The Briar Patch: Thorny Challenges for Directors

The 'Wall' Around the Clinic: Boundaries, Boundaries...

Vic Pantesco, Ph.D
 

The Thorn
       The university-based clinic has a wall around it.  That wall separates the clinic from the department and the community of clients and general population.  As for other 'thorns' described in this column, this wall is often taken for granted or ignored until there is a bump getting our attention.  If the wall – to torture the metaphor a bit more – is in disrepair, marginalized, ignored, or breached with or without aforethought there can be some nasty fallout.
       Take for example the case of a clinic faced with a clinician applicant who has a medical condition that in the view of the clinic director and faculty would significantly compromise providing safe and effective service to clients, especially children.  The clinic’s refusal of such an applicant unwilling to make adjustments or get medical clearances then runs smack into – or through – the wall between the clinic and department and university.  Might this have implications for the student’s ability to remain in the program if its own on-site clinic refuses admission? 
       Or, how about a young student clinician convinced that her social network of friends could be managed so that should a student client of hers show up at a party in this relatively small town it would not interfere with their therapy.  Proscribe local parties?  Seeing students from this university (part of our clinic’s mission)?  Reverse age discrimination?  Perhaps this is an allowable error zone for learning about boundaries?

To Dull the Pain
       We have been wrestling with the firewall between department and clinic: information flow (Both ways? Useful? Necessary? Which kinds?), who carries responsibility for decisions (as in the medical case above: the clinic  Director?  Chair?).  What we have found is that at least keeping the conversations going and addressing ad-hoc cases quickly normalizes raising, examining, and resolving boundary bumps and problems.  One other tool I use on occasion is a written confirmation.  For example, in the medical case above, at one point in the process I wrote for the record:  “As the PSC director I will proceed with the directive that we accept this student.”  As you might imagine, this re-energized the conversation as clear paths for liability materialized.
      
As for being in a community where the university and the local population interactions enhance the possibility for boundary breaches, we pay considerable attention to this matter in student orientation.  For example, we discuss instances in which this has arisen as a problem in past years.  Then, as boundary considerations loom in any given case we involve the supervisor and maybe the director in considering the reasoning, risks, and benefits for accepting a high-risk client (in this context risk adheres, for example, in: a university student client close in age and interests, disposition, social group… to the clinician).  If the clinician does not see the risks that may be obvious, it provides useful learning in processing with supervisor.  In the absence of student clinician willingness to examine the wisdom of their choice, the supervisor or director may have to preempt a longer learning timeline and ensure the boundary if the student persists in advocating for seeing the particular client.