Developing and maintaining therapeutic relationships with clients is a core part of a clinician’s role.
Boundary crossings render this relationship vulnerable whilst boundary violations have the potential to do substantial harm to the client.
New practitioners are particularly vulnerable to boundary errors and can find themselves ‘out of their depth’ without realising this, as the following case demonstrates Psychology Board of Australia v Ross (Review v Regulation [2023) VCAT 110 (9th February 2023).
Here it was alleged that the practitioner failed to: establish and/or maintain professional boundaries, appropriately manage termination of the professional relationship, and to maintain accurate and adequate clinical records about the services he provided to his client.
This client had a history of self-harm, borderline personality disorder, anxiety and depression and consulted with the practitioner at first on a weekly basis and later twice a week seeing him 17 times during 2018–2019. Around 25 September 2018, the client attempted suicide and the practitioner being concerned for her welfare phoned her and her husband which inadvertently gave them his phone number which they used sending text messages to the practitioner outside of office hours. Some time later when she was visiting her home country the practitioner gave her his private email address so that they could continue communicating – a boundary crossing that had the potential to become a violation.
In the email and text messages sent by the patient to the practitioner she mentioned bringing him a coffee at her next session, holiday destinations, her feelings of guilt towards her husband, her wanting to separate from him, and or have sexual relations outside her marriage and that she fantasised about having an intimate relationship with him.
There was no documentation in the patient’s case notes regarding this. After a second suicide attempt the practitioner visited the client in hospital and hugged her before leaving – this was also not included in the patient’s clinical notes. The practitioner whilst initially claiming that this was in his professional capacity later agreed that it was a personal visit. Soon after the practitioner changed his phone number without informing the patient or her husband – weeks later the patient made a complaint about the practitioner to the Board.
The next day the practitioner sent a letter to the patient terminating the professional relationship however, he did not include any emergency treatment telephone numbers or specific crisis management strategies.
It had been the practitioner’s intention to terminate the professional relationship after a discussion with his supervisor where he revealed his concerns regarding her attempts to sexualize their relationship. However he had delayed doing so knowing she was pregnant and being concerned about her welfare and that of her unborn child should she again attempt suicide if he terminated the relationship. It was also the end of the year and he was unable to find another clinic to take over her care.
The tribunal noted the importance of establishing boundaries, particularly with patients who have borderline personality disorders, to create a predictable interpersonal context for the treatment to occur in and a sense of mutual responsibility clarifying roles and responsibilities of each party. The tribunal obtained an expert opinion who determined that if any boundaries had been established they had become blurred very early in the therapeutic relationship. Furthermore, it was noted that the manner in which the patient and her husband had obtained his phone number was not a boundary violation however, the continuation of communicating in this way beyond the initial reason for doing so as well as using his private email was. Reference was also made to the ethical guidelines for psychologists identifying the potential for emerging boundary issues with clients in relation to internet and telecommunication technology and the fact that the practitioner did not appear to have had a process to support the use of this technology in the therapeutic relationship with the patient. There was also concern in relation to the way the practitioner ended the therapeutic relationship being driven by the response to the patient’s allegations rather than a clinically appropriate decision to make.
The tribunal noted that at the time of the conduct the practitioner had been in independent practice for a year and viewed his conduct as an example of an inexperienced practitioner who failed to recognise that he was professionally out of his depth.
Furthermore, the tribunal noted that some of the practitioner’s decision making was well meaning but misguided and this along with his poor judgement led to a cascade of errors where he failed to develop and maintain a therapeutic relationship which then led to the boundary errors. It was agreed that the practitioner had engaged in professional misconduct and that he be reprimanded as he was no longer registered.
An expert in the field of nursing and the law Associate Professor Linda Starr is in the School of Nursing and Midwifery at Flinders University in South Australia