Chapter 3: ethics and boundaries

Ethics

Values and beliefs that guide practice

RPN code of ethics

1. Safe, competent, and ethical practice

2. Respect for inherent worth, right of choice, and dignity of persons

3. Health, mental health, and wellbeing

4. Quality practice

Steps to making ethical decisions

1. Identify the problem.

2. Identify the potential issue.

3. Look at RPN ethical code for guidance.

4. Consider laws, regulations, policies, practice guidelines.

5. Seek consultation.

6. Brainstorm possible actions.

7. Reflection on consequences of possible actions.

   1. Decide what appears to be the best course of action.

Clients’ rights

± Clients have the right to informed consent

± Right to refuse treatment

± Advanced health directives

± Provision of the least restrictive type of mental health care

± Confidentiality and privacy

What can psych nurses teach?

health literacy

Informed consent

involves the right of clients to be informed about their therapy and to make autonomous decisions pertaining to it.

Informed consent: right to be educated about:

Treatment plan, Risks, Benefits, Limitations, Alternative treatments

Confidentiality

We have a legal duty NOT to disclose information about a client

Confidentiality exceptions:

•       Suspected child abuse or neglect of a vulnerable person in their care

•       Believes client under age 16 is victim of incest, rape, child abuse, or some other crime

•       If the client expresses imminent (leaving right here, have a plan – have to report/police) or serious suicidal or homicidal thoughts

•       Determines client needs hospitalization

•       If information is made an issue in court

•       When clients request their records be released to a third party (typically this request is signed and in writing)

•       Serious risk (judge based on that risk; ex. Getting lumpsome of money and using it all on Gambling- call husband or fam member)

Privileged communication

is a legal concept that protects clients from having their confidential communications revealed in court without their permission

Personal Health Information Act (PHIA) gives you 2 primary rights:

the right to access your own personal health information and the right to expect that the privacy of that information will be protected.

-       Duty to report and duty to protect

During an initial session, an 18 year old female tells you she is pregnant and is considering a therapeutic abortion. Which of the following would be the most ethical and professional course for you to follow?

a.     Encourage her to get the abortion as soon as possible

b.     Steer her towards having the baby and then placing the baby up for adoption

c.     Suggest a referral for her if your values might interfere with your objectivity

d.     Help her to clarify the range of her choices based on her own values

Both c and d

Boundaries

are limits that allow a safe connection between the professional and the client and are always based on the client’s needs

•       Establishes and maintains trust

•       Set the tone and direction that keep the work focused on the client’s goals

•       Be aware of our responsibility to others

•       Be cognizant of the need for feedback and reflection

•       Maintaining boundaries is ALWAYS the responsibility of the psychiatric nurse

Boundary crossing

is a departure from a commonly accepted practice that could potentially benefit a client

what is then important to keep note with patients regarding boundaries?

pts will always attempt to push your boundaries it is our duty to uphold and maintain boundaries

Boundary violations- red flags

serious breach that harms the client and is unethical

-       Making the client “special” (giving extra time and attn)

-       Visiting client off hours

-       Doing things for the client they can do for themselves (disempowering)

-       Discounting actions of other professionals

-       Feeling resentment about the ways other team members care for the client

-       Sharing personal issues (inappropriate self-disclosure)

-       Promising availability to the client

-       Persistently thinking about the client off duty

-       Selective reporting of the client’s behaviour

-       Swapping assignments to work with the client

-       Communicating in a guarded and defensive manner when questioned regarding the client

-       Changing dress style for work when working with the client

-       Receiving gifts or maintaining contact/communication with the client after discharge or file closure

-       Acting and/or feeling possessive about the client

-       Denying that you may have already engaged in any of the above

-       Frequently appear harmless

-       Begin as innocent situations

-       Not recognized or felt as a violation until something goes wrong

-       often, “Crossing the Line” is a process with many small steps before a violation occur

Categories of boundary violations:

-       Role boundaries

-       Time boundaries

-       Place and space boundaries

-       Financial boundaries

-       Physical contact boundaries

-       Social media boundaries

What are ways clinicians can be professional with their use of social medial?

·       include and thorough social networking policies as part of informed consent process

·       limit what is shared online

·       regularly update protective settings because social media providers often change their privacy rules

Reflective questions for determining boundaries:

-       Would I do or say the same things if a co-worker was present?

-       Would I document this behaviour in a client’s file?

-       Have I gained at the expense of my client in any way?

-       Am I spending more time thinking about the relationship than the treatment?

-       Am I modeling clear boundaries?

-       Is my agenda clear for both of us?

-       Are self-disclosures relevant and enhancing to the therapeutic relationship?

-       Do I have a special relationship with a client?

-       Is this relationship a secret?

-       Would I be embarrassed if others knew about it?

-       Does this client do any “caregiving “for me?

Prevention

-       Outline your service parameters

-       Recognize limits of the therapeutic relationship

-       Define your role

-       Outline length of service/treatment

-       Set goals with your client

-       Review goals regularly

-       Terminate service clearly

-       Ensure client knows who & how to contact someone should the need arise

-       Ongoing reflection

Mandatory ethics

level of ethical functioning at the minimum level of professional practice

Aspirational ethics

focus in on the best interests of the client

Requirements for functioning on the aspirational level:

• highest standards of thinking and conduct

  • must understand the spirit of the code and the principles on which the code is based

Fear based ethics

focused on avoiding punishment or breaking rules

• motivated by fear of legal action, losing one’s license, or professional discipline

• leads to minimal compliance rather than genuine care for client welfare

• Does not constitute sound ethical practice because it emphasizes self-protection over client well-being 

Concern based ethics

what people should strive towards

• centres on doing what’s right out of genuine concern for clients

• reflects aspirational and positive ethics- striving for the highest professional ideals

• emphasize empathy, integrity, and responsibility rather than fear

  • encourages ethical sensitivity, reflection, and ongoing professional growth

Positive ethics

an approach taken by practitioners who want to do their best for clients rather than simply meet the minimum ethical and legal standards to stay out of trouble

• putting clients needs before your own

Putting client’s needs before your own

·       Counselors must be aware of personal needs, unfinished business, and countertransference that may affect clients. 

o   The therapeutic relationship exists for the client’s benefit, not the counselor’s. 

o   Regularly ask: “Whose needs are being met — mine or my client’s?” 

·       Professional maturity involves honestly assessing how your behavior impacts clients. 

o   It’s not unethical to have personal needs, but they must be kept in perspective. 

o   An ethical problem arises when personal needs are met at the client’s expense. 

·       Counselors must avoid exploiting or harming clients in any form. 

o   As HCP always engage in self awareness to recognize areas of prejudice and vulnerability as it make it less likely to project onto clients  

Identify characteristics and procedural steps of ethnical decision making:

1.     Identify the problem or dilemma  

2.     Gather information that will shed light on the nature of the problem  

o   This will help you decide whether the problem is mainly ethical legal, professional, clinical, or moral  

3.     Identify the potential issues. Evaluate the rights, responsibilities, and welfare of all those who are involved in the situation. 

4.     Look at the relevant ethics codes for general guidance on the matter. Consider whether your own values and ethics are consistent with or in conflict with the relevant guidelines 

5.     Consider the applicable laws and regulations, and determine how they may have a bearing on an ethical dilemma  

6.     Seek consultation from more than one source to obtain various perspectives on the dilemma, and document in the client’s record the suggest you received from this consultation  

7.     Brainstorm various possible courses of action. Continue discussion options for action. Again, document the nature of this discussion with your client  

8.     Enumerate the consequences of various decisions and reflect on the implications of each course of action for your client  

9.     Decide on what appears to be the best possible course of action. Once the course of action has been implemented, follow up to evaluate the outcomes and to determine whether further action is necessary. Document the reason for the actions you took as well as your evaluation measures  

Purpose of informed consent  

·       Creates a working alliance and a collaborative partnership between client and the therapist 

·       Promotes active cooperation of clients in their counseling plan

·         Clients have the right to be informed about their therapy and make autonomous decisions regarding it. 

·        Promotes client empowerment, trust, and active participation in therapy. 

 Scope of Informed Consent 

·       Goes beyond obtaining a client’s signature; it is an ongoing, educational process. 

·       Encourages clients to become active partners in their counseling journey. 

Consent:  Technology and Privacy Considerations

·       Modern technology can compromise client privacy if used inappropriately. 

·       Counselors should discuss potential privacy risks related to emails, texts, and digital communication. 

·       Limit electronic exchanges to basic information (e.g., appointment times). 

Consent: Timing and Delivery of Information 

·       The education process begins at the first session and continues throughout counseling. 

·       Counselors must balance the amount of information given — not too much or too little. 

·       Example: Clients (especially minors) must understand confidentiality limits before disclosing sensitive issues. 

Information to include in informed consent:

• general goals of counselling

• responsibilities of both the counsellor and client

• limits and exceptions of confidentiality

• legal and ethical parameters of the relationship

• counsellor’s qualifications and background

• fees and financial arrangements

• expected services and approximate duration of therapy

• benefits and risks of counselling

  • possible care consultations with colleagues or supervisors

Methods of providing informed consent:

·       Can be written, oral, or a combination of both. 

·       Oral consent must be documented in the client’s clinical record. 

·       Written consent offers clarity, protection, and opportunity for clients to review and ask questions. 

Articulate the dimensions of confidentiality (privacy, privileged communications, and exceptions)  

Core concepts  

·       Root in a client’s right to privacy  

  Legal Aspects 

·       All U.S. states have laws establishing psychotherapist–client privilege, though details vary by state. 

·       Privileged communication does not apply in settings involving multiple people (e.g., group, couples, family, or child/adolescent therapy). 

·       These laws ensure that disclosures made in therapy remain protected during legal proceedings. 

Ethical Responsibilities 

·       Trust and confidentiality are essential for an effective therapeutic relationship. 

·       Counselors must clearly define and discuss the limits of confidentiality early in the counseling process. 

·       Clients should know their therapist may consult with supervisors or colleagues for professional purposes. 

True or false: Certain legal and ethical obligations override confidentiality. 

True

True or false: Counselors must use professional judgment, guided by laws, workplace policies, and ethical codes. 

True

True or false: Consultation and documentation are essential when unsure about confidentiality obligations. 

True

What is the counsellors primary obligation?

To protect client disclosures as a vital part of therapy

True or false: Clearly informing clients about the limits of confidentiality supports — rather than hinders — effective counseling. 

True

True or false: Technology introduces additional challenges to maintaining privacy and confidentiality. 

True

The ACA code of ethics (2014, section H) outlines standards for:

• counsellor competence in using technology

• legal requirements related to distance counselling

• informed consent and security of communication

• client verification and accessibility in telehealth

• professional boundaries in online counselling

• record maintenance and website accessibility

• use of social media in professional contexts

Core Ethical Principle 

o   Ethical counseling requires attention to the client’s cultural context. 

o   Ignoring cultural differences can harm clients and lead to unethical practice

o   Cultural competence is essential for ethical and effective counseling. 

Adequacy of Current Theories 

o   Traditional counseling theories must be expanded to include multicultural perspectives. 

o   Many assumptions about mental health, development, and treatment in existing theories may not be relevant to all clients. 

o   Effective practice requires an interactive person-in-the-environment focus, considering cultural and environmental influences. 

o   Therapists should design strategies that align with diverse values and behaviors found in pluralistic societies. 

Is Counseling Culture-Bound? 

o   Historically, counseling has been based on Western models with Western values and assumptions. 

o   These models may not apply to all populations, such as Asian and Pacific Islanders, Latinx, Native Americans, and African Americans

o   Each theory reflects a specific worldview, shaped by its own biases and cultural assumptions. 

o   Counseling methods often need to be adapted or modified for culturally diverse clients. 

Values in Counseling 

o   Western approaches emphasize individual choice and autonomy, which are not universal values. 

o   In collectivist cultures, group harmony and community well-being may be prioritized over individual goals. 

o   Counselors must listen to clients’ perspectives, understand their reasons for seeking help, and adjust their approaches accordingly. 

Cultural Competence of Therapists 

Recognize themselves as social and cultural beings. 

§  Possess knowledge, awareness, and skills for working with diverse clients. 

§  Avoid imposing their own worldview or values on clients. 

o   They seek to understand clients’ needs within their cultural and social contexts rather than fitting them into predefined models. 

True or false: Counselors who remain centered on dominant culture values risk practicing unethically

True

Ethical multicultural counseling demands for:

self-awareness, cultural sensitivity, and flexibility. 

True or false: Counselors must continually evaluate their biases and adapt their methods to serve diverse clients effectively and respectfully. 

True

Ethical practice involves:

• accepting clients unique worldviews and life assumptions

• avoiding value judgements about clients beliefs or decisions

• being mindful of diversity and social justice issues in all aspects of counselling

Relationship Between Assessment and Diagnosis 

o   Both are essential components of counseling and psychotherapy. 

o   Serve as a foundation for treatment planning and goal setting. 

o   Assessment is ongoing and may be revised as new information emerges. 

o   Diagnosis may result from assessment and involves identifying a specific mental disorder based on patterns of symptoms. 

Purpose of assessment:

• to evaluate relevant factors in a client’s life (past and present)

• helps identify themes, problems, and strengths for deeper exploration

  • provides directions for treatment and facilitates collaborative goal setting

Purpose of diagnosis

identifies disruptions in behaviour, emotions, or lifestyle

• includes:

  • causes and developments of the clients difficulties

  • classification of disorders

  • preferred treatment procedures

  • prognosis or likelihood of successful outcome

• offers a working hypothesis that helps the counselor understand and guide treatment

• begins at the intake interview and continues throughout therapy

Advantages of diagnosis

o   Helps identify specific disorders and informs appropriate treatment planning. 

o   Aligns with the medical model, which attributes disorders to underlying causal factors (biological, psychological, social). 

o   Can enhance communication among professionals using shared diagnostic language. 

Limitations and concerns for diagnosis:

o   A diagnosis is only a label and does not capture the whole person. 

o   Once assigned, a diagnosis may follow the individual even if it no longer applies. 

o   Some clinicians view diagnosis as unnecessary, stigmatizing, or biased, particularly toward people of color or minority groups. 

o   Certain therapeutic approaches do not rely on diagnosis to initiate treatment. 

Cultural and Ethnic Considerations in Assessment and Diagnosis 

o   Failure to account for cultural factors can lead to misdiagnosis or bias. 

o   The DSM-5 emphasizes awareness of unintentional bias and the need for cultural sensitivity in diagnosis

o   Counselors must consider how cultural background shapes: 

§  Behavior, Emotional expression, Thought patterns, Symptom presentation 

o   Behaviors normal in one culture may be misinterpreted as pathology in another. 

Counselors working with diverse populations must avoid labeling clients as “passive,” “unmotivated,” or “repressed” based on culturally influenced traits

Explain how ethnic and cultural factors can influence assessment and diagnosis.

Ethnic and cultural factors shape how clients express distress, view illness, and respond to treatment. The DSM-5 is based on a medical model that locates problems within the individual, often overlooking social, cultural, and contextual influences such as discrimination, oppression, and racism. This can lead to misdiagnosis or pathologizing clients from diverse backgrounds. Ethical assessment requires counselors to consider clients’ cultural realities, spiritual beliefs, and values while avoiding imposing Western or biased definitions of “normal.”

What does DSM-5 stand for?

Diagnostic and Statistical Manual of Mental Disorders

DSM-5 (diagnostic and statistical manual of mental disorders

a classification system for mental disorders based on a medical model- it locates problems within the individual rather than social context

Assessment

A continuous, collaborative process of understanding the client’s functioning—mind, body, and spirit—through gathering and evaluating information.

Diagnosis 

The process of identifying and labeling the client’s condition according to established criteria (like DSM-5)

Ethical dilemma in diagnosis

occurs when a diagnosis is made mainly for insurance purposes rather than clinical accuracy

Compare arguments for and against evidence-based practice (EBP).

For EBP:

• Integrates best research evidence, clinical expertise, and client culture and preferences.

• Promotes accountability, effectiveness, and public health improvement.

• Encourages use of empirically supported interventions for specific disorders.

Against EBP:

• Can become mechanistic, ignoring the human relationship and individual differences.

• Overemphasis on standardized manuals may limit therapist creativity and ignore existential or non-diagnostic issues.

• Risks misuse by insurance companies for cost control rather than quality improvement.

Describe ethical issues related to multiple relationships in counseling practice.

Multiple (dual) relationships occur when a counselor has more than one role with a client (e.g., therapist and friend, teacher, or business partner). Ethical issues include:

• Exploitation or harm due to the power imbalance.

• Loss of objectivity or blurred boundaries.

• Conflicts of interest that compromise client welfare.
  Sexual relationships with clients are always unethical and often illegal. Nonsexual multiple relationships require careful judgment, informed consent, and supervision to prevent harm.

Discuss various perspectives on multiple relationships

Traditional view, modern perspective, consensus

Traditional view

Avoid all multiple relationships because they may exploit clients or impair objectivity.

Modern perspective

Some are inevitable or even beneficial if managed ethically and transparently.

Consensus

They are complex, unavoidable at times, and require ethical reasoning, consultation, self-monitoring, and documentation.
The key is to minimize harm, maintain professional integrity, and protect client welfare rather than automatically avoiding all dual roles.

Boundary violation

a serious breach that causes harm or exploits the client. (ex. Having sexual or financial relationship with a client) Always unethical.

Explain how to manage boundaries and risks associated with using social media.

Social media blurs professional and personal boundaries. Ethical management involves:

• Creating a clear social media policy and including it in informed consent.

• Separating personal and professional accounts.

• Limiting personal information shared online.

• Updating privacy settings regularly.

• Avoiding “friend” relationships with clients online.

• Reviewing ethics codes to ensure clear virtual boundaries.
  Practitioners should think critically about how technology affects confidentiality, professionalism, and client trust.

Explain what is involved in becoming an ethical counselor.

Becoming an ethical counselor is an ongoing process, not a one-time achievement. It involves:

• Knowing and following ethical codes

• Applying ethical principles with sensitivity, reflection, and good judgment.

• Seeking consultation and supervision when dilemmas arise.

• Balancing client welfare, boundaries, and professional responsibility.

• Continuous self-reflection and learning as experience grows.
  Ethical decision-making evolves over a counselor’s career and requires ongoing openness, humility, and commitment to clients’ best interests.

Cultural considerations

Counselors must include contextual, cultural, and social factors (e.g., racism, oppression, discrimination) to avoid pathologizing clients from diverse backgrounds.

Feminist and Postmodern perspectives

These approaches challenge traditional diagnostic systems, arguing they reflect White, Western, male-centered biases and ignore societal contexts.

Evidence-Based Practice (EBP)

The integration of the best available research, clinical expertise, and client characteristics, culture, and preferences

Three pillars of Evidence-based practice (EBP):

1. Best available research

2. Clinical expertise

   1. Client characteristics, culture, and preferences

Empirically Supported Treatments (ESTs)

Therapies that have been scientifically tested and proven effective for specific disorders.

Evidence-based relationships

Focus on therapeutic alliance and relational factors—shown to contribute significantly to positive outcomes.

Multiple (Dual) Relationship

When a counselor has two or more roles with a client—either simultaneously or sequentially (e.g., therapist and teacher, or therapist and friend).

Nonprofessional Relationship

Any personal or social relationship with a client that falls outside the professional role.

Boundary

The framework that protects both counselor and client by defining limits of appropriate professional behavior.

Power Differential

The inherent imbalance of power between counselor and client due to the counselor’s position of authority and influence.

Social Media Policy

A written statement that clarifies how the counselor manages online interactions, privacy, and boundaries with clients.

Transference

When a client projects feelings about others (often from the past) onto the counselor.

Countertransference

When the counselor’s own emotions or experiences interfere with objectivity toward the client.

Digital Boundaries

Professional limits maintained in online settings to prevent multiple relationships, privacy breaches, or ethical violations.

Ethical Sensitivity

Awareness of ethical implications in everyday clinical decisions.

Ethical decision making

A reflective, ongoing process that involves applying ethical principles, seeking consultation, and prioritizing client welfare.

Code of Ethics

Professional guidelines that define ethical standards, protect clients, and guide counselors’ conduct.

Ethical Dilemma

A situation where no clear “right” answer exists—multiple ethical principles may conflict.

Consultation

Seeking supervision or peer advice to gain perspective on complex ethical issues.

The Regulated Health Professions Act (RHPA)

Umbrella legislation for all health professions in Manitoba; It is the LAW, RPNs were added to the RHPA in 2022; has been active since 2009; umbrella law that creates reserved acts

RHPA establishes:

•       Registration & licensure processes

•       Standards of practice

•       Reserved acts (restricted activities)

•       Public protection is the primary purpose

•       Psychiatric nursing regulated through the College of Registered Psychiatric Nurses of Manitoba (CRPNM)

Psychiatric nursing before the RHPA:

•       RPNs were regulated under their own profession-specific Act (The Registered Psychiatric Nurses Act).

•       Each profession had separate legislation, which created:

•       Inconsistency across health professions

•       Confusion for the public about scopes of practice

•       Limited ability to update legislation quickly

Why joining the RHPA was positive:

•       Brought RPNs under the same umbrella law as other health professions

•       Increased consistency and transparency in regulation

•       Strengthened public protection through a standardized framework

•       Highlighted RPNs’ unique scope (mental health focus) alongside other professions

•       Modernized legislation — easier to revise as health care evolves

Reserved acts

Defined under the RHPA as higher-risk activities that only regulated professionals may perform. Purpose is to protect the public from harm.

• The idea is: only people with the right training and regulation should be allowed to do them.

• Not every profession gets all the reserved acts.

• The RHPA says what the acts are, but each profession’s college decides which of those acts are authorized for their members.
  •       Examples across health professions:

•       Performing invasive procedures

•       Administering medications

•       Communicating a diagnosis

•       Providing psychotherapy

-       Each profession gets its own subset of these acts

Psychiatric Nurses (RPNs)

•       May diagnose and treat mental disorders within scope

•       Provide psychotherapy, crisis intervention, suicide risk assessment

•       Administer medications & carry out therapeutic interventions

Registered Nurses (RNs)

•       Broader general health focus (medical, surgical, pediatrics, etc.)

•       Perform many reserved acts related to physical health

•       Do not have authority for independent mental health diagnosis or psychotherapy

College of registered psychiatric nurses of Manitoba (CRPNM)

Regulates the profession under the RHPA; The college translates the RHPA into profession-specific rules.

Responsibilities of College of registered psychiatric nurses of Manitoba (CRPNM)

•       Grant licensure/registration

•       Enforce standards of practice

•       Define how reserved acts apply to RPNs

•       Investigate complaints & ensure accountability