Many are the challenges of a career in health care. Ethics – in particular, boundaries – is one area that is intangible yet cannot be ignored under any circumstances.
By Jonathan Maister
Many are the challenges of a career in health care. Ethics – in particular, boundaries – is one area that is intangible yet cannot be ignored under any circumstances. If this area is neglected, the professional’s entire practice may be compromised and the patient harmed.
This raises the question, how does one define something as esoteric as boundaries in a form that can be clearly recognized and then effectively implemented? This scenario is often complicated further by the vast array of cultural backgrounds of both professionals and patients. Furthermore, the emotional status of both patients and practitioners differs at any given time and must also be considered.
This article serves to offer that elusive template that will guide the health-care practitioner through this muddy macrocosm.
RECOGNIZING THE BOUNDARIES
Boundaries are divided into five distinct groups: physical, emotional, sexual, intellectual and energetic.1 All are to be respected.
The word “respected” is used by design, for there may be situations where boundaries are semi-permeable and the health-care practitioner, as a compassionate entity, may be required to nudge across the line and do the right thing by the patient. For indeed, we, as massage therapists, live in two universes: that of the (ostensibly) dispassionate clinician, and that of the compassionate human being. Hence we must acknowledge the boundaries, uphold their barriers, but know if and when, on that rare occasion, we can shift across the threshold, albeit briefly, for the patient’s benefit – not ours! This will be explained later in this discussion.
In daily life, the physical boundary is the most obvious one and is continuously adjusted depending on the situation. Mainly subconsciously, we alter this boundary depending on whether the other person is a stranger or a familiar person, unkempt or neat, and whether the respective moods of the persons invite a closer physical space. Clearly, in the presence of a foul mood, both persons will likely keep a greater distance. In the medical environment, the physical boundary is clearly much closer than in normal circumstances and absolutely involves a large measure of trust. It also varies depending on circumstances, whether we are referring to contact made during treatment or a handshake greeting in the common waiting area.
The emotional boundary defines people by their emotions, and how closely they allow others to be privy to their emotional status. Once again, trust is paramount because we are sharing that which is supremely private with another person. This is exquisitely so when a patient discloses his or her personal details to the therapist. The degree of comfort and trust we have with the other entity will determine the permeability of our emotional boundary.
The sexual boundary determines the sexual limits between two people. For example, as a platonic relationship evolves into a romantic one, the sexual boundary shifts closer. This boundary must not under any circumstances be violated when there is a clinician-patient relationship. The laws stipulating the limitations of a romantic relationship in this context – which for health-care personnel in our country typically is defined on the level of zero tolerance – must be adhered to beyond any negotiation!
The intellectual boundary reflects one’s beliefs, opinions and thoughts. These, in turn, define our identity and distinguish us from others. In essence, if our “universe” and its belief systems are affirmed or respectfully challenged, we are validated as people. Conversely if our “world view” is mocked or denigrated, our comfort with ourselves is threatened and, clearly, we will avoid giving the other party access to our thoughts. Simply put, how permeable, or how solid, our intellectual boundary is to the other person depends on her/his responses to our world view. As health-care workers, our openness to our patients’ “world view” could impact the nature of our relationship with that patient.
The energetic boundary is probably the least obvious, at least initially. Therapists will become increasingly aware of it over time as their intuitive senses evolve. From our first-year physiology classes, we know that humans are biochemical entities. As our body processes unfold, we generate an electromagnetic field. Just as we adjust our emotional, physical and other boundaries, so too it is wise we protect our own bio-electric field from those of our patients. Often our patients, experiencing health challenges, emit what is described by Ronan M. Kisch, PhD, as psycho-physical toxins.2 These impede the health of our own fields and, if left unchecked, are deleterious to our health.
Exploring boundary models further and how they evolve is beyond the scope of this article. These are excellently investigated by Ben E. Benjamin, PhD, and Cherie Sohnen-Moe in their outstanding book The Ethics of Touch (2003: Sohnen-Moe Associates Inc.).
I differentiate a “boundary violation” from a “boundary crossing.” The former is unwanted, possibly offensive and conceivably damaging at a physical or emotional level. The latter is usually non-threatening to either person, not damaging to the professional relationship, and may even be invited.
Applying these premises to real-life scenarios in health-care practice yields some interesting results. Over the 19 years of experience as a health-care professional, I have been privy to moments when the dispassionate clinician in me is apparently in conflict with the compassionate human.
I recall two parallel situations that illustrate this dilemma. With both examples, there were middle-aged female patients who at some emotional level, I felt, needed a physical response, for example, perhaps a hug.
In the first instance, I had been treating the patient for various physical issues. Parallel with this, she had, in months preceding, been dealing with profound medical challenges of her own. Serious health concerns had unfolded with two other people who were close to her, one of which had resulted in death in extremely tragic circumstances. She was a courageous individual but confessed to having moments of weakness – understandably. Post treatment, one day after a particularly intense catharsis in conversation, I felt an overwhelming urge to hug her in the empty waiting room prior to her departure. The human in me felt compelled to show my support as “one human being to another” in a tangible way. At a deep level, she had given me access beyond her emotional boundary and, clearly, trusted me. Would my response be a violation of her physical boundary?
In the second instance, another usually cheery and gregarious patient silently entered my treatment room looking extremely sad and sullen. Preceding any history or greeting, she blurted out, “I need a hug.” I was taken aback. We had had a wonderful professional relationship lasting years, but this was the first such request. This was one human crying out for support from another. In essence I was being asked to shed my clinician persona briefly, then having hugged her, readjust to my usual clinical identity. Knowing my professional boundaries, this was not something I took lightly.
I was, in both instances, facing a dilemma. In both situations the human in me felt I should hug my patient, yet the clinician in me felt I should remain aloof, albeit not detached.
I believe I made the correct decision with both situations. Understanding boundaries, yet using the premises of “Do no harm” and “What would any rational person do in this situation?” and simple common sense, I did as follows:
In the first instance, I did not make any physical contact with my patient. I allowed my voice, my compassionate words and my body language convey my sentiments. At some deep level, I sensed that a hug in those circumstances was for my benefit rather than hers. And that was the defining factor.
In the second situation, I did as my patient requested. I stepped forward, put my arms around her while minimizing actual body contact, and held her for five seconds. She appeared marginally less distraught, and we proceeded with the history. Her situation involved severe abdominal pain. Ultimately it was due to kidney stones or a hernia. But her concern, until she received the diagnosis otherwise, suggested a possible aggressive cancer. But my hug gave her some physical comfort. Once again, the notion of rational, common sense coupled with the overriding premise that this is for the patient’s benefit, prescribed my course of action. My physical response did not, in any way, disturb our clinician-patient relationship.
Boundaries are strict thresholds that must be respected. They are clear guidelines that primarily protect the patient, but also assist the health-care practitioner in making wise decisions. Boundaries and rational common sense almost always work together flawlessly. However, there are those few moments when an apparent contradiction occurs. These moments are rare but they do happen. At those times boundaries shift – they do so very briefly, and then only to meet the patient’s needs. In essence, it might even be more accurate to define the boundary as having shifted rather than been crossed.
The passage of time, both as a therapist and even more so as a sensitive and rational human, yields many lessons. For this reason, it would be true to say that one becomes a superior therapist. This is so, not only because one adds to one’s repertoire of treatment modalities, but because increased life experiences gives one a greater range of life contexts to draw from. When these unexpected human situations occur, they are far easier to deal with.
Over the years I have acknowledged that the “dispassionate clinician” and “compassionate human” need not be a contradiction. By applying the guideline of boundaries, and rational common sense, I like to think of them as merging.
- Ben E. Benjamin, PhD, and Cherie Sohnen-Moe. The Ethics of Touch: The Hands-on Practitioner’s Guide to Creating a Professional, Safe and Enduring Practice. 2003: Sohnen-Moe Associates, Inc.
- Ronan M. Kisch. Beyond Technique: The Hidden Dimensions of Bodywork. 1998: BLHY Growth Publications.
Jonathan Maister is a Canadian trained Athletic Therapist, Massage Therapist and Sport Massage Therapist. He is in private practice in the Markham area and has lectured on a number of sport massage and sport medicine topics across Canada. He has authored articles that have appeared in various associated journals across North America. He can be contacted at firstname.lastname@example.org or 905-477-8900.