Boundary CrossingsPractice Scenarios & Quizzes

Boundary Crossings
Practice Scenarios &  Quizzes 

August 2019


1. Formula Recommendation

You work as a dietitian at a community health centre. After careful consideration, a client who has just given birth tells you that she has made an informed decision and she will not be breastfeeding. She asks for your recommendation for the best formula on the market for her baby. What do you do?

Dietitians, like most health practitioners, often choose their career to "help" people. They try to establish a therapeutic relationship of trust and openness on the part of the client. It is only human for a dietitian to try to reciprocate by being open as well, without realizing that this may not always be appropriate.
It is also important to keep in mind that a client can initiate a boundary crossing in good faith, without understanding the boundary or the reason why it exists. It's up to the dietitian, as the professional in the relationship, to maintain professional boundaries. In the professional relationship, the dietitian has the power that comes from knowledge and expertise. Unfortunately, because dietitians are often "helpful", they may find it hard to say no.

The request for a formula recommendation is relatively benign. It appeals to your sense of expertise and includes you in the family relationship. However, if the client is trying to include you in a personal decision, it is really hers to make. Limiting comments to relative nutritional qualities of the formulas on the market, in order for the mother to make an informed decision regarding how to feed her baby, would leave you with no legitimate role in the decision. A greater concern would be if you were asked to become increasingly involved in the childcare decisions respecting the baby, moving from dietetic issues to where the baby should sleep.

Be mindful of self-deception. Typically, boundary problems present themselves in a dietitian's area of weakness or vulnerability. A dietitian with a tendency towards rescue fantasies will be able to handle a sexually precocious young client by identifying the need to keep the boundary clear, but may get into trouble with an isolated and depressed teenager, becoming a "friend" in order to help "save" this client. It is always the responsibility of the dietitian to see and maintain the boundary.

2. Hiring a Client

You work as a dietitian for a community agency that serves new immigrants. You have spent some time assisting a client and they have shared some of the terrible things that have happened to them in their life. You know the client is in financially challenging circumstances. The client asks if they could clean your house. In fact, you are looking for a house cleaning service and would be very pleased to pay them generously. Is there a problem?

There are a number of complications arising from this scenario. You are being asked to enter into a dual relationship with the client, to be both dietitian and employer.

Consider how the following difficulties can occur:

  • The employer-employee relationship tends to be more directive than the more collaborative dietitian-client relationship. The client might feel compelled to follow your treatment recommendations without question in appreciation of the other relationship with you or for fear of losing their job with you.
  • If the client failed to meet your house cleaning expectations, you might have to confront them and perhaps even terminate their services. Such actions could easily damage your ability as a dietitian to engage the client in a continuing dietetic program.
  • The client would learn much about your private life, and whether they respect or disdain you for it, this could interfere with the clinical relationship. Either way, the healthy dialogue and give-and-take of the professional relationship could be damaged.
  • You could become dependent on the client’s excellent service and be prone to let it interfere with your professional judgment concerning their clinical care. For example, you may keep them on as a client beyond what is indicated in order to maintain the house cleaning relationship. Or, you may give undue weight to their requests for special or even inappropriate assistance.
  • ‚ÄčOther clients who find out about the house cleaning arrangement might feel that you are treating this client as "special". They might ask for similar consideration and be upset if you say no.

 3. Social Networking

You have been providing nutrition care to Jennifer through her difficult prenatal period. She has been a pleasure to work with. After the birth of her baby, Jennifer updates her Facebook page and sends you an invitation to become her friend. You will be involved for some time still on her postnatal dietetic needs. How should you respond?

Dietitians must separate their personal and professional life when using social media. It would not be appropriate for a dietitian to accept clients as friends under their personal social networking profiles. Accepting the invitation, even with strict privacy settings will involve the dietitian in Jennifer's private life and will expose some information about the dietitian’s non-professional circumstances. Also, accepting the invitation characterizes the relationship as social, as well as, professional. In the interest of maintaining a good professional relationship and open communication, the dietitian may wish to send a polite response or to discuss personally with Jennifer at her next visit, if it is soon, why the social networking invitation was not accepted.   

Any dual relationship has the potential to have the other relationship interfere with the professional one. Even selling non-health products such as cosmetics or insurance to clients can lead to problems (e.g. if the product does not perform as expected or if the client thinks that the price was too high). It is best to avoid dual relationships whenever possible. Where the other relationship pre-dates the professional one (e.g. a relative or friend), it's best to refer to another practitioner. Where a referral is not possible (e.g. in a small town, where there is only one dietitian in a facility), take special precautions.

A dietitian (or their organization) may create a professional social networking page (e.g., on Facebook, Instagram, etc.) that outlines the services and/or posts nutrition info/videos/articles/ resources, etc. Clients or members of the public can “like” the page, receive updates, comment on any postings, and ask questions, etc. This professional page should not be connected to the dietitian’s personal social networking page (if they have one).

Boundary Crossings - Quiz

Select the best answer to each of the following questions. Consider the reason for your choice. Review the correct responses.  

1. In the scenario, "Hiring a Client", what is the primary concern?
a. You are seeing a client in your own home
b. You should not be giving money to a client
c. House cleaning is a demeaning service to perform
d. Your dual relationship will create conflicting duties.

The best answer is (d). Boundary crossings often interfere with the professional relationship in unexpected ways.

Answer (a), while a real concern, is not the primary concern in this circumstance especially as the attendance at the home is for a limited, non-therapeutic purpose and there are no romantic or other connotations to it. Answer (b), while a real concern, does not address the core of the boundary issue. Answer (c) only has significance because of the boundary issue. House cleaning is honest work. By becoming the client's boss, you create an imbalance in the therapeutic relationship.

2. If a client expresses a romantic interest in you, which of the following applies?

a.. There is no boundary crossing unless you respond.
b. You should transfer the client.
c. You should politely explain that you can only have a professional relationship with the client.
d. Tell the client to "hold that thought" until after treatment is completed.

The best answer is (c). It is your responsibility to maintain the boundaries. You may have to take additional action, depending on the response to your attempt to reestablish the boundaries (e.g. transfer the client's care), but that is the first step.

Answer (a), while perhaps technically true, looks to your responsibility for the client's actions rather than a solution to the problem that has been created. You need to take some action.  Answer (b) may ultimately be necessary in some cases but is not necessary in every case. Answer (d) leaves hope that there may be a romantic relationship in the future. Such a response does not deal with the harm that is occurring now to your professional relationship and is inappropriate. With regards to sexual abuse, the Regulated Health Professions Act stipulates that an individual remains a patient or a client for an entire year after the therapeutic dietitian-client relationship has ended. Having romantic or sexual relationships with a client during that time is strictly forbidden. It is considered sexual abuse, even if the client consents.

3. What is the MOST important concern about a boundary crossing?

a) It interferes with your professional judgment.
b) It undermines your client's ability to maintain a therapeutic relationship with you.
c) It can confuse your client.
d) It can confuse other clients who observe it.
The best answer is (b). The concern that is paramount really depends on the circumstances of  the case, although (b) would often be at the top of the list. All of the answers are in fact true.   Answer (c) is really a subset of answer (b).

4. If a client tells a sexual joke, what should you do?

a) Laugh so that the client does not feel bad, but tell the client not to do that again.
b) Laugh only if no other clients are present, but tell the client not to do that again.
c) Report the client on a mandatory basis for sexual abuse.
d) Politely advise the client that such comments are not appropriate in the treatment setting.

The best answer is (d). You can convey this message to the client in a way that does not  embarrass the client or attack their self-esteem. For example, you can suggest that jokes that make fun of dietitians are the only humour permitted in your practice setting.

Answers (a)  and (b) involve your legitimizing the conduct. It is true that answer (a) may not involve sexual abuse on your part, and answer (b) does technically involve sexual abuse on your part.  However, both answers involve at least a technical crossing of a boundary. Answer (c) is incorrect as the mandatory reporting obligations only apply to health practitioners, not  clients.

5. Which of the following statements is true?

a) Boundary considerations are designed to protect the client.
b) Boundary considerations are designed to protect the dietitian.
c) Boundary considerations are designed to protect other clients.
d) Boundary considerations are designed to protect the client, and others exposed to the behaviour.
The best answer is (d). This response is the most inclusive. Answers (a) and (c) are true, but are incomplete. Boundary rules protect the client, and others who observe or otherwise learn of the conduct.