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Complementary Therapies in Clinical Practice (2008) 14, 2–7

1744-3881/$ - sdoi:10.1016/j.c

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Respecting professional boundaries:What CAM practioners need to know

Julie Stone

University of Lincoln, UK

KEYWORDSProfessionalboundaries;Regulation;‘Touchy-feely’practitioners

ee front matter & 2007tcp.2007.09.003

ess: juliestone1@btinte

Summary Professional boundaries are central to professionalism. Failure tomaintain sexual and emotional boundaries can cause patients significant andenduring harm. Although prevalence data is poor, evidence from complaints showsthat boundary abuses do occur in the CAM sector. Concerns are heightened bycontextual, regulatory and therapeutic aspects of CAM relationships. This articleargues that learning about sexual boundaries should be a specific element of CAMtraining and makes recommendations as to how to implement this key element ofpatient safety.& 2007 Elsevier Ltd. All rights reserved.

Introduction

Clear professional boundaries are an importantaspect of CAM professionalisation. The Departmentof Health recently commissioned the Council forHealthcare Regulatory Excellence (CHRE) to pro-duce guidance in this area1 following a spate ofnational inquiries into abuse involving health andsocial care practitioners.2–6 The literature7 revealsthat boundary breaches occur across all health andsocial care professions, as well as in other areasbased on relationships of trust and where there is apower imbalance, such as teaching and religiousministries. Complaints to professional bodies andthe advocacy charity, WITNESS, indicate that aproportion of CAM practitioners also breach profes-sional boundaries. This article will explore the needfor explicit boundaries training in CAM education,

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highlight some generic boundary risks and somerisks specific to CAM relationships, and makerecommendations for future developments in thisimportant area of patient safety.

What do we mean by ‘boundaries’?

Therapeutic relationships depend on a high level oftrust. Patients need to be able to take theprofessionalism of practitioners for granted. Pre-dominantly, this involves a recognition that thepatient’s best interests is the basis for the ther-apeutic encounter. This is critical, as the profes-sional, in the course of a therapeutic relationship,may, quite appropriately, ask patients for highlypersonal and confidential information, performintimate examinations, and create expectations oftherapeutic benefit. All of these things requirepractitioners to be quite clear about what sorts of

d.

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Respecting professional boundaries: What CAM practioners need to know 3

words, actions and behaviours are, and are not,acceptable.

Professional boundaries refer to the limits of theprofessional relationship—limits between accepta-ble and unacceptable behaviours—and the sets ofskills and attitudes which demarcate professionalrelationships from other relationships, such assexual relationships, friendships or commercialrelationships. It is always the professional’s respon-sibility to set and maintain clear boundaries. Thisprovides a safe space for patients to feel securethat the practitioner’s actions are professional andmotivated by the patient’s interests.

Simultaneously, CAM practitioners need to learnhow to forge empathetic and caring relationships,and to gain experience of appropriate and ethicaluse of touch. As well as sexual boundaries, it isimportant that therapists are able to maintainappropriate emotional, physical and financialboundaries in their work. Failure to do so willoften result in disciplinary sanction, and may leadto prosecution.

Learning about boundaries is not about teachingthe large majority of right-minded students andpractitioners that it is unacceptable to rape orsexually assault patients, the thought of which isanathema to most people employed in caringprofessions. Rather, it is about helping ordinaryprofessionals to learn how to deal with vexing andthought-provoking boundary dilemmas, where itmay not be clear how best to act in the patient’sinterests. Examples might include: whether toaccept a patient’s invitation to a party, whetherroutinely to hug a patient, how to respond toimpromptu meeting in a social setting, and whatto do if a patient seems to be sexually attracted toyou.

Students require explicit training to understandwhat boundaries are and why they are important,and to give them the skills to differentiate betweenappropriate actions and behaviours and inappropri-ate actions and behaviours. CAM education andtraining must include clear advice on what actionsare and are not acceptable. This includes learningto respond to the needs of their patients asindividuals, and being sensitive to a patient’scultural needs.

Boundaries may be crossed deliberately or inad-vertently. Whereas education and training may notdeter predatory individuals with serious criminalintent, it may help naı̈ve or inexperienced practi-tioners to develop better insight into their relation-ships with patients, and to recognise how theirbehaviours and actions might be interpreted. Thearea of sexual boundaries is particularly controver-sial. Despite the obvious harm that abuse of this

sort can cause, research shows that views on theacceptability of sexual relationships with currentand former patients vary. As well as teachingprofessionals about their own responsibilities, animportant element of boundaries training is to raiseawareness that abuse does occur, to give studentsand professionals the skills to recognise whencolleagues are acting unacceptably towards pa-tients, and to know what to do in these situations.

Why boundaries must not be breached

Breaching professional boundaries is ethically un-acceptable because it causes harm to patients,breaches professional trust, exploits the unequalpower in healthcare relationships, impairs profes-sional judgment, and reduces patient and publicconfidence in professions.

Harm to patients is the most significant concern,and sexual and psychological breaches of bound-aries may cause significant and enduring harm. Thisis exacerbated in younger patients and patientswho have a previous history of being sexuallyabused.

Research evidence8 shows that the harms causedby abuse can include:

�

Post traumatic stress disorder (PTSD) and dis-tress � Major depressive disorder � Suicidal tendencies and emotional distrust � High levels of dependency on the offending

professional, confusion and dissociation

� Failure to access health services when needed � Relationship problems � Disruption to employment and earnings � Use and misuse of prescription (and other) drugs

and alcohol

Prevalence of boundary abuses by CAMpractitioners

Although there are no specific data relating to CAMpractice, there have been findings of abuse againsta wide range of regulated and unregulated healthprofessionals, in a variety of contexts and settings.It would be naı̈ve to assume that CAM practitionersare exempt in this regard.9 CHRE’s boundariesliterature review found prevalence rates to be inthe range of 3–6% of health professionals, althoughmuch higher percentages of professionals claim toknow of other professionals acting in a sexuallyinappropriate way with a patient.

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Whilst specific research is clearly needed, in theabsence of specific CAM studies, it is necessary toconsider proxy markers, such as complaints toprofessional bodies, and settlements made byCAM insurers. Another indicator is the number ofcomplaints about CAM practitioners made to WIT-NESS (who support victims of professional abuse).Each of these markers suggest that boundaryabuses do take place within CAM professions.

Cultural and structural factors make assessingthe prevalence of boundary abuse within CAMproblematic. The reporting of boundary abuses inCAM might be under-represented for the followingreasons:

�

Absence of formal regulatory structures and lackof clarity as to the appropriate professional bodyto receive a complaint � Unwillingness or embarrassment of a patient to

bring a complaint against a practitioner withwhom the patient has experienced an intenseone-to-one therapeutic relationship

� Feelings of guilt � Fear of reprisal for making an allegation � Fear of not being believed or being blamed � Uncertainty as to what is and what is not

appropriate within the CAM therapeutic rela-tionship

Attraction towards patients andattraction from patients

Students and professionals can and do sometimesfind themselves sexually attracted to patients.Experiencing such feelings is not uncommon.Students and practitioners need to learn that thisphenomenon occurs and that having sexual feelingsshould not make them feel guilty or ashamed.Rather, students and practitioners need to be madeaware of how harmful acting on sexual feelings canbe for patients and, indeed, for themselves.Students and professionals need to learn how toarticulate these feelings and how to manage thesesituations so that patients remain safe.

Learning how to set and maintain effectiveboundaries is important because most therapistsare likely, at some point in their careers, toencounter patients who are unable or unwilling torecognise the limits of the professional relation-ship. For a variety of reasons, some patients canmisconstrue professional caring and compassion,and may experience feelings of sexual attraction orlove towards their health professional. The thera-pist may be the one person who listens to them

attentively, provides a source of touch, and offerscare and support. In some (but not all) cases,apparent sexual or emotional attachment may be aresult of a patient’s having been previouslypsychologically or sexually abused, and may in-dicate an inability on the part of the patient to setpersonal limits and boundaries.

These are very risky situations for therapists andit is vital that they set and maintain appropriateboundaries, and do not to succumb to flattery, andexploit vulnerable patients. Students and practi-tioners need to learn practical skills to managethese situations, to help them to reinforce bound-aries in ways which protect patients and return thefocus to the patient’s clinical needs. Failure to doso may result in harm to the patient, and an end tothe student or practitioner’s career.

Generic warning signs

Students and practitioners need to recognisesituations in which professional boundaries maybe compromised. WITNESS (2005), in a Report forCHRE,10 identified a number of precursors toserious boundary violations. These apply to CAMpractitioners as much as to statutorily regulatedprofessionals.

�

The giving or receiving of gifts: other than tokengifts can affect professional judgment andcreate a pressure for the party who has receivedthe gift to respond. If patients say that theywant to demonstrate their appreciation, thera-pists should seek to reassure them that this is notnecessary, or to encourage a donation to charity. � Personal information disclosure: where profes-

sionals use the therapeutic relationship as anopportunity to talk about their own personalneeds or problems (including talking about theirsexual needs and desires). Professionals must usetheir judgement. Sometimes, limited disclosureof even highly personal information can be anappropriate strategy to gain a patient’s con-fidence and encourage them to trust the profes-sional. However, the key to disclosure is that itshould only ever be in furtherance of thepatient’s best interests, and not an opportunityfor the professional to share their woes or rely onthe patient as a sympathetic ear.

� Special treatment/appointment times: thera-

pists should avoid asking the patient to attendappointments at odd/non-standard/unusualhours, particularly when no one else is present,or meeting at their home or other unusual place.

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Particular care needs to be paid to boundarieswhere care is routinely delivered in the practi-tioner or the patient’s home.

� Social contact and dual relationships: special

care should be taken where the student orprofessional has known the person they aretreating socially, as this may affect their profes-sional judgement. Dual relationships can be aparticular issue in small communities wheresocial opportunities are limited. Students andprofessionals may be aware of colleagues whohave married or are in relationships with formerpatients. Regulation cannot legislate againstadults forming consensual relationships, butstudents and professionals should rememberthat the reason relationships with current andformer patients are ill advised is because of theircapacity to cause patients harm. This is morelikely to happen if the patient was vulnerable atthe time of treatment and remains vulnerableeven though a therapeutic relationship may beat an end. What students and professionals needto remind themselves of is that the ethical basisof relationships with patients is to benefit and dono harm. Bluntly stated, in ordinary circum-stances, CAM therapists should not be looking topatients for a social life.

Factors specific to CAM relationships

Additionally, there are contextual, regulatory, andtherapeutic reasons why CAM relationships may beparticularly open to abuse.11 These will be con-sidered in turn.

Contextual factors

As with counselling and psychotherapy, the contextin which CAM is delivered provides distinct bound-ary challenges. CAM therapists often work in sole,private practice, without colleagues being present,and often work in their own homes. Because fewCAM practitioners are employed, they may not havebeen subject to criminal records checks, will not besubject to organisational requirements, e.g. rou-tine use of chaperones, and may or may not receiveformal supervision. Lack of an employment contextmeans learning about boundaries will not happen aspart of staff induction.

Regulatory factors

The absence of statutory controls over CAMpractice means that there is no prohibition on

predatory individuals setting themselves up inpractice, and such individuals may choose not tojoin any relevant voluntary professional register.The absence/multiplicity of professional bodiesmay make it hard for a complainant to know whoto complain to. The voluntary nature of CAMregulation means that even where a practitioneris struck off the register of a professional body,without protected title, that person can continueto practise in that field, or in other areas of CAMpractice. Significantly, in terms of training, themultiplicity of CAM providers, together with thelack of quality assurance, means that boundarieseducation and training cannot be guaranteed(this is not the case for more established andbetter regulated therapies). Some, althoughnot all, of these issues could be dramaticallyimproved within an effective system of voluntaryself-regulation.

Factors associated with CAM therapeuticrelationships

Compared to contextual and regulatory factors,aspects to do with the content of CAM practice,who practises CAM, and who seeks CAM are harderto define, but potentially more interesting. Interms of specific therapies, touch-based therapiessuch as massage raise distinct boundary issues, andthe ethical use of touch is an important area forstudy in its own right. Additionally, the quasi-psychotherapeutic nature of CAM, and/or theextent to which patients look to CAM therapists inpart as counsellor and life-coach, produces asignificant power imbalance and this can createa dynamic which facilitates transference andcounter-transference. This requires a high levelof insight and self-awareness on the part of thepractitioner. Finally, the origins of CAM incharismatic and ‘guru’ leadership, and the attrac-tion to CAM of ‘touchy feely’ sorts, merits furtherexploration.

Teaching and learning about boundaries

CHRE’s literature review (Ref. 7) found that amajority of healthcare practitioners surveyed feltthat they had not received adequate education ortraining on sexual ethics. Those healthcare stu-dents who experienced a sexual attraction towardspatients and discussed it with their supervisor weremore likely to show an understanding that suchattraction was potentially harmful to clients, andthose who received education on this topic were

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less likely to ‘offend’. The research also indicatedthat specific education changed attitudes towardsexual contact but that training had to be deliveredin a conducive environment. A correlation wasfound to exist between positive training environ-ments (tackling acceptance, safety, encourage-ment, openness, sensitivity, frankness, adequateunderstanding, respect, privacy, and support) andhealthy coping responses.

What do CAM students and professionalsneed to know?

As part of CAM education and training, students andprofessionals need to know the following:12

�

What professional boundaries are: identification,awareness of and need for boundaries, and cleardefinitions of roles and responsibilities of thehealthcare professional in relation to these � What constitutes ‘sexualised behaviour’ and

sexual boundary breaches

� How to set and maintain boundaries and prevent

breaches

� Necessary skills and competencies to work within

clear boundaries, including:

o Explaining clearly what the procedure entailsand ensuring that the patient has understoodthis

o

Obtaining informed consent o Ensuring appropriate undressing facilities andthat the patient can dress in private as soon asthe procedure is over

o

Always offering the patient the presence of atrained chaperone where possible13

o

Having a good understanding of any specificcultural requirements

o

Keeping clear records o Following regulatory bodys’/professional asso-ciations’ guidelines � What to do if boundaries are threatened or

breached by a healthcare professional. If aprofessional recognises that he/she has feelingstowards a patient or family member that make itdifficult to work objectively, this should bediscussed where possible with a professionalcolleague or supervisor, transferring responsibil-ity for the case if necessary. If a healthcareprofessional becomes aware of a professionalcolleague acting inappropriately, he/she mustunderstand the duty to report and how to do this

� Recognising the danger signs of when a patient

may be testing boundaries, and knowing what todo if a patient crosses sexual boundaries

�

Ensuring the healthcare professional under-stands the intrinsic imbalance of power thatexists in patient/professional relationships andthe harmful effect on a vulnerable patient of anabuse of power/trust � Ensuring a sound understanding of ethical. Legal

and professional issues (including Sexual Of-fences Act)

� Patients’ rights and expectations � Healthcare professional’s rights and expecta-

tions. Access to good supervision, peer groupsupport

� Self-awareness/insight/accountability/best

practice

The way ahead

In conclusion, four specific recommendations aremade to take this issue forward. First, thereneeds to be a clearer evidence base as to theprevalence of boundary abuses amongst CAMpractitioners. This would help to establish whetherabuse is more prevalent in certain therapies, thestage/s in a practitioner’s career when abusemay be more common, any discernible trends,and any other CAM specific predictors of abuse.Secondly, this research should be supplemented byqualitative research into the nature of boundaryabuses within CAM, exploring less tangibleareas such as the expectations of CAM patients,and why ‘touchy feely’ people are drawn tobecoming CAM therapists. Thirdly, it is essentialto press ahead with improved regulation in theCAM sector. Plans being developed for voluntaryself-regulation need to include the reciprocalremoval from other registers of practitionerswho are struck off for boundary abuses. Shouldvoluntary self-regulation not prove to provideadequate protection, recommendations for statu-tory regulation might prove necessary, based onpublic protection.

Finally, as CAM therapies move towards greaterprofessionalisation, CAM professional bodiesneed to ensure that boundaries training isan integral element of the pre-registration curri-culum. In time, this might also be usefullyconsidered as a mandatory element of continuingprofessional development (CPD) and, in due course,revalidation.

Whilst is will never be possible to eradicate poorpractice entirely, much could be done to reduceboundary abuses in the CAM relationship. Patientsafety requires boundaries awareness to be dis-cussed within CAM as a matter of urgency.

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Declaration of interests

Julie Stone was Deputy Director, and ExecutiveLead, until December 2006 on CHRE’s ClearBoundaries Project, and a Consultant advisor onthe project until September 2007.

References

1. The DH funded ‘Clear Boundaries Project’ conducted by theCouncil for Health Care Regulatory Excellence includesguidance for professionals, guidelines for patients, and areport on education and training. See /www.chre.org.ukS.

2. Committee of Inquiry: independent investigation into howthe NHS handled allegations about the conduct of cliffordayling, September 2005. Department of Health, Command6298.

3. The Kerr/Haslam Inquiry, HM Government, Command 6640,July 2005.

4. Investigation into the Service for People with LearningDisabilities provided by Sutton and Merton Primary CareTrust, Healthcare Commission 2007.

5. Joint Investigation into the Provision of Services for Peoplewith Learning Disabilities at Cornwall Partnership NHS Trust,Commission for Social Care Inspection & Healthcare Com-mission, 2006.

6. Investigation into issues arising from the case of Loughbor-ough GP Peter Green, Commission for Health Improvement,2001.

7. Halter, M, Brown, H and Stone, J. Sexual boundary violationsby health employees: an overview of the published empiricalliterature (2007). Council for Healthcare Regulatory Excel-lence Council for Healthcare Regulatory Excellence.

8. Halter et al., as above.9. Halter et al., as above.10. Prevention of professional abuse network (2005). A Compar-

ison of UK Health Regulators’ Guidance on ProfessionalBoundaries. Council for Healthcare Regulatory Excellence.Available from: /www.chre.org.ukS.

11. For fuller discussion, see Stone, J. (2002). An ethicalframework for complementary and alternative therapists.Routledge [Chapter 11].

12. Extracted from Stone, J (2007). Learning about boundaries.A report on education and training. council for healthcareregulatory excellence for the Department of Health.

13. For fuller guidance on chaperones, see /http://www.cgsupport.nhs.uk/downloads/Primary_Care/Chaperone_Framework.docS.