Managing Therapeutic Boundaries from within a Positive Behavioural Framework

1. Managing Therapeutic Boundaries from within a Positive Behavioural Framework Dr. David Bladon-Wing Consultant Clinical Psychologist & Company Director of Community Therapeutic Services Ltd

2. Therapeutic Boundaries • Why are therapeutic boundaries so important to the work we do? • And, how do we integrate our understanding of ‘therapeutic boundaries’ into a PBM framework?

3. The Challenge we Face! • Social and health care often operate in challenging circumstances of complex and significant human need. • It has various professionals meeting these needs that have different specialist knowledge and skills but all operate from within a loosely shared therapeutic framework. • Currently, PBS is one of the preferred therapeutic frameworks when working with People with Intellectual Disability. • In providing this service, we encounter many therapeutic challenges and dilemmas that require us to attend to the complex nature of relationships. • As part of our professional standing, we are bound by professional ethics, standards and codes of practice and are held accountable for our conduct and actions. • Now, as ever before, maintaining professional boundaries is an essential part of our clinical / therapeutic work.

4. Exploring Professional Boundaries • Let’s start with an ethical dilemma. • Whenever, if at all, might it be appropriate for a client / service user to do the support worker’s laundry?

5. Treatment and Therapy • Treatment: • The way you deal with or behave towards someone or something • The way you think of and act toward someone or something • Therapy: • A treatment intended to heal or relieve a disorder (Oxford Dictionary) • The treatment of mental or psychological disorders by psychological means (Oxford Dictionary) • Therapeutic treatment especially of bodily, physical or mental illness

6. The Defining Features of Good Therapy • A clearly described, evidence-based intervention captured in a treatment / therapy plan, care plans or behavioural management plan. • It will be coherent with best practice guidelines and agreed by peers or colleagues as an acceptable intervention. • It will serve the best interests of the service user with mutually agreeable person-centered outcomes. • Any intervention or treatment plan should be authoritative, defensible and transparent in order to hold the therapist or therapeutic team accountable.

7. PBS provides a Therapeutic Framework • PBS is increasingly eclectic in its scope but is principally informed by behavioural theory and technique, i.e. Applied Behavioural Analysis (ABA). • It provides this therapy from within a person-centered, least-restrictive / non-punitive framework. • The goal is principally to achieve and maintain an acceptable quality of life by reducing the negative impact of ‘challenging behaviours’ or ‘behaviours of concern’ and/or developing skills that enhance the social functionality / performance of the individual.

8. The Therapeutic Contract. • Is the process of mutual agreement that enables a service to be provided that is intended to benefit the service user. • It is delivered through the personal qualities, knowledge and skills of the therapist or therapeutic team. • It can involve both passive and active participation by the service user. However, active, willing participation is always preferred but passive is acceptable if it is in the best interest of the service user. • It’s objective is to encourage new learning and personal growth and to create a sense of wellbeing, health and improve social functioning. It also intends to alleviate distress or emotional pain.

9. Therapeutic Framework, Contract and Relationship The Therapeutic Contract Operates from within the Framework Positive Behavioural Support informs the Therapeutic Framework The Therapeutic Relationship is defined by the boundaries determined by the framework and Contract

10. To conclude: • Therapy is about understanding the frameworkin which the contract operates, which in turn, provides the boundaries that define the nature of the relationship between the service user and the therapist or therapeutic team. • Boundary issues can emerge at the point of the relationship, the contract and the framework.

11. A relationship can take many different forms Type: Defined by: Regulated by: Intimate Familial Friendships Acquaintances Professional Therapeutic Official Person / State Social / Professional Closeness / Social Distance Function / Purpose Role / Time / Place Consent / Agreement Extrinsic / Intrinsic Reward i.e. for: Pay or Pleasure Social norms and rules Institutions Law: Civil and Criminal Professional bodies / ethics Media

12. The Therapeutic Relationship • The relationship is intentionally formed for the benefit of the service user • The focus is on the needs of the service user • The therapist or therapeutic team will actively evaluate what is happening in the relationship • The goal of the relationship is the therapeutic outcomes agreed in the contract. • The relationship is planned to terminate as the service user grows more independent.

13. Social Relationship • It is initiated for the purpose of friendship • The focus is on the needs of both parties • It develops spontaneously without a plan • The goal of the relationship is shared by both parties, for the benefit of both • Both parties are concerned about the approval of each other • Both parties do not regularly evaluate the relationship. • It is continued for as long as it is beneficial to both parties

14. Activities Associated with Social Relationships • Shared Leisure and Recreational Pursuits • Visiting Family and Friends • Eating and Drinking Together • Mutual Disclosure (chatting) • The Mutual Shared Pleasurable Passing of Time that contribute to the subjective sense of a ‘quality of life’.

15. The Support Worker’s Dilemma! • Support workers provide the greatest front line contribution towards implementing PBS in many, if not all, of our services. • How do you remain therapeutic in your role when you participate in many of the activities associated with being in a social role? • This potential role confusion can create tensions at the boundaries associated with the therapeutic role. • If this role confusion is managed poorly, it can lead to feelings of rejection, anger, sadness and failure and will significantly undermine the therapeutic process. • It can also results in safeguarding procedures.

16. A brief examination of professional boundary regulatory mechanisms • Status, professional titles, pay and influence, dress • Time, availability, control and access, gate-keeping procedures • Environmental setting, office or home • Knowledge, training, language and ’professional culture’ • Whether these controlling / regulating mechanisms serve the best interests of the service user should always be subject to scrutiny via critical self and peer reflective practices, i.e. supervision and professional discourse

17. Defining a Therapeutic Boundary • A boundary is the edge of appropriate behaviour at a given moment in the relationship between the therapist and the service user or client as governed by the therapeutic framework, contract and the immediate context of the relationship. • It may be defined by the physical, psychological, and the social space occupied by the service user in the therapeutic relationship. • Where the boundary line actually falls, or is perceived to fall, depends on the type and stage of therapy and may be subject to judgment and interpretation. • Therapeutic boundaries are not ‘hard and fast’. Rather, they are moveable and context-dependent, and their placement depends on the clinical situation.

18. Excessively Rigid Boundaries • Many services and practitioners, perhaps supported by their professional bodies and by institutions, may allow or even encourage the development of excessively rigid boundaries. • These processes are meant to protect the service user, but can also create far too great a psychological distance between the service user and the therapist. This may well render the therapy ineffective. • It also usually results in blaming the service user and / or the family or front line staff. At its extreme, it may also cause significant psychological harm to the service user. • Rigid boundaries are often experienced as prescriptive and can involve excessive controlling of physical and social contact, space and environment, limiting access and control to privileged others, limiting access to resources and facilities etc…. • From within a PBS framework, these may also perhaps be seen as unnecessary restrictive practices.

19. Boundaries are Complex and Dynamic! Any therapist or therapeutic team will need to consider the following: • The complex nature of relationships, roles and role confusion • Defining the therapeutic contract and maintaining a healthy therapeutic position in the relationship • Defining and maintaining boundaries is an on-going process and should be subject to scrutiny and regular review • Managing conflicting issues and therapeutic dilemmas are common place activities and should be seen as part of the therapeutic process and not as a failure or we risk the development of excessively rigid boundaries • There is a compelling need to work from within a commonly agreed framework, i.e. PBS, that is ethical and serves the best interests of the service user and / or society

20. Maintaining Therapeutic Boundaries • Introducing: • Boundary Crossings and Boundary Violations

21. A Boundary Crossing • A boundary crossing refers to a benign deviations from the standard practice, those that are harmless, are non-exploitative, and may even support or advance the therapy. • A boundary crossing still, however, potentially carries with it the risk of being judged to have failed the service user. Therefore, clarity and transparency over decision-making are essential. • Any boundary crossing must always be in the best interest of the Service User.

22. A Boundary Violation • Some ‘boundary crossings’ are inadvisable because of their intent, i.e. they are not done in the service of the service user’s well-being and growth and involve extra-therapeutic gratifications for the therapist. • .…is where there is a foreseeable risk of harming or exploiting the service user. • A boundary violation is a crossing that takes the therapist out of the professional role. • Such violations may involve professional, civil or criminal sanctions. • In particular, it may well invite a safeguarding enquiry.

23. Boundary Violations and Responsibility • The words ‘boundary violation’ raises questions of accountability. • There are three axioms that will enable boundaries to be explored by the institution, supervisory relationship and individual reflection. • These are:

24. Axiom 1. • The responsibility for setting and maintaining boundaries always belongs to the clinician, therapist or therapeutic team. The service user is not to be blamed or stigmatized for violating therapeutic boundaries. • Axiom 2. • In any interaction between two people, the actions of both play a contributing role. However, by axiom 1, the fact that the therapist and Service User are in that sense responsible for their actions cannot be translated into blaming the Service User. • Axiom 3. • Careful, candid, clinically informed exploration of professional misconduct, with attention to actual cause-and-effect relationships, will, in the long-run, be beneficial to Service Users, illuminating to the mental health professions, and valuable to society.

25. The Slippery Slope of Boundary Crossings and Violations • It is perhaps obvious that left unchecked, relatively minor boundary crossings can incrementally develop into boundary violations. • From the outset, care needs to be taken around establishing the therapeutic framework and the therapeutic contract. • Any significant deviation from said framework or contract needs careful consideration. • Cultural and social differences need to be considered. • The therapist must always consider their personal circumstances and any significant life-events. • Any wish not to make a record, disclose or discuss events with colleagues or outside agencies should ring alarm bells.

26. The Therapeutic Dilemma! • Therapy is about either setting and extending personal limits depending on the present clinical context of the service user. • Personal growth and development can only emerge from actual lived experience. Therefore, if therapy is about encouraging growth and development, then boundary crossings may well be an inevitable consequence of the therapy process. • Therefore, some boundaries may well need to be crossed, whilst at the same time, other boundaries may well need to be observed and maintained! • An intolerance of boundary crossings often leads to a desire to impose excessively rigid and harsh boundaries with the result of poor therapeutic progression.

27. Boundary Relationships

28. Some Guiding Principles: • In order to act in the best interest of the service user we might turn to four established ethical principles: • Altruism:doing for others even at the cost to oneself. • Beneficence:striving to do good. • Non-maleficence:striving to do no harm. • Compassion: acting out of the sufferings of others.

29. Some Areas of Boundary Tension: • Role, Time and Place • Handling money, providing services and gifts • Self-Disclosure • Communication and out-of-service/office contact • Clothing and Physical Contact • Sexual Misconduct • The ‘Special Relationship’ • Leaving the Job – continued contact?

30. Developing Scenarios to explore the Dimensions of Therapeutic Boundaries • Every service will doubtless have experiences of clinical dilemmas. • Use these experiences to develop a better understanding of the challenges of managing boundaries.

31. Some examples of Scenarios • You are at the counter of a coffee shop and the service user is short of 20p to buy a drink. What do you do? • Getting a gift from a service user? • Giving out personal details, phone numbers or addresses? • Discussing your own personal difficulties, relationship break-up, problems at home? • Flirtatious behaviour with a service user? • Using intimate words, such as, darling, love or dear? • Borrowing items or money from a service user? • Hugging a service user?

32. Some More Scenarios…. • Bringing in old/used clothes or books from home for a service user? • Personal disclosures such as holidays, days off • Stretching time available into personal time • Doing errands for the service user in your own time • Ask: crossing or violation? What risk to the service user, the staff or service? What action should the team take? • Document specifically and in detail, focus objectively on the service users needs and best interests • Be clear about your own personal and professional boundaries

33. Personal Boundaries • We ask our staff teams to explore their own personal preferences about boundaries. • We also make it clear that wherever there is a conflict, professional boundaries will always take precedent! • For example, we discuss self-disclosure and make sure that any disclosure made must be in the best interest of the service user and once disclosed the information no longer belongs to them and is in the public domain. You should not expect the same confidentiality as if in a social relationship.

34. What Harm might be Caused by Poor Boundary Management? • Much depends on the nature of the violation, the context and the individual vulnerabilities of the service user. • Such vulnerabilities would include: • The degree of intellectual disability • A previous history of abuse and exploitation • The presence of a mental illness or poor mental health • Poor physical health • Instability of the present or future living circumstances • Poverty or low disposable income • Poor or inadequate professional support network • Unstable or conflictual family relationships

35. The Nature of the Harm Caused: • Ambivalence • Guilt • Emptiness • Cognitive Dysfunction • Identity Disturbance • Inability to Trust • Sexual Confusion • Mood Liability • Suppressed Rage • Increased Suicidal Risk • Pope and Bouhoutsos (1986) • Ambivalence and mistrust towards future therapists • Questioning one’s sanity and reality • Repetition not exploration of childhood traumas • Exacerbation of original symptoms • Constricted intimacy with others • Rage, desire for revenge • Guilt and shame • Crisis and disorganization • Apfel and Simon (1985)

36. Potential harm to the Therapist? • The risk of being unreasonably judged to have breached professional boundaries. • Being placed in the impossible position • Feeling misunderstood and judged unfairly • Splitting of teams is not an infrequent consequence of boundary crossings • Personal issues can emerge or blindside a therapist • Professional misconduct

37. Doing Laundry: the importance of context! • Would it ever be appropriate for the service user to do the support worker’s laundry? Is this a Violation or Crossing? • If it is a crossing, under what circumstances might it be appropriate for the service user to do the support worker’s laundry? If it is a violation, why so? • What if the service user had OCD and was undertaking a CBT intervention on over-coming anxieties from touching items considered to be contaminated. Would this make a difference?

38. The Danger of Ignoring Context: • The context is critical in understanding any events that raise the question of the actions of others. • A man grabs a woman throwing her forcibly to the ground and then beats her all over her head and body with his hands. • The woman was on fire! • A middle aged man removes the clothes of a three year old child and touches her all over her body. • A father was bathing his child!

39. The Problem with Reductionism and Simplicity: • Boundary Crossings can also be misunderstood by not only ignoring the context and by failing to grasp the complexity of the situation and/or the service user but also by having a simplistic understanding of the demands and challenges of therapeutic boundary management. • We must continue to appreciate the complex nature of therapeutic boundaries and to meet the challenge of continuing to learn from our experience.

40. Thank you Dr David Bladon-Wing Consultant Clinical Psychologist & Company Director Community Therapeutic Services Ltd 81 High Street Worle Weston-super-Mare North Somerset BS22 6ET Office: 01934 708772 Mobile: 07973524327