Professional Boundaries Guided by Respect
I remember the wintry day she called from a phone booth not too far from the office, barely hanging on. I got somebody to take me out to find her and bring her back to the office. I remember the moment when I realized that the absurd choice before me was to do grief work or find insulin. After a frustrating morning on the phone trying to find some public or private source of help—a struggle she was in no shape at the moment to handle—I took her to a drug store and bought the insulin myself.
I was feeling a bit of shame. There’s an emphasis in our field now on maintaining proper boundaries, with the implication that those who do not are overfunctioning, codependent, and other compound words even more dreadful. Emotional disengagement was expected. Technically—though no one forbade it—it was not part of my job to go find people in phone booths or pay for their medicine. I was aware of stretching the limits of what I usually do.
—B. Jessing1
Chapter Objectives
• Describe why the idea of professional boundaries is relevant to respect
• Distinguish a respectful, professional approach from one based on objectivity and efficiency alone
• Identify clues that may alert you that your sympathy is becoming pity
• Define overidentification and its negative effects
• Describe what it means to care too much
The health care provider in the quote is struggling with the appropriate limits of her involvement with her homeless patient. She is experienced and knows she could overstep an appropriate boundary in their relationship and in so doing may cause more harm than good in the long run. Still, almost everyone can sympathize with her attempt to be respectful of her patient’s desperate situation. As she suggests, her challenge is not only to show respect by honoring the bonds of the relationship but also its boundaries.
A good general rule is that the physical and emotional boundaries between you and patients must always be guided by the goal of facilitating a patient’s well-being and maintaining profound and caring respect in the interaction (Figure 11-1). But knowing the general rule does not necessarily help one with the complex human stories that face you in the line of work you have chosen. For one thing, relationships are dynamic, and there are changes in them with every encounter. As the authors of one article critical of boundary language correctly noted, “‘Boundaries,’ for us, is a metaphor that, like ‘resources,’ leads to images of people as skin-bound containers with fixed contents or identities. This metaphor has implications for how subscribers to it view people and change.”2 Still, one has to appreciate the large body of literature that exists and the long tradition of behaviors that are considered appropriate for the type of relationship we are exploring here. As you read on you will see our attempt to provide some more details and examples of what it means to maintain professional boundaries and why.
What Is a Professional Boundary?
A professional boundary is the usual way of talking about physical and emotional limits to intimacy, the general contours of which were introduced in Chapter 5 when you were considering the differences between personal and therapeutic relationships. An extreme example sometimes is reported of health professionals losing their licenses or in other ways being sanctioned for engaging in sexual intercourse with patients or clients. We will briefly discuss this type of concern in a section that more broadly describes physical boundaries. Guidelines regarding emotional boundaries are designed to prevent psychological dynamics that are harmful to the patient or to you during the relationship. We will discuss these, too. While studying this chapter bear in mind that some boundaries come from external sources (e.g., the time you spend in the encounter), whereas others are internal (i.e., characteristics you and the patient bring to it).
The guidelines for physical and emotional boundaries are derived from several sources. Some are from professional ethics codes; others are from laws. These in turn have grown out of the experience of health professionals and patients in the past. Sometimes the guidelines change on the basis of insights from psychology regarding tensions that may arise from human needs for privacy, intimacy, and acceptance. Today studies of power differentials among persons within institutions and relationships add another component of understanding.
One way the wisdom of maintaining boundaries has been dramatized in the past is through the erroneous idea that being professional requires one to be aloof, objective, and efficient at the price of personal warmth and affectionate conduct. But to suggest that respect entails aloofness is a distortion of the highest goals to which we aspire and is often substituted for, rather than a sign of, competence.3
Recognizing a Meaningful Distance
In human interaction, psychological and physical distances take on deep meaning, determined by the degree of intimacy it represents for both parties. At one pole, there may be a complete sense of separateness, and at the other there is the realm of togetherness that is highly personal, informal, and familiar (i.e., intimate). At any point along this continuum, certain behaviors are put into play, whereas others remain in the background. In Chapter 8 you learned that a patient’s narrative unlocks doors to what the patient thinks and feels. Listening with care to this information will help you to be sensitive to the patient’s needs, including those that may go beyond what you can respond to in your role. A health professional dare not place too great an expectation on the patient or his or her family for emotional support in times of the professional’s own crisis. The delicacies with which the boundaries of respect must be maintained are the impetus for many of the reflections on this topic, some of which we share here.
Physical Boundaries
As a general rule Western societies do not condone much touching, especially among strangers. You may find a clerk in a store who physically touches the palm of your hand in returning change. You may be jostled in a crowd. You may shake a stranger’s hand in meeting. Among some a formalized form of kiss or buzz on the cheek is expected. Strangers may impulsively hug the man or woman next to them in the midst of an important sports event. However, the occasions when touching among strangers is socially sanctioned can probably be counted on the fingers of one hand. At the same time, many tasks in the health professions environment require caregivers to be in close physical contact with strangers who are their patients, and to do so respectfully. In addition, displays of affection expressed by a pat on the shoulder, a gentle hug, or other signs of support are behaviors you may be comfortable engaging in as a part of your interaction.
REFLECTIONS
We all experience a stranger’s touch on a regular basis.
Think of a time in the past couple days that you and a stranger came into physical contact.
Was it comfortable? If so, what made it so? If not, what happened that you had a flash of discomfort?
All cultures and their subcultures have socially constructed rules about when and between whom touching is condoned. Such rules and mores often extend to the acceptable conduct between health professionals and patients. For example, in some a male caregiver may not touch or even look at a woman’s body. At the same time, when taken seriously appropriate touch can be an effective means of establishing rapport or showing reassurance—and may be required for diagnostic or treatment regimens. In short, acceptable contours of physical contact between health professional and patient deserve your attention.
Unconsented Touching
Informed consent mentioned at the end of Chapter 10 is one of the most basic societal acknowledgments that professional contact may permissibly depart dramatically from general accepted social norms of physical contact. Informed consent arose in part from the legal concept of battery. Battery is a legal term acknowledging society’s deep prohibition against unconsented touching. By giving informed consent the patient is saying, in effect, I give you—and others involved in my care—consent to hold, stroke, rub, poke, or even puncture or cut me, depending on the scope of practice in your professional role. Obviously the permission to make physical contact already puts the health professional and patient relationship into a special category where usual, socially acceptable distances are breached on a regular basis.
Your right to make physical contact does not give you permission to impose on a patient’s sensitivities or dislikes regarding physical contact. Many cultural, social, and personal factors will come together to create a patient’s comfort zone regarding physical contact, and you should be guided by a sensitivity to individual differences.
Sexual Touching
Some types of physical contact are deemed unacceptable in the health professional and patient relationship under any conditions, even with the consent of the patient or client. Under law you cannot make contact with a patient with an intent to harm him or her physically or psychologically. If you do, you will be charged with abuse.
The type of touching that has received the most attention is physical contact delivered with an intent to excite or arouse the patient sexually. Although sexual intercourse is the most verboten, the prohibitions are not limited to it. For example, the American Medical Association’s 2010–2011 Code of Medical Ethics: Current Opinions with Annotations addresses the broader notion of sexual misconduct.4 Why should it be forbidden if a competent, adult patient consents to or even seems to invite sexual contact? The strongest argument against this type of contact is that it betrays the reasonable expectations built into the essence of the health professional and patient relationship. Patients have a right to receive the best care possible without having to satisfy the professional’s needs.
However, what about the idea that sexual activity between professional and patient may be taking place between two consenting adults? An objection to this argument is that sexual activity is never free from other types of claims on the other person, so both patient and health professional may begin to alter the conditions of the relationship in light of the power of its sexual dimensions rather than the conditions under which a patient sought professional care in the first place. In short, it is never considered fair that the patient would have to meet your need for sexual pleasure, sexual intimacy, sexual fulfillment, dominance in a relationship, or any other gain, no matter what the patient might believe will be gained.
Sexual Harassment
The importance of the idea that sexual distance must be maintained in public settings is being aired today in the notion of sexual harassment. The U.S. Equal Employment Opportunity Commission (EEOC) defines harassment as unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct and includes activity that creates a hostile or unwelcome work environment for the person who feels “harassed.” A more specific description follows:
Sexual harassment is a form of sex discrimination that violates Title VII of the Civil Rights Act of 1964. Unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature constitute sexual harassment when this conduct explicitly or implicitly affects an individual’s employment; unreasonably interferes with an individual’s work performance; or creates an intimidating, hostile, or offensive work environment. Sexual harassment can occur in a variety of circumstances, including but not limited to the following: The victim and harasser may be a woman or a man. The victim does not have to be of the opposite sex. The victim does not have to be the person harassed but could be anyone affected by the offensive conduct. The harasser’s conduct must be unwelcome. It is helpful for the victim to inform the harasser directly that the conduct is unwelcome and must stop.5
Most state licensing acts have provisions prohibiting such behavior by professionals, and many institutions include prohibitions in their policies. You will have ample opportunity to learn more about the particulars of the legal issues involved in this evolving area of the law. An important aspect of sexual harassment that has not been explored deeply enough involves sexual behaviors that issue from patients or their family members toward professionals. One of the only studies we found was of physical therapists: 63% of respondents reported having experienced some form of sexual harassment perpetrated by patients.6 At the heart of the discussion is the degree of distance and quality of exchanges that must be maintained for respect to be expressed and for human dignity to flourish for everyone involved.
What about Dual Relationships?
Dual relationships are defined as those in which “[a] professional . . . assumes a second role with a client, becoming . . . friend, employer, teacher, business associate, family member, or sex partner.” In the past the typical belief has been that once a health professional and patient relationship formally has ended, two consenting, competent adults ought to be free to do whatever they please. This makes good intuitive sense on the face of it. We call your attention, however, to insights from literature on the dynamics of dual relationships. It may begin before, during, or after the [professional] relationship. Dual relationships in the professions for the most part involve professionals who often rationalize their behavior, arguing that the situation is unique. “However, dual relationships are potentially exploitative, crossing the boundaries of ethical practice, satisfying the practitioner’s needs and impairing his or her judgment.”7
Friendships initiated after the termination of a professional relationship can be injurious to a former patient. Others warn that other relationships, such as business partnerships, can interfere dramatically with the professional’s ability to be sensitive and appropriately objective in the professional and patient relationship.8
More research in this general area is necessary. Current thinking about dual relationships is not conclusive. Not even all major health professions caution against it, especially once the formal therapeutic relationship has ended. To take seriously the potential for harm to a patient or former patient is to err on the side of better judgment. Although an exception may present itself, a good rule is to honor physical and emotional boundaries with great thoughtfulness and care.
We turn, then, to three types of experiences in which maintaining emotional boundaries become a tool of respect in the health professional and patient relationship.
Psychological and Emotional Boundaries
Some specific ways the emotional responses and psychological attachments of the health professional or patient can interfere with respect for the patient can be summarized in the term enmeshment:
. . . the nurse who has become enmeshed often develops an emotional connection with or an emotional availability to the client that may be impossible to maintain over the life span of the client. This can ultimately lead to client feelings of anger or emotional pain and to a sense of abandonment. The process of enmeshment may also complicate provision of adequate care at a later time. This can occur if the patient sees the other care team members as not caring sufficiently or as providing inadequate care, in comparison with the nurse who is enmeshed.9
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