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Friday, January 16, 2009

How are your boundaries?

In an entry a few months ago I referred to my new position on the Boundaries Awareness Committee at work. I promised details, and aim to begin delivering. For those of you in public service roles this is a familiar concept, and for some others of you this might be a completely foreign world so hang in there.

"Boundaries" in this case refer to a psychosocial barrier between a medical provider and a patient. Violations of this line disrupt therapeutic relationship by causing a status shift, creating distrust, blurring the personal rights of one or both parties, or otherwise upsetting the delicate balance of a provider-patient relationship. Some boundary violations are clear, such as carrying on a sexual relationship with a patient, or buying from or selling drugs to a patient. Boundary violations, however, can be far more subtle, and even very well intentioned, but in the end undermine therapeutic results. I can not stress enough how much more serious this is when working in a community with a ton of psych issues. Boundary violations of the subtle nature are kind of a case by case thing. However, almost always what would fly just fine on a med-surg floor is not going to have the same results in a psych unit. Accepting gifts from patients, bending small rules, sharing personal stories... these are all well intentioned innocent behaviors that could completely ruin the dynamic of a provider-patient relationship particularly with psych clients.

Therefore, I can not tell you how appalled I am by the recent ruling in Washington state that teachers are not barred from sexual relationships with students. A teacher is in a therapeutic position with his or her students. He or she must have their trust and respect. Even the teachers who use a "buddy" approach must have a line drawn somewhere in the sand. In turn, the students can look to the teacher to teach them. To know their strengths and weaknesses and to guide them. All of these benefits are lost to the student who enters into a relationship with their teacher, and to any of their mutual friends in the know. A sexual relationship levels the playing field where a field should not be leveled. I don't care how mature you are at 18, it's not really about consent to me. It's about the relationship damage. My patients are over 18 too. That's not the issue. A psychologists clients may all be "of age," but it is NOT helpful to the patient to allow such a severe slip of boundaries to occur.

Here is my own story of my first boundary violation on the job.

I saw a man on a train one day. I recognized him as a former patient of my facility, though not someone I had ever directly cared for. He recognized me before I could walk away and we began talking. As we chatted, I gave him half of my sandwich because he was hungry. (Wrong move #1) He began to speak about his children and how he wished he could still take them to the movies. "Say, " he said, "wouldn't it be great if someday when I have my life back together, and a car, we could go to the movies?" Not having had any experience in what to do in these situations, but remembering from some psych class somewhere that imagining a positive future can help to stop self destructive thinking I answered, "I bet that would be fun. " (Wrong move #2). Wrong move #3 came when he asked for my number. Suddenly, and too late, I realized he had been hinting at this all along and I had been clueless. I refused to give him my number, but I said it was "against policy" instead of saying that I personally was refusing to do it.

Everything I did was done to be "nice." Nothing was done to get something I wanted, or to hurt the guy in any way. It was all wrong.

The next week he called me every day at work. He called while I was off duty, so I didn't know. Then one day he got through to me. He said he was at a hotel. He wanted me to meet him there. There was a hot tub. He was going to give me the number, did I have a pen? With the stakes so clear and so high I was finally able to give the answer that I should have given in the first place. I told him it was "inappropriate" to call me. Period. He got upset and told me he thought I "was different." I called my supervisor.

She listened to the story and nodded a lot and we went to the DON and I was told that although my heart was in the right place when I gave away the sandwich I had unintentionally crossed a boundary. In that man's eyes we were friends as soon as I shared my lunch. And it's not a bad thing to be friends with people. It's even not bad for me, as a nurse to be friend-ly. But as your nurse, at the end of the day I can not be your friend. It's bad for me and bad for you. There's a reason surgeons don't operate on family members.

Christmas that year he showed up to where I worked, drunk, and brought me a full length leather jacket. It was gorgeous. I was terrified. I called my boss back up and I had to promise I hadn't had any new contact with him, which I hadn't. We can laugh about it now, but at the time, it was serious stuff.

It's important in fields like this to check in with your co workers and ask "how are your boundaries?" It seems corny, but it's a very real question and is aimed at helping people to check in and keep from being under or over involved, both of which are a symptom of issues with boundaries.

And yeah, it's hard. I've always hate the word "inappropriate," when used to define behavior. It leaves a terrible taste in my mouth. But learning the language of behavior management has been necessary. The most recent issue I've had with a patient crossing a boundary was this past year. He told me he had feelings for me and asked if I could spend some "quiet time" with him discussing it. As a human being my reaction was to let him down easy, perhaps to make a joke and let him save face. But it isn't enough, especially when it comes to populations with damaged social history or outright psych issues. I had to actually say, "you're being inappropriate, and I know you're aware of it. I am not interested and this conversation is over." Try it out loud. It's harder than you think.

It's hard to be friendly, and nice, caring and giving while also being prepared to quickly draw the line without any hesitation or mixed messages. How can you be Florence Nightingale and also the General? One of my co workers tonight wondered out loud if maybe we were better off just being bitchy to begin with so patients don't get attached. Sometimes I wonder at all the unfriendly nurses or doctors I have encountered and whether maybe they just had a bad boundaries experience in their past. But that's not a solution. If a boundaries violation is, by definition something that upsets the therapeutic relationship, then choosing to not have a therapeutic relationship doesn't make much more sense. You might as well leave the field.

We're meant to be compassionate, yet professional. There is a delicate balance, and every interaction must be careful weighed. Medical providers must be continually self aware, and never end vigilance over their own behaviors. Every action must be double checked no matter how well intentioned. It's kind of exhausting.

How are your boundaries?

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