Good Fences make Good Neighbours
Ann Heesters
University Health Network
Associate Director, Bioethics
Debbie Talbot
University Health Network
Manager, Volunteer Resources
Mending Wall
Why do we need boundaries?
• safety – cows or threat
• ownership/property
Do we always need boundaries?
• pine & apple trees
Some influences on boundaries
are out of our control – Mother
Nature
Robert Frost
Poem written in 1914.
Good fences, make good neighbors…
Frost was drawing on a
17th century adage.
His narrator came to the
realization that the wall
helped to establish and
sustain retain their
relationship.
A portion of the CAMH wall built by
psychiatric patients in the mid 1800’s. It too
has changed in meaning & significance.
From that perspective, it
was in part, a “retaining
wall.”
BOUNDARIES: An attempt at a definition…
boundaries are the
spaces between the professional power
and the vulnerability of another
Boundary violations
Boundary violations can
result when there is
confusion between the
needs of the professional
and those of the client.
Boundary crossings
Boundary crossings can
be brief excursions across
boundaries that may be
inadvertent,
thoughtless or perhaps
purposeful if done to meet
a special therapeutic
need.
Sometimes familiarity is warranted & therapeutic
and sometimes it is not…
Boundary issues (an incomplete list):
May be acceptable
Always unacceptable
• Self-disclosure
• Abuse of clients (sexual,
emotional, verbal, physical,
neglect)
• Gift-giving or receiving
• Caring (professionally) for
family members or friends
• …
• Financial exploitation
• Disregard for client’s values
(religious, cultural, etc.)
• ….
Boundaries can be a challenge…
Factors influencing vulnerability
• When do you feel vulnerable?
• What are the circumstances creating that
feeling?
Risk factors for boundary violations
Volunteer
• significant changes, life crises
• a tendency to identify a client
as special even familiar
Client
• over-dependence on a
therapeutic relationship
• using therapy to find love
or an intense relationship
• an inability to set limits
• A belief that it could never
happen to them
• an acceptance of abusive
or one-sided relationships
An Ounce of Prevention:
•
•
•
•
•
•
•
•
Screening – application form, interview, references, CRC
Orientation – general orientation to organization
Training – specific to role
Volunteer manual – outlines policies/procedures
Confidentiality – sign same oath as staff
Volunteer agreement – defines “dos” and “don’ts”
Position descriptions – specifies expectations of role
Mentorship – lead or senior volunteers
When to go a little bit further
• Screening criteria for volunteers – i.e. 1 year out of loss,
in the same unit as loved one is/was
• Training –additional provided where risk is higher i.e.
palliative care, oncology
• Professional Boundaries – ensure they understand i.e.
former nurse, foreign-trained physician
• Position description – outlines clear boundaries
• Supports – ensure high risk placements have access to a
sounding board/mentor
Keeping clients safe is our number one priority
Types of boundary crossings:
Issues may be related to:
1. client care
2. access to or disclosure
of information
3. gifts, services and
financial relationships
4. dual relationships
5. ???Others???
Types of boundary crossings:
1.
client care –
touching, behaviour while
client is disrobed, displays of
affection, response to
culture, tone, communication
style…
2.
access to/disclosure of
information –
failure to comply w/ policy or
legislation pertaining to
privacy/confidentiality,
inappropriate selfdisclosure…
3. gifts, services, financial
relationships –
appropriateness of gifting
depends on motivation, timing,
cost, client vulnerability…
4. dual relationships –
business relationships, romantic
attraction/ entanglement,
treating family members or
friends
5. ???Others???
Signs that a boundary may have been crossed:
• Frequently thinking of the client when away from work.
• Planning other clients’ care around the client’s needs.
• Spending free time with the client.
• Sharing personal information or work concerns with the client.
• Feeling responsible for the client’s progress ....
• Inappropriate or sexual touching in interactions with client.
• Favouring one client’s care at the expense of others.
Signs…continued
• Keeping secrets with client.
•Receiving gifts or continuing
• Selective reporting of client’s
behaviour (negative or
positive).
contact after discharge.
• Swapping client assignments.
• Communicating defensively
when questioned re.
relationship
• Changing dress style for work
when working with the client.
•Denying the fact that the client is a
client.
•Acting or feeling possessive about
the client.
•Giving advice to the client that
may contradict what others have
provided
•Giving attention to client which
differs from that given to others.
Kate: A Friend in Need
Kate was a volunteer at a regional distress centre taking calls
from various community members in need of support. All callers
were to remain anonymous. One teen caller described her
difficulties fitting in with the other girls at school. The volunteer
heard that her client lived alone with her unemployed mother. The
family was struggling with significant financial stressors.
Kate desperately wanted to help the client by providing her with
clothes, make-up and costume jewelry to help her fit in. She was
sure she could “fix” the situation. Kate went to the Manager of
Volunteers to ask if she could purchase some items and deliver
them to the young girl.
Questions for further reflection
• What are the needs of the client?
• Is the volunteer’s behaviour therapeutic for that client?
Why/Why not?
• Does the volunteer’s behaviour make it more or less
likely that the needs of all of the clients will be met?
Why/Why not?
• Are there signs that might alert the volunteer manager to
a possible boundary issue?
CEFIT for identifying & managing boundary dilemmas:
1.
2.
3.
4.
5.
How is the Context of the situation important?
What are the Ethical principles/values at stake?
What are the Facts of the case
What Indicators of boundary crossings apply?
Identify the Type of boundary crossing:
•
•
•
•
•
Client care
Access to/disclosure of information
Gifts/services/financial relationships
Dual relationships
Other
What options for managing this can you recommend? Why?
Dave and his Manager
• Dave is a former patient (post motor vehicle accident)
who volunteers at a hospital with the research team.
He suffers from occasional panic attacks and seizures
which are well controlled by medication. One
afternoon he comes to the volunteer manager’s office
to tell her that he will have to miss his shift because he
feels a panic attack coming on and he has left his
medication at home. She notes that his medication is
the same as her own so she offers him one of her
tablets.
Questions for reflection
• Are there any potential boundary issues in
this case?
• If so, what type(s) are they?
• What factors were relevant to your
determination?
• Do you anticipate any future challenges
following from the manager’s gesture.
Brad’s Cardiac Case
• Brad is a volunteer in a physical rehab facility. He
befriends an isolated middle aged man who has a
cardiac and social history similar to his own. The
client asks Brad to accompany him to his
apartment for a few hours so that he can take out
the garbage and turn off the lights.
• When they arrive at the apartment Brad is shocked
to discover what appears to be the home of a
“hoarder.” The client begs him to kept this
information confidential.
Questions for reflection:
• What kind of boundary issue(s) can you identify in
this case?
• How might this be managed?
• Could this have been anticipated or prevented in
some way?
• If you were Brad’s manager, what direction would
you give?
No one is asking you to stop caring…
http://piccsy.com/2011/07/
tightrope-dancers/
and remember that you are not taking this journey alone.
Thank you!
www.uhn.ca
550 University Avenue, Toronto, Ontario
[email protected]
[email protected]
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