The topic of boundary crossing and boundary violations is vividly discussed by scholars. In order to understand the difference between the terms, it is important to clearly conceptualize them. Boundaries are ‘the edge of appropriate (therapist) behavior adopted to the needs of the individual patient to create an atmosphere of safety and predictability’ (Glass, 2003, p. 430). Boundary crossing aims to ‘enhance the treatment without harm to the patient’ (Glass, 2003, p. 430). Regardless of the fact that this behavior might be regarded as ‘unusual’ or ‘inappropriate’, it leads to client’s well-being. In contrast, ‘a boundary violation is harmful or potentially harmful to the patient and the therapy, it constitutes exploitation of the patient’ (Aravind, Krishnaram & Thasneem, 2012, p. 21). Given that boundary crossing and boundary violations are closely intertwined, one way to prevent one type of treatment progressing in another one, is to apply an evidence-based decision making model.
Evidence-based practice integrates three basic principles: 1) the use of empirical data in making decisions regarding the treatment; 2) clinical expertise (may override research evidence); 3) patient’s preferences (Satterfield et al, 2009, p. 368). Clinical expertise is often regarded as the most important element of the model. Given that boundary violation by its definition cause harm to patient’s physical and/or mental health, it is important to refer to the available empirical data indicating the potential outcomes of the treatment. It is, however, important to note that boundary crossing is often intertwined with the application of unusual treatment, and thus the previous data indicating whether or not the treatment works might be absent.
As to the clinical expertise, a special emphasis is to be placed on the examination of individual’s unique state of physical and psychological health. In case the treatment is not applicable to the state of patient’s psychological and physical well-being, and might potentially harm it, the ethical decision will be to reject the treatment. One of the core elements of evidence-based decision making model is, in my opinion, taking into account patient’s preferences.
There is a commonly shared view of some therapists on patients as ‘lay people’ with ‘lay beliefs’ who are not qualified enough to make personal decisions regarding their treatment. However, an ethical approach to decision making places a focus on individual’s own agency and right to choose the needed treatment. In terms of preventing boundary violations, a patient is to be asked about whether or not he or she feels comfortable adhering to a certain type of treatment, and whether or not it violates his or her beliefs or attitudes. In case the treatment had already started, and the client understood that he or she would want to reject the treatment, it is to be stopped.
My own understanding of counselor’s code of ethics includes the special focus on the need to respect patient’s preferences, feelings and attitudes. If this aspect of evidence-based decision making model is neglected, chances are very high that client’s treatment will result in a failure, and a number of studies is a proof. More specifically, a study conducted by Sermabeikian (1994) showed that the violation of client’s moral beliefs, attitudes or values generate boundary issues between therapist and a client, and treatment thus becomes ineffective. Apart from this, my code of ethics emphasizes that a lot of research is to be made by a therapist before choosing a treatment for a client. Such actions will thus minimize the chances of harm.
More specifically, in my opinion, a therapist violates ethical norms when introducing a treatment without the careful examination of the respective literature indicating that this type of treatment had proved to have harmful consequences. Also, the violation of the element of clinical expertise in terms of the evidence-based practice might lead to serious boundaries violation. More specifically, even in case the client’s agreement on the treatment was obtained, and the treatment’s success received empirical support, but client’s health was not examined properly, treatment might not only be ineffective, but also cause harm to patient’s mental health and emotional well-being.
To conclude, boundary crossing sometimes might be a needed way to provide the highest effectiveness of a treatment. It should, however, not lead to actions that can be regarded as ‘boundary violations’. and are characterized by harm made to the client. One way to do it is to apply the interdisciplinary evidence-based decision making model that consists of three elements of a successful treatment. These principles include the need of clinical expertise, the need of empirical grounding of a treatment, and a special focus placed on individual’s preferences. The violation of these principles also violates counselor’s code of ethics, and might lead to serious consequences to client’s mental and physical health.
