Professional Boundaries:

..Therapeutic & Professional Boundaries

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The Alberta College of Speech-Language Pathologists and Audiologists (ACSLPA) is the regulatory body for the professions of speech-language pathology and audiology in Alberta. ACSLPA carries out its activities in accordance with provincial legislation to protect and serve the public by regulating and ensuring competent, safe, ethical practice of speech-language pathologists and audiologists.

The intent of this guideline is to support regulated members in practicing in compliance with the standards of practice with respect to therapeutic relationships and professional boundaries. The guideline is founded upon the following guiding principles:

• ACSLPA believes that the sexual abuse of and/or sexual misconduct towards patients by regulated members is unethical and an abuse of the therapeutic relationship. ACSLPA holds a zero-tolerance stance towards any abuse or misconduct of this nature by regulated members. Regardless of the patient’s conduct and/or consent, it is always the responsibility of the regulated member to maintain professional boundaries and abstain from engaging in sexual abuse and/or sexual misconduct.
• ACSLPA regulated members are expected to be fully informed of the terms and implications of the Health Professions Act (HPA) and the issues related to the avoidance and prevention of sexual abuse and/or sexual misconduct.
• ACSLPA regulated members are accountable for practicing in accordance with the ACSLPA Standards of Practice and Code of Ethics regardless of their role, practice area or practice setting. Breach of the Standards of Practice or Code of Ethics may constitute unprofessional conduct.

In accordance with the ACSLPA standards of practice on Professional Boundaries and Standard Area 5 – Sexual Abuse and Sexual Misconduct, regulated members must maintain appropriate professional boundaries with clients, professional colleagues, students, and others at all times; and protect patients from sexual abuse and sexual misconduct.  The Health Professions Act (HPA) requires that colleges take measures to for preventing and addressing sexual abuse and sexual misconduct by providing educational requirements and guidelines for the conduct of regulated members. This guideline is meant to provide this educational component to regulated members, along with ACSLPA’s Jurisprudence E-Course. Both educational components include concepts related to trauma informed practice.

Clarification of Terms Used

It should be noted that throughout this guideline, the more narrowly defined terms of health services and patient are used in reference to sexual abuse and sexual misconduct.

• Health services, as defined in the HPA, refer to the specific services provided by regulated members in their professional roles as speech-language pathologists and audiologists.
• Patient, as defined by ACSLPA, is the direct recipient of the health services provided
  by the regulated member and does not include others such as their parent, guardian
  or substitute decision-maker. If service is provided in accordance with the Standards
  of Practice, ‘patient’ does not include the regulated member’s spouse, adult
  interdependent partner or other person with whom the regulated member is in an existing sexual relationship.

ACSLPA foundational documents, including the Standards of Practice, use broader definitions for the following terms, which are used in reference to professional boundaries and trauma informed services in this guideline:

• Client refers to “a recipient of speech-language pathology or audiology services, and may be an individual, family, group, community, or population. An individual client may also be referred to as a patient.”
• Professional services refer to “any service that comes within the practice of a regulated profession; for the professions of speech-language pathology and audiology, these are as outlined in section 3 of Schedule 28 of the HPA.”

The relationship of the four terms can be illustrated as follows:

Clarification of Terms Used

For the purposes of this guideline, in reference to therapeutic relationships, the term ‘patient’ is used. In reference to professional boundaries, the more broadly defined term ‘client’ is used. Regulated members are encouraged to review the section ‘Clarification of Terms Used’ in the Introduction section of this guideline for a more comprehensive explanation of the differentiation between these terms. Definitions of both terms are also included in the Glossary of this guideline.

Therapeutic Relationships with a Patient

The therapeutic relationship is the professional relationship between a regulated member and a patient. This relationship is different from a personal non-professional relationship, as the regulated member must consider the patient’s needs first and foremost, and because there is an expectation that the regulated member will not use the therapeutic relationship for any personal reasons or benefits.

The table below highlights some key differences in the characteristics of therapeutic versus personal relationships.

Power, trust, respect, and personal closeness are key components that regulated members must consider when managing the boundaries of a therapeutic relationship. It is extremely difficult to maintain a therapeutic relationship if any of these are violated.

Power

The therapeutic relationship involves an imbalance of power between the regulated member and the patient, whereby greater power is held by the regulated member. This imbalance of power is due to a number of factors:

• The regulated member has greater knowledge, authority and influence in the health system. This includes influence in decisions made about the patient’s care.
• The patient is reliant on the regulated member for their care.
• The regulated member has access to personal information about the patient.
• The provision of professional services may involve physical closeness and varying degrees of undress (e.g., bedside evaluations, mother nursing an infant).

As a result, the patient may feel vulnerable and avoid confronting the regulated member or challenging their knowledge or expertise, for fear that the services they need will be compromised or withheld. Patients may also feel vulnerable in a therapeutic relationship because it creates a dependence on the healthcare provider and requires trust that the provider will act in their best interest.

Regulated members must keep this power imbalance in mind and strive to minimize the power imbalance in the therapeutic relationships with patients. This can be accomplished through a patient centered approach, which recognizes the inherent vulnerability of the patient, and creates an environment where the patient feels safe and free to ask questions and is an active participant within the therapeutic relationship.

Trust

The therapeutic relationship between the regulated member and the patient is based on trust. The patient must:

• Trust that the regulated member has the necessary knowledge, skills, and competence to provide quality care;
• Trust that the regulated members will act in the patient’s best interest and will do no harm; and
• Trust that the regulated member will not divulge personal information.

If a regulated member does not use their skills and abilities to address the patient’s care needs, or otherwise does not act in their best interest, a loss of trust may occur. It is the responsibility of the regulated member to be sensitive to the vulnerability of the patient and take the necessary steps to establish and maintain trust.

Respect

Regulated members must act in a way that is respectful of the patient’s participation in their care. Respect for the patient’s beliefs, values, and morals is required to develop a therapeutic relationship. The regulated member is not required to adopt or agree with the patient’s views but must accept the patient’s perspectives and ensure that their own values and beliefs do not compromise the quality of care that they provide.

Regulated members have an ethical obligation to respect all persons regardless of differences in background, particularly with respect to protected human rights grounds, including gender, race, religion, disability, ancestry, etc. The regulated member must also respect and support the autonomy of the patient by obtaining informed consent for the professional services provided.

Personal Closeness

The context of the therapeutic relationship can include physical closeness, varying degrees of undress, and disclosure of sensitive personal information. While these practices are acceptable when carried out appropriately, they may deepen the patient’s feelings of vulnerability. Regulated members must practice sensitivity to protect the trust and respect of the therapeutic relationship. Regulated members must respect patient autonomy and ensure that patients share control in decisions about their care.

Professional boundaries are the parameters that define safe therapeutic relationships (between a regulated members providing a health service to patients) and safe professional relationships (between a regulated members providing a professional service to clients). Note that throughout this section on professional boundaries, this guideline uses the broader term ‘client’ (i.e., any recipient of speech-language pathology or audiology services).

These parameters set limits for these relationships and are based on the recognition of the inherent power imbalance, the vulnerability of the client and the responsibilities of the regulated member in the therapeutic or professional relationship. Professional boundaries help the regulated member and the client recognize the difference between therapeutic and personal relationships and avoid potential misunderstanding of words and actions.

Professional boundaries can be influenced by factors such as the physical environment, the length of time of the therapeutic relationship, and the achievement of certain therapeutic goals. A professional boundary can therefore be a dynamic line which, if crossed, will constitute unprofessional conduct and misuse of power.

Inherent to establishing therapeutic relationships is knowing where to draw the line between a professional relationship and a personal one, and how to avoid crossing that line. To do so,
regulated members must acknowledge:

• The power imbalance inherent to the client-provider relationship;
• The expectations for appropriate care; and
• The regulated member’s duty of care.

• Introducing yourself to the client by name, professional title, and a description of your role in the patient’s care.
• Addressing the client by their preferred name and/or title.
• Approaching the therapeutic interaction considering the client as an equal. This includes how you greet the client, how you position yourself during the interaction, and using plain language to explain what you are doing.
• Being attentive to and addressing the client’s concerns.
• Validating the client’s concerns and individualizing your approach to address their
  unique needs.
• Obtaining and documenting the client’s informed consent to proposed health services, ensuring consent is specifically obtained for procedures that could be misinterpreted
  (e.g., touching and physical closeness).
• Practicing non-judgemental active listening.
• Being aware of and avoiding comments, attitudes, or behaviours that are not appropriate in a therapeutic relationship or that may cause discomfort (e.g., self-disclosure, sexually suggestive comments/actions, or the expression of inappropriate personal opinions/remarks).
• Adapting your communication strategies to facilitate the client’s understanding of
  proposed services.
• Avoiding practicing outside of professional norms (e.g., outside of typical hours or settings).
• Maintaining an environment that protects the privacy and confidentiality of patient information
  in all contexts of service delivery.
• Maintaining accurate clinical records.
• Engaging in self-reflection of your interactions with clients.

SLPs and Audiologists need to maintain clear separation between their therapeutic or professional relationships and personal relationships by:

Practicing Self-Reflection

Self-reflection requires practitioners to give serious thought about their own character and actions. Participating in reflective activities is a necessary first step in gaining self-knowledge.

Examples of professional self-reflection include journalling, meditation, debriefing with a colleague, and/or tracking the frequency of reoccurring emotions and conflicts.  Regulated members may also benefit from regularly checking in with themselves to assess if they are operating within therapeutic boundaries as defined in ACSLPA’s Standards of Practice and Code of Ethics.

Gaining Self-Knowledge

Self-knowledge is the understanding a practitioner gains about their own attitudes, behaviors, beliefs, and values because of their participation in self-reflection activities.

Having self-knowledge allows regulated members to engage authentically with their clients and set mutually beneficial, healthy boundaries in their work environment.

Communicating Empathetically

Empathy, or the ability to understand and share the feelings of another, is the first link in a chain reaction that develops an effective therapeutic relationship.

Empathy allows regulated members to be compassionate in their care, by adapting their approach to respectfully acknowledge and mindfully accommodate the experiences of individual clients. The rapport developed through compassionate communication in turn leads to increases in trust and client participation.

Understanding Role Limitations

Pressure to breach professional boundaries can happen when regulated members lose sight of the limits of their role as an SLP or Audiologist. Empathy experienced during service provision, such as after disclosures of abuse, may motivate the regulated member to take on duties best suited for a social worker or other professional helper.

Regular self-reflection, self-knowledge, and firm professional boundaries can keep regulated members mindful of their role limitations. Regulated members should be able to recognize when they are at risk of providing professional help that is outside of the scope of practice for their profession, i.e., when support the client requires is outside of their range of their professional knowledge, skills, and expertise. It is important to acknowledge role limitations with clients, and to inquire if they would like support seeking a referral to a more appropriate provider.

Boundary crossings are inappropriate behaviours such as feelings, conduct or remarks that compromise and violate the nature of the therapeutic relationship, regardless of who initiates the boundary-crossing interaction. Boundary crossing behaviours may be deliberate and clearly not appropriate, or they may be unplanned and accidental. It is important to note that how the client perceived the behaviour matters, not the intention of the behaviour.

Boundary crossing can result when regulated members confuse their own needs with those of the client, or when regulated members do not recognize their own boundaries or have misunderstood the client’s boundaries. Boundary crossings can cause harm even when the client does not recognize the distress that resulted from the crossing.

Some examples of boundary crossing behaviours include:

• Inappropriate verbal and nonverbal behaviours such as retaliation, intimidation, teasing or taunting, swearing, cultural slurs, and inappropriate tones of voice that express impatience or exasperation.
• Disclosure by the regulated member of excessive amounts of personal information.
• A reversal of roles that results in the client supporting the regulated member.

A boundary crossing can have a serious impact on the therapeutic relationship such as:

• Breaking the trust between the regulated member and the client,
• Causing the client or regulated member to make decisions about service provision that are not in the best interests of the client,
• Affecting the regulated member’s professional judgement and the services being provided,
• Preventing the client from asking questions and providing voluntary consent, and
• Violating professional standards which may result in unprofessional conduct.

It is the responsibility of the regulated member to frequently assess and manage boundaries in order to maintain the therapeutic relationship. Boundary crossing can be prevented in part by regular self-reflection as regulated members’ check-in with their behavioral motivations and realign themselves with the Standards of Practice and the Code of Ethics as needed. Regulated members may also contact ACSLPA for support, as needed.

Risk Factors for Boundary Crossing

A number of potential risk factors that may result in boundary crossings by regulated members have been identified including:

• Physical and mental health issues, including stress and burnout,
• Belief that the rules “don’t apply to me” or to the situation at hand,
• Lack of knowledge or respect for standards of practice and other professional obligations,
• Working in isolation (either as a sole charge practitioner or due to team dysfunction resulting
  in isolation),
• Lack of clinical knowledge/experience or failing to maintain currency of knowledge, and/or
• Workload or other system factors.

Warning Signs of Professional Boundary Crossing

The blurring of boundaries often occurs gradually and unintentionally. However, minor transgressions tend to lead to more significant ones if left unchecked.

It is important to be aware of the warning signs of boundary crossings such as:

• Selecting clients based on appearance, age, or social status.
• Acting defensively, being uncomfortable or making excuses when your relationship with a client is questioned.
• Being hesitant (except for reasons of confidentiality) or embarrassed to discuss the relationship between you and your client.
• Denying the fact that the client is a client.
• Dressing differently when a particular client is booked.
• Offering treatment or attention to a particular client that is different from normal practice (e.g., frequently extending appointments beyond the scheduled time, keeping the client on treatment longer than what is needed, offering appointments in “off“ hours, cancelling appointments to fit the client in, extending credit for payment for services).
• Deliberately scheduling client sessions to take place at a time when others are likely to not be present (e.g., early or late appointments), particularly when this has not been requested by the client or is unrelated to therapeutic needs.
• Sharing secrets with a client.
• Selective reporting of client’s behavior (positive and negative).
• Doing something unethical or illegal for a particular client (e.g., lending money, providing false receipts, checking the hospital records of a relative of the client).
• Exchanging expensive or personal gifts with a particular client.
• Experiencing feelings of mutual or one-sided attraction to a particular client that are beyond the therapeutic or professional relationship.
• Flirting or responding to personal advances by a client.
• Deliberately meeting socially with a patient.
• Sharing excessive personal information with a client (e.g., personal issues, contact information for non-clinical reasons).
• Providing the client with a home or personal phone number or email address unless it is required in the context of a therapeutic or professional relationship.
• Spending time with a client beyond what is needed to meet their therapeutic needs.
• Assisting a client with something that is outside of the therapeutic or professional relationship.

It is the regulated member’s duty to establish, maintain, and monitor the boundaries of a therapeutic or professional relationship. When the actions of the regulated member fall outside of what is considered typical, or when the regulated member is concerned that they may have crossed a professional boundary, they should reflect on the following questions:

• Who is benefiting from my actions?
• Are my actions in the client’s best interest?
• Are my actions something the client needs in order to achieve the agreed upon treatment plan?
• Do my actions affect the professional services I am delivering?
• Will my actions be potentially confusing for the client?
• Will my actions change the client’s expectations in any way?
• Are my actions different than what I would do for my other clients?
• Are my behaviours different from those of other practitioners in the same circumstance?
• Am I comfortable recording my actions in the patient/client’s record?
• Would I tell a colleague about this activity?
• Would my colleagues, employer, the College, the funder and family/friends view my actions as acceptable?
• Would a third-party payer (e.g., an insurance company) fund the action as part of the plan of care?
• Could my actions be perceived to be inappropriate in a therapeutic or professional relationship (e.g., violate professional standards, be deemed unprofessional conduct, or break the law)?

If a boundary crossing is suspected, it is important to take action:

• Reflect on what led to the boundary crossing.
• Consult with colleagues and/or ACSLPA representatives, as required.
• Take necessary steps to re-establish the therapeutic or professional relationship, if possible. This may include clarifying the roles of the regulated member and the client, as well as therapeutic goals.
• Terminate treatment if the therapeutic or professional relationship cannot be re-established. Considerations when taking this action include:
  • Advising the client of the reasons that treatment must be discontinued.
  • Advising the client that continuing with their care would not be in their best interest.
  • Ensuring the client is not adversely affected by any interruptions in care (e.g., by providing options for alternative care providers if care is still required).
• Document the actions that lead to the boundary crossing and actions taken to re-establish or terminate the therapeutic or professional relationship.

Clients Crossing Professional Boundaries

During the delivery of health services, situations can arise when the client crosses professional boundaries and demonstrates inappropriate behaviour or remarks toward the regulated member. In this case, it is the responsibility of the regulated member to ensure that professional boundaries are maintained. The following strategies should be considered to manage boundary crossings and promote patient safety.

• Identify situations of high potential risk for boundary crossings and sexual abuse and/or sexual misconduct and conscientiously take active measures to maintain professional boundaries.
• Think before acting or speaking, and refrain from any comments or actions that could be misinterpreted.
• If a client makes sexual advances and/or comments/gestures of a sexual nature, or otherwise attempts to cross a professional boundary, regulated members should use their judgement and implement the following actions as necessary:
  • Refuse to be engaged; explain the ethical and regulatory responsibilities of maintaining professional boundaries.
  • Remove themselves from unsafe environments if the actions of the client cause the regulated member to be concerned about their safety.
  • Discharge the client and transfer them to another provider. Regulated members must ensure that appropriate discharge procedures (including documentation) are followed if this step is taken.
• Document in the client’s chart the dates, the nature of their conduct and remarks and the measures taken to maintain professional boundaries.
• Report the client’s behaviour to a supervisor or colleague. Regulated members should review and comply with any employer policies on reporting and documentation of clients crossing boundaries.
• Consult with colleagues and ACSLPA representatives as required.

There is often a grey zone of behaviours that may or may not be appropriate, and it can sometimes be difficult to know if a line has been crossed. For example, there may be situations where a single comment or action may seem harmless, but when considered with other behaviours could result in a situation where the professional boundary has been compromised or crossed.

In ethically grey interactions, the appropriate course of action may not be immediately or overtly apparent. Consider the example of an SLP or Audiologist sharing their own personal experience of a similar circumstance after a client discloses sensitive information. The professional’s disclosure may normalize the client’s feelings, reduce embarrassment, and build rapport; OR it may alter the focus of the interaction from client to practitioner, which left unchecked may shift the relationship from therapeutic or professional to personal.

Navigating ethically grey areas requires the use of good judgement and careful consideration of the context. The most appropriate decision will be contextual and will require a case-by-case analysis of the regulated member’s personal values, the client’s needs, professional standards and ethics, and any institutional or organizational policies.

The following examples illustrate ethically grey situations where boundaries may become blurred and there is an increased risk of boundary crossing. The examples show how seemingly insignificant or innocent actions may lead to boundary crossing. Each example poses questions/considerations for the regulated member to reflect on in order to prevent or avoid inappropriate conduct.

Giving or Accepting Gifts

Generally speaking, giving and accepting gifts are part of a personal relationship rather than a therapeutic or professional relationship. A small gift given as a token of appreciation by a client may in some cases be acceptable. However, giving or accepting a gift may also suggest that a personal relationship is developing and may cause confusion for the client. Accepting a gift from a client can carry some degree of risk, so it is important to consider the context of the situation. The table below shows how situational factors affect the risk of accepting a gift from a client.

Gift giving may be viewed differently depending on individual and cultural values and norms. It is important to consider clients’ perspectives regarding gift giving and approach situations accordingly. For example, some cultures may perceive refusal of gifts as offensive, which can unintentionally erode the therapeutic relationship. It is important to approach these situations with care, taking into consideration the impact of refusing the gift. Using discretion when accepting gifts or having universal rules around gift refusal may be helpful in these situations. In addition, clients should be provided clear and thorough explanations for why a gift cannot be accepted.

The following are questions that the regulated member may wish to consider when giving and/or receiving gifts:

• What motivated the client to give me this gift (e.g., a desire for a “special relationship” or preferential treatment, something I disclosed which made the client feel obligated)?
• What is the context of this gift giving (e.g., thank you, goodbye, ‘just because’ etc.)?
• Will accepting this gift affect my clinical decision-making ability with this client?
• Will accepting this gift create confusion or a misunderstanding where the client feels the relationship is personal (e.g., friendship or something more)?
• Why do I want to give a gift to this client (e.g., if I am not giving all of my patients a gift, why this one? Are my reasons in the best interest of the client?)?
• Will giving this gift make the client feel the need to give me something in return?
• Will the client’s family or others think that the gift from the client was the result of theft, fraud or manipulation on my part?

It is up to the regulated member’s discretion to accept or decline a gift. However, it may also be helpful for regulated members to develop strategies to discourage personal gift giving (e.g., policies that make it clear what regulated members will do with any gifts, such as donating monetary gifts to charity, or placing consumables in a staff room). This may help to minimize the pressure to give or accept gifts.

Treating Relatives or Friends

Treating relatives/friends (including the spouses or children of relatives or friends) results in an overlap between personal and therapeutic or professional relationships that can make maintaining boundaries a challenge. This type of dual relationship should be avoided for a number of reasons:

• The regulated member may not be able to be objective.
• The regulated member may make assumptions and be less thorough.
• The patient may not want to answer questions honestly (due to embarrassment or reluctance to share confidential information).
• The client may not feel that they can refuse to provide consent.
• The regulated member may be placed in a situation of conflict of interest.
• The personal relationship may be affected, especially if the therapeutic or professional relationship is not successful.

In some instances, such as when practicing in a rural setting, it may be difficult to avoid treating relatives/friends as there may not be another provider available. In these instances, the regulated member must consider how they can manage professional boundaries to ensure that they remain objective and that the services are client-centred, and privacy/confidentiality is respected. Separating personal feelings, values, and beliefs from professional and ethical responsibilities and obligations can be difficult, and potential conflicts of interest must be acknowledged.

In situations where the regulated member is considering providing services to a relative or friend, the following questions should be considered:

• Do I have the necessary competencies to treat this relative/friend?
• Do I feel right treating this relative/friend? Will they be at ease being treated by me?
• Will I be able to be objective and provide client-centred care?
• Will I be able to maintain my professional obligations?
• Will I be able to maintain privacy and confidentiality of all information? How will this be done?
• How will differing opinions be managed, if they occur? What if I disagree with the choices made by the client?
• Are financial arrangements an issue and if so, how will they be managed?
• Is any type of special treatment expected? How will this type of expectation be managed?
• Will I be able to discontinue the services if/when required?

Regulated members providing services to relatives or friends should inform themselves about liability concerns, and be aware that third-party payers may require such a treatment relationship to be disclosed. In addition, the conflict of interest of treating a relative or friend and the processes put in place to manage the conflict of interest must be documented in the client file.

Social Media

The same professional obligations for face-to-face interactions with clients also apply for online activities. As a result, the regulated member needs to reflect on how to establish and maintain professional boundaries when using social media for professional and personal purposes.

Regulated members should consider the following when using social media:

• Developing clear and comprehensive policies if using social media for business.
• Maintaining a high standard of E-Professionalism on social media.
• Managing friend requests from clients in a manner that avoids conflicts of interest.
• Avoiding giving professional advice on online platforms.
• Maintaining a professional communication style in all electronic communications.
• Establishing and maintaining separate personal and professional social media pages and email accounts. Keep your personal life private.
• Assuming that every post is public. Posts intended to be private or for friends only are easily shared.
• Respecting client privacy and confidentiality. Do not post on social media any information where a client may be identified. Do not initiate personal online contact with patients. Developing or referring to workplace policy for responding to client requests for online communication.

Touch and Proximity

Many clients, due to factors such as culture, background and/or individual preferences, are uncomfortable when others come too close and invade their personal space. Regulated members, during the delivery of health services, must approach patients respectfully and thoughtfully, and with sensitivity, recognizing that one’s tolerance for touch and proximity is highly individual. Physical proximity and actions such as an innocent comforting hug or a pat on the knee of encouragement could be misinterpreted by clients and lead to accusations of sexual abuse or sexual misconduct.

Although clients may be aware that physical contact/touch is a requirement of many therapeutic procedures before seeking care, regulated members cannot assume that the client fully understands, or consents to physical contact. Regulated members should also remain mindful that physical contact/touch as part of the provision of services may be misunderstood by the client.
Some examples of physical contact/touching commonly used by speech-language pathologists and audiologists, which could be misinterpreted include:

• Tactile facial prompts provided as part of phonological therapy.
• Abdominal and/or chest touch during breathing exercises.
• Close physical proximity and facial/head contact as part of an audiologic assessment or hearing aid fitting.
• Contact with the neck and face during feeding and swallowing interventions.

The regulated member should ensure that the client understands the intent and nature of the touch and proximity and consents to the physical contact throughout the delivery of professional services.  The following provides some considerations for respectful physical contact with clients:

• Recognize how culture and past experiences can affect the client’s attitude about physical contact.
• Recognize that physical contact is context specific (e.g., consent for treatment does not necessarily include consent for physical contact such as hugging).
• Keep in mind that consent must be specific and ongoing:
  • Always ask for consent prior to touching a client.
  • Always explain the reason and nature of physical contact as part of asking for consent.
  • Check-in regularly with the client throughout the treatment to ensure you have ongoing consent.
  • Keep in mind that the client has the right to revoke or change what they are consenting to at any time.
• Use gloves as required for infection control and to reduce intimacy.
• Use appropriate draping to respect client dignity at all times.
• Avoid unnecessary physical contact and use physical barriers (e.g., pillows or draping) to prevent contact with other body parts.

Special consideration is required for clients who cannot give consent for touch and proximity independently, for example pediatric clients (except in the case of mature minors) or adult clients in care who require surrogate decision makers. While these clients cannot give consent for care independently, it is still important to involve them in the process of obtaining consent for touch and proximity, as this may helps with establishing rapport and building trust into the professional relationship. Care should be taken to involve the client in the consent process, explaining the purpose and reasoning behind any physical touch, ensuring to obtain the consent from both the client as well as their guardian/parent whenever possible.

Occasionally, client norms around physical touch and proximity may differ from what is expected in a professional therapeutic context (e.g., preschool aged clients, clients with autism spectrum disorder, clients with different cultural norms around touch, etc.). Although professionals do not have to accept touch that they are uncomfortable with (e.g., kisses or hugs), is important to take into consideration these contextual factors when interpreting client behaviour and acting accordingly to find alternatives or discuss boundaries. For example, obtaining weighted items of clothing, such as vests, in replacement of the deep pressure experienced by a hug for clients with sensory preferences. To maintain the integrity of the professional relationship, regulated members should acknowledge and explain why touch cannot be accepted in a manner appropriate to the client’s understanding.

The client’s culture may influence their health-related priorities, decisions, and behaviours. Culturally sensitive care considers the preference and expressed needs of the client which may be influenced by their culture (e.g., the involvement of family members or friends in their care, preference for the care provider to be the decision maker for their care).

While it is impractical to have an in-depth knowledge of all the cultures that one may encounter in daily practice, understanding a client’s culture allows their care to be customized to better address their needs. Although regulated members must be sure to treat clients as individuals and avoid stereotyping based on membership in certain groups, there are some strategies that regulated members can use to promote cultural sensitivity in the care that they provide. These include:

• Acknowledging and reflecting upon your own culture. Recognize that both the client and provider bring their culture to the therapeutic or professional relationship.
• Being open to learning about the client’s culture or beliefs, incorporating cultural practices into client care.
• Asking the client before incorporating cultural practices you believe would be associated with their perceived culture based on appearance or presentation.
• Respecting the legitimacy of the client’s health beliefs.
• Applying a biopsychosocial model approach to health care. Please see the ACSLPA guideline: Anti-Racist Service Provision for Speech-Language Pathologists and Audiologists for more information on the biopsychosocial model of healthcare.
• Encouraging the client to discuss their explanations of their concerns/diagnosis and its perceived causes.
• Discussing your understanding of the client’s diagnosis/concerns and its perceived causes, using patient friendly language.
• Encouraging the client to participate in the planning, implementation, and evaluation of their own care plans.
• Negotiating an understanding and a safe, effective, and mutually agreeable treatment plan.
• Maintaining an awareness of using verbal and nonverbal communication which avoids cultural harm (i.e., demeaning or diminishing the patient’s culture, culturally based explanations of their concerns, or cultural health practices). Please see the ACSLPA guideline: Anti-Racist Service Provision for Speech-Language Pathologists and Audiologists for more information on cultural harm and practicing cultural safety.

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