The Line:

By: Liz Wolf

• After two years of seeing Susan, no progress has been made in therapy. I went to Susan for mental health issues, Susan has her CAP, and she is an addiction counselor. In the beginning of the treatment process there were clear boundaries and goals with Susan. As time went on Susan and I began to be friends and she started disclosing her personal life to me such as her sex life. Then we started going out to coffee and out to eat, and she started accepting and giving gifts such as an old laptop I gave her. Susan did not know how to treat me because I did not have an issue with addiction I went to Susan for mental health, so Susan went out of her scope of knowledge and expertise and tried to do DBT with me, which did not work because she was not certified in it, did not have the proper training in it and did not have a supervisor to assist her in DBT training. Susan also did not have any supervision in any other issues she was having in treating me. Susan didn’t know what treatments were effective with me and how to implement them so I ended up teaching Susan how to use different therapy techniques and methodologies such as art therapy. On top of Susan and me becoming friends, Susan self-disclosing too much personal information, being incompetent to treat me, Susan also spoke to my mother without consent from me.

Ethical Codes Broken:

• Lack of boundaries • Conflict of interest • dual relationship• self-disclosure • Incompetent• broke confidentiality

• “Boundaries help ensure that no external factors interfere with the relationship or compromise the level of care being provided” (Nickel, 2004).

• “Therapy boundaries provide a framework that can guide and manage client expectations of the therapeutic encounter as well as distinguish therapy from other social events in the clients life. More specifically, client and therapist roles are maintained by boundaries intended to define and delineate behavior that it acceptable in therapy” (Audet, 2011).

• “Boundary issues occur when social workers face possible conflicts of interests in the form of what have become known as dual or multiple relationships. Dual or multiple relationships occur when professionals engage with clients or colleagues in more than one relationship” (Reamer, 2003).

• “A professional enters into a dual relationship whenever he or she assumes a second role with a client” (Reamer, 2003).

• “The code goes on to say that social workers should not engage in dual or multiple relationships with clients or former clients in which there is a risk of exploitation or potential harm to the client” (Reamer, 2003).

• “Therapist disclosure can infringe upon client therapist boundaries and compromise professionalism” (Audet, 2011).

NASW Code of Ethics:

• 1.01 Commitment to Clients• Social workers’ primary

responsibility is to promote the well being of clients. In general, clients’ interests are primary. However, social workers’ responsibility to the larger society or specific legal obligations may on limited occasions supersede the loyalty owed clients, and clients should be so advised.

NASW Code of Ethics:

• 1.03 Informed Consent• (a) Social workers should provide

services to clients only in the context of a professional relationship based, when appropriate, on valid informed consent. Social workers should use clear and understandable language to inform clients of the purpose of the services, risks related to the services, limits to services because of the requirements of a third party payer, relevant costs, reasonable alternatives, clients’ right to refuse or withdraw consent, and the time frame covered by the consent. Social workers should provide clients with an opportunity to ask questions

NASW Code of Ethics:

• 1.04 Competence• (a) Social workers should provide

services and represent themselves as competent only within the boundaries of their education, training, license, certification, consultation received, supervised experience, or other relevant professional experience.

• (b) Social workers should provide services in substantive areas or use intervention techniques or approaches that are new to them only after engaging in appropriate study, training, consultation, and supervision from people who are competent in those interventions or techniques.

• 1.06 Conflicts of Interest• (a) Social workers should be alert to

and avoid conflicts of interest that interfere with the exercise of professional discretion and impartial judgment. Social workers should inform clients when a real or potential conflict of interest arises and take reasonable steps to resolve the issue in a manner that makes the clients’ interests primary and protects clients’ interests to the greatest extent possible. In some cases, protecting clients’ interests may require termination of the professional relationship with proper referral of the client.

• (c) Social workers should not engage in dual or multiple relationships with clients or former clients in which there is a risk of exploitation or potential harm to the client. In instances when dual or multiple relationships are unavoidable, social workers should take steps to protect clients and are responsible for setting clear, appropriate, and culturally sensitive boundaries. (Dual or multiple relationships occur when social workers relate to clients in more than one relationship, whether professional, social, or business. Dual or multiple relationships can occur simultaneously or consecutively

NASW Code of Ethics:

• 1.07 Privacy and Confidentiality• (b) Social workers may disclose confidential

information when appropriate with valid consent from a client or a person legally authorized to consent on behalf of a client.

Florida Statutes & Laws:• 397.401 License required; penalty;

injunction; rules waivers.—• (1) It is unlawful for any person or agency to

act as a substance abuse service provider unless it is licensed or exempt from licensure under this chapter.

• 397.405 Exemptions from licensure.—The following are exempt from the licensing provisions of this chapter:

• (1) A hospital or hospital-based component licensed under chapter 395.

• (2) A nursing home facility as defined in s. 400.021.

• (3) A substance abuse education program established pursuant to s. 1003.42.

• (4) A facility or institution operated by the Federal Government.

• (5) A physician or physician assistant licensed under chapter 458 or chapter 459.

• (6) A psychologist licensed under chapter 490.• (7) A social worker, marriage and family

therapist, or mental health counselor licensed under chapter 491.

• 394.4615 Clinical records; confidentiality.—• (1) A clinical record shall be maintained for

each patient. The record shall include data pertaining to admission and such other information as may be required under rules of the department. A clinical record is confidential and exempt from the provisions of s. 119.07(1). Unless waived by express and informed consent, by the patient or the patient’s guardian or guardian advocate or, if the patient is deceased, by the patient’s personal representative or the family member who stands next in line of intestate succession, the confidential status of the clinical record shall not be lost by either authorized or unauthorized disclosure to any person, organization, or agency.

Solution 1: Set boundaries with Susan

Pro’s:• This is good practice for me

to be assertive• If boundaries were set it is

more likely that I would get more out of therapy

Con’s:• Could cause awkwardness

between us• I’m passive• She could get offended

Solution 2: Terminate treatment and get referral to new therapist

Pro’s:• The new therapist might

actually help me• I could get a therapist that

is trained and educated in mental health

• I would learn new skills and coping tools instead of just sitting around chatting

• Therapy could be productive

Con’s:• It would hurt Susan’s

feelings• It’s hard for me to trust

Best Solution: Terminate and get refferal for new therapist

• 1.) Susan broke Florida state law and was unethical by breaking confidentiality and practicing outside of her knowledge and expertise.

• 2.) There is a lack of boundaries which is causing a conflict of interest especially with Susan self-disclosing her personal life; are we friends or is this a therapeutic relationship?

• 3.) My best interest is not Susan’s first objective, being my friend and hanging out is

• 4.) Susan accepted a gift from me that was more than $100 and she gave me gifts as well

• 5.) I’ve seen her for 2 years and have not progressed, learned coping tools, or skills

• 6.) I don’t have an addiction problem and she is an addiction counselor, I need to see a therapist who specializes in mental health

References:• Audet, C. T. (2011). Client perspectives of therapist self-disclosure: Violating • boundaries or removing barriers?. Counselling Psychology Quarterly,

24(2), • 85-100. doi:10.1080/09515070.2011.589602• Clinical social work, family & therapy & mental health counseing: Florida statutes

and rules. (2012). Retrieved from • http://www.leg.state.fl.us/Statutes/index.cfm?

App_mode=Display_Statute&• Search_String=&URL=0300-0399/0394/Sections/0394.459.html• NASW Delegate Assembly. (2008). National association of social workers .

Retrieved from http://www.socialworkers.org/pubs/code/code.asp• Nickel, M. (2004). Professional Boundaries: The Dilemma of Dual & Multiple • Relationships in Rural Clinical Practice. Counseling & Clinical Psychology • Journal, 1(1), 17-22.• Reamer, F. G. (2003). Boundary Issues in Social Work: Managing Dual

Relationships. Social Work, 48(1), 121-133.