An understanding of personal and professional boundaries is crucial to the work of chiropractors. When touch is involved in the therapeutic relationship confusion about boundaries often arises.
Chiropractic is a very high-touch healing profession, such as massage and other types of body therapy. Think of a boundary as a perceptual line or zone that defines our personal space in relation to others. It can be as literal as the skin on our body or the distance within which a person feels safe next to someone else.1 There are physical, sexual, intellectual and emotional boundaries that define areas of privacy. Boundaries can be created through language, type of touch, clothing, money, time, the roles we take on at a given moment and the attitude we present. Non-verbal cues such as voice tone, facial expressions, eye movements or expressions, tilts of the head, sounds, breathing and body gestures can signal change and create boundaries between people.
All of us differ in the types of boundaries we feel comfortable with. How we respond, will depend on our personal history, our comfort zones, our cultural background and how we feel at a particular moment during the day. Our boundaries can change during the course of the day, depending upon who we are with. Our boundaries will be different when we hug someone we care about, nurse a baby, meet a boss, see a chiropractor, feel under attack or share an intimate moment with a friend.
SEXUAL ABUSE
One’s personal history with boundary violations will have a profound effect on all relationships. One in three women and one in four or five men have been sexually abused before the age of eighteen. Sexual abuse is the violation of a person’s sexual boundaries by a person of greater authority or power, With an adult, it is really the same. In the professional context, the intimidation is still there. It is someone who uses their leverage to gain access to a person sexually in a way that the person wouldn’t really agree to.”” When someone who has been sexually abused comes to our office, we need to take special care. But, will we know who needs such special care? Probably not. Abuse survivors will generally not tell a practitioner.
Therefore, we’ll need to be aware of our attitudes and behavior patterns so that we can be as sure as possible that even someone who has a personal history of abuse, will feel safe with us.
SEXUAL MISCONDUCT
Sexual misconduct is not just having sex with a patient! There is a continuum of behavior that can be considered sexual misconduct. This continuum goes all the way from looking at a patient in a way that could be considered seductive and making subtle comments, to verbally and physically more obvious flirtatious behavior; to inappropriate touching and behavior relating to actual sexual contact. A very wide range of behavior can be considered to be sexual misconduct.
Chiropractors who are unaware of the effects of their behavior and their attitudes on their patients, may be at risk for sexual misconduct. The sexual misconduct risk factor analysis has been created with that in mind. If you find that your score indicates that you are at risk, please get help before you find yourself in trouble.
EXAM DIRECTIONS
Circle the number (1, 2 or 3) of any statement that applies to you. When you’ve completed the questionnaire, add up all of the numbers that are the same – ie. add up all the number 1s and write that number in the totals column. Then add up all the 2s and 3s on each sheet. Add up the totals for each number on the next page in the space provided. Directions for assessing your risk factor number are on the following page.
The purpose of this questionnaire is to give you information about the clarity of your professional boundaries. Please answer these questions as honestly as you can. No one need see this but you. If you answer these questions honestly, you will get an accurate risk factor assessment.
- I want this particular patient to like me.
- I like it when my patients find me attractive, but I keep this myself.
- Sometimes I schedule the patients that I really like last so that I can spend more time with them.
- I am surprised by how much I anticipate this particular patient’s visit.
- I think about this patient frequently.
- I have not been in a relationship in a long time.
- I feel lonely much of the time, unless I’m working.
- With certain patients I have trouble asking to be paid my full fee.
- I talk about my personal life to my patients.
- I find myself working weekends to accommodate a few patients who I like.
- I have noticed that some of my patients are very dependent on me.
- I feel under tremendous personal/professional pressure and I’m I might burn out.
- I like it when my patients look up to me.
- I feel like I have very little to give lately.
- My relationship with my significant other(s) isn’t meeting my needs.
- I’ve touched patients in inappropriate ways at times.
- I’ve had sex with patients.
- I’ve had sex with patients in the office.
- I dress particularly well when I know one or more of my patients has an appointment that day.
- I fantasize about what it would be like to have sex with some of my patients.
- I’m not charging one or more of the patients I’m attracted to.
- I have some of my patients take off more of their clothes than needed.
- I sometimes sneak looks as patients are undressing.
- I feel it’s okay to date patients.
- I sometimes tell dirty jokes to my patients.
- I like doing adjustments in those areas of patient’s bodies that are close to their erogenous zones.
- I feel totally comfortable socializing with patients.
- I compliment patients when I think they look nice.
- This patient feels more like a friend.
- I often tell my personal problems to one or more of my patients.
- I feel sexually aroused by one or more of my patients.
- I’m waiting to dismiss this patient so that I can become romantically involved with him/her.
- To be honest, I think that good-bye hugs last too long with one or more of my patients.
- The appointments with one or more of my patients regularly lasts longer than with others.
- I tend to accept gifts or favors from this patient without examining why the gift was given.
- I have a barter arrangement with this patient that is sometimes a source of tension for me.
- I have had sexual contact with one or more of my patients.
- I have attended professional or social events at which I knew that this patient would be present.
- This patient often invites me to social events and I don’t feel comfortable saying either yes or no.
- Sometimes when I’m working on this patient, I feel like the contact is sexualized for myself and maybe for the patient.
- There’s something I like about being alone in the office with this patient when no one else is around.
- I am tempted to lock the door when working with this patient.
- This patient is very seductive and I often don’t know how to handle it.
- I have invited this patient to public or social events.
- I find myself cajoling, teasing, joking a lot with this patient.
- I allow this patient to comfort me.
- Sometimes I feel like I’m in over my head with this patient.
- I feel overly protective of this patient.
- I sometimes have a drink or use some recreational drug with this patient.
- I am doing more for this patient than I would for any other patient.
- I find it difficult to keep from talking about this patient with people close to me.
- I find myself saying a lot about myself with this patient telling stories, engaging in peer-like conversation.
- If I were to list patients with whom I could envision myself in a sexual relationship, this patient would be on the list.
- I call this patient a lot and go out of my way to meet with him/ her in locations convenient to him/her.
- This patient has spent time at my home.
- I often tell my personal problems to this patient.
- I enjoy exercising my power over some of my patients.
- I’m going through a crisis at this point in my life. I need someone to take care of me.
- If a patient consents to sex, it’s okay.
RISK FACTOR ANALYSIS
Circle the number (1, 2 or 3) of any statement that applies to you. When you’ve completed the questionnaire, add up all of the numbers that are the same – ie. add up all the number 1s and write that number in the totals column. Then add up all the 2s and 3s on each sheet. Add up the totals for each number on the last page in the space provided. Directions for assessing your risk factor number are on the following page.
The purpose of this questionnaire is to give you information about the clarity about your professional boundaries. Please answer these questions as honestly as you can. No one need see this but you. If you answer these questions honestly, you will get an accurate risk factor assessment. During times of stress and personal loss, we are more prone to overstep our professional boundaries. There may be training available for health professionals in your area in professional boundaries and the prevention of sexual misconduct. There are therapists, mentors, friends and colleagues who could help you at such times. Your risk is greatest when you attempt to go through it all by yourself. At times of greatest stress, seeking professional help in the form of therapy or consulting with peers can be the best prevention.
HOW TO EVALUATE YOUR SCORE
If you have checked off one or more number 3s, you are at the highest risk level. You are in danger of violating professional boundaries. This could not only damage patients, but could damage your career. Asking for professional help from a therapist or a consultant would be a good idea. You may also benefit from attending professional trainings in the area of personal and professional boundaries. Ignoring such a high risk level can have serious consequences. If you checked off more than three number 2s, you have the potential to move into a higher risk category at any time, especially when under stress. If you checked off between four and eight number 2s you’ve entered a risk factor that is heading toward possible danger. You could use some help getting yourself on track concerning professional boundaries.
If you checked off more than five number 1s, you could be overstepping your professional boundaries. You may not be in danger of crossing a sexual boundary, but you might be crossing other boundaries that may involve unforseen consequences.
CONCLUSION
It is always better to be preventative than to wait until there are big problems. This is the philosophy of chiropractic. It would be wise to make it our philosophy in how we practice our profession as well! For those of you who have completed this risk factor analysis, congratulations! For those of you who have not, go ahead, find out if you are at risk.
This risk factor analysis is partially derived from the work of Estelle Disch, previously published in “”Discovering Your Boundary Issues”” written with Dr. Ben Benjamin in the “”Massage Therapy Journal Summer 1992.
Dr. Angelica Redleaf, a 1977 graduate of New York Chiropractic College, has been in practice since 1978. Dr. Redleaf sees a need in the chiropractic profession for education about the doctor-patient relationship and has written numerous articles about sexuality and the doctor/patient relationship. She has consulted with state boards, has lectured and taught seminars throughout the U.S. on the subjects of touch, gender, sexuality and sexual misconduct for health care providers. Dr. Redleaf, of Johnston, Rhode Island, is currently writing a book on this subject.
Ben E. Benjamin, PhD is founder and president of the Muscular Therapy Institute in Cambridge, Massachusetts. Dr. Benjamin has a PhD in Sports Medicine and Education. He served for four years as the chairperson of the AMTA Council of school’s Professional and Sexual Ethics Task Force. Long interested in issues surrounding professional boundaries, he has written extensively on the topic of boundaries and sexual abuse in the Massage Therapy Journal, and hascompleted a monograph on Massage and Bodywork with Survivors of Abuse In addition to his other books, Are You Tense? Exercise without Injury and Listen to Your Pain, Dr. Benjamin is currently writing a book entitled, Creating Healthy Boundaries in Health Care Settings. He has been teaching throughout the country since 1973 and maintains a private practice at Spectrum Medical Arts in Arlington, Massachusetts.