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Setting Clear and Ethical Boundaries with Clients

Section 10
Rural Mental Health Care

Question 10 | Test | Table of Contents

Mental Health practitioners in rural settings are confronted with ethical dilemmas on a daily basis with regards to confidentiality, dual relationships, and boundary issues. The following article will address several situations involving these issues and practical solutions in handling these potential ethical dilemmas without compromising the practitioner’s commitment to their Professional Code of Ethics.

In small towns, people often joke that what you do beats you home, makes headlines in the local paper, or is the main topic of conversation at the beauty and coffee shops. For obvious reasons, confidentiality can be somewhat problematic for the practitioner.

As a school therapist, the clients I work with many times end up being one of the following: the child/children of a neighbor, my insurance agent, grocer, police officer, all the way down the line to my personal friends. It would be great if there was another school counselor to refer these cases to, but unfortunately, I’m it! How can these ethical gray areas be dealt with?

How to Set Boundaries on Gossip
First, let us visit about confidentiality. The best practice, in order to eliminate confidentiality problems, is only to share information about clients with those people whom the client has signed a release of information for. The client needs to be told this unwritten rule up front.

Then, if someone in the community has privy information, it is either because the client has shared that information or someone who I have signed a release for has shared. By having releases signed, it covers me legally and puts the responsibility back on the clients and their providers to maintain confidentiality. Another issue faced almost on a daily basis is constantly being in situations where people are discussing children/parents that I am working with. The information being discussed may not even have any merit or, on the other hand, may be true.

It is very difficult not to want to set the record straight, but the best thing to do is to exit the area (teachers’ lounge, break room, local eating establishment) if at all possible. If you can’t leave, you need to refrain from comment. If asked a question directly, it is best to tell people you can’t discuss the case without a release of information signed by the client allowing you to do so. Sometimes, people are not happy with this response, and on occasion, I have mentioned that I’m sure they wouldn’t want me to share their personal information if the tables were turned. This usually pacifies the majority, but as always, you can’t please everyone.

A Way to Handle Dual Relationship
Having a professional relationship with people you do business with in the community is another ongoing issue. A few of these people may include the following: your physician, clergy, department of human services, public health, your child’s teacher, and numerous others. If at all possible, one should try to limit these connections, especially if the person is your client in your professional capacity, as it puts the practitioner in a one-up position which skews boundaries, and may even cause the client to feel obligated to give you special treatment that they wouldn’t give under other circumstances.

For example, you are working with one of the local law enforcement officer’s children, and he/she stops you for speeding. Upon seeing you, they say they will give you a warning. My response would be, “If you didn’t know me, would you give me a warning?” If their response is no, they would give me a ticket—I would have to insist that they write me up. Crazy—yes, but ethically sound. The best rule of thumb, again, is to try and avoid those dual relationships if at all possible. (If they can’t be avoided, discuss openly with the client, up front, what problems could occur, and try to be active problem-solvers rather than reactive after the fact. Engage the client by empowering him/her to come up with a plan to assist in dealing with the potential issues that you both have brainstormed.

Setting Boundaries in Public Places
What about those times when clients feel compelled to share their life story or latest life event with the practitioner in the grocery store, gas station, laundry mat, church, and numerous other public places.

Grocery Store Encounter
Let’s talk about how each of these situations might be handled should they arise. For example, Julie (a client) approaches me in the produce aisle at the grocery store. Julie starts to tell me about the huge fight she and her daughter got into the previous night. Several people we both know are within hearing distance.

I take Julie aside and model by whispering, “Julie, it would be better if we could discuss this in a more private place. Would it work for you to come by my office tomorrow at 3:15pm?” Julie says, “Yes,” and I respond, “Great, I’ll talk to you then.” I then proceed to another section of the store and return to the produce on my way out of the store. I’ve just done two things. First, I gave Julie a definite time so she knew she would have a chance to talk, and secondly, I’ve assisted her by modeling how she should be talking about private matters (i.e., voice tone and place).

Using Redirection to Set a Boundary
My next example finds me pumping gas at the local gas station. Tom, one of my special needs students, is riding his bike by and sees me. He approaches me with a big grin and says, “Mrs. Brush, you know that problem I have with wiping? I went all day today and didn’t get any on my underwear.”

I reply in a soft voice, “That’s great Tom. This is one of those things we talked about that is private. So next time, I know you’ll remember to tell me when we meet at school.” “What if I forget?,” says Tom. “Whisper to your teacher to write it down for you along with anything else you’d like to tell me.” Tom says, “OK, Mrs. Brush,” and rides off on his bike. In this situation, the words were already out of Tom’s mouth before I could redirect him, so I tried to salvage the conversation by making it into a learning experience.

Exit the Scene
Now the laundromat poses some interesting boundary issues. Not only do you have clients approaching, you but you also have other people who feel at liberty to share a wealth of information with you about your clients. It might look and sound something like this: I’m putting my rugs in the washing machine when two girls approach me and say, “Do you work with Danielle Thompson?”

My response, “I’m not allowed to tell people who I work with. It is confidential.” “Well, she’s been leaving her children alone while she goes out drinking. We’ve told DHS (Dept. of Human Services), and they haven’t done a thing about it.” I say, “That’s frustrating. It sounds like you are really concerned about the children, and you have done everything within your power.” I politely excuse myself and exit the laundromat. I’ve not broken confidentiality, as I didn’t acknowledge that I work with Danielle, and I attempted to validate their concerns without engaging in the conversation.

Take Control of the Conversation
What does one do when confronted at church of all places? Several teachers attend the same church as I do. They sometimes have difficulty catching me during school hours, so they find church a prime opportunity to discuss children we are jointly working with.

For example, Sara, a special education teacher, stops me outside the sanctuary and says, “We need to have a meeting about Gonzales. They leave for three months every winter, and Hernandez is missing too much school.” I respond, “When is a good time to call you tomorrow to discuss this?” Sara states, “Call before 8:30am and...” I quickly cut her off with “Great - talk to you then,” and head into the sanctuary.

Calls at Home!
How about when the practitioner is sitting down at home to enjoy a rare meal with the entire family, and a client, who doesn’t see a problem reaching you at home, calls? More than likely, your number is in the book, or they know someone who has it. And of course, the best one yet, thanks to technology, they have caller ID. I feel the best way to handle such occurrences is to be preventative. I tell clients up front that their lives are private, and what they have to say is very important.

I discuss with them that in such a small town, we will likely run into each other, and I would prefer for them to call and set up an appointment, so I can give them the attention and privacy they deserve rather than discussing their personal lives in public. When a person does start sharing information, I politely remind them about our initial conversation, and ask them to please call me at the office where we won’t be interrupted and excuse myself.

I also tell my clients that I will not take calls at home unless it is an emergency, and I define emergency as potentially life threatening events. I also give them 800 numbers for emergency hotlines. I try to screen my calls at home, and if by chance someone calls, I ask if it is an emergency and explain that my time with my family is limited and ask that they contact me the following day during office hours.

Boundaries with Friend
Last but not least, what do you do when a personal friend asks you to provide services to them or one of their family members? It is best practice not to provide professional services to friends at all costs. If you provide services and it is a success, sometimes this can be pulled off, but if things don’t work out as the friend has imagined, the friendship is often damaged beyond repair.

I try to explain this to my friends before the situation arises and give them a list of resources if needed. As a last resort, I have completed ADHD evaluations, screened for depression and other mental health concerns with the agreement that the information would be given to another professional to assess. In those cases, I kept strictly to factual diagnosis symptomology as substantiated by the DSM-IV criteria.

Avoiding Clouded Judgment
Finally, as a rural practitioner, it is important to stick to what you know to be the truth/facts and not let gossip or other information cloud your judgment. You need to avoid work and social situations that will compromise your ethical standards when possible. You constantly need to be troubleshooting and thinking in a preventative fashion. It is helpful to discuss these ethical situations with the client in the initial visit, and give them the opportunity to make an educated decision on whether or not to pursue a therapeutic relationship with you or seek outside resources.

Most of all, don’t become the Lone Ranger. Make sure you have someone to discuss these ethical dilemmas with and get feedback. This will also help you to avoid burnout, which is another dilemma facing social workers that can be discussed at length at a later date.

- Brush, Janel J. (2005). Employed by Healthcare Training Institute to research and write the article Ethical Boundary Challenges Facing Therapists in a Small Town.
Bio - Janel Jean Brush, LISW, Jefferson, Iowa, with experience in domestic violence, Licensed Independent Social Worker currently working at an area education agency as a school social worker, work history as youth counselor for shelters and group homes, department of human service worker, and psychiatric technician.

Personal Reflection Exercise #2
The preceding section contained information about ethical boundary challenges facing therapists in a small town. Write three case study examples regarding how you might use the content of this section of the Manual in your practice.

Urban-Rural Differences in Mental and Physical
Health among Primary Care Patients
with Multiple Chronic Conditions:
A Secondary Analysis
from a Randomized Clinical Trial

- Bonnell, L. N., Clifton, J., Rose, G. L., Waddell, E. N., & Littenberg, B. (2022). Urban-Rural Differences in Mental and Physical Health among Primary Care Patients with Multiple Chronic Conditions: A Secondary Analysis from a Randomized Clinical Trial. International journal of environmental research and public health, 19(23), 15580.

Peer-Reviewed Journal Article References:
El-Amin, T., Anderson, B. L., Leider, J. P., Satorius, J., & Knudson, A. (2018). Enhancing mental health literacy in rural America: Growth of Mental Health First Aid program in rural communities in the United States from 2008–2016. Journal of Rural Mental Health, 42(1), 20–31.

Jensen, E. J., Wieling, E., & Mendenhall, T. (2020). A phenomenological study of clinicians’ perspectives on barriers to rural mental health care. Journal of Rural Mental Health, 44(1), 51–61.

Weinzimmer, L. G., Dalstrom, M. D., Klein, C. J., Foulger, R., & de Ramirez, S. S. (2021). The relationship between access to mental health counseling and interest in rural telehealth. Journal of Rural Mental Health, 45(3), 219–228.

What are three techniques for setting boundaries?
To select and enter your answer go to Test.

Section 11
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