Dual Relationships and Boundaries

1. Being a Friend vs. Being Friendly

How do we know what the boundaries are between being friendly and being a patient’s friend? As addressed in the previous section, we want to make sure that we are warm, caring, and friendly towards patients and their families.

To ensure that we are being friendly and not a friend, we must avoid discussing personal issues with patients and caregivers. Lines between personal and professional can sometimes become blurred. We want to be authentic and build rapport without oversharing.

Here are some contrasting examples of being a patient's friend and being friendly:

Being friendly involves sharing general and non-personal information. You can have a great rapport with a caregiver while still avoiding crossing professional boundaries.

big idea

Avoid sharing overly personal information as it can potentially lead to what we call dual relationships.

Now, what do you do if the patient overshares with you? Well, when a caregiver shares a personal situation without your provocation, it can be hard to redirect the conversation without appearing indifferent or embarrassing the caregiver, leaving you struggling to keep your professional boundaries along with a friendly relationship with the patient.

IN CONTEXT

Suppose as you enter a home, a caregiver begins crying and states that they are furious with their partner for failing to help around the house and with the care of the children, and that it’s too much for one person to do alone.

Here is an example of what not to do, which is being a friend:

“This is awful. I would really be unhappy having to do everything on my own. Have you tried talking to them about your concerns?”

Providing a personal statement about the situation and how you would feel in that position is not a good idea. While it acknowledges the caregiver’s feelings, your opinion could be construed as friendship or agreement to act against the behavior of their partner. Further, once the situation is resolved, the caregiver may regret having shared this information but may not forget the statement you made regarding their partner. Asking a follow-up question as shown opens the door for further sharing of personal details that the caregiver may later wish they hadn’t disclosed.

Now, here is an example of an appropriate friendly response:

“I am so sorry to hear about this struggle. Our BCBA may have resources that could help you in this situation. Without sharing the details, I will have her contact you to schedule a time to talk about helpful resources for caregivers.”

Acknowledging the caregiver’s experience and quickly directing the issue to the BCBA for support can show that you care while keeping you from crossing a professional boundary. Sometimes excusing yourself from the area can help to diffuse the situation and buy time to develop a plan to redirect.

2. Dual Relationships

Dual relationships, also referred to as multiple relationships, are ones in which multiple roles or relationships exist between individuals. You should avoid developing them in the field.

Dual relationships are ones that include anything other than a therapeutic one between a practitioner and a patient. In our practice, it's also important to avoid them with guardians and any other caregivers of the patients who we work with.

Here are additional reasons to avoid dual relationships:

• They are forbidden by the ethics that govern our positions.
• They make it difficult to maintain boundaries and they impair judgment.
• They are against policies.

All of the following constitute a dual relationship:

• Sexual relationships
• Friendships
• Outside employment (babysitting)
• Accepting money or gifts (any gift of monetary value)
• Any form of barter
• A caregiver of the patient also being your doctor, dentist, etc.

think about it

A caregiver has tickets to your favorite team’s game tonight. Something comes up unexpectedly and they can’t go. They know you are a big fan and offer you the tickets, saying, “If you don’t use them, they just go to waste.” What do you do?

The answer is simple. You can’t accept the tickets nor can you pass them off to a friend, even though this is disappointing.

think about it

You meet with a new family in their home and they invite you to have a glass of tea with them. It's something they offer to everyone. What do you do?

Again, you can’t accept. You want to be culturally sensitive, but doing so would interfere with your relationship with the families. Especially when we work in their homes, we need to maintain our unique professional relationship.

You are likely to spend more time in the home than other service providers. By setting an expectation that you cannot accept food or drinks, you will prevent the family from feeling obligated to prepare them for you every day and avoid inadvertently forming a dual relationship.

Be honest! You might say, “Thank you so much for the kind offer! I must adhere to some strict ethical guidelines that prevent me from accepting any gifts, food, or even water! But don’t worry, I have my own!”

3. Setting Boundaries

Because of the potential for dual relationships and crossing over from being professionally friendly to being a patient or caregiver’s friend, it is important to set boundaries, both personal and clinical. This helps protect the patient and clinician relationships.

Here are some tips to help you set and maintain personal boundaries:

• Do not give out home phone number, home address, or email address.
• Avoid personal discussions.
• Do not accept or give gifts.
• Avoid correspondence after hours.
• Use *67 if you ever have to dial a patient from your personal phone.

hint

This also applies to social media. Do not give caregivers or patients your personal social media account information. Instead, you might have a professional account without overly personal information. Use this account to participate in groups in which caregivers may also be members, such as a Facebook group for consumers and practitioners of behavior analysis, or a local social skills group page.

To set clinical boundaries, make sure you do the following:

• Do not provide extra services without proper documentation.
• Do not drive patients.
• Do not discuss company policies; refer patients to your BCBA.
• If a caregiver is violating your boundaries, talk to your BCBA.

think about it

What if a caregiver calls you after hours?

That’s a trick question. The caregiver shouldn’t have your number. If you ever have to call a caregiver on the weekend or because you have to cancel, etc., you should use *67.

think about it

What if a caregiver asks for your number so they can coordinate where to meet at the mall for the scheduled outing?

In this case, tell them to email or instant message (IM) on your company iPad.