A regulatory board complaint may be filed against a counselor by a client, colleague, employer, and/or other regulatory agency, such as the Department of Health, or Department of Family and Children Services. Complaints are subsequently investigated by the regulatory board in order to ensure that licensed/certified counselors are practicing safely, professionally, and ethically. Regulatory board investigations can lead to outcomes ranging from no action against the counselor to revocation of the counselor’s license/certification to practice. This case study involves a licensed mental health counselor who worked as a solo practitioner.
The insured in this case is a licensed mental health counselor (“the counselor”) with three years of experience. The counselor had recently begun working as a solo practitioner when she started treating the client, a woman in her early 20s. The client’s intake form stated that she was seeking therapy for her borderline personality disorder (BPD), and the counselor’s treatment plan for her included dialectical behavior therapy (DBT). During the initial session, the counselor learned that the client was also in recovery for an eating disorder (anorexia nervosa), and she had a history of depression that was being managed by medication.
As part of the counselor’s treatment for the client’s BPD that included DBT, the counselor gave the client her cell phone number. Typically, in DBT, telephonic consultations between a counselor and their client allow the client to receive in-the-moment guidance that can help them apply the skills they have learned in therapy in everyday situations, especially during times of crisis.1
However, in the counselor’s case, she simply encouraged the client to “text [her] any time.”
At first, the client would only contact the counselor to help her avoid engaging in dysfunctional behaviors, but eventually the client began texting the counselor frequently throughout the day for casual conversations. Rather than addressing the client’s therapy-interfering behavior, the counselor and the client began engaging in a close personal friendship. The counselor and client texted almost daily, as they were close in age and had many interests and hobbies in common. In addition, they began regularly socializing and exercising together. The counselor and client gave each other “pet names”, with the counselor repeatedly telling the client that she was her friend and that she “loved” her. The client also visited the counselor in the hospital following the counselor’s emergency appendectomy.
After the client’s estranged father suddenly passed away, the client began to withdraw from the counselor, ignoring her text messages and missing appointments. The client also began to relapse and engage in disordered eating practices consistent with anorexia nervosa. As the client’s eating disorder and BPD became worse, she stopped taking her antidepressants. The counselor became increasingly frustrated with the client and allowed her frustration to be evident in her communications with the client. The counselor texted the patient messages such as “I can’t help you if you won’t help yourself” or “I feel like I am wasting my time talking to you.”
One day, as the client was driving herself home from work, she lost consciousness. The client had barely eaten anything for several days. Her car veered off the road and eventually came to a stop when it hit a tree. The client was taken to a local hospital and admitted for treatment and observation for the minor injuries she sustained in the car accident. When the client’s mother came to visit the client in the hospital, she saw multiple text messages come through from the counselor on the client’s phone. After the client’s mother became aware of the extent of the relationship between the client and the counselor, she and the client later filed a complaint against the counselor with the state licensing board.
The client and her mother accused the counselor of violating professional boundaries by engaging in a personal relationship with the client. The state licensing board complaint also asserted that the counselor mishandled the transference phenomenon between herself and the client and failed to provide proper care for the patient’s BPD.
The licensing board investigators requested the counselor’s client healthcare information records, billing records, and her personal mobile phone records. As part of the investigation, the board investigators also conducted interviews with the client and her mother. The client stated that the counselor exacerbated her mental health problems and stress, which contributed to her eating disorder relapse. The client also told investigators that the counselor prolonged the client’s emotional distress with the counselor’s ongoing attempts to contact her after she terminated their professional and personal relationship.
The board concluded that the counselor failed to safeguard the integrity of the counselor-client relationship and placed the counselor on probation for two years. As part of her consent agreement with the board, the counselor was also ordered to pay $2,500 in fines and complete 15 hours of continuing education, in addition to other normally required continuing education courses.
This matter took nearly three years to resolve and incurred more than $8,000
in legal defense expenses.
Risk Management Recommendations
In this matter, the counselor breached clinical, ethical, and legal boundaries and standards of care by engaging in a personal relationship with her client. Clients in need of counseling and therapy may have an impaired ability to judge the appropriateness of their own or others' actions. If the client made initial friendship overtures toward the counselor, or if the counselor identified inappropriate personal feelings for the client that she was unable to resolve, the counselor should have arranged for her client to be timely and seamlessly transferred to another counselor rather than continuing treatment and engaging in an inappropriate relationship.
Although state statutes and regulations regarding scope of practice may differ, it is not ethical, appropriate, or acceptable for a counselor to enter an intimate personal relationship with a client. Remember that the counselor is solely responsible for maintaining appropriate boundaries in the counseling relationship
. Although not all professional boundary issues are equally serious, they tend to impair the objectivity and judgment of both parties, thereby potentially compromising the client-provider relationship and distorting expectations.
Below are some proactive concepts and behaviors to include in your practice to help mitigate the risk of professional boundary violations and Board complaints:2
- Know and understand the scope of practice for your specific professional designation, certification and/or licensure in your state and understand the standard of care to which you will be held.
- Provide clients with written rights and responsibilities, including expectations for treatment, as well as acceptable behaviors by both the counselor and the client prior to initiating treatment. Include a statement that any inappropriate behavior on the part of the client will result in termination from counseling/treatment with facilitated transfer to another counselor/therapist.
- Maintain appropriate boundaries with clients and avoid any interactions that are not within accepted counseling practices (e.g., agreeing to meet them at social events or communicating with them on social media outside of the parameters of a professional relationship).
- Maintain confidential client session documentation in a protected manner as part of the client's clinical record throughout the duration of the client's course of therapy/treatment and until the statute of limitations for litigation has expired. The use of e-mail, texting, or other forms of communication related to client care is not confidential and, as in this case, may be discoverable in the event of an administrative action or litigation.
- Terminate any client who requests or initiates inappropriate discussion and/or behaviors and facilitate the transfer of the client to another counselor/therapist.
- If inappropriate feelings toward a client arise, immediately obtain professional supervision and guidance. If the feelings cannot be properly and timely managed, terminate the client from treatment and facilitate the transfer of the client to another counselor/therapist.
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- May, J. M., Richardi, T. M., & Barth, K. S. (2016). Dialectical behavior therapy as treatment for borderline personality disorder. Mental Health Clinician, 6(2), 62-67. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6007584/
- HPSO & CNA. (2019). Counselor Spotlight: Boundaries. https://www.hpso.com/getmedia/a7c4acab-29a5-474d-a87d-f442e4cae1f7/counselor-spotlight-boundaries.pdf
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