an outside source, and equally imperative that the patient (and parent/guardian for teens) gives explicit consent for that sharing to occur.
Boundaries are often thought of as the line between appropriate and inappropriate behavior in a situation. But proper boundary management in a therapeutic setting with an eye to ethics goes beyond behavior and conduct. It becomes an understanding of and sensitivity to the patient's physical, emotional, spiritual, and relationship boundaries. Our consistent respect of these boundaries fosters recovery, and is vital to providing effective and ethically sound treatment.
By collaboratively creating and abiding by your professional code of ethics, you will put yourself in a great position to "touch" your clients.
Kimberly Dennis, MD, is the Associate Medical Director at Timberline Knolls (www.timberlineknolls.com), an innovative residential treatment center located in Lemont, Illinois that is designed exclusively for women with emotional disorders, including eating disorders, addiction, and self-injury behavior. Dennis is a member of the American Medical Association, the Academy for Eating Disorders, the American Academy of Addiction Psychiatry, and the American Society of Addiction Medicine.
BY KIMBERLY DENNIS, MD