Hutcherson, MS, RN Abstract During the last century the world has become increasingly reliant on a variety of technologies to manage information needs. Escalation in deployment of remote technology to enhance health care, accompanied by expanded public and private reimbursement for distant care, indicates increasing acceptance of these technologies. Yet many legal and regulatory questions regarding the provision of health care using these technologies remain.
The authors systematically examine the concept of boundaries and boundary violations in clinical practice, particularly as they relate to recent sexual misconduct litigation. They selectively review the literature on the subject and identify critical areas that require explication in terms of harmful versus nonharmful boundary issues short of sexual misconduct.
These areas include role; time; place and space; money; gifts, services, and related matters; clothing; language; self-disclosure and related matters; and physical contact. While broad guidelines are helpful, the specific impact of a particular boundary crossing can only be assessed by careful attention to the clinical context.
Heightened awareness of the concepts of boundaries, boundary crossings, and boundary violations will both improve patient care and contribute to effective risk management. Like many concepts in psychotherapy, such as "therapy," "transference," and "alliance," the term proves slippery on closer observation.
The literature tends to focus on patient-therapist sexual misconduct 3 as an extreme violation and not on the wide variety of lesser and more complex boundary crossings, many of which are, at first glance, less obvious but pose difficulties of their own for clinicians.
Clinicians tend to feel that they understand the concept of boundaries instinctively, but using it in practice or explaining it to others is often challenging.
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Empirical evidence suggests that boundary violations frequently accompany or precede sexual misconduct 2, 4, 5but the violations themselves do not always constitute malpractice or misconduct or even bad technique. However, modern clinicians should be aware of three principles that govern the relationship among boundaries, boundary crossings, boundary violations, and sexual misconduct.
A direct shift from talking to intercourse is quite rare; the "slippery slope" is the characteristic scenario. As Gabbard 4 and Simon 6 have pointed out, a common sequence involves a transition from last-name to first-name basis; then personal conversation intruding on the clinical work; then some body contact e.
Second, not all boundary crossings or even boundary violations lead to or represent evidence of sexual misconduct. A clear boundary violation from one ideological perspective may be standard professional practice from another. Bad training, sloppy practice, lapses of judgment, idiosyncratic treatment philosophies, regional variations, and social and cultural conditioning may all be reflected in behavior that violates boundaries but that may not necessarily lead to sexual misconduct, be harmful, or deviate from the relevant standard of care.
Third, despite this complexity, fact finders-civil or criminal juries, judges, ethics committees of professional organizations, or state licensing boards-often believe that the presence of boundary violations or even crossings is presumptive evidence of, or corroborates allegations of, sexual misconduct.
This metaphor is not trivial. In a notorious Massachusetts case in which the doctor accused of sexual misconduct was eventually exoneratedthe Board of Registration in Medicine, the state licensing authority, noted in the course of the process, "There was an undisputed level of intimacy between the two [patient and doctor] that supports the inference of sexual relations" transcript of board proceedings, citation withheld.
In its language here, the board clearly articulated its "inference" of fire from the "undisputed" presence of smoke. Moreover, recent court decisions suggest a trend toward findings of liability for boundary violations even in the absence of sexual contact 7.
On this basis, the risk-management value of avoiding even the appearance of boundary violations should be self-evident. This communication has three goals: Is it too amorphous, protean, and abstract to define at all? Should we take refuge by saying, as St.
Augustine was supposed to have said about time, "Time? I know what time is, provided you do not ask me"?
Part of the difficulty encountered in defining appropriate boundaries can be related to the historical tradition that modern therapists have inherited.
The great figures in the field gave out mixed messages on the issue. He sent patients postcards, lent them books, gave them gifts, corrected them when they spoke in a misinformed manner about his family members, provided them with extensive financial support in some cases, and on at least one occasion gave a patient a meal 8.
During vacations he would analyze Ferenczi while walking through the countryside. In one of his letters to Ferenczi, which were often addressed "Dear Son," he indicated that during his holiday he planned to analyze him in two sessions a day but also invited him to share at least one meal with him each day unpublished manuscript by A.
For Freud the analytic relationship could be circumscribed by the time boundaries of the analytic sessions, and other relationships were possible outside the analytic hours. Freud was not alone in establishing ambiguous analytic boundaries.Learning Objectives. This is a beginning to intermediate course.
Upon completion of this course, mental health professionals will be able to: Explain the role of the Federal Trade Commission and the interest of the states in advertising issues and marketing statements as they relate to ethics. Type or paste a DOI name into the text box.
Your browser will take you to a Web page (URL) associated with that DOI name. Send questions or comments to doi. Ethics Reflection Paper November 5, STR/ Ethics Reflection Paper Ethics oftentimes determines what is right and what is wrong.
It is a moral code that determines values, morals, standards of behavior, principles, and ideas (“ Ethic,” ).
OJIN is a peer-reviewed, online publication that addresses current topics affecting nursing practice, research, education, and the wider health care sector.
A Journey to Social Work - I always received great satisfaction from helping others. I remember at a young age, helping my grandmother with chores that she was no longer able to do for herself.
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