Home Practice Standards Professional Conduct 1.8 Undue Influence & Abuse
Undue Influence & Abuse

Standard 1.8: Undue Influence & Abuse

The Professional Practice Standards regarding undue influence and abuse. This includes the three standards, examples in demonstrating the standard, definitions, and related resources.


Professional Conduct
Undue Influence & Abuse

Standard 1.8: Undue Influence & Abuse

The Professional Practice Standards regarding undue influence and abuse. This includes the three standards, examples in demonstrating the standard, definitions, and related resources.

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The Standard

 

1.8.1 Registrants are respectful of clients. They refrain from verbal, physical, psychological, emotional, and sexual abuse of clients.

 

1.8.2 Registrants are respectful, both during and outside of treatment sessions, of clients’ representatives, family, partners, or other individuals with whom clients maintain a close personal relationship. They refrain from sexual, verbal, physical, psychological and emotional abuse towards any of these individuals.

 

1.8.3 Registrants do not unduly influence clients, their representatives, family, or partners, including but not limited to personal life decisions, the making of wills, or powers of attorney.

 

 

Key Definitions

 

Sexual Abuse

Under the Regulated Health Professions Act, 1991 (RHPA), sexual abuse is defined as: sexual intercourse or other forms of physical sexual relations between the registrant and the client; touching, of a sexual nature, of the client by the registrant; or, behaviour or remarks of a sexual nature by the registrant towards the client.

 

Sexual Nature

In the RHPA, the term “sexual nature” does not include touching, behaviour, or remarks of a clinical nature appropriate to the service provided. For example, discussing a client’s sexuality, sexual experiences, or issues in a manner relevant to their therapeutic treatment or referring a client to a sexual surrogate are not considered sexual abuse.

 

In the latter instance, however, the surrogate shall not be an employee of the registrant, or an associate supervised by the registrant. In addition, there is an onus on the registrant to take reasonable steps to ensure that the surrogate is appropriately trained or certified, and that they adhere to accepted norms and standards for sex surrogacy.

 

While some forms of touch or bio-energetic work may form a legitimate part of psychotherapy practice, any form of disrobing or sexual touching of clients is inappropriate conduct on the part of registrants.

 

Boundary Crossing

“Boundary crossing occurs any time a professional deviates from the strictest professional role. Boundary crossings can be helpful, harmful, or neutral. Boundary crossings can become boundary violations when they place clients at risk for harm.”7 Generally, a helpful boundary crossing will be one that is clinically indicated, modality-appropriate, and done with informed consent from the client and with safeguards in place. Harmful boundary crossings would result in discomfort for either the client or practitioner and may negatively impact the therapeutic relationship. Notably, the same action – for example, supportive touch, could be helpful, harmful, or neutral depending on the client, context, and interpretation.

 

7Knapp, S. and Slattery, J. M. (2004). Professional boundaries in nontraditional settings. Professional Psychology, 35, 553-558.

 

Boundary Violations

Boundary violations are harmful boundary crossings that place the client at risk of harm. They typically occur when therapists are engaged in exploitative dual relationships.

 

Undue Influence

Using the therapist’s position in a way that reduces the client’s autonomy and advances the therapist’s agenda.

 

Physical Abuse

Pushing, shoving, shaking, slapping, hitting, or other physical force that may cause harm.

 

Verbal Abuse

Derogatory or demeaning comments, cultural slurs, use of profane language, or insults.

 

Emotional Abuse

Examples include threats, intimidation, insults, humiliation and harassment, dismissive behaviour, manipulation, scolding.

 

Financial Abuse/Exploitation

Examples include forging a signature, theft, influencing a client to change their will, charging exploitative or manipulative fees.

 

Cyber Abuse

Bullying by conveying inappropriate images or words through any form of electronic media.8 8From the College of Respiratory Therapists of Ontario

 

Client

Any individual who received treatment from a registrant – for any period of time – is considered a client. For the purposes of sexual abuse, an individual remains a client for one year following the termination of the professional relationship.9

 

9 The Health Professions Procedural Code defines a client for the purpose of sexual abuse to include someone who was a client within the past year. However, CRPO believes sexual contact with someone who has been a client within five years to be unacceptable. See CRPO’s Policy on Sexual Contact with Former Clients within 5-Years Post Termination of Care. CRPO has asked the Government of Ontario to increase this time period to five years.

 

Intersectionality

“The ways in which systems of inequality based on gender, race, ethnicity, sexual orientation, gender identity, disability, class and other forms of discrimination ’intersect’ to create unique dynamics and [amplified] effects.”10 10 From the Center for Intersectional Justice.
Trauma-Informed ApproachA program, organization, or system that realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, and practices, and seeks to actively resist re-traumatization.11

 

11 From SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach, prepared by SAMHSA’s Trauma and Justice Strategic Initiative.

 

Standard 1.8

Demonstrating the Standard

  • Standard 1.8

    A registrant demonstrates meeting the standard, for example, by:

     

    • Practising the profession with integrity and professionalism.
    • Setting, communicating, and maintaining appropriate boundaries with clients and individuals with whom clients maintain a close personal relationship.
    • Refusing sexual advances from clients, their representatives, family members, partners, or other individuals who may be influenced by the therapeutic relationship and power dynamic between the RP and client.
    • Acknowledging that clients are incapable of consenting to sexual contact with their RP due to imbalance of power.

  • Standard 1.8

    A registrant demonstrates meeting the standard, for example, by:

     

    • Understanding that the imbalance of power between a client and RP will continue to grow over time spent in treatment.
    • Assessing oneself for the existence and extent of personal biases or belief systems that may influence interactions with a client.
    • Preventing personal biases, structural biases, or belief systems from influencing the treatment of or interactions with a client.
    • Being cognizant of the individual vulnerabilities of clients and their representatives.
    • Being respectful of the best interests of clients.

  • Standard 1.8

    A registrant demonstrates meeting the standard, for example, by:

     

    • Apologizing for lapses in courtesy or inappropriate language.
    • Avoiding boundary violations with clients and minimizing contact with clients outside the therapeutic relationship as much as possible.
    • Thoroughly documenting boundary crossings, including relevant context, justification, and safeguards put in place to protect the client.
    • Using professional and ethical judgment to determine whether conduct outside the typical therapeutic relationship is appropriate.
    • Consulting another RP, one’s supervisor or case consultant, or the College if the registrant finds themselves in challenging circumstances.
Standard 1.8

Commentary

CRPO has a zero tolerance policy for sexual abuse. Sexual abuse is an extremely serious form of professional misconduct and is dealt with directly in the RHPA. It is so serious, in fact, that the RHPA prescribes specific penalties: sexual intercourse with a client, for example, carries a mandatory revocation of registration for a minimum of five years. Other forms of sexual abuse may result in equally severe disciplinary action. The College’s Client Relations Program is primarily devoted to preventing and dealing with sexual abuse of clients.

 

The College’s Professional Misconduct Regulation requires that registrants not inflict any form of verbal, physical, psychological and/or emotional abuse on clients.

 

Clients, their representatives, family members, partners, or other individuals with whom clients maintain a close personal relationship may be emotionally and otherwise vulnerable. At the same time, clients and those in their circle may be particularly influenced by the views or suggestions of their psychotherapist. It is the responsibility of registrants, therefore, to ensure that clients feel safe and that they are not subjected to inappropriate influence or abuse.

Boundaries are derived from social or cultural norms and customary social behaviour as well as ethics, morality, and law. They ensure the professional, therapeutic relationship and exist to protect clients from harm. Boundaries delineate the expected and accepted psychological and social distance between practitioners and clients, transgression of which involves the therapist stepping out of the clinical role or breaching the clinical role.

 

RPs must avoid boundary violations with clients, as they can be a precursor to abuse. However, it is important to understand when a boundary crossing may be justifiable. The ethical principles of beneficence (promoting client well-being) and equity (promoting care for those facing barriers to access) sometimes warrant departing from customary practice. For example, RPs typically do not conduct sessions in the home of a client. However, an exception would be made for a client with severe agoraphobia or complex physical health needs, in particular where they are unable to participate in virtual therapy.

 

It’s important to also note that RPs will have boundaries themselves, which clients may inadvertently or intentionally cross. When such boundary crossings emerge, it is important to address the concern at the earliest appropriate time.

 

RPs should open conversations about boundaries with clients early in the therapeutic relationship to better understand and potentially adjust expectations the clients may have about conduct, communication, or other matters.

 

To assist in maintaining boundaries, RPs should consider establishing policies and protocols around common boundary matters like after-hours communications and scheduling procedures.

RPs are expected to understand the inherent power dynamic at play with a client and the responsibilities that come with holding such a position.

 

RPs are expected to be aware of how the power dynamic impacts therapeutic work, as clients may feel pressured to provide consent or positive feedback. It is important to make sure clients understand the relationship will not be impacted if they decline to try different therapeutic techniques or are not responding to treatment as intended.

 

Power dynamics will shift over time, likely intensifying as the client continues with treatment, and may be impacted by a number of factors.

 

The presence of a dual relationship between a practitioner and client will likely magnify the power dynamics within the therapeutic relationship.

 

Clients from marginalized communities are often at a greater risk of exploitation due to structural inequities, and as a result RPs should be aware of intersecting identities and their influence on the power dynamic and therapeutic process. Similarly, individuals who have experienced trauma are at an increased risk of traumatization and may interpret the existing power dynamic differently.

 

RPs are expected to integrate intersectional and trauma-informed approaches into their work, taking into consideration the unique circumstances of individual clients within the therapeutic process.

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