After the professional relationship ends
The APA National Professionals Standards Panel, in collaboration with the NSW Physiotherapy Council, examine the boundaries between physiotherapist and past patient.
Maintaining appropriate professional relationships when working with patients is an ethical requirement of all physiotherapists. The Physiotherapy Board of Australia (PBA) is unequivocal in its guidelines with respect to preserving clear professional boundaries with current patients.
The PBA Code of Conduct states that good practice involves ‘never using a professional position to establish or pursue a sexual, exploitative or otherwise inappropriate relationship with anybody under a practitioner’s care.’
Furthermore, a ‘clear separation should exist between professional conduct aimed at meeting the health needs of patients or clients, and a practitioner’s own personal views, feelings and relationships which are not relevant to the therapeutic relationship (PBA 2014).’
Physiotherapists have the privilege to operate as first-contact practitioners in Australia. This is a reflection of the trust that has been placed in our profession by our patients, regulatory authorities, and the community.
As APA members, one of the values we uphold as part of our own Code of Conduct is to ‘Build Trust—we ensure the trust placed in us is justified.’ Trust is an essential component of any therapeutic relationship because the physiotherapist–patient professional relationship is not based on equality.
There is an inherent power imbalance resulting from physiotherapists having qualifications, skills and knowledge that are actively sought by our patients.
However, when a physiotherapist breaches the professional boundary, trust is compromised, and the physiotherapist may face significant consequences.
What about relationships with former patients?
The PBA does refer to relationships with former patients within our Code; however, specific guidance for this situation is less clear.
The PBA Code states: ‘recognising that sexual and other personal relationships with people who have previously been a practitioner’s patients or clients are usually inappropriate, depending on the extent of the professional relationship and the vulnerability of a previous patient or client.’
It should be noted that the PBA advises relationships are ‘usually inappropriate’. Even though the patient may have been formally discharged from treatment, the power imbalance will still exist in many cases.
There is, however, a proviso that suggests a relationship with a previous patient may be possible ‘depending on the extent of the relationship and the vulnerability of the patient’.
This proviso needs careful consideration by any physiotherapist who may develop a relationship of any kind with a former patient.
Referring to the PBA Code, it is incumbent on each member to reflect on the professional relationship with their former patient prior to entering into any form of relationship, be it romantic or otherwise.
Reflective questions could include: Was it a one-off visit where the session was exclusively spent on diagnosis and treatment of a specific problem? Or was treatment provided over an extended period of time? Were all discussions exclusively focused on the clinical issue at hand?
If there was disclosure from either side which was unrelated to the presenting problem, what was the nature and extent of that information? Was there any evidence of the power imbalance? If you answered ‘yes’ to any of these questions does it mean that it would be wrong to have any relationship with a former patient? In short, yes and no!
The National Professionals Standards Panel (NPSP) of the APA has previously been approached by members seeking guidance on the issue of relationships with former patients. The APA holds the view that we cannot comment on discrete cases as the decision, as to whether or not the relationship proceeds, really needs to come from the physiotherapist themselves, as only they will know the nuances of the therapeutic relationship with their patients.
While the focus of any interaction between a physiotherapist and their patient is primarily clinical in nature, it is almost impossible for any conversations not to stray into clinically unrelated topics. It could be argued that this is a vital component of the therapeutic relationship. We know that getting too close to our patients is wrong; however, being too distant from them can be equally harmful.
The solution is in finding the middle ground but given that no two patients are alike, then the middle ground is not easily defined.
Does it pass the pub test?
The codes of conduct were developed by physiotherapists for physiotherapists. They are not an arbitrary set of rules imposed by a regulatory authority without profession-specific input.
With this in mind, being open and discussing your dilemma with colleagues is one positive step you can take.
As stated above, only the treating physiotherapist can truly know what occurred within a specific therapeutic relationship but because the decision to develop a non-clinical relationship with a former patient is not straightforward, it can be helpful to consider broader perspectives.
It will take a certain degree of bravery to openly discuss what is potentially a taboo subject; however, if a relationship is entered into in a secretive manner then it almost hints that it was wrong to do so in the first place.
Sex in the country
Maintaining professional boundaries while working in a rural and remote setting can be a particularly challenging proposition for physiotherapists.
Often without access to immediate mentors or peers to model their professional behaviours on, physiotherapists may find themselves on a slippery slope as boundaries between physiotherapist and patient become blurred as the relationship transforms into physiotherapist and friend.
Dual relationships need to be avoided at all costs, but this is not easy to achieve in a small country town. Rural practitioners need to be cognisant of the fact that while they are walking the tightrope between professional and friendship relationships, the eyes of the community are upon them at all times.
If they commence a relationship of any kind with a former patient, then the whole town will know about it. More reason for physiotherapists in the country to be self-monitoring their behaviours both in and out of their work environment.
But it does happen
There is some evidence to suggest that the majority of physiotherapists reading this article know a colleague who has dated a former patient or at least developed a non-romantic relationship with them (Cooper & Jenkins 2008). It could even be the reader themselves. If it’s so widespread, then why isn’t this a more commonplace discussion within the profession? In part, it may be because there are no clear right and wrong answers.
But the relationship is neither romantic nor sexual
Whether the relationship is romantic or not, the same considerations should apply, including the key question: Is it exploitative in any way? As tempting as it may seem, having an electrician former patient who offers to re-wire your house for ‘mates rates’ is use of your position for personal gain and is exploitative in the same sense as a romantic liaison—sorry!
So, what to do?
As suggested earlier, the decision on whether to pursue any form of relationship with a former patient lies with you. The Code provides an insight into the thinking of the PBA, but the guidance is not black and white.
Only you can decide the extent of the therapeutic relationship and the potential vulnerability of the patient. You need to be very careful that a dependent relationship has not formed between you and the patient, and ensure that there are not any mental health issues that the patient could be suffering from which will impact their own actions and behaviours towards you.
Last year the NSW Physiotherapy Council published some videos on its website (tinyurl.com/yap7n42p) which give examples of the right and wrong way to approach some of these issues—both if the patient makes an unwanted advance to the practitioner, and where a practitioner’s actions are misinterpreted by the patient.
While these videos don’t cover all potential scenarios, they nevertheless offer some guidance.
While it is good to be open and discuss your thoughts with your peers, the ultimate decision lies with you. In addition to the reflective questions suggested previously, and consideration of peer opinion, two other questions should be considered:
- can I defend my actions should a report be made against me to AHPRA?
- what would the person I most respect, or whose respect I most value, think if this were to be made public?
In cases where a physiotherapist has been reported for commencing a relationship with a former patient, the most common argument put forward by the physiotherapist is that the relationship was initiated based on mutual consent. This is not an argument that you can win.
There are no published rules of engagement available for patients to refer to, prior to seeing a physiotherapist. It is wholly reliant on the physiotherapist to operate within the PBA’s and APA’s published codes of conduct, not the patient.
Ultimately, when deciding whether a physiotherapist has crossed the professional boundary to engage in a relationship with a former patient, AHPRA and the NSW Physiotherapy Council may, at its discretion, consider a range of factors including:
the duration, frequency and type of care provided by the physiotherapist; for example, if they provided long-term treatment, or acute management of an injury
- the degree of vulnerability of the patient
- the extent of the patient’s dependence in the therapeutic relationship
- the time elapsed since the end of the professional relationship
- the manner in which, and reason why, the professional relationship ended or was terminated
- the context in which the sexual relationship (if that is what it was) started.
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