Jurisprudence E-Course Module 4: Therapeutic Relationships, Trauma Informed Service Delivery, and Professional Communication Therapeutic Relationships

The therapeutic relationship is the relationship between a regulated member and a client[1]. It is different from a personal, non-professional relationship as the regulated member must consider the client’s needs first and foremost. Regulated members must not use the therapeutic relationship for any personal reasons or benefit, as this is considered conflict of interest.

There are three key components of the therapeutic relationship that regulated members should be aware of:

Power Imbalance: Power imbalance is inherent to the therapeutic relationship. The regulated member, as the healthcare provider, is in a “power-over” position with the client, due to:

  • The regulated member having greater knowledge, authority, and influence in the health system.
  • The regulated member having access to the personal information about the client.
  • The potential for the provision of professional services to involve physical closeness or touch.
  • The client’s dependence on the regulated member for necessary professional services.

It is the responsibility of the regulated members to recognize and take steps to reduce the power imbalance of the therapeutic relationship. Regulated members should take steps to ensure the client feels safe and empowered to be an active participant within the therapeutic relationship.

Trust: The therapeutic relationship is based on trust – clients must trust that the regulated member has the necessary competence, will act in the client’s best interest, and will do no harm.

  • It is the responsibility of the regulated member to be sensitive to the need for trust, and to take the necessary steps to build, establish, and maintain trust.

Respect: The regulated member has the responsibility to respect all clients, particularly with respect to any protected grounds as defined by the Alberta Human Rights Commission. This includes race, religious beliefs, color, gender identity/expression, disability, age, ancestry, sexual orientation, family or marital status, or place of origin.

  • The regulated member must also respect and support the autonomy of the client.

[1] ‘Client refers to a recipient of speech-language pathology or audiology services. An individual client may also be referred to as a ‘patient’. For the purposes of s.1(1)(x.1) of the Health Professions Act, a patient is any individual to whom a regulated member provides a health service in their capacity as a speech-language pathologist or audiologist, but does not include: the patient’s substitute decision-maker, legal guardian, or parent; or the regulated member’s spouse, adult inter-dependent partner, or other person with whom the regulated member is in an existing sexual relationship if the service is provided in accordance with ACSLPA Standards of Practice. The term ‘patient’, and the differentiation between ‘client’ is used when enforcing standards on Sexual Abuse and Sexual Misconduct.

Maintaining Therapeutic Relationships

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

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:

  • Journaling,
  • Meditation,
  • Tracking the frequency of reoccurring emotions and conflicts, and/or
  • Debriefing with a colleague.

SLPs and Audiologists may 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.

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.

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; 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.

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 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 SLPs and Audiologists mindful of their role limitations.

Professional Boundaries

Professional boundaries are critical for safe therapeutic relationships. Boundaries set limits on the therapeutic relationship to avoid it crossing into a personal relationship and avoid potential misunderstandings of words and actions. It is the responsibility of the regulated member, the more powerful party in the therapeutic relationship, to establish and maintain professional boundaries with clients.

Boundaries, maintained consistently over time, build trust. Trust that is lost through poor quality, exploitive, or harmful care is not easily re-established.

Boundary crossings are any behaviours (feelings, remarks, or conduct) that compromise the professional nature of the therapeutic relationship. Boundary crossing is a serious issue and applies regardless of who initiated the crossing.

Boundary crossings can have serious impacts on the therapeutic relationship such as:

  • Breaking the trust established in the therapeutic relationship,
  • Affecting the regulated member’s professional judgement and the services provided,
  • Preventing the client from asking questions and providing voluntary consent, and
  • Violating professional standards which may result in unprofessional conduct.

It is easy to presume that clients are capable of advocating for and maintaining clear boundaries in therapeutic relationships. However, clients may hesitate to speak up about boundary crossing on the part of the clinician because:

  • they have so much respect for a regulated member’s position and expertise as a health professional that questioning the SLP/Audiologists would be unacceptably rude.
  • they have inherited beliefs or lived experiences that lead them to distrust authority figures on principle.
  • trauma, experienced in the past and/or present, is affecting their ability to advocate for themselves.

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

  • Physical and mental health issues (e.g., stress, burnout).
  • Belief that standards, policies, and protocols do not apply to the regulated member or to the situation at hand.
  • Lack of knowledge or respect for the Standards of Practice, Code of Ethics, and other professional obligations.
  • Working in isolation — either as a sole charge practitioner or due to team dysfunction.
  • Lack of clinical knowledge and/or experience.
  • Failing to maintain currency of knowledge.
  • An overwhelming workload or other systemic factors.

Giving and accepting Gifts

While a small gift given as a token of appreciation by a client may in some cases be acceptable, generally speaking, giving and accepting gifts are part of a personal, rather than therapeutic relationship. Gift giving or accepting may suggest that a personal relationship is developing and may cause confusion for clients. The context of the situation should be considered.

  • Will accepting a gift affect my clinical decision-making ability with this client?
  • Will accepting a gift create confusion or misunderstanding where the client feels the relationship is personal (e.g., friendship or romantic)?

Treating Relatives/Friends

Treating relatives or friends results in an overlap between personal and therapeutic relationships which can make maintaining boundaries a challenge. For example, the regulated member may not be able to be objective, may make assumptions, or may be less thorough in their interactions with the client. Also, clients who are relatives may not feel that they can refuse to provide consent or answer questions honestly.

Social Media

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

For example, regulated members should:

  • Develop clear and comprehensive policies if using social media for business.
  • Maintain a high standard of E-Professionalism on social media.
  • Manage friend requests from clients in a manner that avoids conflicts of interest.
  • Avoid giving professional advice on online platforms.
  • Maintain a professional communication style in all electronic communications.
  • Establish and maintain separate personal and professional social media pages and email accounts. Keep your personal life private.
  • Assume that every post is public, akin to a news broadcast. Posts intended to be private or for friends only are easily shared.
  • Respect client privacy and confidentiality. Do not post on social media any information where a client may be identified.
  • Develop or refer to workplace policy for responding to client requests for online communication.

Ethically grey interactions are interactions where 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 alter the focus of the interaction from client to practitioner, which left unchecked may shift the relationship from therapeutic to personal.

The best decision in an ethically gray interaction is contextual and requires a case-by-case analysis of personal values, the client’s needs, professional standards and ethics, and any institutional or organizational policies.

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 and the Code as needed. Regulated members may also call ACSLPA for support, as needed.

Remember that it is the responsibility of the regulated member to establish, manage, and monitor the boundaries of a therapeutic relationship. If boundary crossing is suspected, it is important to take action by:

  • Objectively reflecting on if and/or how the boundary crossing occurred. To assist in their reflection, regulated members may wish to review key College documents (e.g., the Standards of Practice or the Code of Ethics), and consult with colleagues and/or ACSLPA, as required.
  • Taking necessary steps to re-establish the therapeutic relationship, if possible, or terminate the relationship and transfer care, as necessary.
  • Documenting the actions that led to the boundary crossing and the actions taken to re-establish or terminate the therapeutic relationship.

If a client challenges the regulated member’s professional boundaries with inappropriate feelings, conduct, or remarks, it is the responsibility of the regulated member to ensure that boundaries are explicitly expressed to the client and maintained.

The following strategies should be considered when managing boundary crossings:

  • Identify situations of high potential risk for boundary crossings and take proactive measures to maintain professional boundaries.
  • Request a co-worker be present during client visits.
  • If a client makes sexual advances, comments, and/or gestures, refuse to be engaged. Be assertive in explaining the ethical and regulatory responsibilities of the therapeutic relationship and maintaining professional boundaries.
  • Think before acting or speaking, and refrain from any comments or actions that could be misinterpreted.
  • Document event details in the client’s chart: date, client remarks and/or conduct, regulated member response(es).
  • Consult with colleagues and ACSLPA representatives as required.
  • If the behavior does not stop, discharge the client, transfer to another provider, and document appropriately.

Self-reflection may reveal warning signs that a professional boundary with a client or client has been crossed or may be about to cross, a professional boundary with a client.

Warning signs may look like an SLP or Audiologist:

  • Spending extra time with a client outside scheduled appointments or normal office hours.
  • Sharing personal contact information and/ or other unnecessary personal information.
  • Acting or feeling possessive of a client.
  • Providing a different standard of care for one client in comparison to others.
  • Keeping secrets with a client.
  • Selective record keeping or reporting.
  • Responding defensively when questioned about their interactions.
    • Denial that the client is a client (e.g. informal service provision to a friend).
  • Making exceptions to office rules and protocols for the client’s benefit.

The patient’s culture may influence their health-related priorities, decisions, and behaviours. Culturally sensitive care considers the preference and expressed needs of the patient which may be influenced by their culture (e.g., the involvement of family members or friends in 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 patient’s culture allows their care to be customized to better address their needs. Although regulated members must be sure to treat patients as individuals and avoid stereotyping based on membership in certain groups, there are some strategies that 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 patient and provider bring their culture to the therapeutic relationship.
  • Being open to learning about the patient’s culture or beliefs.
  • Respecting the legitimacy of the patient’s health beliefs.
  • Applying a biopsychosocial model approach to health care.
  • Encouraging the patient to discuss their explanations of their concerns/diagnosis and its perceived causes.
  • Discussing your understanding of the patient’s diagnosis/concerns and its perceived causes, using patient friendly language.
  • Encouraging the patient 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.
  • Incorporating cultural practices when possible.
  • 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).

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