Code of Professional Conduct Clarifying and Establishing Boundaries in SCDMH Peer Delivered Services

Peers as Providers Peer delivered services are still seen as relatively new concepts in formal systems of mental health care. Subsequently, concern has been voiced about: Dual relationships Professional ethics and boundaries Peers being viewed as a “friend” rather than as a provider

Objectives The learning objectives for the peer support specialist in this training are to: Understand what dual relationships are & why they can be harmful. Understand SCDMH policies surrounding ethics & acceptable employee conduct. Clarify different types of boundaries. Understand how violations are harmful & how to recognize boundary violation patterns. Develop a framework for making better ethical decisions at work.

Dual Relationships A dual relationship is one in which roles are or could be mixed. For example: A peer support specialist is providing services to a client with whom they also have a friendship. Or A peer support specialist supervisor and case manager is the same person.

Ethics For the purpose of this training “Ethics” are: The hard and fast non-negotiable rules that all SCDMH employees are subject to. The Professional Code of Conduct that govern all SCDMH Certified Peer Support Specialists (CPSS).

Boundaries require the use of good judgment. Boundaries are more ambiguous. They are: The unseen lines that you won’t cross Undefined physical and emotional distances Parameters that make you unique Self imposed and self defined Boundaries require the use of good judgment.

Why all the Concern? All of the helping professions (medicine, nursing, psychology etc.) have established codes of conduct. This is because there exists an accepted inherent belief that not addressing these issues unacceptably increases the chances of harm and/or exploitation for a person (client) seeking services.

Concerns continued In as much as peer support specialist’s are SCDMH employees they should not be treated differently or have additional rules created to enhance or excuse them from standards of conduct that is expected of all SCDMH employees or contracted affiliates.

Concerns continued When acting within one’s role as a professional, a peer must be able to recognize, maintain and balance boundaries that establish appropriate limits to relationships. If we lose our ability to be objective, we tend to become too involved in a person or situation.

Concerns continued Good, healthy, and appropriate boundaries are the distance and emotional detachment that need to be maintained to ensure an effective perspective on a situation. Maintaining personal boundaries is indicative of a well-trained, experienced peer supporter.

Ethics & Dual Relationships

Ethical Practice, Duality & SCDMH Policy For all professional staff, it is uniformly contrary to standards governing the practice and conduct of the respective health care professions to form personal or business relationships with patients or clients under their care. Directive 885-07 Abuse, Neglect or Exploitation of Patients and Clients Prohibited

Ethical Practice, Duality & SCDMH Policy All employee relationships with patients and clients of the SCDMH should be therapeutic and professional in nature. In order to protect the welfare of patients and clients, encourage adherence to professional standards and preserve the public image and integrity of the Department, the following guidelines are issued to supplement the prohibited conduct listed in paragraph III of the directive: Physical Abuse Psychological Abuse Neglect Exploitation Directive 885-07 Abuse, Neglect or Exploitation of Patients and Clients Prohibited

Ethical Practice, Duality & SCDMH Policy It is the policy of the SCDMH that an employee shall not be directly involved in providing care or treatment of a patient or client who is a friend or relative of the employee. Employees are prohibited from forming social or business relationships with patients or clients or former patients or clients except as outlined in the directive. Directive 885-07 Abuse, Neglect or Exploitation of Patients and Clients Prohibited

Ethical Practice, Duality & SCDMH Policy Any professional employee who engages in conduct contrary to the standards published by the licensing body of the employee's respective profession is subject to discipline by the Department. Directive 885-07 Abuse, Neglect or Exploitation of Patients and Clients Prohibited

Ethical Practice, Duality & SCDMH Policy Regardless of the circumstances for the CPSS it is: Never appropriate to develop social relationships with those that you provide services to. Never appropriate to provide services to those with whom you have a pre-existing social relationship. Never appropriate to discuss work concerns /issues with clients whether you provide services to them or not.

SCDMH Certified Peer Support Specialist Code of Professional Conduct

SCDMH Certified Peer Support Specialist Code of Professional Conduct Peer Support is a helping relationship between mental health clients and Certified Peer Support Specialists (CPSS) encouraging respect, trust, and warmth. The primary responsibility of Certified Peer Support Specialists is to help empower clients to achieve their own needs, wants, and goals as specified in the plan of care. As such they are committed to providing and advocating for effective recovery based services for the people they serve. SCDMH Peer Support Specialists recognize the importance of a Code of Conduct and are dedicated to these standards being rigorously enforced.

SCDMH Certified Peer Support Specialist Code of Professional Conduct Certified Peer Support Specialists will not practice, condone, facilitate, or collaborate in any form of discrimination on the basis of ethnicity, race, sex, sexual orientation, age, religion, national origin, marital status, political belief, mental or physical disability, or any other preference or personal characteristic, condition, or state. Certified Peer Support Specialists will adhere to policies set forth by the South Carolina Department of Mental Health directive 885-07 (4-100) Abuse, Neglect or Exploitation of Patients and Clients Prohibited Certified Peer Support Specialists will maintain high standards of personal and professional conduct and shall not be party to any type of behavior, activity or policy that denies any client equal, non-discriminatory access to service and/or support; or which deliberately demeans the rights and/or dignity of any client, staff or colleague.

SCDMH Certified Peer Support Specialist Code of Professional Conduct Certified Peer Support Specialists will, at all times, respect the dignity, privacy and confidentiality rights of the clients they serve. Certified Peer Support Specialists will never engage in sexual/intimate activities with the clients they serve. Certified Peer Support Specialists shall avoid being drawn into dual (friendships, business bartering etc.) relationships with clients while the support relationship is ongoing. Certified Peer Support Specialists never give out their personal contact information to clients, but will ensure clients know how to contact them through the mental health center.

SCDMH Certified Peer Support Specialist Code of Professional Conduct Certified Peer Support Specialists shall only provide service and support within the hours, days and locations that are sanctioned by the mental health center. Certified Peer Support Specialists will conduct themselves in a manner that fosters their own recovery. In so doing, Peer Support Specialists are expected to conduct themselves in a professional manner and take the necessary steps to ensure their conduct does not negatively impact on the perception of this program. Certified Peer Support Specialists will openly share with clients and colleagues their recovery stories from mental illness as appropriate for the situation in order to promote and support recovery and resilience.

SCDMH Certified Peer Support Specialist Code of Professional Conduct Certified Peer Support Specialists will keep current with emerging knowledge relevant to recovery, and openly share this knowledge with their colleagues while refraining from giving advice or opinions that exceeds the scope of practice as defined in the Community Mental Health Services Provider Manual Section 2 Policies and Procedures 2-68 for the Peer Support Service. As state employees Certified Peer Support Specialists cannot accept personal gifts.

Establishing Professional Boundaries

What are Professional Boundaries? Professional boundaries define effective and appropriate interaction between professionals and the public they serve. They are the space between the professional's power and the client's vulnerability. They exist to protect both the professional and the client.

Boundaries When we talk about interpersonal or workplace boundaries, it can sometimes be a difficult concept to grasp because it isn’t something that we can see.

Boundaries But just because we can’t see a boundary doesn't mean that it isn’t there or that it isn’t important. 

Boundaries The definition of a boundary is the ability to know where you end and where another person begins.

Boundaries are an Important Issue The amount & type of boundary responsibility you have with a person differs according to the type of relationship: Friendship Colleague Client

Friendship Boundaries This is a person that you know, like, and trust and one with whom you have a close personal connection. It can be a person with whom you are allied in a struggle or cause. The difference between this person and a client you work with is in the equitability of the relationship. No One has Power or Authority Over the Other

Colleague Boundaries A colleague is a fellow member of a profession. That person may have power and authority over you, be equal in power and authority to you or have less power and authority than you.

Power and Authority Are Not Always Equal Colleague Boundaries Like the relationship with clients, professional or business relationships can become sticky because of the types of power and authority and who has the ability to enforce them. Power and Authority Are Not Always Equal

Power and Authority Varies Client Boundaries With respect to the SC Department of Mental Health the term client is used to describe a person who is seeking professional psychiatric services. Depending on their circumstances each individual may hold different types of power and authority. Power and Authority Varies

What are Boundary Violations? They are any behavior or interaction which damages a client, a professional, and/or the professional interaction. The victimization and/or exploitation of a client by a professional. A betrayal of the sacred covenant of trust. Adapted from MINNESOTA BOARD OF NURSING, January 2000

How do Violations Occur? A boundary violation occurs when a professional, consciously or unconsciously, uses the professional-client relationship to meet personal needs rather than client needs. Adapted from MINNESOTA BOARD OF NURSING, January 2000

Who can be Harmed?  Boundary violations can harm both the client and the professional. The ramifications can be widespread. Damage can extend to marriages, families, other clients communities, clinics, institutions, and the profession in general. Adapted from MINNESOTA BOARD OF NURSING, January 2000

How Do Boundaries Help? Preservation of boundaries needs not be seen as a barrier to the professional relationship, but rather as a way to facilitate it. Maintaining boundaries protects the safe space in the relationship thereby enhancing the building of the trust which is essential to enable clients to reveal their needs. Adapted from MINNESOTA BOARD OF NURSING, January 2000

Boundary Violations: Four Common Elements Four elements characteristically appear in boundary violations: Secrecy Role Reversal Double Bind Indulgence of Professional Privilege Adapted from MINNESOTA BOARD OF NURSING, January 2000

Secrecy Secrecy involves the professional keeping critical knowledge or behavior from the client and/or others or selectively sharing information. Example: A CPSS takes a client into their home and tells the client the CPSS’s employer cannot know about this or they will lose their job. Adapted from MINNESOTA BOARD OF NURSING, January 2000

Role Reversal Role reversal occurs when the client takes care of the professional. They look to the client for satisfaction and gratification, rather than placing client needs first. They may not be consciously aware of this role reversal or may attempt to justify it by contending his or her actions are for the client's benefit. Example: A client becomes a CPSS’s A.A. or N.A. sponsor. Adapted from MINNESOTA BOARD OF NURSING, January 2000

Indulgence of Professional Privilege Indulgence of professional privilege involves using information obtained in the relationship with a client for the benefit of the professional. Because professionals can have or exert authority over a client's situation, they can be at risk to extending that authority to intrude on the client. Adapted from MINNESOTA BOARD OF NURSING, January 2000

Indulgence continued Having access to information does not constitute a right to it. Access is a professional privilege; it is not a professional’s right to use the information for one's own benefit. Example: A CPSS has been helping a client with severe financial problems develop a budget. The CPSS uses that information to try to purchase the client’s car below market value. Adapted from MINNESOTA BOARD OF NURSING, January 2000

Double Bind A double-bind consists of messages that contradict each other while discouraging the receiver of the messages from noticing the difference. The client is left feeling caught in a conflict of interest and any attempt at resolution places the client at risk of loss. The client is torn between the desire to end the relationship and the realization that this may also end any form of help from the professional. Adapted from MINNESOTA BOARD OF NURSING, January 2000

Double Bind continued The double-bind contains an implied threat. A sense of guilt and fear of possible abandonment by the professional blocks the client from taking action. The double-bind constricts the client from using all available options and thus limits growth. Examples: (1) A CPSS makes negative comments about other CPSS’s caring for a client who has development of trust as a therapeutic goal. (2) A CPSS’s tells a client that they may begin a personal relationship when the client is no longer receiving services. Adapted from MINNESOTA BOARD OF NURSING, January 2000

Boundaries: Are You Helping or Are You Hurting? There are more gray areas than black and white ones when thinking about boundaries. Peer specialists can make more considerate decisions if they will take time to think about some of the basics of

Some Warning Signs of Boundary Violations Although not an exhaustive list, the following are helpful “cues” when setting professional boundaries: Choosing sides Making exceptions Keeping secrets Giving or receiving gifts Borrowing or lending money Feeling as if no one but you has interest in the client Feeling no but you will be able to assist the client Feeling responsible for a client’s progress or failure “Owning” a client’s success’s or failure’s Confiding personal or professional issues or troubles

Developing A Framework

The “Yes’s” and the “No’s” If you are unsure about your interactions try asking yourself the following questions: If you answer “No” to 1 - 2 or “Yes” to 3 - 4 you need to stop and evaluate your interaction. Is the relationship in the client’s best interest? Is this something that other CPSS’s would do? Can this affect my objectivity in providing care? Will this cause confusion in my role?

Still Unsure? If you are still unsure try asking: How would this appear to others (peers, family, colleagues and/or supervisor)? How does this appear to the client? Is this decision making me uncomfortable?

Trouble Shooting Problem Spots: Time When, where, and how often you meet with a client can be a troublesome issue. If it feels wrong it probably is, but ask yourself the following questions to help clarify the situation: How much time am I spending with a client? Does it vary from that spent with other clients? Am I spending "off duty" time with the client?

Trouble Shooting Problem Spots: Location If a client wants to talk or meet somewhere other than a center approved location you're beginning to slide toward a questionable boundary as well as possible policy violation. Try asking: Is the location of the interaction appropriate to the relationship? Would you provide peer services to other clients at this location? Is there is a legitimate need to meet? Have I made the meeting known to others and documented it?

Trouble Shooting Problem Spots: Gifts Accepting or giving a gift can get tricky. If you are unsure ask: Does the gift giving create a sense of obligation on the part of you or the recipient? Do you do this routinely as part of your job, regardless of the age or gender of the client? Is the gift of a personal nature that would only be to or from a specific person? Is there a department or center policy regarding gifts?

Asking For Help ? At all times, if you are unsure about a situation or confused about whether an interaction could be interpreted as a boundary violation you always should: Consult your supervisor Refer to SCDMH Directives Consult the Quality Assurance Coordinator or Client Advocate Consult other clinical colleagues ?

ALWAYS Remember… It is never a good idea to ignore a situation or interaction and just hope all works out. The chances are that if you are experiencing problems other CPSS’s are too!

Thank You!!! Clarifying and Establishing Boundaries in SCDMH Peer Delivered Services For more information Contact: Katherine M. Roberts, MPH Director SCDMH Office of Client Affairs kmr50@scdmh.org Bobbie Lesesne, CCETT Coordinator