Maintaining professional boundaries

[Ceke2002]

Just what it says on the tin, how do you do this, how do you not allow yourselves to get too caught up in a patient's life situation, for example. I assume lots of training helps, but is there anything specific in training, or in how you approach things with patients (a mantra to remind yourself not to overstep the mark, perhaps?)

Our move to Melbourne is now pretty much locked and loaded. There are a few places over there, which I've heard on the grapevine may be interested in taking on volunteer 'lived experience' peer workers, with a possible view to having it move onto paid employment. For paid employment peer work I would most likely need to do a Cert IV diploma specifically for the mental health field, and I assume I would learn about managing boundaries then as well - but I wanted to pick some brains here as well.

What can I say, I have a pathological caretaker side, and I'm a sucker for sob stories and lost puppies. So how do you ensure you don't end up with a patient sleeping on your couch, whilst you proceed to counsel half a dozen more at 3 in the morning? (hyperbole, sort of 😉).

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[NontradCA]

It’s just the nature of medicine. Recently I had a patient with pretty bad anxiety surrounding his very serious medical illness. His fear prevented him from coming to terms, and seeking specialty care, so he repeatedly showed up to the PC clinic I was at for treatment.

One day I gave him the “you’re going to die soon” talk. I thought I had gotten through to him that day. He had told me his worst fear was that he would die in his home and nobody would be there. He also talked about not having family, friends around. Well on the way out the door I saw him waiting for an Uber. I thought, I could give this guy a ride and convince him to go to the specialist or take him myself.

I instead just told him to have a good day. The next week he died at home alone. He was 40.

 

[Ceke2002]

It’s just the nature of medicine. Recently I had a patient with pretty bad anxiety surrounding his very serious medical illness. His fear prevented him from coming to terms, and seeking specialty care, so he repeatedly showed up to the PC clinic I was at for treatment.

One day I gave him the “you’re going to die soon” talk. I thought I had gotten through to him that day. He had told me his worst fear was that he would die in his home and nobody would be there. He also talked about not having family, friends around. Well on the way out the door I saw him waiting for an Uber. I thought, I could give this guy a ride and convince him to go to the specialist or take him myself.

I instead just told him to have a good day. The next week he died at home alone. He was 40.

See that's the thing, I can look at that from a hypothetical point of view and think, "Okay, that's how a health worker obviously should respond in this type of situation', but then there's also a big part of me that is going, "Oh come on, you know very well you would've given him a lift, and taken him to his specialist's appointment'. I take it with this being the nature of medicine you kind of learn to care without 'caring', if that makes sense?

I know as a peer worker I would have the guidance of mental health professionals I'd be working alongside, there are just certain issues I'm kind of known for that I need to be aware of. Does the awareness itself help at all?

 

[NontradCA]

See that's the thing, I can look at that from a hypothetical point of view and think, "Okay, that's how a health worker obviously should respond in this type of situation', but then there's also a big part of me that is going, "Oh come on, you know very well you would've given him a lift, and taken him to his specialist's appointment'. I take it with this being the nature of medicine you kind of learn to care without 'caring', if that makes sense?

I know as a peer worker I would have the guidance of mental health professionals I'd be working alongside, there are just certain issues I'm kind of known for that I need to be aware of. Does the awareness itself help at all?

Yes having awareness will help. It sounds like you’ll have a lot empathy for patients, which is a good thing. However, in psych it’s even more important to have boundaries because your patients are mentally vulnerable and a lot of times can’t fully grasp what an appropriate relationship with their provider should be. I can’t imagine wanting to see any psych patient outside of the hospital, let alone in my house.

 

[singasongofjoy]

Yes having awareness will help. It sounds like you’ll have a lot empathy for patients, which is a good thing. However, in psych it’s even more important to have boundaries because your patients are mentally vulnerable and a lot of times can’t fully grasp what an appropriate relationship with their provider should be. I can’t imagine wanting to see any psych patient outside of the hospital, let alone in my house.

YES- the above. You have no idea what someone's past experience has been and what type of traumas they may have been through in the past. What may seem like a benign, or even altruistic good-natured action on your part can be misconstrued and you might never know. You might do something you think of as just "nice" for a client and then your relationship/rapport with them starts going south because their "there is some sort of weird boundary thing happening I am not comfortable with" radar is going off. This is particularly important if you're working with people who are likely to have been taken advantage of in the past. Regardless of your words, they may interpret your actions as possibly having ulterior motives. One of many reasons it is extremely important to keep clear professional boundaries and making sure everyone knows what they are. Or you might have the opposite problem, that you are working with someone who has really loose boundaries and the next thing you know they think you're their soulmate and things get creepy fast. Or you just get over-involved and burn out and then you can't do anybody any good, and your own relationships and work/career start suffering. OR, when you are working in your professional role you can maintain appropriate boundaries, work during normal-people work hours to help hook people up with OTHER community resources that can meet those needs, realize that ultimately people have to reach the point of being invested enough to do the hard work themselves and follow through with your suggestions and that you can't be everything to everyone. You're just one little pieces of the much bigger picture that is their life, so you do your best with what you can given your well-defined role and just try to point them in the right direction for them to connect with the other pieces. But you can't do it for them. And whatever you do, never let anyone have/give out your personal phone/email or people will think they have special status with you (unless it's part of your job and generally known that it's given out to everyone equally, but I can't imagine that would EVER be a job expectation without very explicit rules- e.g., I used to have a job where I provided transportation to clients. We exchanged numbers but with very clear rules about when and for what reasons it would be OK to call, i.e., if running late or calling in sick).

It's excellent that you're self-aware about these traits. That'll go a long way towards helping you be vigilant about setting and maintaining appropriate boundaries. Find some professional colleagues you look up to that you can bounce things off of when you aren't sure if something is appropriate or not.

 

[Shikima]

Use selective and narrow focused personal experiences to help normalize the other person's emotions and response and this also can help you build rapport.
I'm sure there is a literature citation about this somewhere on pubmed.

 

[nitemagi]

I advocate for cultivating a state of detached compassion. Compassion for their experience, but a detachment from attaining a specific outcome (thus not having to fix anything).

 

[thoffen]

Most often, when you are most strongly compelled to act in a way that is different from your normal sense of clinician-patient relationship, that has a whole lot less to do with external reality and a whole lot more to do with the patient communicating something to you about their life, identity, pattern of relationship with others, etc. The key isn't to try to detach yourself or run away from those feelings. You must be able, however, to experience the patient in multiple ways. Some detached, and some not. If you are able to experience them in a way that is detached from those emotions, it gives you a safer starting point to try to understand what those emotions are communicating. And if you ever feel that you don't know why you are acting differently with a patient, you need to get supervision and potentially terminate a patient relationship. Those are times where maintaining boundaries is most important.

Outside of actual boundaries, yeah, sometimes patients will take an emotional toll on you that goes beyond your treatment even though boundaries are maintained. In those cases, maintenance of boundaries helps you keep the feelings contained, and otherwise your own psychotherapy and supervision may be paramount, but also understanding that sometimes you need to slow down.

 

[20gauge]

Ceke:

I'm not a psychiatrist, but I am a nurse who worked in mental health AND happens to have a "pathological caretaker side", as you describe. I also had a close family member who was drug-addicted and homeless, whom I was desperate to save. I can now say that I have a solid appreciation for the importance of solid boundaries when caring for people with mental illness.

Though our intentions are good, we do more harm than good by not maintaining professional boundaries. Harming others is not our intention, but it is the unintended consequence. The question is: why do we want to save people? Why do we want to offer them our couch and/or counsel them at 3am? Do we think it will actually help them, or is it somehow filling a need in us?

I have had my share of therapy (best investment I ever made), and I learned that the "pathological caretaker" in me was more about me than the person I was purporting to care for.

I now have no difficulty setting boundaries with patients and their families. I meet a lot of needy people in the hospital. Patients have asked for my phone number. Families have asked to hire me privately to care for their loved ones at home after discharge. People have told me stories that bring me to tears (it's gut wrenching, it really is), but I remind myself that I can't fix that person. Offering them a spot on my couch won't fix the underlying problem, but I can give them the best possible care within my role as their nurse by listening to them, treating them with respect, showing them that they have value as a person, and by not judging them. I give them 100% of myself when they are under my care, and I am satisfied with that. Everyone plays a role in the big picture, and that is mine.

 

[FlowRate]

I advocate for cultivating a state of detached compassion. Compassion for their experience, but a detachment from attaining a specific outcome (thus not having to fix anything).

This. Being outcomes oriented is the fastest way to burnout in the MH field IMO.

Also, it's just a simple ethical lens used differently: "If I do/say X for this patient, am I going to be OK doing it for every patient?" It's not the only way to evaluate actions, but it's an easy way to figure out one of many reasons why giving patients money or rides is a potential issue.

 

[Shikima]

This. Being outcomes oriented is the fastest way to burnout in the MH field IMO.

Also, it's just a simple ethical lens used differently: "If I do/say X for this patient, am I going to be OK doing it for every patient?" It's not the only way to evaluate actions, but it's an easy way to figure out one of many reasons why giving patients money or rides is a potential issue.

I disagree. Being detached allows me to go home without a concern about what is going on with others. It's not mine to own - it's boundaries.

 

[FlowRate]

I disagree. Being detached allows me to go home without a concern about what is going on with others. It's not mine to own - it's boundaries.

Disagree with what? I'm pretty sure we agree on that point.

 

[Ceke2002]

Wow, thanks for the advice, there's some really great stuff here and I will definitely take it on board. 🙂 I also had a chat with my Psychiatrist today about stuff, and we went into the differences between cognitive and emotional empathy, plus some DBT ideas of wise mind versus emotional mind, and so on - so that's helped too. I've also found out that apparently there are mentorship programs on offer in Melbourne for people looking to work in the mental health field, so I'l look into that as well. Thanks again. 🙂

 

[Shikima]

Disagree with what? I'm pretty sure we agree on that point.

I may have misunderstood your point. sorry bud.

 

[Ceke2002]

Ceke:

I'm not a psychiatrist, but I am a nurse who worked in mental health AND happens to have a "pathological caretaker side", as you describe. I also had a close family member who was drug-addicted and homeless, whom I was desperate to save. I can now say that I have a solid appreciation for the importance of solid boundaries when caring for people with mental illness.

Though our intentions are good, we do more harm than good by not maintaining professional boundaries. Harming others is not our intention, but it is the unintended consequence. The question is: why do we want to save people? Why do we want to offer them our couch and/or counsel them at 3am? Do we think it will actually help them, or is it somehow filling a need in us?

I have had my share of therapy (best investment I ever made), and I learned that the "pathological caretaker" in me was more about me than the person I was purporting to care for.

I now have no difficulty setting boundaries with patients and their families. I meet a lot of needy people in the hospital. Patients have asked for my phone number. Families have asked to hire me privately to care for their loved ones at home after discharge. People have told me stories that bring me to tears (it's gut wrenching, it really is), but I remind myself that I can't fix that person. Offering them a spot on my couch won't fix the underlying problem, but I can give them the best possible care within my role as their nurse by listening to them, treating them with respect, showing them that they have value as a person, and by not judging them. I give them 100% of myself when they are under my care, and I am satisfied with that. Everyone plays a role in the big picture, and that is mine.

Since reading through the all the great advice on here, and talking with my own Psychiatrist, I've started to ask myself, "How would I want a mental health worker to behave?" And the answer is a definite, "Not like me in my pathological caretaker mode". I know for myself if my shrink, or anyone involved in my care, started acting what I consider to be 'out of bounds' (which definite includes slipping too far into the role of carer), I'd be out of there so fast my feet wouldn't even hit the ground. If that's not how I would want someone to behave towards me, then I should consider that that's not how I should then behave towards others I am purporting to help.

This is definitely something I need to be very aware of though, and I am hoping, if there are mentorship places available (along with the cert IV studies), that I can make good use of any help that is available as I (hopefully) transition into a new career. 🙂

 

[Ceke2002]

I'm not sure what Cert IV studies are (must be an Aussie thing). Have you thought about a career in nursing? It is incredibly meaningful work for those of us "pathological caregivers," provided boundaries are respected and maintained. I know you have a particular interest in mental health, however even if you don't work in the psychiatric unit you will find mental health issues everywhere. It's pretty pervasive.

It is incredibly fulfilling to be able to make a small difference in people's lives on a daily basis.

Unfortunately I can't apply for Nursing, because I have a criminal record. In Australia for Social Work, and Nursing, any criminal record (mine is for drug possession and theft, I had some issues to deal with in my 20s) automatically precludes you from enrolling in the necessary University courses. I was looking into doing medicine as a post graduate degree, but I have peripheral neuropathy which also precluded me from that as well. Then I decided to try for Psychology, but the Government here recently changed the University fee structuring, and I had to drop out of the course due to not being able to afford to continue. Because I have a lived experience with mental health, there is a TAFE (Technical and Further Education) course I can do, which is 6 months to a Year, which is a Certificate IV course in Mental health peer work and support. So that's what I'm trying for, and the city we're moving to has a lot more opportunities for that type of work than where I am now. I'd be happy to do some sort of voluntary work to be honest. I mean sure a paid job would be great, but even just volunteering somewhere to help out is something I would love to do.

 

[Ceke2002]

I advocate for cultivating a state of detached compassion. Compassion for their experience, but a detachment from attaining a specific outcome (thus not having to fix anything).

Yes, absolutely, I think for me this sums up exactly the sort of approach I wish to try and cultivate as well. This is very much the way my own Psychiatrist works: completely present, empathetic, but contained at the same time. I've experienced both ends of the spectrum when it comes to Psychiatrists and/or Therapists, either too detached and clinical, or too over invested 'rescuer' personality types, and I know for myself that I prefer and indeed feel safer, and more comfortable with a more middle ground approach - the 'detached compassion' as you describe it.

 

[Ceke2002]

And thank you, once again, everyone, for the awesome advice and guidance I have always received in this forum. This has been a long, and at times very frustrating road for me with a lot of setbacks and disappointments along the way. I have had to re-evaluate, reassess, and change both my goals, and aspirations, but working in the mental health care field is something I feel strongly drawn to and it is something I want to do well in for the benefit of the patient population I hope to work with.

 

[857770]

Ceke, have you thought about working as a suicide and crisis phone counselor? In the U.S., one can get a full-time job doing this (at least where I live).

 

[Ceke2002]

Ceke, have you thought about working as a suicide and crisis phone counselor? In the U.S., one can get a full-time job doing this (at least where I live).

I do vaguely remember looking into it some years back, but decided it wasn't for me, although I can't remember why I thought that now just off the top of my head. It might have had something to do with the qualification requirements.

 

[pizzicarella]

Ceke, I am late on responding to this but I am a mental health nurse with lived experience and thought perhaps I could give some insight. I have bipolar disorder, and also had puerperal psychosis after the birth of my son. I was qualified as a nurse and midwife prior to having a baby, and I mostly worked between cardiac units and high risk antenatal/gynae- and I actively avoided any mental health work because I found it too upsetting and triggering to be involved in involuntary treatment or restraint. I also didn't feel comfortable or safe to disclose my mental health history to my colleagues (let alone my patients!) because of stigma and fear. My experience having my son changed my goals and my feelings around my work. After I gave birth, I became unwell very quickly and it was the most unwell I had ever been - I was in a mother-baby inpatient unit for just under six months, failed to respond to any pharmacotherapy, and eventually had involuntary ECT which was very effective. While I was in hospital I developed an excellent rapport with most of the staff, and grew to admire them immensely. I am certain that they are why both my son and I are alive today.

I felt compelled to do something so that other people would have the kind of positive experience I did - initially I went to universities to speak to midwifery and nursing students about my lived experience of bipolar disorder and puerperal psychosis (and I've continued to give this talks to students, as well as to staff in other hospital settings). I started to talk to other women who had experienced perinatal related mood and anxiety disorders and found myself getting really angry at the lack of services for women who didn't have my kind of history - for people who had no prior history of mental illness, with first onset "mild" anxiety or depression, and how they really slipped through the gaps. And I felt like I did a good job of talking to them, and of making appropriate referrals - some would thank me for not judging them and for 'understanding.' So I decided that I would become a perinatal mental health nurse to be able to work with that population.

And nowadays I work in a MBU (obviously not the one I was treated in!!), and I have a mix of inpatient and outpatient care working mostly with mums with BPD. And I facilitate a DBT group, have individual clients for therapy (mostly DBT, but a few with a mix of CBT, ACT and CPT), and have two days a week on the inpatient unit. And perhaps my lived experience meant that I am less judgemental, and it is certainly what made me feel passionate about working with this population - but there is no need for me to disclose for me to be able to help them. I will say that being open with disclosure among my colleagues has been nothing but positive - I feel that it has helped them to support me better if I've struggled with a client, or if my own health wasn't great; and most of all it's helped fight stigma by giving people an example of a person with 'severe mental illness' thriving.

Good luck with your move to Melbourne - it's a great place to live (I miss it very much). Peer work is a wonderful area to get in to - some of my happiest moments in hospital have come when a peer worker came and spent time with me, or gave me hints about being on a psych ward, or took me out on my very first supervised leave to the hospital cafe. I hope your application goes well.

 

[Ceke2002]

Ceke, I am late on responding to this but I am a mental health nurse with lived experience and thought perhaps I could give some insight. I have bipolar disorder, and also had puerperal psychosis after the birth of my son. I was qualified as a nurse and midwife prior to having a baby, and I mostly worked between cardiac units and high risk antenatal/gynae- and I actively avoided any mental health work because I found it too upsetting and triggering to be involved in involuntary treatment or restraint. I also didn't feel comfortable or safe to disclose my mental health history to my colleagues (let alone my patients!) because of stigma and fear. My experience having my son changed my goals and my feelings around my work. After I gave birth, I became unwell very quickly and it was the most unwell I had ever been - I was in a mother-baby inpatient unit for just under six months, failed to respond to any pharmacotherapy, and eventually had involuntary ECT which was very effective. While I was in hospital I developed an excellent rapport with most of the staff, and grew to admire them immensely. I am certain that they are why both my son and I are alive today.

I felt compelled to do something so that other people would have the kind of positive experience I did - initially I went to universities to speak to midwifery and nursing students about my lived experience of bipolar disorder and puerperal psychosis (and I've continued to give this talks to students, as well as to staff in other hospital settings). I started to talk to other women who had experienced perinatal related mood and anxiety disorders and found myself getting really angry at the lack of services for women who didn't have my kind of history - for people who had no prior history of mental illness, with first onset "mild" anxiety or depression, and how they really slipped through the gaps. And I felt like I did a good job of talking to them, and of making appropriate referrals - some would thank me for not judging them and for 'understanding.' So I decided that I would become a perinatal mental health nurse to be able to work with that population.

And nowadays I work in a MBU (obviously not the one I was treated in!!), and I have a mix of inpatient and outpatient care working mostly with mums with BPD. And I facilitate a DBT group, have individual clients for therapy (mostly DBT, but a few with a mix of CBT, ACT and CPT), and have two days a week on the inpatient unit. And perhaps my lived experience meant that I am less judgemental, and it is certainly what made me feel passionate about working with this population - but there is no need for me to disclose for me to be able to help them. I will say that being open with disclosure among my colleagues has been nothing but positive - I feel that it has helped them to support me better if I've struggled with a client, or if my own health wasn't great; and most of all it's helped fight stigma by giving people an example of a person with 'severe mental illness' thriving.

Good luck with your move to Melbourne - it's a great place to live (I miss it very much). Peer work is a wonderful area to get in to - some of my happiest moments in hospital have come when a peer worker came and spent time with me, or gave me hints about being on a psych ward, or took me out on my very first supervised leave to the hospital cafe. I hope your application goes well.

Thank you so much for your encouragement, and for sharing your story. I've had that 'angry at the system' feeling too, I guess it's part of the reason I want to work within the system, to try and improve things for patients. Also to try and give some hope back, lead by example in a way I guess - not just for patients, but for mental health professionals as well, show them that people with chronic mental health conditions can recover, they can manage their symptoms effectively, and they can do things like return to work. I know what it's like to be dumped in the 'too hard' basket, if it weren't for my current (soon to be former) Psychiatrist I'd probably still be there. So I think I'd like to pay some things forward, you know?

I'm taking things one step at a time. The removalists are arriving this Friday coming, then my husband is returning to Adelaide until Monday when we fly our two cats over, and after that we're gonna look to just taking some time to unpack, settle in, and get to know our way around. It's a big move, but the opportunities for both of us in Melbourne just far surpass what we have at the moment. I'll miss my friends here, and my Doctors who have looked after me of course, but I'm psyched to see what's around the corner. 😀

Thanks again.