Recognizing and Managing Boundary Issues in Case Management

Much of the literature on worker-client boundaries in clinical practice is based on assumptions that the relationship between the two parties is structured and formal. These assumptions do not always apply in community-based case management practice, where the worker and client interact in a wide variety of settings and circumstances. The relative informality of case management makes the establishment of appropriate worker-client boundaries both critical and difficult. In this article key principles for recognizing and managing boundary issues are presented and discussed.

In community-based case management practice with persons having mental illness, the worker and client interact in a variety of settings such as fast food restaurants, the client's home, grocery stores, laundromats, parks, job sites, and recreational settings. The case manager often develops relationships with the client's friends, family members, landlords, employers, and other helping professionals. The scope and intensity of intervention challenges the case manager's ability to develop appropriate working relationships with clients. Considering relationship issues from the perspective of boundaries provides an important source of guidance for the case manager. This concept is most fully developed in the psychology literature. Other professionals are familiar with the concept, but do not always appreciate that attention to boundary issues can help them negotiate clear and consistent relationships with clients, their significant others, and members of interprofessional teams. In this article the author presents and reviews principles for managing interpersonal boundaries in case management practice.

BOUNDARIES IN CASE MANAGER/ CLIENT RELATIONSHIPS

Boundaries can be understood as the assumed, and generally unspoken, rules that we internalize about the physical and emotional limits of our relationships with other people and groups. They protect our privacy and reflect our individuality. Through boundaries we organize our social worlds and communicate our positions within them. We differentially construct boundaries to facilitate our desire to be close to, or separate from, others. We open and close them to control the flow of our interactions. Each person's boundaries are unique; we covertly communicate them to suit our assumptions and intentions about particular relationships.

Curtis and Hodge (1994) state that, "if community workers are not facing relationship boundary issues in their daily work, they are probably not doing their jobs most effectively" (p. 341). The nature of community based case management, with the worker providing services in the client's territories, ensures that boundary dilemmas frequently develop. Still, as indicated in two research studies, case managers do not often focus on them. In their review of a pioneering community case management program, Diamond and Wikler (1985) observed that case managers did not ordinarily view their work as raising significant ethical issues, and that they did not see extended discussion of ethical concerns to be a good use of their time. Case managers tended to be more active than reflective. In a more recent study (Fisk, Rakfeldt, Heffernan, & Rowe, 1999), ethical issues related to worker-client boundaries were still not a routine topic of reflection among case managers. Staff did not want to be perceived as resisting program procedures or as inept. Still, when asked, case managers readily admit to frequent boundary dilemmas (Perkins, Hudson, Gray, & Stewart, 1998). The possibility that such issues are common and yet not confronted in supervision seems dangerous for both clients and case managers.

Case managers often participate in a broad range of their clients' life activities. They need to be careful in developing interpersonal boundaries and deciding when they can be crossed. When these issues are openly addressed, and boundaries are consistently negotiated, clients are more willing to participate in the helping process. Mutually understood boundaries provide for both clients and case managers an appropriate sense of control, power, protection, and selfdetermination. Any case manager's actions perceived by clients to be violations of interpersonal boundaries, intentional or not, may have negative consequences for the intervention. Clients may feel exploited, angry, and lose their trust in the worker (Gutheil & Gabbard, 1998). In extreme circumstances, boundary violations can have legal consequences for the worker.

Boundaries include rules about the following aspects of relationships:

* Contact time. How much time is appropriate for me to spend in the company of the other person? Will this vary depending on whether that time is spent face to face, on the phone, on-line, or otherwise? On the time of day, day of the week, or time of the year? On the purpose of the contact?

* Types of information to be shared. What is the appropriate range of topics for me to discuss with the person? Will it be limited to job topics or social topics? What about politics, religion, and sex? How much depth can I be expected to provide about these topics?

* Physical closeness when together. What are my expectations about personal space when in the person's company? How closely will I sit with him or her? Can she look me in the eye? Can he touch me? What range of nonverbal communications is appropriate?

* Territoriality. To which of my environmental spaces does this person have access? Is he or she restricted from others? Can we meet at my home? Her home? Will our interactions be limited to social settings? Recreational settings? The office?

* Emotional space. To what extent am I willing to share my feelings about sensitive topics with this person? Are there limits to the topics about which I will share my feelings?

Boundary-making begins as early as 6 months of age, when as infants we first develop a sense of separateness from parent figures (Gabbard & Lester, 1995). Boundaries continue to develop through life, and like our personalities, they tend to become more stable over time. Still, it is healthy to be flexible in boundary setting, as this promotes our adaptation to changing relationships and environments.

Clear boundaries help the case manager-client relationship by providing the following benefits for clients:

* A relationship in which the client feels affirmed, respected, and empowered.

* A safe, predictable environment in which the client is likely to feel comfortable about sharing personal information.

* A stronger sense of individuality which derives from having control over boundaries.

* A basis from which to determine whether and when the case manager can cross certain boundaries. Boundary crossing implies appropriate efforts to adjust boundaries toward greater intimacy, while boundary violations are inappropriate transgressions into a person's privacy and space (Hermansson, 1997).

* For some clients, such as those with psychosis, the external structure produced by clear and consistent boundaries becomes a model for the development of a more clear internal structure (this speaks to the inner boundaries described earlier).

Clear boundaries provide the following benefits for the case manager:

* Role clarity regarding the range and limits of the worker's activities.

* A basis from which to make decisions about how and when to cross physical or psychological boundaries.

* A means of preventing burnout by avoiding role overload.

* Reminders about legal issues which may emerge if certain boundaries are violated

* Physical safety, when territorial boundaries are maintained (Ranter, 2000).

It is important to understand the distinction between inner and outer boundaries (Gabbard & Lester, 1995). Inner boundaries separate what is real from what is unreal in our perceptions. They may be conceptualized as ego functions. Outer barriers, about which this article is primarily concerned, separate the self from the outside world, and from other persons. In some mental disorders such as schizophrenia, both types of boundaries may be weakened.

Our social and personal characteristics determine our boundaries (Bruhn, Levine, & Levine, 1993; Wallace, 1997). We may be included with or excluded from other groups based on, for example, our gender, race, ethnicity, class, position in a hierarchy, and cultural traditions. Natural boundaries tend to exist between members of successive generations, gangs, students at different schools, and subgroups of families (such as children vs. parents). Boundary patterns are also reflected in personality types. The person with rigid boundaries tends to be intolerant of ambiguity, to have a high internal locus of control, to value predictable behavior, and to be controlling, confrontational, and guarded. The person who maintains flexible boundaries, generally considered to be desirable, likes autonomy but is adaptable, arbitrative, and open. The person with fluid boundaries, which is not a desirable trait, is tolerant of ambiguity but has a high external locus of control, needs to be liked by others, and is impulsive, prone to interpersonal withdrawal, and ambivalent.

In summary, boundary establishment is important to the professional survival of case managers. Caring for clients may foster strong emotions in professionals, and clear boundaries provide protection from overextending themselves (Farber, Novack, & O'Brient, 1997). When clients violate boundaries about which they may be unclear, case managers may feel angry, manipulated, and lose objectivity about the client's needs. This can interfere with the quality of the intervention as well as lead to burnout.

Crossing Boundaries

The discussion thus far has focused on boundaries as limits, but the concept also has implications for bridging, access, and integration (Petronio, Ellemers, Giles, & Gallois, 1998). All of us experience natural tensions to remain apart from and to join with others, and this tension underscores the importance of flexibility, permeability, and balance in boundaries. We decide whom to "let in" as well as whom to "keep out." In most of our relationships that persist, boundaries change. We test the boundaries of others to determine who they are, how we should behave toward them, and if and when we can move closer. If we attempt to cross a boundary about which another person is not comfortable, he or she may choose to withdraw, and perhaps erect new, tighter boundaries in response.

Boundaries and Power

Boundary awareness is particularly important in case manager-client relationships because a power differential exists between the two parties (Backlar, 1996). A client will loosen a boundary when he or she perceives some benefit to doing so. The client needs to trust the worker and feel confident that the relationship will be enriched as a result of realigning a boundary. Despite the prescriptions of client empowerment and partnership in recent literature (e. g., Saleebey, 1997), case managers have more formal power in those relationships. They control certain material and emotional resources needed by the client, and the client must be compliant with the worker's agency-sanctioned procedures to qualify for and receive those resources. The lack of equal power in the relationship may compromise the client's ability to defend him or herself with regard to privacy issues. Any negative reactions to ambiguous boundaries will not necessarily be articulated by the client, however, who has less power and perhaps is unclear about what appropriate professional boundaries should be. Some workers fail to see how their power may stir the client's resentment in times of conflict.

BOUNDARIES AND PROFESSIONAL GROUPS

The case manager's ability to successfully coordinate interventions for clients also necessitates the existence of clear boundaries with other professionals. As with case managers and clients, members of professional groups maintain boundaries between themselves and other such groups, marked by different bodies of knowledge, languages, values, histories, and intervention preferences. Issues of power among the professions have consequences for the quality of client care (Teram, 1999). For physicians, psychologists, social workers, and nurses, boundaries set conditions for group identity and demark realms of expertise.

Professionals tend to assert that the problems relating to their specialty should be kept within their domain. This presents challenges to case managers, who may represent a variety of professions, or perhaps do not identify with any profession. Case managers tend to have relatively unclear professional boundaries. Because of their diverse educational backgrounds they experience a lack of clarity about their range of job responsibilities, professional identity, and organizational status. They may be excluded from the activities of other professional groups with more clearly defined areas of specialization. Case managers may at times act out their relative lack of organizational power by overpowering their clients in some ways. Separation from other staff may also result in case managers restricting their case consultations, and thus not benefiting from the input of other professionals (Petronio, Ellemers, Giles, & Gallois, 1998).

WARNING SIGNS OF POSSIBLE BOUNDARY TRANSGRESSIONS

Fourteen possible boundary violations that may emerge in the course of the case manager's work are listed below. None of these is necessarily a transgression- whether it is so depends on various circumstances, which will be considered later.

* Most dual relationships, or those in which the professional interacts with the client or the client's significant others in more than one role (Herlihy & Corey, 1997). For example, the client or significant other might be the case manager's mechanic, grocer, neighbor, fellow church member, and so forth. These situations create potential conflicts of interest as well as opportunities for confidentiality violations. They are most common in rural settings but can occur anywhere.

* Fluid boundaries between home and work environments may indicate that the case manager does not maintain good personal boundaries and is at risk for job burnout (Nippert-Eng, 1996). Examples of fluid boundaries include a single home and work wardrobe, home and work items kept together in one's purse or wallet, addresses and phone numbers for clients, friends, and family kept in the same book, few distinctions between work time and personal time, and making or receiving job-related phone calls from home.

* Intrusion into the client's territory. The higher utilization of home visits provides one example of how community care has shifted the balance of power somewhat back to the client. The home represents an especially private territory in which persons can exercise control and expect that visitors abide by their rules (Bruhn, Levine, & Levine, 1993). Intrusive activity includes visiting the client who does not want to be visited or making unannounced home visits, both which are commonplace, for example, in child protective services work.

* Self-disclosure by the case manager. This practice may be legitimate at times as a means to a therapeutic end, but it may also reflect a sharing of personal information for the worker's benefit. A case manager who shares that he had an argument with his son that morning may be using the client as a resource for venting. This may put the client in the inappropriate position of being a caregiver.

* Socializing between intervention and socialization (talking about or attending to issues that are unrelated to the major purposes of the interaction) is often difficult to distinguish in community care. A case manager may be invited to a client's graduation ceremony, a family's holiday cookout, or a party planned by a group of clients. These may be appropriate activities, depending on what the case manager communicates in doing so. Sometimes, however, the case manager may spend too much time socializing with a client, even during a contact that is taskspecific. While socializing is useful for establishing a relationship and building a client's social skills, it may indicate that the case manager is gratifying his or her own needs.

* Referring to clients as friends. Case managers rarely interact with their clients in the same manner as they do with their friends. With friends, we tend to be self-disclosive about our weaknesses and fears, willing to sacrifice personal time to offer assistance, loan money, and give advice about personal matters. Communicating to clients that they are friends is misleading. It may cause eventual hurt to the client or discourage clients from developing their own friends.

* Investigating certain details of clients' personal lives (Doreen, 1998). The need to know some personal information about clients does not mean that the case manager has a right to know everything. The case manager's curiosity may be voyeuristic at times (about, for example, a client's sexual practices).

* Sharing information about a client with an outside party, particularly for reasons that have nothing to do with coordinating an intervention. This is a violation of the client's right to privacy.

* Loaning, trading, or selling items to a client. This includes such practices as lending money, trading compact discs, or buying and selling items such as artwork and furniture.

* Accepting or giving gifts. This may or may not be appropriate, depending on the client and worker's motivations, the nature of the relationship, and the value of the gift. It may be an important action to help clients practice reciprocity in relationships (expressing gratitude for assistance, for example). Often, agencies have policies that the worker must follow to establish limits in this area.

The final four items represent countertransference reactions by the case manager, or responses to clients based primarily on personal feelings and the client's helping the case manager get his or her personal needs met.

* Exceptional behavior with clients, such as doing too much, protecting too much, identifying too much, or having extended meetings (Walker & Clark, 1999). The case manager should attempt to examine his or her reasons for this behavior so that certain clients are not treated with more of less favoritism.

* Experiencing strong positive feelings about a client (Hepworth, Rooney, & Larsen, 1997). This is a normal human process that happens frequently to all case managers and should not be denied (as it tends to be). It is an indication that the case manager needs to understand the reasons for the feelings, and how they have impact on service delivery.

* Touching or physically comforting the client. While appropriate at times, this needs to be monitored in relation to its purpose and the message it gives the client.

* Sexual contact. Most codes of ethics prohibit this behavior, although it remains a leading reason why professionals are dismissed from their organizations (Strom-Gottfried, 1999). A client's flirting may not need to be confronted. It may be mild, a function of the client's illness, or a harmless characteristic of the client's general interpersonal style (Ranter, 2000).

Intervening Factors

The above list consists of possible, not actual, violations. A variety of intervening factors must be considered when assessing the case manager's boundary conduct (Curtis & Hodge, 1994). These include:

* consultation with colleagues or a supervisor in assessing the situation.

* the functioning level of the client (his or her ability to use judgment in interpersonal situations).

* the client's history in relationships (patterns of behavior and his or her ability to manage conflicts or differences of opinion).

* the history and dynamics of the particular relationship (what patterns of interaction have been established, and whether a boundary-crossing activity by the worker is likely to be growth-enhancing or a setback for the client).

* the case manager's level of professional experience (more experienced practitioners tend to develop better judgment about whether, when, and how to negotiate boundaries).

* cultural norms reflected in the behavior of both the worker and client.

* legal liabilities that the case manager might face.

* the value base of the case manager (and his or her consideration of principles from relevant codes of ethics).

MANAGING BOUNDARY ISSUES

Listed below are guidelines that case managers and supervisors can follow to help them reflect on boundary dilemmas and decide what to do about them.

Guidelines for Case Managers

* Set clear boundaries with clients at the beginning of those relationships about what the case manager's roles and activities will and will not include. Clients should participate in establishing these boundaries.

* Clarify boundaries with the client over time, as they will change. As examples, the case manager and client may decide that home visits, not made before, are now indicated, or that they will address a broader or narrower scope of the client's issues than was done initially.

* Consider the preservation of the client's privacy to be a major guiding value. The case manager should always reflect on how much he or she needs to know about a client, and what the purposes are of acquiring certain information.

* Be aware of one's own emotional and physical needs as much as possible, and be wary of obtaining too much personal gratification at the expense of a client.

* Secure the client's informed consent for all service activities. This may involve written consent for some activities but may otherwise involve explaining the rationales for all interventions, and providing clients with choices about services.

* Promote the psychological separateness of the client (Simon & Williams, 1999). All activities should be focused on the goal of making the client more self-sufficient, rather than dependent on the case manager.

* Be educated about the client's cultural and community standards of behavior, so as to understand what boundaries are reasonable in those contexts (Herlihy & Corey, 1997).

* As much as possible, avoid dual relationships with clients or significant others. When considering situations where such a relationship may exist, the worker should assess potential risks and benefits, discuss these with the client, and then make a decision about acting as the service provider. If the dual relationship is unavoidable, the case manager should secure informed consent, seek ongoing supervision, and document all activities to minimize the risk of charges of conflict of interest (Herlihy & Corey, 1997).

* Use peer consolation and formal supervision routinely.

* Refer to codes of ethics when applicable.

* In any situation where ethical dilemmas arise, consider the following questions: What is the justification for my action, and its intended effect? Are there other ways of achieving the same outcome? What is the benefit to me of this action? What possible problems might this action provide to the client, other staff, my agency, and myself?

Guidelines for Supervisors

* Be proactive in identifying and evaluating boundary concerns of case managers. Most of the guidelines that follow expand on this principle. Supervisors need to prepare case managers to expect boundary dilemmas, and to feel confident that their supervisors are open to discuss them.

* Promote clarity in staff roles. Communitybased case management is stressful in part because boundaries are blurred. Supervisors and job developers have a responsibility to specify limits in case manager functions. With role clarity, case managers have an easier time deciding about what is or is not appropriate in their activities with clients.

* Model the process of boundary maintenance in relationships with staff.

* Provide a safe forum for worker disclosure. Because many boundary dilemmas are related to the personal needs of workers, they are not always easy to discuss with another person unless trust is established.

* Pursue discussions of boundary dilemmas with guided exploration rather than crossexamination (Gutheil & Gabbard, 1998). In guided exploration, the case manager is helped to reflect on and resolve his or boundary concerns in an atmosphere of support and affirmation. A case manager's experience of confrontational cross examination puts him or her on the defensive and discourages the processing of dilemmas. Likewise, supervisors should avoid writing policies as "dos" and "don'ts."

* Be sensitive to the worker's personal situation, and help him or her differentiate normal emotional reactions from feelings that promote boundary violations. This point is related to the one above. Case managers cannot be concerned that an admission of a boundary dilemma will put his or her job or reputation at risk. It is in fact a sign of maturity when a case manager admits to uncertainty about how to work with some clients.

* Pay attention to countertransference issues. This is related to the above two points, but it refers more generally to the supervisor's awareness of the case manager's positive and negative reactions to certain types of clients.

* Focus with workers on those clients who have a tendency to be manipulative in relationships as a means of establishing influence. These clients tend to have fluid boundaries and to violate the boundaries of other persons.

* Advocate for case managers within the agency with regard to status issues. In this way interprofessional and departmental conflicts can be minimized. Case managers will be less likely to isolate themselves from others and negatively act out their frustrations related to status.

SUMMARY

The proliferation of community-based case management models of intervention since the 1970s has created an array of challenges to practitioners. One of the most striking of these is the establishment and maintenance of appropriate worker-client boundaries. The many informal settings where meetings take place, and the complex problems and interpersonal deficits of clients, evoke a range of conscious and unconscious reactions from case managers. These must be acknowledged so that the worker can maintain a focus on goals that are client-centered, rather than focusing (perhaps unconsciously) on his or her own wishes for the client. The purpose of this article has been to detail procedures for recognizing and managing boundaries for the benefit of clients and also case managers, who tend to "burn out" because of a lack of role clarity in their work. Both case managers and their supervisors share responsibility for managing these boundaries.

[Sidebar]

Case managers often participate in a broad range of their clients9 life activities. They need to be careful in developing interpersonal boundaries and deciding when they can be crossed.

[Sidebar]

When clients violate boundaries about which they may be unclear, case managers may feel angry, manipulated, and lose objectivity about the clients needs. This can interfere with the quality of the intervention as well as lead to burnout.

[Reference]

REFERENCES

Backlar, P. (1996). The three Rs: Roles, relationships, and rules. Community Mental Health Journal, 32, 505-509.

Bruhn, J. G., Levine, H. G., & Levine, P. L. (1993). Managing boundaries in the helping professions. Springfield, IL: Charles C Thomas.

Curtis, L. C., & Hodge, M. (1994). Old standards, new dilemmas: Ethics and boundaries in community support services. In L. Spaniol (Ed.), Introduction to psychiatric rehabilitation (pp. 340-354). Columbia, MD: International Association of Psychosocial Rehabilitation Services.

Doreen, C. (1998). Knowing patients: How much and how well? In P. Griffiths & J. Ord (Eds.), Face to face with distress: The professional use of self in psychosocial care (pp. 135- 146). Oxford, England: Butterworth-Heinemann.

Diamond, R. J., & Wilder, D. I. (1985). Ethical problems in community treatment of the chronically mentally ill. In L. I. Stein & M. A. Test (Eds.), The training in community living model: A decade of experience (pp. 85-93, New Directions for Mental Health Services Series, 26). San Francisco: Jossey-Bass.

Farber, N. J., Novack, D. H., & O'Brient, M. K. (1997). Love, boundaries, and the patient-physician relationship. Archives of Internal Medicine, 157, 2291-2295.

Fisk, D., Rakfeldt, J., Heffernan, K., & Rowe, M. (1999). Outreach workers' experiences in a homeless outreach project: Issues of boundaries, ethics and staff safety. Psychiatric Quarterly, 70, 231-246.

Gabbard, G. O., & Lester, E. P. (1995). Boundaries and boundary violations in psychoanalysis. New York: Basic Books.

Gutheil, T. G., & Gabbard, G. O. (1998). Misuses and misunderstandings of boundary theory in clinical and regulatory settings. American Journal of Psychiatry, 155, 409-414.

Hepworth, D., Rooney, R., & Larsen, J. (1997). Direct social work practice: Theory and skills (5th ed.). Belmont, CA.: Brooks/Cole.

Herlihy, B., & Corey, G. (1997). Boundary issues in counseling: Multiple roles and responsibilities. Alexandria, VA: American Counseling Association.

Hermansson, G. (1997). Boundaries and boundary management in counseling: The never-ending story. British Journal of Guidance and Counseling, 25, 133-146.

Kanter, J. (2000). Clinical issues in delivering home-based psychiatric services. In A. Menikoff (Ed.), Psychiatric home care: Clinical and economic dimensions (pp. 19-37). San Diego, CA: Academic Press.

Kanter, J. (2000). Beyond psychotherapy: The communal relationship in community care. Smith College Studies in Social Work, 70, 397-426

Kanter, J. (Ed.) (1995). Clinical issues in case management. San Francisco: Jossey-Bass. Nippert-Eng, C. E. (1996). Home and work: Negotiating boundaries through everyday life. Chicago: University of Chicago Press.

Perkins, D. V, Hudson, B. L., Gray, D. M., & Stewart, M. (1998). Decisions and justifications by community mental health providers about hypothetical ethical dilemmas. Psychiatric Services, 49, 1317-1322.

Petronio, S., Ellemers, N., Giles, H., & Gallois, C. (1998). (Mis) communicating across boundaries: Interpersonal and intergroup considerations. Communication Research, 25, 571-595.

Saleebey, D. (1997). The strengths perspective in social work practice (2nd ed.). New York: Longman.

Strom-Gottfried, K. (1999). Professional boundaries: An analysis of violations by social workers. Families in Society, 80, 439-450.

Simon, R. I., & Williams, I. C. (1999). Maintaining treatment boundaries in small communities and rural areas. Psychiatric Services, 50, 1440-1446.

Teram, E. (1999). A case against making the control of clients a negotiable contingency for interdisciplinary teams. Human Relations, 52(12), 263-276.

Walker, R., & Clark, J. J. (1999). Heading off boundary problems: Clinical supervision as risk management. Psychiatric Services, 50, 1435-1439.

Wallace, A. C. (1997). Setting psychological boundaries: A handbook for women. Westport, CT: Bergin & Garvey.

[Author Affiliation]

Joseph Walsh, PhD, LCSW

[Author Affiliation]

Offprints. Requests for offprints should be directed to:

Joseph Walsh, PhD, LCSW

School of Social Work

Virginia Commonwealth, University

1001 West Franklin Street

Richmond, Virginia 23284-2027