Counselling Dilemma: Dealing with Therapeutic Boundaries
You work as a family counsellor for a community service organisation. As a counsellor you are required to see your clients at their own home to offer counselling support. You have been working for quite some time with Lucy, a single mother with 2 kids (boys). However, you have been unable to develop good rapport with this client. After you last visit to Lucy’s home you feel that she is starting to develop rapport and is feeling more comfortable to open up and disclose her issues.
One week has passed and you are looking forward to continue building your relationship with Lucy. However, when you get to Lucy’s home she looks very distressed. One of her kids is feeling very sick and couldn’t go to school. Lucy wants to take him to see a doctor, but she doesn’t have a car, her house is 3 miles away from the closest bus stop and she discloses to you that she does not have enough money to pay for a taxi.
Your organisational policy states that counsellors should not offer services such as money, ride, baby sit, grocery shopping, etc, to clients. If the client needs any of these services they need to contact the community centre to arrange such support. However, when you call the community centre to arrange transportation, nobody is available to help at this time. Lucy asks if you could take them to see a doctor as your car is equipped with a baby seat.
As the Counsellor, what would you do? What factors do you need to consider? What are the consequences if you agree to give the client a ride? What are the consequences if you deny the ride to the client? How could it impact your relationship with the client?
If we look at the pros and cons of this situation, the positive aspect of helping Lucy is that it will most probably help you continue building rapport with her. Another pro is of course helping out a potential child in need of medical assistance ? this opens up the issue of ?duty of care? that we need to consider and uphold as her family counsellor.
The cons of this situation are first the fact that to take Lucy and her child in your car is a breach in your workplace policy. The ramifications are not only for your employment at the community organisation, but you may also be placing both yourself and your organisation at legal risks. After all, what happens if you have an accident on the way? Or perhaps even something small like Lucy or her child injuring themselves getting in or out of your car. Could you be liable for Lucy and her child?s injuries? The potential answer here is unfortunately ?yes?, because you are technically at a place of work, so your organisation may become liable for any injuries or accidents that occur on your trip to the hospital. Also, if Lucy accidently breaks something in your car (or her poor sick son threw up all over your backseat!), fixing this would not be covered by your workplace if you breached their rules. You may even run into problems with car insurance if you were using it as a work vehicle at the time.
Another negative aspect may be that whilst Lucy may be very grateful for your assistance with getting her and her child to the hospital, and whilst this may increase your rapport, this may also now put you into the role of ?rescuer?. Lucy may now look to you for future help when she needs transport. By helping her out you have not enabled Lucy to engage her own support or problem solving abilities to open up future options for similar circumstances. Therefore ?rescuing? can also be disempowering for the client.
Each situation is different and there are resources that can be explored further to help Lucy out in this situation. For example, you can discuss with Lucy about other friends and family she has that may help her out. This enables her to take control of her situation, and start to think about what resources she has available. She may even come up with some new ones such as people she hadn?t thought of to contact and ask for help, or new community organisations. Whilst you may be able to do some research for Lucy, it?s also important to allow her to make calls and take responsibility for the situation so she can feel that she is in control and is helping herself and her child.
If all options are exhausted, it may be necessary to phone your organisation and discuss this rule to further explore what the exceptions are, and very importantly what the ramifications are. If Lucy?s child is so seriously sick that it cannot wait, it may be more appropriate to contact an ambulance service.
There are four Factors to take into consideration. First, Organisational policy is driven by a variety of interests, including safety issues for both worker and client; insurance criteria and liability potential; as well as maintaining functions that have been agreed upon for funding.
Secondly, Purpose of Service. This Agency has a policy that I don?t offer ?money, transport, baby sitting or grocery shopping for my clients?. That sounds like my role is to deliberately NOT foster dependence; that I am there for another role. Is this psycho educational, resilience building and general support?
Thirdly, Meaning of Client/Counsellor dynamic. It has taken a while for me to begin building rapport and trust with Lucy. Last week the trust was noticeably building. Is it coincidence that this week that trust is being tested? Fourthly, Duty of Care. It would be easy to want to strengthen my recent inroads by ?rescuing? Lily in a difficult situation.
Questions to ask…
Before I came along, how would Lucy have got to a doctor? Is there any other local welfare provider (Council, Salvo?s) that might be able to provide emergency transport? Are any neighbours in a position to help? If the child?s health is critical, call an ambulance.
Consequences if… I Agree. The Organisation may discipline me; I could lose my job; I could become liable if there is an accident. The client will see me as ?above? the Organisation. I become the Rescuer in the relationship. My power in the relationship increases. If anything should go wrong it will be ?my fault?.
Consequences if… I Disagree. I may be seen as hiding behind the Organisation. The child may become much sicker due to delay. The client may read my refusal as rejection. I may be recognised as someone who is not easily manipulated. The client may discover new local connections or resources (e.g. a neighbour).
Impact on Client Relationship. Certainly the attitude I bring to the request will have a huge impact on my relationship with Lucy. My goal is to be available to support HER to manage this situation. I will respectfully encourage her to problem solve, believing her to be capable while acknowledging the seriousness of the situation.
CONCLUDING REMARKS. Setting a precedent in over-ruling organisational policy, especially when I am the vulnerable party (house calls make the worker extremely vulnerable!), undermines the agreed- on contract with the client. Also, I will set a precedent here for the balance of power within the relationship: Rescuer or Resilience Maker?
On the other hand, is there a Loophole in the Policy? I may not give money directly to the client! It does not specify I cannot give money to the taxi driver to take Lucy to the doctor! If neither Lucy nor I could find an alternate way to the doctor, and I believed the child needed to see one immediately, an option could be to pay for a taxi (hoping I could refund it from Petty Cash) rather than take Lucy and family in my car. How then, would they get back home? Building dependency creates complication!
Reflecting on meaning (whether for rules or relationship, documenting or driving) assists me understand the significance of my decisions. Choices require balancing the meanings.
It would be easy to lose sight of one’s role as counsellor to the mother in the desire to attend to the needs of the child. As already stated, as counsellor, encouraging the mother to explore other solutions is the way to go … even if it runs the risk of a set back in the rapport building.
After exhausting possible solutions I would be tempted to loan her the money for the taxi. That is something I would do as caring human being … at least the problem solving process would have been engaged, and I would have performed my professional duty to the client. My duty as a human being then kicks in for the welfare of the child.
it is best not to rescue as it disenables the client and disempowers them. One needs to remain professional and explore alternatives with the client. If mother and child is needed a doctor. And no neighbour, friend and family can help. Then look to other resources like is the doctor able to do home visit, or ring the national nurses number it is free and they can let you know when to see a doctor or what help is able, or if a ambulance is needed. If money is given then the client will ask in furture times. It is rescueing instead of empowering the client. It is emotional but it is better to remain within the professional boundaries.
It’s great and productive to analyse the situation and have the luxury of time to think about it. This helps us be prepared, however in the moment of the situation described (which as an outreach counsellor I have encountered) long experience prompts me to first be concerned about myself!
Proximity to or contact with very ill children can result in very ill and innefective counsellor’s! I would have been grateful if the client had called me to advise there was illness in the family and she would like to cancel for this week. However, being on the door step, I would advise that I can’t assist with transport using my car (or come in to the house).
It is important to keep the boundaries of responsiblity clear, unless there is an identified cognitive impairment, or concern for child neglect, the client does not need me to organise seeing a doctor. They can ring an ambulance if warranted. This can all be conveyed with due respect and concern and empathy, but that includes giving credit to the client for being competent and resourceful.