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Mental health providers and their clients can develop close relationships over the course of therapy. When does it cross an ethical line, and what types of behavior can result in professional discipline?
Healthcare provider ethics help ensure that patients obtain the care that they need. Ultimately, most ethical rules about “unprofessional conduct” aim to protect the patient from the provider’s actions. For mental health professionals, who often work with their clients for extended periods and become intimately familiar with their emotional vulnerabilities, the line between appropriate and inappropriate behavior between the client and therapist can blur.
It’s not a big deal, you might think. Those ethics rules are just suggestions. However, violating ethical boundaries can not only challenge your authority as a provider — it can have legal consequences. While the code of ethics for each professional licensure may not include a specific enforcement mechanism, many states have incorporated ethical rules into their practice acts. In other words, breaching professional boundaries could directly violate state regulations.
For instance, the Illinois LCPC and LCSW practice acts allow the IDFPR to discipline providers for “engaging in dishonorable, unethical or unprofessional conduct of a character likely to deceive, defraud or harm the public as defined by the rules of the Department, or violating the rules of professional conduct adopted by the Department.” Notably, the “rules of professional conduct” mentioned in practice acts are often the ethical rules established by the licensee’s professional organization.
What Boundary Issues Can Spell Trouble for Therapists?
Engaging in Personal or Sexual Relationships With Clients
Romantic and sexual relationships with clients should be considered off-limits. The prohibition seems obvious, yet mental health providers often face discipline for forming improper relationships with clients. Most professional ethics codes for mental health providers have sections dedicated to such relationships, and violations of these rules often trigger some of the strictest punishments from state licensing boards.
Spending Time With a Client Outside of a Therapy Session
When you talk with a client each week in a therapy session, you might find that they’re someone you’d like to hang out with outside of work. However, therapists who become friends with their clients violate the ethical rules for professional boundaries. States can enforce disciplinary action upon therapists who decide to spend extended time with their clients, even in a non-romantic setting. In one Michigan disciplinary opinion, a therapist took her client bowling after their therapy session. Another professional had a client do maintenance on her home. Both professionals were placed on probation and fined.
If a client sees you in public and approaches you, you don’t have to run away. But spending free time with clients, taking them on outings, or inviting them into your home can invite scrutiny.
Overusing Personal Contact Information With the Client
While not as obviously inappropriate as engaging in a formal relationship with a client, simply exchanging emails and texts can cross ethical boundaries.
This standard may seem more surprising — many mental health practitioners provide personal contact information to clients as a practical matter, and sharing personal contact information doesn’t seem as impactful as having physical contact or face-to-face personal time with a client. Still, emailing or texting clients with personal contact information can push ethical boundaries.
Social media presents a particularly tricky medium: connecting with clients may seem harmless, but it creates an outside-of-treatment link between the provider and the client. Communicating with clients on the weekend, late at night, or about matters unrelated to treatment can cross the line from “provider” to “friend.” Moreover, exchanging health information on an unsecured platform raises HIPAA concerns.
Best practices include:
- encouraging clients to set up a scheduled time to talk if they have therapy needs;
- keeping protected health information off unsecured platforms;
- keeping personal and professional contact information as separated as is practically possible; and
- avoiding crossing the line between friend and client over text, email, or social media.
Terminating the Provider-Patient Relationship for an Improper Purpose
If someone wishes to pursue a personal relationship with a client, they might assume ending the client relationship removes any ethical obstacles. However, ethics rules often expressly forbid the practice. For instance, the social work code states, “Social workers should not terminate services to pursue a social, financial, or sexual relationship with a client.”
States that adopt similar rules to the social work ethics code may cite these provisions. However, some states may still discipline professionals for terminated relationships more broadly. In one case, Michigan’s disciplinary board viewed a therapist who began a relationship with a client after termination as having “a lack of good moral character” in violation of their Code.
See our related article, “Terminating the Patient Relationship: Planning a Legally Compliant Breakup.”
Improper Billing
While improper billing practices can violate a multitude of state and federal fraud, waste, and abuse laws, they can also breach an ethical boundary. States with broad ethical practice act regulations can consider improper billing practices “negligence” or a failure to exercise due care. Improper billing may seem less of an ethical problem than many of the relationship rules stressed by the ethics codes, but it can still constitute a violation on its own in some states.
Violating a Client’s Privacy
Sharing a client’s health information can not only pose a HIPAA violation, but it can also constitute an ethical and regulatory one. Ethics codes, such as the psychology code, typically dedicate a section to privacy and confidentiality. Breaches of privacy and confidentiality can break trust in any health provider, especially in those dealing with sensitive mental health information.
Enforcement and Discipline
Blurred boundaries can harm the patient-provider relationship and your professional integrity. Even if you don’t intend to harm your clients, these behaviors (among others) can negatively affect them and damage the professional relationship.
Clients, coworkers, and peers are often allowed to make reports about potential ethics violations. It may even be required for some professionals. If your behavior catches the attention of your state, your fate will be in the hands of the board.
State disciplinary boards vary in how they punish ethical violations. Often, states take a holistic approach, looking at all factors in the situation at hand. Still, punishments can (and frequently do) include loss or suspension of licensure, probation, continuing education requirements, fines, or any combination of the above, depending on the severity of the violation.
Minimize the Risk of Violations.
Mental healthcare involves building a trusting relationship with the client. It’s not always easy to recognize the boundaries. However, there are actions you can take to promote ethics amongst yourself, your clients, and your practice:
- Keep a close eye on ethical and professional regulatory guidelines in your state.
- Maintain practice policies that promote professionalism.
- Collaborate with trusted peers.
As a professional, you are responsible for ensuring that vulnerable individuals aren’t taken advantage of by someone they trust. In this case, that someone is you. Set boundaries. And, if you’re a practice owner, ensure your staff is aware of and respects these boundaries, too.
Understanding ethical boundaries in mental healthcare can be challenging. If you want to understand your obligations and how to create policies that meet your ethical goals, a healthcare attorney can help. We offer free consultations to mental health professionals who practice in the states where we have licensed attorneys. Book a call with us to find out if we fit your needs.
This blog is made for educational purposes and is not intended to be specific legal advice to any particular person. It does not create an attorney-client relationship between our firm and the reader. It should not be used as a substitute for competent legal advice from a licensed attorney in your jurisdiction.
