Professional Boundaries

Professional boundaries have been defined as a series of behaviours that allow for a safe connection, based on the patients needs (Peterson 1992, Gabbard 1989). They encompass the way we dress, the management of gifts, the amount we talk about ourselves, the way we speak with patients and colleagues, the settings we work in, the kinds of relationships it’s okay and not okay to have, the attachments we form and the clinical and meta-clinical choices we make. Boundaries have also been articulated as a kind of inter-personal phenomenon, something which can’t be touched and which are established, negotiated and re-negotiated in every interaction we have (Celenza 2002). This mixture of the tangible and the conceptual means that effective learning about boundaries is a blend of developing some concrete tools and of learning new ways of being, from which the management and maintenance of boundaries becomes an established professional skill, like an instrument you have learnt how to play, and on which you continue to learn new tunes.

Boundaries may be conceptualised as existing on a spectrum, with safe boundaries at one end, boundary violations at the other, and with a large grey section in between. Here are areas of practice which involve boundary crossings, which may be benign or may tend towards the risk end of the spectrum. Some behaviours are always okay, some are never okay and some are sometimes okay. Much depends on circumstances, on the characteristics of individual patients and on the way that language is used. There are some areas of practice (like having sex with a patient, assaulting a colleague, withholding medication without cause) where there are unequivocal restrictions and prohibitions, the breaching of which is likely to end in professional censure of some kind; the second two sections of this module deal with these areas. There are also many areas of practice, like the extent of self-disclosure, how best to manage demanding patients, feelings of attraction or dislike etc, where fixed and constant rules are not available or possible, and it is these areas which the first two sections of this module are concerned with.

In the first section you will be asked to reflect on a series of questions designed to help you to consider where you locate yourself on a wide range of issues to do with boundaries. They are there to prompt reflection and you are asked to allow yourself some proper time to see what connections you can make with your working practice and experience. Some questions deal with aspects of your working life that you may not have considered before, or which you may feel are quite personal. We can re-assure you that whatever comes up for you is not unique to you, and that all clinicians will have faced similar challenges at many points of their working lives.

In the second section we have grouped together some notes on each question for your additional consideration. These comments represent the experience of the writers in working with the public and of working with a wide range of practitioners, including those who have got into trouble around a breach of boundaries. They are not answers to the questions, rather they are further areas that you might consider, and which have been demonstrated to be helpful.

The third section is a short guide on where you can seek help and assistance if you believe that you or a patient may be at risk. Also listed are some of the most relevant guidance and publications produce by regulatory and professional authorities, along with a recommended reading list.

The Fourth section is a Multiple Choice Questionnaire, designed to help you to increase your knowledge about what the formal rules say about boundaries. It focuses on the facts, i.e. it is concerned with what the rules actually say, rather than with the more personal and nuanced questions of the first sections.

The fifth section is a short set of suggested activities designed to assist you in putting your learning into practice.

The sixth section is a list of works referred to and consulted.

Author: Jonathan Coe and Associates, The Clinic for Boundaries Studies

Thank you: Julia Whiteman, Jocelyn Hewitt, John Launer, David Mendel, Alex Jamieson, Catherine O’Keefe, Joyce Antubam, Bobby Wilcox

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