Part Two: Thinking about professional boundaries: what would you do?

Last month, I kicked off the first in a series of scenarios presenting some tricky situations for you to think about (by yourself or perhaps more helpfully with others), with the aim of helping to support you in the application of the Osteopathic Practice Standards (OPS) in your practice. If you haven’t taken a look at that first scenario yet, you may wish to read last month’s blog before scrolling down to see my response – or you could just get started with Scenario 2 now.

Professional Boundaries Scenario 2

A newly graduated osteopath starts working from home. She treats a number of patients from her local village, including an elderly woman (87 years old) who used to be her primary school teacher. The patient has mobility issues, and the osteopath offers to see her at home, which she agrees to. They get on well, and when she’s due to see her, the patient will often ask if the osteopath can pick up any shopping for her from the local shop. Sometimes, as she sees her at the end of the day, the osteopath will even stay and cut her small lawn for her. One day she is surprised when the patient tells her she has changed her will to leave her £25,000 when she dies.
The osteopath contacts you to seek advice as to what she should do.

Q: Some questions for you to consider:

• What are the boundaries issues in this case?
• What are the relevant OPS and areas of guidance to support decision making?
• If a colleague reported this case to you and asked for your guidance, what would you say/do?
• If you were presented with a similar scenario, how would you manage this?

Remember, we would be pleased to receive your thoughts if you would like to share your reflections with us. Please email: standards@osteopathy.org.uk

Watch out for the third scenario and our thoughts on this one next month.

My response to Scenario 1

There is nothing in this scenario to indicate the relative ages of the osteopath and the patient, nor whether a sexual relationship might possibly develop. There are however some potential boundaries issues, and we can look to Standard D2 of the OPS to consider these in the light of the guidance.

D2 states: ‘You must establish and maintain clear professional boundaries with patients, and must not abuse your professional standing and the position of trust which you have as an osteopath.’

The guidance in relation to this standard within the OPS is quite extensive. D2.1 says that the ‘most serious abuse of your professional standing is likely to be the failure to establish and maintain appropriate boundaries, whether sexual or otherwise’.

In this case, we have an emotionally vulnerable patient with a longstanding health issue, who has been treated regularly through a particularly stressful period. The recent bringing in of cake at each visit, and the booking of the patient in a slot where they can share a coffee and cake afterwards indicates a potential inappropriate dependency arising, and it could be argued that the osteopath may be taking advantage of this. The fact that the osteopath has shared details of his own relationship break up, may have intensified this feeling of connection and dependency. D2.3 acknowledges that it may support empathy and trust with a patient to disclose personal information, but there is a spectrum, and it is the osteopath’s job to ensure that patients who may be vulnerable are protected throughout the duration of the professional relationship.

If a colleague were to ask my advice as to how to manage such a situation, I would have a number of questions. For example:

• what is the osteopath’s view of the relationship – is it strictly professional and therapeutic, or has it developed into a friendship?
• is there any chance that the relationship might become sexual?

D2.5.1 of the OPS outlines some of the issues that might be sexualised or regarded as so by the patient, including sharing inappropriate intimate details, visiting the patient’s home without an appointment, making inappropriate sexual remarks to or about the patient, or unnecessary physical contact. What would be the osteopath’s honest reflection on his behaviour in this context? What do they talk about over the coffee and cake, for example?

Suppose the osteopath admits that there is a burgeoning close relationship here – it may not have become sexual at this stage, but it is heading in that direction, and he wants advice as to what to do. D2.5.4 states that it is the osteopath’s responsibility not to act on feelings of sexual attraction to or from patients. D2.5.5 suggests seeking advice from a colleague or professional body, and says that if you cannot remain objective and professional in relation to the patient, and it is not possible to re-establish a professional relationship, then you should refer the patient to another healthcare practitioner.

It may be that the osteopath suggests referring the patient elsewhere, in that case, in order to allow the personal relationship to develop. However, it’s not that simple. D2.5.6 states that you must not take advantage of your professional standing to initiate a personal relationship with a patient. There is a power imbalance, which may exist even if the patient is no longer in your care. D2.5.7 explicitly states, also, that you must not end a professional relationship with a patient solely to pursue a personal relationship with them.

Issues to consider in exercising professional judgement around relationships with patients are the nature of the professional relationship, the length of time it lasted and when it ended (in this case – longstanding and ongoing), and whether the former patient was or might continue to be vulnerable (she was, and is).

Even assuming there is no potential sexual relationship here, then there are still boundaries issues to consider. Socialising with a patient, in fact combining this with the therapeutic visit as they’ve been doing, or visiting her new flat for a meal, puts the therapeutic relationship at risk.

The key question at the heart of all this is what is in the best interests of the patient? My advice to a colleague in these circumstances would be to pay heed to the guidance within the OPS, and take action to recalibrate the therapeutic relationship to a more professional footing.

One final point in relation to the OPS is to consider standard D7 ‘You must uphold the reputation of the profession at all times through your conduct, in and out of the workplace’. The guidance to this states further that the public’s trust and confidence in the profession and its reputation generally can be undermined by an osteopath’s professional or personal conduct.

Remember, we would be pleased to receive your thoughts if you would like to share your reflections with us. Please email: standards@osteopathy.org.uk