Many of us start our practices and only begin to address ethical issues as they arise. But when you want to create a full, thriving business, it is important to know where you stand on issues that can get thorny. It is vital to get support and put plans in place before you run into trouble.
In our experience, developing clarity in this realm has been key. Engaging with these topics increases our self-awareness. Our increased awareness allows us to be more present for our clients. And our referral sources consistently tell us they value and rely on our high level of professionalism.
We cannot foresee every ethical dilemma we may encounter, but by thinking through those we can anticipate, we can avoid panic when something unexpected crops up. We have developed a sense of our own ethical standards and can apply what we have learned to new situations. Knowing where you stand ethically supports you, your business, and your therapeutic field as a whole. In this article, adapted from our book Elements of a Successful Therapeutic Business, we will discuss how we interact with clients, including being honest about skill level, licensing, certifications, and scope of practice; intimacy and touch; and sharing personal information with clients.
Being Honest About Skill Level, Licensing, and Certifications
We believe clients can receive benefit from practitioners at all skill levels: ones who are just starting out and those who have decades of experience. It is the fit between client and practitioner that is key. So, it does us no good to pretend to have more experience than we actually do (nor does it serve us to sell our years of experience short). Be honest about where you are in your practice. Clients can tell when we overstate or hedge our experience.
Consider this example: At what point in our practice do we work with populations with special needs or who may require specialized training or skills beyond our core training? In craniosacral therapy (CST), one such population is children. Their bodies are just different enough from adults that a specialized curriculum has been developed for the therapists who work with them.
Some colleagues feel it is sufficient simply to have read the cautions that should be observed when working with young children, but we have each chosen to receive specific pediatric training. There is no rule that prevents therapists who do not have this training from working with children; it is a choice that each therapist has to make, based on their personal and professional sense of ethics. Can you think of an issue like this in your own practice? These questions can help guide you:
• Where is my skill level?
• What is my experience?
• What is my licensure? Does it entitle me to work with this population?
You can then make an informed decision you feel comfortable standing behind.
Being Honest About Your Scope of Practice
Kate is a licensed physical therapist, and her scope of practice is by definition wider than Robyn’s as a massage therapist. We both practice craniosacral therapy, but Kate has more latitude in other techniques she can employ.
Think about the recommendations you make to clients. For instance, you might ask yourself whether your licensure allows you to diagnose or advise on medication. This area is one that is clearly defined. Working within the boundaries of your professional licensure is vital to the integrity of your business.
You can also take a fresh look at your intake form, which should only include questions that are covered by your scope of practice. It may be tempting to use intake forms from medical practices since they are widely available. But using a form that asks for information that is out of your scope can give the wrong impression to a client. It also may not give you the information that is most relevant for your work.
Committing to staying within our scope of practice helps us quickly identify when we are out of our depth. That is our cue to make a referral to an appropriate professional, such as a physician or licensed mental health professional.
Unearned Intimacy
In therapeutic work, there is an unavoidable power differential. We can aim to minimize it, but the fact is that there is always a certain amount of what one of our mentors called an “unearned intimacy.” People share with us much more than we share with them, in the hopes that we can help them.
In addition, there is an intimacy in the conversations that happen. We imagine most of you have heard a client say, “I’ve never told anybody this.” Kate recalls being asked by a male client, “Kate, do people fall in love with you?” In exploring the question with him, she found what he meant by that was, “A lot of what we talked about today, I’d only really talk about with my spouse.”
Often, clients are sharing something for the first time, and they are taking a chance to trust us. This is a healthy process that can promote a healing response in our clients. We may be accustomed to this level of therapeutic connection, but it could be new for our clients. It can be a place where clients get confused because there is deep sharing, and so it is vital that we honor our client’s vulnerability by having clarity around our therapeutic role.
Touch Outside Session Work
Our work involves touch, and the boundaries between touch as therapy and touch that conveys more than a therapeutic relationship can be tricky. We need to honor our own boundaries, communicate those clearly and kindly, and, above all, do our very best not to violate our clients’ boundaries.
One common dilemma we have encountered and heard about from our colleagues is how to approach hugging. It is not uncommon for clients and therapists to share a hug at the end of a session. Do you know where you stand on this issue? The close of a session is still the session, so the work is continuing, and therefore we want any action we take to be centered on the client’s well-being.
We think therapists get into trouble ethically when they feel very comfortable initiating a hug to end the session. That brings up the question: Who is this contact for, the client or the therapist? Kate had a client who shared with her that he would not continue to see a colleague of hers because she hugged him at the end of the session, and he was not comfortable with that. For him, it felt like a violation of his boundaries.
There are certain clients for whom a hug is a routine at the end of the session. They like to have a hug, and we are more than happy to oblige, but we wait for their initiation. If for any reason you are not comfortable with a hug, you may wish to think about how you will approach that before the situation presents itself. Consider what your physical stance will be and how you will end the session warmly, but without contact.
Sometimes with young children we will have the ritual of a hug at the end of their sessions. One of the reasons we started offering them hugs is that we found once we ended the session and they were out the door, they would run back to have one! It seemed the session was not complete for many of our small children until they had that hug to end it. When we do offer a hug, we kneel down to ask, “Would you like a hug?” A hug with them is always on their grounds, with their permission. It is not assumed. A high five or fancy handshake can work just as well: it is a ritualized form of contact to signal the session has ended since children do not have the ritual of paying and rescheduling.
Sharing Personal Information with Clients
Over the years, we have had encounters that prompted us to create our own guidelines around how much personal information we are willing to share. The guidelines we follow are based on two rules:
• Keeping the focus on our clients and their process
• Lowering the power differential whenever possible
Following both of these means that sometimes we will share personal information and sometimes we will not. Context is everything.
We remember a client we worked with together in a multihands session. It was his very first session, and he was deep into what we would call a somatoemotional release process. All of a sudden, he said, “So where do you live, Robyn?” We just took that as, “Oh, perhaps he needs a little break.” So Robyn shared where she lives, and a little later in the session he asked, “So you didn’t grow up in America, Kate. Where did you come from?” Kate’s accent gets people’s attention. Again, Kate was more than happy to answer. It is not like we gave long answers, just an honoring of his requests, and it was information both of us were happy to share. It was not too personal.
But it was also a choice for us in how we answered. We could have given a slightly clipped or blunt answer, or we may have redirected him to sensations in his body. It can be tempting to judge these questions as inappropriate, and sometimes that can be true. However, in this situation (and what we have found to be in true in most situations), it was more about the client feeling safe with us and pacing his own session. When we answered him, we were also paying attention to what was happening therapeutically through our touch. Because he was still deeply in his process, we knew our answers were not derailing his work.
Over time, our clients may wish to know us as people, and it is up to each of us, in every situation, to decide what we want to reveal and what we wish to keep private. It is useful to think about this ahead of time, so when the moment arrives and a client asks, “Do you have children?” or “Who’d you vote for?” you know what you will want to say. When we are at ease with what we are willing to share and what we keep private, our clients will be too.
Exploring issues that can create detrimental barriers to our communication with our clients is essential. To have a thriving therapeutic business, we need to have explored ethical issues that can engender trust or threaten it.