COTBC Professional Boundaries (PB) Practice Standards

Date posted: May 11, 2017
Please note that these are currently being adjusted to reflect the October 2, 2017 changes to our bylaws. Your patience is appreciated.

Statement of Purpose

These Practice Standards for Professional Boundaries assist the occupational therapist to foster therapeutic relationships and recognize, prevent, and manage professional boundary issues. The reader will note that these standards are closely related to the Practice Standards for Conflict of Interest and Practice Standards for Prevention of Sexual Misconduct. This design is intentional, recognizing that the latter two sets of standards represent specific complex professional boundary issues. Used alongside COTBC’s Bylaws and Code of Ethics, as well as Essential Competencies of Practice for Occupational Therapists in Canada (3rd ed.), Practice Standards for Professional Boundaries serves to clarify the occupational therapist’s accountabilities and the College’s expectations respecting the occupational therapist’s management of professional boundary issues.

Overview

The occupational therapist is in a fiduciary relationship with his or her clients, and as such, has an ethical and legal responsibility to act in the client’s best interest. In therapeutic relationships, the occupational therapist acknowledges his or her position of power, recognizes that the client’s trust is both delicate and a privilege, demonstrates respect for the client, and ensures that the occupational therapist’s personal opinions, beliefs, and values do not affect the care provided. Additionally, the occupational therapist demonstrates empathy, balancing the ability to remain objective with sensitivity regarding issues of personal closeness and/or disclosure that arise during the course of treatment. Finally, the occupational therapist uses professional judgment to adapt his or her approach, meeting professional responsibilities in the most appropriate manner for a given situation.

The occupational therapist is responsible for maintaining the therapeutic relationship. By establishing and maintaining professional boundaries, the occupational therapist demarcates professional relationships from personal ones. This supports objectivity and the ability to keep the client’s interests as the primary focus of service delivery. Clear professional boundaries also provide a framework for appropriate relationships with other stakeholders in occupational therapy services, such as business partners, colleagues, third-party funders, and vendors.

Professional boundaries are dynamic and can vary with the client’s presentation, the physical context of the intervention, and time. Occasionally, professional boundaries are crossed, either intentionally or unintentionally. When a boundary crossing is unavoidable, as can arise when working in small, rural, or remote areas where access to alternative health care providers is limited, it is the occupational therapist’s responsibility to effectively manage identified risks. Examples of boundary crossings include asking a client something personal that is not related to the therapeutic relationship, and disclosing personal information about the occupational therapist’s own stressors. Crossings have the potential to destabilize the therapeutic relationship, influence the occupational therapist’s objectivity and competence, and shift the power balance. Therefore, it is important that the occupational therapist use professional judgment, actively monitor interactions for these crossings, anticipate potential high-risk activities, and reestablish appropriate professional boundaries where possible.

Left unchecked, boundary crossings can become boundary violations, where personal or nontherapeutic elements unfold within the therapeutic relationship. This can bring harm or the potential for harm to the client as well as the occupational therapist. Examples of boundary violations include having sexual relations with a client or borrowing money from a client. Client consent is not a defence for violating a professional boundary.

PB Practice Standard #1: Fostering Therapeutic Relationships

Principle Statement:
As related to professional boundaries, the occupational therapist will foster therapeutic relationships with his or her clients in a transparent, ethical, client-centred manner with respect for diversity of beliefs, uniqueness, values, and interests.

Practice Expectations
The occupational therapist must do the following:

  1. Assume responsibility for anticipating, establishing, maintaining, and communicating appropriate professional boundaries with the client.
  1. Respect each client’s uniqueness and diversity, taking into account such factors as the client’s capacity, beliefs, values, choices, religion, lifestyle, sexual orientation, socioeconomic status, and culture.
  1. Obtain, maintain, and document informed client consent. Refer to Obtaining Consent to Occupational Therapy Services.
  1. Use a client-centred approach.
  1. Apply skills to build rapport with the client including the use of active listening skills and communicating in a respectful, nonjudgmental manner.
  1. Regularly reflect on the occupational therapist’s own practice and participate in professional development related to fostering therapeutic relationships.

PB Practice Standard #2: Recognizing Professional Boundary Issues

Principle Statement:
The occupational therapist will take action to recognize potential professional boundary issues.

Practice Expectations
The occupational therapist must do the following:

  1. Acknowledge that there are circumstances where it is never acceptable to cross a professional boundary (e.g., entering into a sexual relationship with a current client). Refer to Practice Standards for Preventing Sexual Misconduct.
  1. Recognize types of professional boundary crossings and violations and situations that may lead to them.
  1. Recognize the implications professional boundary violations have for clients and for the public’s perception of the profession.
  1. Recognize any personal beliefs, opinions, or values which may affect the occupational therapist’s ability to meet the client’s needs (e.g., beliefs regarding race, sexual orientation, or nationality).
  1. Recognize any personal or professional risk factors that may make the occupational therapist vulnerable to boundary crossings or violations (e.g., his or her own physical or mental health, personal stressors, social or professional isolation, loneliness, or lack of knowledge about professional boundaries).
  1. Recognize situations that may involve any direct or indirect benefit (i.e., personal, professional, political, academic, financial, or material benefits) to the occupational therapist that could reasonably influence professional judgment, competence, or objectivity. Refer to Practice Standards for Conflict of Interest.
  1. Monitor the occupational therapist’s own warning signs and psychological, emotional, and physical reactions that may indicate an emerging professional boundary issue, such as
    • selecting a client based on looks, age, or social standing;
    • providing increased attention or continued therapy when not professionally required;
    • disclosing information about his or her personal situation when not with the intent of benefiting the client or the therapeutic relationship;
    • being preoccupied with the client’s social life outside the therapeutic relationship;
    • looking forward to physical contact with the client and feeling betrayed if the client pulls back;
    • dressing differently for specific clients;
    • experiencing discomfort or defensiveness when discussing or documenting client interactions; or
    • receiving feedback that others perceive potential professional boundary issues with the client.
  2. Monitor the client and the therapeutic relationship for warning signs that may indicate an emerging professional boundary issue, such as the client
    • discovering a dual relationship during the course of treatment,
    • pulling away when touched neutrally or indicating jealousy regarding physical contact,
    • disclosing more personal information than necessary,
    • inviting the occupational therapist to social or personal events or to be friends on social media platforms, or
    • appearing to be sexually attracted to the occupational therapist.
  1. Recognize any potential professional boundary risks within the occupational therapist’s practice context (e.g., providing sexual education, supporting self-care activities, working with clients with generational or cultural differences, or working in a small, rural, or remote location).
  1. Consider feedback from others who may perceive a professional boundary issue.
  1. Seek proper advice when uncertain whether there is a professional boundary issue.
  1. Review workplace policies and procedures related to professional boundaries.

PB Practice Standard #3: Preventing Professional Boundary Issues

Principle Statement:
The occupational therapist will take necessary actions and precautions to prevent or avoid boundary crossings and boundary violations.

Practice Expectations
The occupational therapist must do the following:

  1. Establish, maintain, and communicate professional boundaries with the client, his or her family, and other stakeholders in both clinical and nonclinical settings.
  1. Advise the client that his or her consent does not make a boundary violation permissible.
  1. Provide the client with information on alternative options for receiving occupational therapy services in circumstances that have a potential for professional boundary issues.
  1. Modify the practice setting or therapeutic approach to minimize any identified or emerging professional boundary concerns (e.g., ask the client whether he or she would like to invite a family member to attend, drape the client appropriately, dress appropriately, provide therapeutic rationale if offering services outside traditional practice settings, or create private professional treatment spaces).
  1. Touch clients in a therapeutic manner only, after reconfirming consent.
  1. Avoid special or discriminatory treatment towards a particular client or organization, such as
    • preferentially scheduling client appointments;
    • billing irregularly (i.e., offering variable rates or bartering or exchanging health care services for services provided by the client);
    • providing personal telephone numbers or other means of nonprofessional contact (e.g., personal social media pages or email addresses);
    • receiving or exchanging gifts (refer to Practice Standards for Conflict of Interest); and
    • completing for clients activities that do not fall within the therapeutic relationship.
  1. Not exploit therapeutic relationships or the occupational therapist’s professional status for any form of nontherapeutic or personal gain, benefit, or advantage. This includes obtaining access to privileged information or knowledge the occupational therapist receives in working with the client or organization.
  1. Avoid participating in activities or establishing therapeutic relationships where the occupational therapist’s objectivity, judgment, or competence could be impaired because of his or her present or previous familial, social, sexual, emotional, financial, supervisory, political, administrative, or legal relationships. For example, avoid entering into dual relationships with his or her own partner, past romantic partners, family members, friends, and colleagues, except in emergency or unavoidable situations, such as can occur when working in small, rural, or remote communities.
  1. Never enter into nontherapeutic relationships that could adversely affect an existing therapeutic relationship, or otherwise compromise the occupational therapist’s objectivity, judgement, or competence. Examples include entering into nontherapeutic relationships with  any of the following:
    • A current client.
    • A former client, unless it can be established that sufficient time has passed since the professional relationship ended and that it will not be reestablished. If the care provided involves an especially vulnerable client, the occupational therapist should never enter into a personal relationship with the client.
    • A client’s parent, a colleague’s client, or a client receiving care in the same service or area of practice.
  1. Provide colleagues with feedback if professional boundary issues or the potential for such issues are identified.
  1. Apply any workplace policies and procedures related to professional boundaries. Where they do not exist or are insufficient, advocate for or participate in their development as able (e.g., policies related to consent, conflict of interest, personal financial relationships with clients, gift giving, dual relationships, and nontherapeutic interactions with clients).
  1. Seek proper guidance if there are concerns about professional boundaries.

Practice Standard #4: Managing Professional Boundary Issues

Principle Statement: The occupational therapist will manage and address any identified professional boundary crossings and violations.  

Practice Expectations
The occupational therapist must do the following:

  1. Accept responsibility for boundary crossings and violations as they occur.
  1. Seek proper assistance as required.
  1. Discuss any identified professional boundary issues or concerns with the client (e.g., those encountered when entering into an unavoidable dual relationship).
  1. Clarify roles and set or reestablish professional boundaries, if possible.
  1. Obtain and revisit informed consent, acknowledging that there are circumstances when it is never acceptable to cross a professional boundary despite the client’s consent.
  1. Document the circumstances, an account of why a dual relationship is unavoidable (if applicable), risk assessment, precautions taken, plan, client reactions, and informed consent process.
  1. Where there is a potential or actual professional boundary issue that cannot be adequately resolved, arrange for care by another occupational therapist or appropriate health care professional, and end the client relationship, ensuring that the client is not adversely affected during this process.
  1. Follow duty to report procedures where there are reasonable grounds to believe that an occupational therapist or other health professional has abused a client sexually, physically, verbally, psychologically, financially, or otherwise, or where an occupational therapist contravenes the standards of practice or COTBC Code of Ethics. Refer to the COTBC Bylaws and Practice Standards for Preventing Sexual Misconduct.