Ethical standards in a practice setting: respecting boundaries in the broadest sense holds the key to humane treatment

Addiction Professional,  March-April, 2008  by Kimberly Dennis

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The media is rife with examples of boundary violations toward patients and families in the arena of addiction treatment. We need look no further than Dr. Phil's "Al-Anon relapse" with Britney Spears to see the effect of offering patients or potential patients unsolicited help. But that's extreme, and the truth is we face ethical dilemmas every day as we learn about, understand, and treat the individuals with whom we work.

Whether you're a counselor, therapist, psychologist, or psychiatrist, you understand the need to practice according to ethical codes. The word "ethical" undoubtedly means many things to different people. For the purpose of this article, we will define "ethical" in the Hippocratic term of "first, do no harm." In part, doing no harm means to practice in the therapeutic relationship without violating the patient (and family for minors) while helping the patient (and family and yourself) recover to the fullest possible extent. Doing no harm does not mean protecting the patient and/or family from the powerful healing that comes with getting in touch with, expressing, and feeling their feelings--a necessary part of the family recovery process.

Sometimes, lay persons, families, and patients themselves view a therapist supporting a patient in feeling difficult and intense emotions (i.e., rage, shame, sadness, hurt, loneliness) as harmful, or even unethical. The disease of addiction or an eating disorder operates in the service of avoiding feeling emotions. In the service of recovery, we support families in feeling emotions, and deep healing ensues.

Respecting boundaries

Most of us possess an inherent capacity to know the difference between what is useful or constructive (referred to by many people as "right") and what is harmful or destructive (referred to by many people as "wrong"). How do you manage the "gray" areas of those codes in a health care practice setting? As we operate a service-oriented practice, we must constantly be mindful of boundaries in all aspects of treatment for our clients: not only patient-doctor boundaries, but also the boundaries between the therapeutic setting and the outside world--families, referral sources, collaborating treatment providers, insurance companies, etc.

Helping patients build and maintain healthy boundaries through modeling is an important aspect of treatment that results in recovery: knowing what information is important to share, with whom that information needs to be shared, and sharing that information in a manner that fosters recovery rather than in a way that violates a patient's boundaries or separates them from family members, sponsors, or other care providers who may provide support.

We naturally go to the client when we think boundaries, but we must also address the family. Because addiction is a family disease, all members of a family unit are affected--not only by the pain and consequences of an addiction, but also by the treatment and recovery process. Family education, support, each member's own healing, and involvement in recovery programs such as Al-Anon or Families Anonymous play an incredibly strong role in effective treatment.

For us, as the providers, it is critical that we respect those relationships, but also avoid violating the patient's boundaries around confidentiality in the therapeutic relationship. Maintaining this integrity in the therapeutic relationship is an essential aspect of healing for patients seeking recovery from eating disorders, addiction, and other behavioral illnesses. Many of these patients have had experiences where their boundaries (physical, emotional, and/or spiritual) have been violated, discounted, or neglected.

Of course, this respect of the individual's boundaries can lead to frustration at the family level, leading further to possible dissatisfaction with your practice and treatment. At Timberline Knolls, we counter this possible conflict by creating an atmosphere of high-touch customer service, which can be easily replicated at practices large and small. Instead of treating the client alone, treat the family. Invite members to participate in family sessions weekly, and create an environment where the resident, your client, can take the opportunity to share directly, removing you from the ethical challenge of feeling the need to be a "messenger" to inquiring parents, siblings, spouses, or friends.

But what if we are dealing with a client who has disclosed risky, dangerous, or life-threatening behavior? This gray area requires careful consideration of the client's age, the client's awareness level, the type of behavior, and whether the behavior is life-threatening. Would your client be better served if her family knew about the behavior or actions in question? Our initial goal, which meets our ethical responsibility, is to have the patient become aware her behavior is dangerous, then to help her take responsibility for asking for help. The best way we can help our patients do this is by teaching them how, and by supporting them in disclosing the behavior or activity to their family and other supportive people themselves.