Prévention et traitement des abus sexuels et violations des limites

• The Health Professions Procedural Code (Code) being Schedule 2 of the Regulated Health Professions Act, 1991 (RHPA) strictly prohibits sexual involvement between a client and a member and defines sexual abuse as:
  (a) sexual intercourse or other forms of physical sexual relations between the member and the patient¹
  (b) touching, of a sexual nature, of the patient by the member, or
  (c) behaviour or remarks of a sexual nature by the member towards the patient.²  
  
  This prohibition does not include touching, behaviour or remarks of a clinical nature appropriate to the service provided.

• The profession maintains a zero tolerance policy for any form of sexual contact/abuse of a client by a member. 
• Psychological services are built upon a trusting and objective relationship; bringing sex into the relationship destroys both trust and objectivity. 
• There is a power imbalance between a client and health care practitioner. Consequently, it is impossible for a client to give meaningful consent to any sexual involvement in the context of the professional relationship.
• Any sexual behaviour, whether physical or verbal, by a member that involves a recipient of psychological services is strictly prohibited both by law and by the College.
• Such conduct by a member is always unacceptable, under any circumstances.  It can never help but can cause serious and long-lasting harm to clients and others related to them.

 Appropriate and Inappropriate Interactions

• Not all touching is inappropriate. Appropriate touching in a professional relationship may take the form of a comforting hug or congratulatory pat on the back. This is fine as long as it is respectful of the client’s personal and cultural values and it feels comfortable to the client. 
• Ethical professional practice may include talking about sex but only if it is relevant to the client’s concerns. 
• In some cases, an inappropriate relationship can feel like a positive romantic relationship. It is often normal for clients to develop feelings of love, affection, and even sexual attraction towards a helping professional. A good, caring professional knows that it is harmful to exploit these feelings by either initiating or consenting to a sexual relationship. Instead, the professional will help clients find others in their lives with whom they can develop loving, caring, and mutually fulfilling relationships.

Advice for Clients who May Have Been Abused

1. It is very common for people who have been sexually involved with a professional to feel confused about what has happened, and sometimes to simultaneously feel both love and anger towards the practitioner.  While it can be very frightening to seek out another professional, it can be helpful to seek help from a qualified clinician to talk with about these feelings and experiences.
2. If you think a professional’s behaviour has been inappropriate, report their actions to a supervisor, an agency/facility director, and to the College.
3. You may be concerned that your clinician will find out that you raised concerns.  You may also worry about their job, reputation, or family.  Unfortunately, professionals who have sexual contact with their clients often take advantage of this natural desire not to cause harm to another person.  If a professional has taken advantage of you in this way, the person who has been betrayed is you.  Be aware that if no one reports the professional’s unethical behaviour, the professional is likely to harm others as well.
4. Sexual relationships between professionals and their clients are never the fault of the client. You are not to blame if this has happened to you, even if you were the one who first felt and expressed attraction for the professional.  It is the professional’s responsibility never to exploit your feelings of attraction.
5. Some professionals may engage in such behaviour under the influence of alcohol or drugs, or during a life crisis of their own, however this does not remove their responsibility to practice ethically.

Clients who have been sexually abused by a psychologist or psychological associate may be eligible for funding from the College, paid directly to the clinician, to help pay for therapy or counseling required as a result of the sexual abuse.  More information about the Funding for Therapy for Victims of Sexual Abuse Program is available on the College website or by contacting the College.  For further information, please contact the College of Psychologists of Ontario. For further information, please contact the College of Psychologists of Ontario. You may do this anonymously, if you wish. 

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¹Legislation refers to recipients of health care as “patients” while the College of Psychologists of Ontario refers to recipients of members’ services as “clients”
² Section 1(3)

Every health regulatory College in Ontario is required, under the Regulated Health Professions Act 1991, to establish a program to provide funding for therapy and counselling for individuals who were sexually abused by a member of that College while they were a client (patient). The legislation assigns the responsibility for administering this program to the College’s Client (Patient) Relations Committee. It is the responsibility of this Committee to review each request for funding under the program and determine if the eligibility criteria are met. The Client Relations Committee of the College of Psychologists of Ontario is composed of members of the profession as well as members of the public appointed by the Lieutenant Governor in Council, with staff support provided by the Deputy Registrar.

For more information or to apply to the program for funding for therapy or counseling for victims of sexual abuse, please contact:

Barry Gang, MBA, Dip.C.S., C.Psych.Assoc., Deputy Registrar
The College of Psychologists of Ontario
110 Eglinton Avenue West, Suite 500
Toronto, Ontario  M4R 1A3

(416) 961-8817/(800) 489-8388, ext. 235
bgang@cpbao.ca

Definition of Sexual Abuse

Section 1 of the Health Professions Procedural Code (Code) of the RHPA defines sexual abuse as follows:

(3) In this Code, “sexual abuse” of a patient (client) by a member means,
    (a) Sexual intercourse or other forms of physical sexual relations between a member and the patient (client);   
    (b) Touching, of a sexual nature, of the patient (client) by the member; or
(c) Behavior or remarks of a sexual nature by the member towards the patient (client).

(4) For the purposes of subsection (3), “sexual nature” does not include touching, behaviour, or remarks of a clinical nature appropriate to the service provided. 

Penalties for Sexual Abuse and Other Forms of Misconduct

The Code defines the penalties for a member who has been found guilty of committing an act of professional misconduct by sexually abusing a client (section 51(5)). A panel of the College’s Discipline committee must:

1. Reprimand the member.
2. Revoke the member’s certificate of registration if the sexual abuse consisted of, or included, any of the following:
   i. Sexual intercourse.
   ii. Genital to genital, genital to anal, oral to genital or oral to anal contact.
   iii. Masturbation of the member by, or in the presence of, the patient.
   iv. Masturbation of the patient by the member.
   v. Encouraging the patient to masturbate in the presence of the member.
   vi. Touching of a sexual nature of the patient’s genitals, anus, breasts or buttocks.
3. Suspend the member’s certificate of registration if the sexual abuse does not consist of or include conduct listed above and the panel has not otherwise made an order revoking the member’s certificate of registration.

 In addition to the above penalties, if a panel of the Discipline Committee finds a member guilty of professional misconduct, it may do one or more of the following [Code section 51(2)]:
– Direct the Registrar to revoke the member’s certificate of registration.
– Direct the Registrar to suspend the member’s certificate of registration.
– Direct the Registrar to impose specified terms, conditions and limitations on the member’s certificate of registration.
– Require the member to appear before the panel to be reprimanded
– Require the member to pay a fine of not more than $35,000 to the Minister of Finance.
– Require the member to pay all or part of the College’s legal costs and expenses, the College’s costs and expenses incurred in investigating the matter and the College’s costs and expenses incurred in conducting the hearing.
– Require the member to reimburse the College for funding provided under the program for therapy and counselling for patients.

Further, an application for reinstatement by a person whose certificate of registration was revoked for sexual abuse of a client shall not be considered earlier than five years after the revocation [section 72(3)].

Sexual Abuse and the Member’s Obligation to Report

The RHPA makes it mandatory, in accordance with section 85.1 of the Code, to “file a report in accordance with section 85.3 if the member has reasonable grounds, obtained in the course of practising the profession, to believe that another member of the same or different College has sexually abused a patient.”

Failure to report sexual abuse of clients when there are reasonable grounds to believe that abuse has occurred is an offence under the RHPA and can lead to severe penalties.

PLEASE NOTE . . .

• Members are required to report only information obtained in the course of practising the profession.
• Members must submit a report only if the name of the practitioner who was involved in the alleged abuse is known. 
• Members must not include the client’s name without his or her written consent.

Specifically, if a member obtains information in the course of their professional activities that leads them to believe that another member of the same or different College has sexually abused a client or patient, the member must:

• Submit a written report within 30 days to the Registrar of the College representing the profession of the person who is the subject of the report.

or

• Submit the report immediately if there is reason to believe the abuse will continue or abuse of other clients will occur.

The RHPA provides protection to a member, who files a report in good faith, from actions or other proceedings being taken against that person.

While the legislation sets out prohibitions with respect to sexual conduct with clients, the College also sets out similar prohibitions with respect to professional services that involve others, including those associated with clients, e.g., family members of clients, students, supervisees and research subjects. While the legislation does not specifically address inappropriate conduct with respect to those who are not clients, the College’s Standards of Professional Conduct, 2017 do, as follows:

14.1 Sexual Harassment

A member must not engage in sexual harassment in any professional context.  Sexual harassment includes, but is not limited to, any or all, of the following:
  (a) the use of power or authority in an attempt to coerce another person to engage in or tolerate sexual activity including, but not limited to, explicit or implicit threats of reprisal for noncompliance or promises of reward for compliance;
  (b) engaging in deliberate and/or repeated unsolicited sexually oriented comments, anecdotes, gestures, or touching, where the member knows or ought to know that such behaviours are offensive and unwelcome, or creating an offensive, hostile, or intimidating professional environment; and
  (c) engaging in physical or verbal conduct of a sexual nature when such conduct might reasonably be expected to cause harm, insecurity, discomfort, offence, or humiliation to another person or group.

14.2 Other Forms of Abuse and Harassment

A member must not engage in any verbal or physical behaviour of a demeaning, harassing or abusive nature in any professional context.

14.3 Sexual Relationships with Students and Psychology Interns, Psychology Trainees and Supervisees

A member must not engage in a sexual relationship with an individual with whom the member has a current evaluative relationship or with whom the member might reasonably expect to have a future evaluative relationship.

Most members treat their clients respectfully, compassionately and responsibly and would not knowingly compromise the professional relationship established with them.  This does not mean however, that relationship dilemmas or difficult situations do not arise from time to time.

The following outlines the nature of the professional relationship and provides information to help members recognize potential problem situations and suggests some strategies to consider in managing professional boundaries.

Characteristics of Professional Boundaries

Boundaries are the framework within which the clinician/client relationship occurs.  Boundaries make the relationship professional and safe for the client, and set the parameters within which psychological services are delivered.  Professional boundaries typically include the scheduled length and time of a session, limits of personal disclosure, limits regarding the use of touch, consistent fee setting and the general tone of the professional relationship. In a more subtle fashion, the boundary can refer to the line between the private, personal life of the client and of the clinician.

The primary concern in establishing and managing boundaries with each individual client must be the best interests of that client.  Except for behaviours of a sexual nature or obvious conflicts of interest, boundary considerations often are not clear-cut matters of right and wrong.  Rather, they are dependent upon many factors and require careful deliberation of all the issues, always keeping in mind the best interests of the client.

Who Negotiates the Boundaries in the Professional Relationship?

In any professional relationship there is an inherent power imbalance.  The clinician’s power arises from the client’s trust that the clinician has the expertise to help with his or her problems, and the client’s disclosure of personal information that would not normally be revealed.  The fact that services cannot be provided unless clients are willing to cooperate introduces a fundamental power imbalance.  The clinician therefore, has a fiduciary duty to act in the best interest of the client, is ultimately responsible for managing boundaries and is accountable should violations occur.  Given the power imbalance inherent in the professional/client relationship, clients may find it difficult to negotiate boundaries or to recognize or defend themselves against boundary violations.  As well, clients may be unaware of the need for professional boundaries and therefore, may at times even initiate behaviour or make requests that could constitute boundary violations.

Typical Areas Where it May Be Difficult to Draw a Line or Boundaries Can Become Blurred

There are a number of areas in which one has to maintain boundaries, that is, “draw a line”.  Below are some typical areas that can present difficulties

Self-disclosure:  Although in some cases self-disclosure may be appropriate, members need to be careful that the purpose of the self-disclosure is for the client’s benefit.  A number of dangers may exist in self disclosure including shifting the focus from the needs of the client to the needs of the clinician, moving the professional relationship towards one of friendship.  The blurring of boundaries may confuse the client with respect to roles and expectations.  The primary question to be asked is, “Does the self-disclosure serve the client’s clinical goals?”

Giving or receiving significant gifts:  Giving or receiving gifts of more than token value is contrary to professional standards because of the risk of changing the clinical relationship.  For example, a client who receives a gift from a member could feel pressured to reciprocate in order to avoid damaging the relationship and consequently receiving “inferior” care. Conversely, a member who accepts a significant gift from a client risks altering the clinical relationship and could feel pressured to reciprocate by offering “special” care.

Dual and overlapping relationships:  Dual relationships should be avoided.  These occur in situations where the member is the clinician but also holds a different significant authority or emotional relationship with the same person.  For example, a member may also be a course instructor, work place supervisor, family member or friend.  Members need to remain cognizant that the purpose of avoiding dual relationships is to avoid exploiting the inherent power imbalance in the clinical relationship.   Overlapping relationships, while potentially problematic, may not always be possible to avoid.  Overlapping relationships, where a member has contact but no significant authority or emotional relationship with the client may occur particularly for clinicians who are members of small communities, or for clinicians who work with a particular client population with which they are also affiliated.  Such overlapping relationships can occur in situations where, for example; the clinician is a member of a particular religious or ethnic group and tends to practice within this community; or, the member has a child with a learning disability and is also active in a local association and does learning disability assessments.  Situations where there may be overlapping relationships need to be judged on a case by case basis.

Power Imbalances: Members should avoid relationships with their clients outside of the professional relationship where either the clinician or client is in a position to give a special favour, or to hold any type of power over the other.  For example, some situations to be avoided include: 

• employing a client or his or her close relatives;
• seeking professional consultation from a client in the client’s area of expertise;
• involving oneself in business ventures where one could benefit financially from a client’s expertise or information;
• engaging in therapy or conducting an assessment with a current student; or
• requesting favours from a client, such as baby-sitting, typing, or any other type of assistance that involves a relationship outside of the established professional one

Becoming friends:  Generally, members should avoid becoming friends with clients and should refrain from socializing with them.  Although there are no explicit guidelines that prohibit friendships from developing once therapy has terminated, members must use their clinical judgment in assessing the appropriateness of this for the individual client.  Potential power imbalances may continue to exist and influence the client well past the termination of the formal clinical relationship. In the course of therapy, some clinicians, on occasion, may engage in activities that resemble friendship, such as going on an outing with a child or adolescent, or attending a client’s play, wedding, or special event.  In all cases it is the clinician’s responsibility to ensure that the relationship remains clinical and does not develop into a friendship or a romantic involvement. 

Dating: The definition of « sexual abuse » within the legislation makes it clear that it is unacceptable to date a current client.  Since power imbalances may continue to influence the client well past termination, professional standards prohibit a member from engaging in a sexual relationship with a former client to whom any professional service was provided in the past two years, or longer if the member reasonably ought to know that the former client is vulnerable to exploitation or may require future services from them.  Members are reminded that even the most casual dating relationship may lead to forms of affectionate behaviour that could fall within the definition of sexual abuse.

Maintaining established conventions:  Ignoring established conventions that help to maintain a necessary professional distance between clients and members can lead to boundary violations.  Examples include providing treatment in social rather than professional settings, not charging for services rendered, not maintaining clear boundaries between living and professional space in home offices, or scheduling appointments outside of regular hours or when no one else is in the office.

Physical Contact:  There are a variety of ways of using touch to communicate nurturing, understanding and support such as a pat on the back or shoulder, a hug or a handshake.  Such touch however, can also be interpreted as sexual or inappropriate.  This necessitates careful and sound clinical judgment when using touch for supportive or other clinical reasons.  Clinicians must be cautious and respectful when any physical contact is involved, recognizing the diversity of cultural norms with respect to touching, and cognizant that such behaviour may be misinterpreted.

Diagnostic and clinical work with children requires special consideration.  Some agencies or institutions for example, advise their staff to avoid any touching of children.  In other settings however, touching may be permitted, ordinarily if it is to occur in public.  In working with children and considering the question of touching, one might ask, “Would I do this in the presence of my colleagues or this child’s parents?”  Again, good clinical judgment should prevail for the protection of both the client and the practitioner.

Some clinical situations such as neuropsychological testing and biofeedback, or clinical interventions such as bioenergetics, require touching the client.  When such touch is necessary, it is important to explain this to the client, ensure the client’s understanding and obtain the client’s fully informed consent.  If there is concern that a particular client may misinterpret a clinician’s actions, members may wish to have someone else present in the session, consider an alternate clinical approach, or think about a referral to an appropriate  other practitioner.

Informal Communication and Humour:  Miscommunication between a psychologist or psychological associate and a client may cause the client to misunderstand a member’s intent.  While it may seem harmless to make a personal compliment about a client’s appearance, or tell a ‘racy’ joke, this type of behaviour can be misinterpreted by a client as an interest in them personally. It is important to set a professional tone in dealing with clients and avoid remarks of a sexual nature (jokes, offhand comments or use of vulgar language) that could be overheard by a client or a member of the public.

Questions to Consider in Examining Potential Boundary Issues

In each individual case, boundary issues may pose dilemmas for the clinician and there may be no clear or obvious answer.  In considering how to proceed, considering the following questions may be helpful.

• Is this in my client’s best interest?
• Whose needs are being served?
• Will this have a negative impact on the service I am delivering?
• Should I make a note of my concerns or consult with a colleague?
• How would this be viewed by the client’s family or significant other?
• How would I feel telling a colleague about this?
• Am I treating this client differently (e.g., appointment length, time of appointments, extent of personal disclosures) than other clients?
• Does this client mean something ‘special’ to me?
• Am I taking advantage of the client?
• Does this action benefit me rather than the client?
• Am I comfortable in documenting this decision/behaviour in the client file?
• Does this contravene the Regulated Health Professions Act, the Standards of Professional Conduct or the Canadian Code of Ethics for Psychologists, etc.?

Boundary Violations and Sexual Abuse

Sexualizing a professional, health-care relationship is against the law.  In Ontario, the Regulated Health Professions Act, 1991 (RHPA) prohibits sexual involvement of clients with health-care professionals.  The RHP defines sexual abuse broadly as:  sexual intercourse or other forms of physical sexual relations between a member and a client; touching of a sexual nature; or, behaviour or remarks of a sexual nature by a member toward a client.

There are NO circumstances in which sexual activity between a psychologist or psychological associate and a client is acceptable.  Sexual activity between a client and practitioner is always detrimental to client care, regardless of what rationalization or belief system the health-care professional chooses to use to excuse it.  The unequal balance of power and influence makes it impossible for a client to give meaningful consent to any sexual involvement with their clinician; client consent and willingness to participate in a personal relationship do not relieve the member of his or her duties and responsibilities for ethical conduct in this area.  Failure to exercise responsibility for the professional relationship and to allow a sexual relationship to develop is an abuse of the power and trust which are unique and vital to the clinician/client relationship.

Prevention and Avoidance of Sexual Misconduct

The best way to maintain the appropriate boundaries in a professional/client relationship is through the clinician’s focus on maintaining good, personal psychological health, the clinician’s awareness of potential problems and good, clear communication.  One’s power and control over a client should not be underestimated.  One should also remain aware that the client may experience touch, personal references and sexual matters very differently from the clinician due to a variety of factors including gender, cultural or religious background, or personal trauma such as childhood sexual abuse.   Risky situations should be avoided and the proper boundaries of any professional/client relationship should be communicated clearly and early in the treatment process. 

Warning Signs

There may be times in the practice of psychology when a member could feel drawn toward a client or could experience feelings of attraction to a client.  It is vital that the psychologist or psychological associate recognize these feelings as early as possible and take action to prevent the relationship from developing into something other than a professional one.  If a client attempts to sexualize the relationship, the obligation is always on the psychologist or psychological associate not to cross that line. 

Before actual physical contact or abuse occurs there are often a number of warning signs or changes in the clinician’s behaviour.  Members should be alert to such signs that suggest he or she may be starting to treat a particular client differently.  These may include sharing personal problems with the client, offering to do therapy in social situations such as over dinner, offering to drive a client home, not charging for therapy, or making sure the client is scheduled to see you when no one else is in the office.

The following guidelines suggest approaches to prevent boundary violations and avoid complaints of sexual misconduct.

1. Be cognizant of cultural and individual diversity and developmental and other issues that shape relationships and client perceptions
2. Do not use words, gestures, tone of voice, expressions, or any other behaviours which clients may interpret as seductive, sexually demeaning, or as sexually abusive; take care to appreciate what a client may infer or understand to be the purpose of a communication.
3. Do not make sexualized comments about a client’s body or clothing.
4. Do not criticize a client’s sexual orientation or values concerning sexuality.
5. Do not ask details of sexual history or sexual likes/dislikes unless directly related to the purpose of the psychological service.
6. Do not request a date with a client.
7. Do not engage in inappropriate “affectionate” behaviour with a client such as hugging or kissing; do offer appropriate and clearly supportive contact when warranted.
8. Do not engage in any contact that is sexual (from touching to intercourse).
9. Do not talk about your own sexual preferences, fantasies, problems, activities or performance.
10. Learn how to appropriately respond to seductive clients and to control the clinical setting.
11. If conducting assessments (e.g., neuropsychological evaluations) or using methods (e.g., conditioning, bioenergetics, etc.) which involve physical touch or contact, take care to obtain informed client consent and be aware of how potentially sensitive a client may be to this.
12. Maintain good records that reflect any intimate questions of a sexual nature and document any and all comments or concerns made by a client relative to alleged sexual abuse, and any other unusual incident that may occur during the course of, or after, an appointment.

What Members Can Do if Concerns about Boundaries Arise?

If a member experiences a problem with how they are treating or feeling about a client or how clients are feeling about them, they should seek assistance as soon as possible.  If the client sexualizes the relationship, this should be documented, as should actions taken to defuse the situation.  Members are encouraged to talk to a trusted colleague or mentor, seek professional help from a qualified practitioner in the psychological community or elsewhere, or call the practice advisory service at the College.

The following scenarios were developed by the Client Relations Committee of the College for the purpose of facilitating reflection and discussion among peers. Members are invited to select and explore any of these scenarios that they believe will be helpful.  They are all intentionally gender and culture neutral and gender neutral pronouns have been used. There would be added benefit to discussing these scenarios with a group of colleagues of different ages, gender identities, sexual orientations and cultures. 

Members login link to view and share your responses to the scenarios via an anonymous survey.

A summary of member responses will be shared with the membership.  

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The following questions may be of assistance in considering how to prevent or address potentially problematic situations:
A. Would this situation make you feel uncomfortable; if so, why?
B. Was there any reasonable way to prevent this situation from occurring?
C. What would be the best way to respond to this situation?
D. Would it make a difference what kind of work you were doing with the client or what kind of difficulties the client was seeking help for; if so, how?
E. Would your own culture or the culture of the client make any difference to your response to the situation? 
  

1. You have just finished working out at a new health club and are in the locker room, undressed. A client to whom you are providing services comes into the same area. You immediately recognize each other.  The client gives you a nod of recognition. You would like to abruptly cover yourself up but this feels like it would be very awkward to do without calling attention to the situation, so you go for your towel as casually as possible.
   
2.  Like so many other people, you are using on an online dating service to find romantic companionship.  You discover that one of your clients is also registered on the site and the client discovers that you are too. If not for your professional relationship, according to the person’s profile, this is a person with whom you would be interested in pursuing romance. The client contacts you via the site to ask whether there is any way to shift the relationship from a professional to a personal one.
   
3. A client you have been working with for a few months begins to behave in what you believe to be a sexually suggestive manner and to make significantly more eye contact with you. You are not sure if the client is behaving flirtatiously but believe this to be possible.
   
4. Same scenario as above but you also feel flattered by the idea that someone as attractive as the client would flirt with you.
   
5. Several months ago, your spouse passed away. You have just received a heart-felt condolence card from a former client you had helped at the time of their own bereavement, when you both lived in another town. The message was welcome and very helpful. The former client is well adjusted and high functioning but says they would love to have some support to  get through a difficult time as they are new in town and far away from close friends and family. The card suggests that you get together for coffee, not as client/practitioner, but as peers who could support each other. Although you are not interested in a new romantic relationship at this point, this would be someone you might like to have coffee with.
   
6. You have been working with a client who wishes to address trauma resulting from sexual abuse. You have established good therapeutic rapport and the client has made several very painful disclosures that they had been unable to make before. At the end of a particularly painful session, the client says they are lonely, frightened and wishes there was someone in their life that could hug them in a way that would make them feel cared for and safe. You believe that you could use this as an opportunity to demonstrate healthy support.
   
7. Same scenario as above but with the additional information that you too are feeling a bit alone and isolated.
   
8. You have struggled to address substance abuse issues but have been “clean” for the past 18 months. You attribute this, in large part, to a 12-step program you have been attending in the community for the past two years. A client comes to a program meeting and states openly that you are their therapist and have been very helpful to them. You value your participation in this group and place importance on the support of other members of the group. 
   
9. Last year, during the holiday season, a client brought you a scarf as a gift. You decided that the scarf was of token value, that the client recognized that this was an entirely professional relationship, and that accepting the gift was appropriate in the circumstances. This has occurred many times throughout your career, without any difficulties arising. This year the same client brings you a piece of gold jewelry, with your name engraved on it. You know that the gift cannot be returned to the store and believe that the client would be hurt at any suggestion that they had given you a gift that you considered to be inappropriate.  
   
10. Through some common acquaintances, a client has gained some information about your own intimate relationships, and lets you know this. The client is experiencing some difficulties with intimacy and asks pointed questions about how you managed your own feelings in a situation they know you experienced. You believe that you managed your feelings adaptively and that the information could be useful to the client. Answering the question would, however, require discussion of your sexual practices.
    
11. During an assessment interview, a client expressed distress about their appearance. They asked you, as an objective person who had just met them, to tell them whether you think they are attractive. You say that while they believe it might help them if you answered that question, it would probably be counterproductive for you to rob them of an opportunity to explore their own self- image. They say that you are “copping out” and avoiding hurting their feelings by not telling them the truth. They press you on this and ask you to agree to give your opinion, as a person not a practitioner, after the assessment is completed. You think to yourself that objectively speaking, you could provide such an opinion and that it might be a good “reality check” for the client.
    
12. You are conducting an assessment of a client’s eligibility for insurance benefits. The client has steered the conversation towards their ability to maintain a high level of sexual activity, despite sustaining traumatic injuries, and offers details about their sexual practices. You work hard to refocus on what you believe to be the more relevant avenues to explore in this assessment, to no avail. 
    
13. Same scenario as above but additionally, you are beginning to feel aroused by the comments the client is making.
    
14. While getting dressed in the morning you realize that you are thinking about how you will look to a particular client you are scheduled to see that day. In the past, you hadn’t realized that you have felt any attraction to the client and are not sure whether you do now.
    
15. A client you have been treating for performance anxiety invites you to their concert, believing that your presence will be reassuring and supportive to them in overcoming their anxiety. You believe this would be clinically appropriate. The performance goes well, and after the concert, you wait to congratulate the client. Upon seeing you, the client brings over a friend, puts their arm around you and introduces you as a good friend.
    
16. You awake one morning and realize that you had a dream in which you had sex with a client whom you find attractive. The dream is disturbing to you. You are in a committed relationship with a partner in which you are very happy and have never considered pursuing a relationship with this client.
    
17. A client has increasingly been making sexually suggestive jokes. You have dismissed them as the client’s inappropriate, but innocent, attempts at humour. The client has progressed to making physical gestures while telling the jokes. Initially you were shocked and couldn’t think quickly enough to respond, so did not say anything.  You are uncomfortable about not having responded differently.
    
18. A client has disclosed to you that they have been sexually abused by a member of another regulated health profession. You remind the client that you have a mandatory duty to report this abuse to the other professional’s College and that this is non-negotiable. The client, as single parent, tells you that their partner has “jealousy issues” and that it would likely cause the end of the relationship, if the spouse ever learned what had occurred.
    
19. You have noticed that the psychologist in the next office has been scheduling long sessions with the same client at end of day. You have often been the last one to leave in the evening but have recently noticed that the lights are still on in the other psychologist’s office while you are doing the usual office closure routine. You have checked the schedule and believe that the psychologist has been with the client for more than two hours.  
    
20. A recent immigrant was referred for treatment of depression. Upon first greeting the client, you extend your hand to them. The client looks anxiously at the floor and shakes your hand. Early in the first session, the client begins to cry and discloses that their family was unsupportive of the referral because only “crazy” people go to therapy. You hand the client a tissue and place a hand on their shoulder as a gesture of comfort. The client stands up and runs out of the office where a family member is waiting for them. The client says something in another language to the relative and seems distraught while gesturing at the office.