Listen to thisAbstract: To date, there is scant literature addressing the topic of professional boundaries with teenagers in residential treatment programs. Because the gap in the literature has left many questions unanswered, a qualitative case study was conducted in order to gain a more thorough understanding of professional boundaries as they relate to adolescent females placed in residential treatment for emotional and behavioral difficulties.
The young women articulately expressed their desire to have a physical (nonsexual) and emotional relationship with both their peers and staff members. In addition, the young women asserted that they wanted staff to set limits so that boundary violations could and would not occur. However, within the daily living environment teens expressed a desire to have the confines of boundary crossing situations to be more relaxed. Based on the findings, implications for practice are suggested.
Essentially, youth workers employed in residential treatment facilities are the primary agents of change (Rosen, 1998). The daily interactions that take place in residential treatment provide workers with an opportunity to use every exchange with youth as a pedagogical moment. Without question, a significant component of youth work is the relationship that is developed and cultivated between the youth worker and youth (Burns, 1984; Felicetti, 1987; Krueger, 1995; Krueger, 1998; Parry, 1985). Attributes that are important to the relationship are trust, an inviting atmosphere to disclose personal information, objectiveness, professional self-awareness (Lipchik, 2002), empathy, respectfulness, genuineness, patience, (Patterson and Hidore, 1997, p. 71/90), attentiveness to what the client is saying, comprehension of the client's experience (Crone, 1984), admittance to mistakes, and being a “fellow traveler" with your client (Yalom, 2002, p. 8).
While the youth worker-adolescent relationship is important in the care of teens in residential treatment, so are professional boundaries. In short, boundaries are the parameters or limits that are established, usually by the staff members (Soth, 1997), regarding interactions between teens and workers. Whitfield (1993) explains: “A boundary or limit is how far we can go with comfort in a relationship. It delineates where I and my physical and psychological space end and where you and yours begin" (p. 1). Professional boundaries can be addressed under umbrella terms such as dual relationships (see Kagle and Giebelhausen, 1994; Kitchener, 2000; Herlihy and Corey, 1992; Valentich and Gripton, 1992), transference and countertransference (see Corey, Corey, and Callanan, 1998; Kahn 1991; McGuire, 1996), and professional ethics (see Chang, 1994; Congress, 2001; Garfat and Ricks, 1995; Lowenberg and Dolgoff, 1992; National Organization of Child Care Worker Association, 1995).
One can safely assume that no highly regarded agency would knowingly allow their youth workers to engage in sexual behaviors with adolescents. Yet, the enactment of relational boundaries with adolescents is much more unclear, specifically in residential treatment facilities (Richmond and Padgett, 2002). Because teens are in 24-hour care, a worker's role can fluctuate between authority figure, mentor, and counselor. As a result, some examples of boundary challenges for youth workers are “... friendships and friendliness, gift giving, advocacy, and bartering and employment" (Spence, 1999, p. 44).
To date, there are scant empirical studies investigating the topic of boundaries within youth work. For example, only three studies that I am aware of explored the perceptions of youth workers on the subject of boundaries (see Okamoto, 2003; Richmond and Padgett, 2002; Zirkle, Jensen, Collins-Marotte, Murphy, and Maddux, 2002). Why is it disconcerting that the topic of boundaries is not more consistently addressed within the youth work literature? Three important reasons can be highlighted.
First, the composition of families can vary for each adolescent in treatment (Rose and Fatout, 2003). In my practice experience, the family composition, personalities of family members, socio-economic status, and general living environment is going to impact teens very differently. For instance, Congress (2001) suggests that “...appropriate physical contact may be especially important for immigrant children [or youth] who have experienced many losses and who may expect this form of comforting behavior from adults" (p. 36). Yet, when teens are placed in residential treatment, are these familial differences taken into consideration during staff interactions?
A second reason why the topic of boundaries is important to youth work is the variation in the adolescents' treatment issues. Teens can be admitted into a residential program with a host of diagnoses: attachment issues, substance abuse, aggressive behaviors, mental health difficulties, sexualized challenges, issues with authority, criminal behavior, and so forth. Certainly, dependent on the adolescent's treatment issue, boundaries will be managed in different ways. Davidson (2004) indicates,"... the context, the individual's needs, the professional's role, and the potential for misinterpretations are import factors in defining what is balanced practice" (p. 36).
Finally, the chronological age may not accurately portray the needs of the adolescent. Let's consider the case of “D", an eighteen-year-old female in a residential program. “D" could be described as needy. She whines, talks in a baby voice, stands at the staff office door asking personal information, and needs to know where staff is at all times. Clearly, this is not typical behavior of an eighteen-year-old. However, what has to be considered when working with “D" is that she was abandoned by her mother when she was five and had grown up in and out of foster homes. It became apparent that because “D" felt secure in the program and with the staff, she had regressed to a developmentally younger age. While this is just one example, it is important to consider the chronological/ developmental age concept. Do teens feel that staff interactions are representative of their individual needs? Clearly, more investigation into the topic of professional boundaries in the youth work profession is warranted.
While there are very few empirical studies on the topic of boundaries between youth workers and adolescents in treatment programs, even more to my complete surprise, there were no studies that I came across that discussed boundaries from the perspective of teens in residential treatment programs. As a result, because the gap in the youth work literature has left many questions unanswered, a qualitative case study was conducted in order to gain a more thorough understanding of professional boundaries as they relate to adolescent females placed in residential treatment for emotional and behavioral difficulties. Common to case study format (Rossman and Rallis, 2003), several data collection strategies were used. For example, procedures that were used in this study to investigate the topic of professional boundaries as they relate to one agency included interviews with teenagers, observations, and a review of agency documents.
Based on my previous interaction with a residential treatment program called TT (fictitious name) for adolescent girls in the mid-West, a purposeful sampling approach was used in requesting participation. The broad-based research question that I sought to answer through interviews, observation, and agency documents was the following: From the perspective of female adolescent youth in a residential treatment setting for emotional and behavioral challenges, how are professional boundaries described?
Method
Adolescent participants. Ten adolescent female teens between
the ages of 13 and 18 were asked to participate in the research study.
Specifically, the age of participants engaged in the study was between
13 and 17 years of age. Racial and ethnic composition of teens
participating in the study was White, Hispanic, Biracial, African-
American, and Asian. The length of time teens stayed in the residential
facility ranged from one month to over one-and-a-half years.
Qualifications considered in selecting teens to participate in the study were: speaking English (I speak no other language fluently); enrollment in the treatment program for at least a month; and admission in at least one other out-of-home placement before being admitted into the current placement.
Data collection. The interviews were held in a private room at the residential agency. All teens who were asked to participate in the study agreed to be interviewed and audio-taped. In addition, parents or guardians of all teens participating in the study signed informed consent forms and audio-tape permission documents. Regardless of whether or not permission was granted for tape recording, notes were taken during the interviews.
In order to minimize any confusion about what the term boundary meant the Whitfield (1993, p.1) definition was provided to the teen at the start of the interview. Questions that were used as a guide in the semistructured interviews focused on the term boundary, the benefits and consequences of having boundaries, and situational types of boundary situations (for example, hugging, gift giving, and disclosing personal information).
In addition to the interviews with teens, observations also took place after the interviews were held. Observations are important because, as Gillham (2000) indicates, “it is not what they [participants] say they do.... it is what they actually do.... “ (p. 46). The intent of the observations was not to use an individual “viewing" of each adolescent to compare to what was revealed in the interviews. Rather, the purpose was to use the “collective whole" of observations to be compared and contrasted to the sum of all interview findings.
Rather than me making observations on the milieu, youth workers were asked to observe for five days (during their work shift) the teens that I had interviewed. All observations took place after I had interviewed the teen. The same youth worker completed the observation form on a particular teen for all five days (with input from their colleagues working the shifts with them). I trained the youth workers on what information should be observed and documented (for example, how many times a teen asks for or initiates a hug). Of importance, the teens volunteered to participate in the study by being interviewed and agreed to be observed by youth workers (although the teens did not know when they were being observed or what was being observed). The observation questions addressed a variety of areas such as, for example, how many times the teens requested a hug from a staff member or asked a worker personal information.
Data analysis. I transcribed all of the interviews. All transcriptions were completed before the next grouping of interviews took place. In addition, transcriptions were primarily conducted verbatim. However, some information, such as small pleasantries, instructions, and information that was duplicated, was not transcribed.
In order to ensure that my analysis of the interviews was unambiguous, a social work colleague reviewed all of the transcriptions. A short time after my colleague submitted her ideas, I read through each transcript. Once my identified topics emerged, they were compared to those of my colleague's. A conversation ensued until my colleague and I reached consensus on the topics. The interview data was coded by hand after the topics were obtained.
The observation checklists were analyzed for the frequency of boundary inconsistencies. The primary use of the policy and procedure manual and unit rules in this study was to compare what the written materials stated to what teens disclosed in the interviews and what youth workers observed.
Findings
The following topics emanated from my conversations with the teens.
Physical contact. One of the most discussed areas among teens was physical contact. Of the ten teens that were interviewed, nine made comments specific to physical connection within the treatment milieu. Eight teens expressed their desire and frustrations regarding hugs in the milieu. In reference to how the use of the term boundaries is used in the milieu, one teen stated, “Um, sometimes when staff come in, the kids just run up and give 'em hugs. And they'll [staff] say 'that's my personal boundary and you need to ask before you hug me'."
Another teen explained that staff consider hugs to be “unprofessional". She states, “If you want affection, like, you have to ask and even then, it's not warm." Several teens clearly indicated that they could receive consequences for physical touch.
Benefits and differences with hugging. Teens articulately described the benefit of hugs. For example, a teen remarked, “...I think they should provide a nurturing environment for us. So I think that should be part of their job description “provide warm hugs."
Teens were clear, though, about the differences between hugging and physical touch. Two teens explain that if physical touch is going to be given, the person should be asked first.
A further comment from one participant suggested that hugging would be done with people that they knew. She said, “'Cause like, if a new girl comes in, we're not just going to hug her, and she's not going to think we're crazy 'cause we don't know her, why would we hug her?"
Homosexuality/bisexuality. Four teens made reference to how staff equate nonsexual physical touch with homosexuality /bisexuality For example, when asked why hugging was not allowed, one young person remarked, “Oh yeah, 'cause some girls go both ways [are bisexual] here, and they think it's a sexual thing."
Another added, “Like, they won't let us do each other's hair or anything, so ...so that's, like, a boundary I wouldn't mind having but...."When I inquired as to why teens couldn't do each other's hair, she responded, “Because, for sexual reasons. 'Cause sometimes, like, gay girls come here and they start touching on other girls “it's confusing “so they, like, made the rule that you can't do hair now “you can't do nails, you can't do anything."
According to the observations conducted by youth workers, five teens asked a staff member for a hug. Collectively, over the course of five days, teens asked for hugs a total of 34 times. I found no information in the Policy and Procedures Manual that provided guidance for workers regarding nonsexual physical contact with teens.
Teens want to be trusted by staff. Four teens remarked that they wanted staff to trust their decision-making. One teen said, “'Cause, like, here we're not so responsible for ourselves. 'Cause a lot of times we rely on the staff and that's not healthy."
One teen suggested that staff should trust teens to take more of a leadership role with other teens. Another young woman explained how decision-making could be demonstrated in the hypothetical case of a staff member talking about their personal life and a teen not wanting to hear about it. She suggested,
Isn't that why there's a residential where you learn how to express your feelings? And say be assertive and say I don't want to hear about it today “I'm having a bad day. And most staff would not go on about [the issue] if, um, they know a patient is not having a good, um, day.
Teens' reference to fairness. Many teens made mention of fairness and how a particular action would impact other teens. Gift-giving prompted a response from a teen that seemed to reflect the ideals of several young women, “Um, I think its okay as long as they buy it equally for the girls or the residents, whatever. You know, don't favor just one girl or whatever, you know."
Exceptions to fairness. Nearly half of the young women indicated that there were exceptions to one teen being treated differently than another. For instance, one teen, when referring to her stay at a group home, offered, “This girl did not have anywhere to go for the holiday because her mom and dad died. So, the supervisor took her home for Christmas .... We [other teens] wanted her to go somewhere to be happy." The teens provided examples of exceptions that they deemed appropriate in the residential treatment facility such as staff giving clothing and hair supplies to residents in need and staff gift-giving.
Protection of staff. Teens seemed concerned about the safety of staff and how a resident could retaliate. One participant offered, “They shouldn't do it.... because if they get into an argument with one of the residents that they told about their personal life “it'll be all over the unit..." And another teen said,
Like, residential treatment facility “I mean, you never know what type of people you could run into in residential treatment. You've got your drug addicts, your psychopaths, your suicidals, your homicidals. You never know what people are in here for. And especially based on someone's past. You don't really want to give information out.
The questions on the observation check sheet did not address any areas listed in this category. Fairness and trust seem to be implied in the Unit Rules by reference to the level system. TT has a multiple level system with specific tasks associated with each gradation. In addition, the higher a teenager progresses through the level system the more privileges and trust they are afforded by staff.
Staff is not nurturing. Teens had thoughts on the way staff communicated with teens. For example, one teen exclaimed,
...It's different if they approach you 'cause then it shows they care or whatever. But if, like, I go to them then, unless it's one of the staff that I really like, like, I know, like, cares somewhat, then it seems like I'm just burdening them.
Staff provoking teens. Teens' perception of staff provoking the young women prompted a host of thoughts. One teen said,
...Like, they can be really mean sometimes. There should be emotional boundaries. Like, some staff, like, don't keep their thoughts to themselves.
When I questioned if there were boundaries that should be taking place at TT but were not, a response was,
I would say, like, only with their words “that's it. Like, they really need to learn to restrain themselves when they [staff] say certain things because “sometimes it's just overboard. Like, and then I tell them about it “like, they just justify their actions. They never “I've never ever once heard them apologize “like ever....
Teens can't express themselves. Several teens made remarks that they felt they could not express themselves. One teen commented, “You can't express your feelings 'cause everything is so negative to the staff on the unit...."
Another teen expressed that there was, “Miscommunication.... Sometimes they [staff] think we're all attitudy and bitchy when we're not. They take the tones of our voice wrong and they mix our words up."
Sensing staff responses. Adolescents indicated that they could gauge staff's attitude and could adjust their interactions accordingly. One young woman remarked, “You can see it in their eyes “if, if you've been there, been here long enough you'll know the staff ....you just know'em. You'll know if they're in a bad mood, happy mood, sad mood, crabby mood, any mood."
Staff disclosing personal information to assist with treatment issues. Many teens indicated that staff disclosing personal information during interactions would be helpful. One young woman said, “Like ...them being an example for me “like,...I grew up like you did and I turned out fine because they got treatment or they got help or something like that." When I asked what if it were a staff that they weren't particularly fond of “would the relationship change? The teen responded, “I think it would be beneficial because it would show that I can actually relate to them..."
When I asked a teen if, for example, a staff came in and they had had a fight with their boyfriend and started telling you about it, would that be appropriate. The response:
And in which case I think it wouldn't be appropriate because that's not anything beneficial to our treatment.... [Whereas] if they're sharing something about their past and something that we could benefit from or, like, maybe have a little bit more faith in them or, you know, feel like they understand where we're coming from, like, that would be more beneficial to us then it would be to them. And, like, they don't come here to, um, get condolence from us.
Discussion
Physical Contact
Perhaps the topic that was raised the most during interviews pertained
to physical contact. The young women expressed a desire to be able to
hug one another, style each other's hair, and paint the fingernails of
their peers. Given the nature of the residential setting, teens
frequently spend a significant amount of time with their peers and as a
result, a group identity is formed (Easson, 1996, p. 36). Based on the
amount of time that teens spend with one another and the close proximity
in which they live, it appears inevitable that a friendship and
acquaintance type of relationship will develop. Because adolescence is a
time for young people to interact with friends by imitating one
another's “dress, speech, language, and thoughts" (Stuart and Laraia,
1998, p. 778), this finding was not surprising.
Based on the observations conducted by youth workers at TT, there was a distinct implication that hugs were important to teens. For example, collectively over a five day period, hugs were requested by teens a total of 34 times. While the agency policy and procedure manual did not support that no hugging or nonsexual physical contact was a rule, teens indicated that they were interpreting a different message. One rationale for the teens reading of the nonsexual physical contact limit could be attributed to the unit rule that teens cannot be in each others' bedrooms or loiter by another teen's doorway, or they would receive a consequence.
The adolescents suggested that there should be
parameters regarding hugging. Teens indicated that people should ask the
other person first before hugging, know the person, have a reason for
giving a hug, and respect the fact that some people do not want to be
touched. Nurturing
relationships between youth and workers and between youth and their
peers take time to develop (Krueger, 1988). Therefore, the idea that
teens wanted input on if and when hugs should take place was not
unexpected.
Prior to beginning this study I had knowledge that an event of sexual physical contact between two teens at TT had taken place within the past five years. Schultz (1981) indicates that there is an informal norm that has been historically enforced by institutional settings and that is to ensure that teens are asexual while in care. Therefore, that the topic of physical sexual contact was raised during the interviews was not unanticipated. Based on the remarks from the teens, it appears that the anxiety TT experienced as an organization regarding issues of physical sexual contact has been inadvertently transferred onto the teens currently in placement.
In my discussion with the young women at TT, they indicated that they would prefer to have explanations of decisions made rather than have rules set for them without being offered a rationalization. I sensed that the teens may be suggesting that, perhaps, if workers used a consistent approach to addressing the nonsexual touch issue, teens would not internalize such frustration regarding the topic. Perhaps, rather than workers at TT issuing consequences for physical touch or labeling bodily contact by words such as homosexuality or bisexuality, other strategies can be considered. For example, Kools and Spiers (2002), indicate that the topic of sexuality be discussed in an upfront manner with teens. In addition, one recommendation to minimize homophobia offered by Soth (1997) is to educate both teens and staff members about same-sex relationships.
Staff safety. Teens implied a concern for the safety of staff members. For instance, teens were honest and insightful in recognizing the reality that some young women would use personal information about staff members to retaliate. Also, teens expressed sensing staff moods and altering their behaviors accordingly. I did not find these two findings to be unexpected. Because residential treatment facilities provide 24-hour care, workers are often times placed in a parental role (Rosen,1998). Therefore, as a result of the length of time workers spend with teens and the tasks that are performed, it is not shocking that teens would feel a sense of safety for workers or have insight into their mood or behavior.
Fairness. Within the daily living environment, the young women expressed being very aware of the notion of fairness among teens. For instance, regarding staff giving gifts to teens, many indicated that, unless it was going to be done for everyone, it should not be done at all. Half of the teens expressed exceptions to the rule of fairness to all young women. Examples that were given include a teen spending a holiday with a staff member when they had nowhere else to go, and staff giving their used clothing to teens who were in need. In my years of experience in working with adolescents, the majority of teens placed in residential treatment programs have had to contend with a variety of circumstances in their lives in which they were violated and not treated with justice and fairness. As a result, it was not unexpected that teens would reference fairness as being so important. Paradoxically, it is for the very same reasons that teens described situations in which violating the fairness parameters would be acceptable. Because teens have experienced being treated in an unjust manner, they are highly sensitive to circumstances in which their peers are “deserving" of being dealt with differently.
Emotional connection with staff. It was apparent after my discussions with teens that they felt and wished for a connection with staff members. For example, many of the teens expressed a desire to have staff members disclose personal information to assist with treatment needs. Yet, the young women had parameters regarding what information they felt would not be beneficial for them to know about, such as, for example, sexual encounters between a worker and their boyfriend or girlfriend. The teens that participated in this study have been in other out-of-home placements and, as a result, have been socialized to the nuances of what typically is and is not asked of workers or disclosed by workers (for example, the sex life of a worker). One teen seemed to capture the essence of knowing what is and is not appropriate to ask workers by stating, “It's called a trick question .... Trick question because the stupid staff actually answer the question “the smart staff say, 'you know you're not allowed to ask me this question' and then we shut up." When I asked what was done with the information after the staff had been tricked the teen said, “Just tell the next people that come or tell [other] staff they said that “if we don't like the staff, then we'll tell, like, the head staff what they said."
Respect. What was a most surprising finding to me was the teens' expressions about the lack of respect from the staff members. The professional relationship is critical to the change process (Brunstetter, 1998; Fahlberg, 1990, Finkelman, 1997; Soth, 1997). Moreover, Easson, (1996) reminds us that a teen does not need to be deserving of respect; it should be given unconditionally. While I expected to delve right into the boundary limitations placed on the relationship, I was initially taken aback when teens began to express a variety of emotions. For example, teens indicated that they did not feel nurtured and that they could not tolerate staff engaging in power struggles with them.
What I found most startling was the inclination towards verbal and physical provocation (reported one time to a supervisor) by staff members. It is important for youth workers to execute the agency's policy statements while working on the unit (Pazaratz, 2001, p. 3), and clearly stated in TT's policy and procedure manual is the notion of a caring and nurturing daily living environment. Moreover, the unit rules indicate that relationship building is attached to the level system (the higher the level the teens achieve, the more privileges and responsibilities they are afforded).
What teens seemed to describe regarding their relationships with staff is in part reflective of a custodial care approach rather than a pure implementation of the treatment milieu philosophy. In essence, Barnes (1991) indicates that the primary goal of custodial care is to govern the daily living environment while implementing “social control" and farming youngsters out to other “special services" (p. 130). In regard to the TT facility, there was no evidence in the interviews conducted nor in the agency documents to support the notion that youth workers were not providing other services necessary to the teens' treatment. Yet, what appears reasonable to infer is that in the eyes of teens, workers are focused on maintaining safety and control on the unit and not fostering relationship building.
Limitations and implications for practice
The intent of this study was to glean a broader understanding of the
topic of boundaries from the perspective of adolescent females residing
in a residential treatment program. A case study approach was used in
order to examine the topic of boundaries from a variety of viewpoints to
include interviews with adolescent females, observation of the teens,
and a review of agency documents. What resulted from the investigation
is a rich and descriptive explication of how boundaries are enacted in
one residential treatment facility from the perspective of adolescent
females.
Limitations
Despite the rigor used, no study is without limitations (Rossman and
Rallis, 2003). Perhaps the largest and most obvious limitation to this
study is my interest in the topic of professional boundaries and my
previous extensive work with teens in a residential treatment setting.
While safeguards were used (for example, using multiple forms of data
collection) it is through my knowledge of residential treatment that the
study was developed and analyzed.
While adolescents from 13 to 18 were invited to participate in the study, teens of varied ages may view boundary perspectives differently. Therefore, the findings from this study may be very different from information that would have been obtained had the investigation focused on one group “either younger or older teens.
Implications for practice
Given that the teens at TT raised notion of the importance of
strengthened relational interactions between workers and adolescents, an
emphasis on what a relationship is, how relationships are different with
teens in a treatment facility, and steps to building professional
relationships is warranted. Some relational areas that teens raised for
consideration include respect and ways of communicating, nonsexual
physical touch, and self-disclosure to assist with treatment issues.
Based on my conversations with teens, I would add that workers would
benefit from discussing, recognizing, and having an awareness of their
viewpoints on adolescent sexuality (to include heterosexuality,
bisexuality, and homosexuality) and how their opinions impact the
professional relationship. A practical and instrumental plan would be to
have advanced level practitioners employed in the treatment facilities
mentor youth workers on how to develop, implement, and maintain
relationships with adolescents.
Unquestionably, youth workers spend most of their time with youth while they are being cared for in residential treatment settings (Rosen, 1998), and as a result, there is a strong likelihood that professional boundaries will be transgressed. Consequently, it would behoove practitioners, administrators, and policy-makers to advocate for increased funding in order to provide youth workers with on-going training and consultation to ensure that workers are providing developmentally age-appropriate nurturing and limits for adolescents.
Conclusion
This study has attempted to elucidate the topic of boundaries from the
perspective of teens who are impacted by the professional limits that
are set on a daily basis. The particular strength of this study is that
adolescents in treatment were invited to discuss the topic of
professional boundaries in a candid manner. Only female teens were asked
to participate in this study “future studies would benefit from
including male participants. In addition, while a variety of ethnic and
cultural backgrounds were represented in this study, a greater emphasis
on how diversity impacts the professional relationship with teens in
residential treatment is warranted. It would also be helpful to
distinguish if professional boundaries are divergent between teens with
mental health issues and those with behavioral challenges. Finally, in
prospective studies, each topic area that was identified in the findings
section can be explored in more depth.
In summary, as a result of the honest input from the
young women in this study, new light has been shed on how professional
boundaries are perceived by teens in a residential treatment program. In
addition, new insights regarding the professional relationship from the
wisdom of teens' understanding of residential living were highlighted.
Workers can now take the new information and use it judiciously to
shepherd the professional relationship and boundaries with adolescents
in residential treatment.
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This feature: Richmond, P. A. (2006). Boundary realties from the wisdom of female youth in residential treatment. Journal of Child and Youth Care Work, 21. pp. 80-93.
