“Do you know my friend Bill? He’s in a wheelchair too!”
There comes a time in every disabled persons life where a well-meaning but nosy stranger asks that question.
There’s a persistent assumption that all individuals with similar needs or matching impairments share a social connection. In previous generations, this was met with awkward laughter or a non-committal response. It was, after all, a ridiculous assumption to make. Fast-forward a little and it’s no longer quite so ridiculous. If Bill the wheelchair user is on twitter, or visited Naidex, or ever joined a hypermobility related Facebook group there is a decent chance that I actually do know Bill!
We are living in an increasingly interconnected world. I regularly talk with Occupational Therapists from Australia, literally as far from my home as it’s possible to get. And yet, with the click of a few buttons we can swap stories, send resources and build connections.
The internet has opened up a whole host of possibilities. These possibilities don’t just extend to professionals. I have friends in Australia who share a genetic disorder with me. Believe it or not, I have a friend in Australia who shares a genetic disorder with me and is also an Occupational Therapist.
This inter-connectedness has some amazing benefits, I’ve swapped and shared research articles with people I will probably never meet. I’ve shared ideas for practice with people I would never have spoken to if we were relying on geographic convenience alone. I’ve even given lectures to Occupational Therapy students at a university in another country.
The internet allows me to work as an Occupational Therapist despite my health issues. I frequently find myself unable to leave the house, sometimes I’m unable to leave my bed. Despite those complications, I am still able to do my job. In many respects, my own struggles were the reason for my whole JBOT enterprise. If remotely delivered therapy benefits my health, why can’t it can do the same for my clients?
I’ve also been told that my own experiences with an un-cooperative body are a benefit. I’m not just a therapist, I’m a peer. I’m a patient. I’m someone who understands. Much of the OT theory I deliver is mixed in with a heavy dose of personal experience. It allows me to understand the patient narrative in a way that ‘healthy’ or ‘able bodied’ therapists usually cannot.
This dual-nature does have some really obvious benefits. Empathy and understanding come naturally when you’ve personally experienced the same things as your clients. I understand the value of validation, clear communication, patience and flexibility in health-care because those are things I yearn for myself.
There are also some challenges, it’s not un-common for me to have the same consultants, physiotherapists and specialists as my clients do. Initially, it can be a little awkward adding your personal physio on LinkedIn because you need them as a professional connection too. It can be a little awkward discussing a client’s case with a consultant who has seen you in your undies (and odd socks) during a personal appointment.
It can also be a bit grey in other areas. Rare-disease groups and specialist interest areas tend to be pretty niche communities. As patient we’re all up in each others business. When you live with a diagnosis that baffles the average medical professional, you end up spending a lot of time online with other people in the same situation. I learnt almost everything I know about self-management and condition specifics from other patients, then I taught it to my doctors.
I now work in these areas as a professional too. Because it’s a relatively close community I frequently work with people I consider acquaintances or even friends.
If you’re a healthcare professional yourself you’re probably a little unsure about that. You might even be flat-out against it. We’re taught as students that you don’t work with friends or family. In the RCOT code of ethics were told:
“As far as is reasonably practical, you should not enter into a professional relationship with someone with whom you already have, or have had, a close personal relationship.”Royal College of Occupational Therapists, Code of Ethics Update (2017)
(i.e. family and friends). This is fabulously easy guidance to follow if you work in an office with 5 other OT’s. Unfortunately for self-employed therapists this can be a fair bit harder. For self-employed therapists in niche or specialist job roles it becomes even more difficult. As far as I’m aware, I’m the only OT working with the ‘long-term, variable conditions’ user group who offers video-chat appointments. I am absolutely sure I’m the only one offering a Pacing Masterclass since I created it myself! So…
“Where there is no reasonable alternative you must make every effort to remain professional and objective while working with the individual you know or have known.”Royal College of Occupational Therapists, Code of Ethics Update (2017)
How to do that is what i’d like to focus on. My reasoning for this is three-fold. Firstly, it’s useful reflection for myself. Secondly, it’s useful information for my acquaintances who may go on to become clients. Thirdly because Occupational Therapy has the potential to be an incredibly accessible career path for individuals with a wide range of health issues, impairments and experiences. I know (through internet based discussions) that many other therapists are in a similar situation to myself. Almost accidentally becoming an expert practitioner where they already wear the ‘patient’ label.
This is one of the fundamental starting points of all healthcare. It’s especially important where the potential for blurred boundaries exists. It’s not as simple as ‘do you want my advice’, if the client doesn’t know what that entails then the ‘informed’ part of the consent has not been achieved. Before engaging in anything resembling an appointment with someone I have an existing relationship with, it’s important that both parties understand the boundaries for this new relationship. The therapeutic relationship.
As far as therapists go I share a LOT of my personal experiences. I feel safe doing so and it’s often incredibly beneficial to my clients for me to do so. It’s always in context, never ‘for the sake of it’ and I don’t share anything that I wouldn’t be comfortable sharing in a public forum like Twitter. That said, what I share with my friends is often more personal. It needs to be clear that they cannot expect that level of ‘sharing’ when working with me in a professional capacity. Likewise I would not expect them to share anything they wouldn’t also tell their GP. Slang, pet-names, in-jokes and gossip are likewise not appropriate for the duration of therapy. The session needs to remain focused and on-task. Goal setting is a common feature of all Occupational Therapy appointments but with ‘grey areas’ it’s doubly important and can help maintain focus.
None of that means you can’t have a polite conversation the same way you would with any other client. What it does mean is that you need to be mindful of whether that discussion is appropriate and whether it’s relevant. A good example of this is the student/teacher role. It’s not unusual for Lecturers to be ‘Facebook Friends’ with students. This can be beneficial and totally acceptable as long as boundaries are respected. Just because you’re FB friends with your students, does not mean you can bring up their hilarious holiday shenanigans in a lecture.
Communication is something all healthcare professionals need to be good at. It’s a series of skills we learn from birth but most of us will find we have a specific communication style for certain situations. Think ‘Telephone voice’ but for healthcare. I know I go into therapist-mode when I’m working but also at times when my OT skills are just plain useful day-to-day. I also know I have a communication style with my friends and family. I’m sure most of you do too. When working it’s important to stick to therapist-mode. It’s equally important that clients know to expect this. It might seem impersonal but it’s a useful way to maintain the ‘clinical’ reasons for the session in the first place.
Working within your professional competence is essential when maintaining ethical and high quality practice. This (fairly obviously) covers your qualifications, certifications, experience and capabilities but perhaps less obviously also applies here. Maintaining an appropriate professional boundary with a stranger is potentially much easier than doing so with a friend. Recognisng and analysing your own skills at maintaining therapeutic relationships should be part of your professional reasoning when deciding whether to work with any client. Turning away work as a self-employed person can be hard but you may need to, if the clients best interests are not served by you. (Do feel free to help them find an alternative though).
Conflict of Interest
This is an interesting one. Often, the example of conflict of interest we’re given is one where financial gain is at odds with the clients best interests. Working in private practice, it’s hard not to be more aware of finances in general since you finish blocks of work by sending over an invoice but this is another one of those potential grey areas where it’s important to ask yourself questions and double check your reasoning. The clients best interests must remain at the forefront of the decision making process.
When looking at interpersonal relationships Vs therapeutic ones we must ask ourselves if our professional goals are at odds with our personal preferences. In my experience the answer is usually, no. That said, I’ve yet to work with anyone I have a negative personal relationship with! You can also fully expect to have other professionals question whether you do have a conflict of interest. You may have to be prepared to share your clinical reasoning and even your information gathering methods in order for your professional opinion to be taken seriously. Likewise, if there is a potential for conflict of interest it needs to be clear that you have recognised and considered it. This is really not all that different from being prepared to justify any other aspect of your practice from your uniform choice to your use (or not) of a standardised outcome measure.
One of the biggest differences between self-employed work and employed work is policy. If you accept a job with a company you accept the need to work within their policies. The rules about whether you can follow your clients on twitter or if you can work with friends are dictated to you. With self-employed work the policy is something you often need to decide for yourself. HCPC and RCOT guidelines are an excellent starting point but they do not give you all the answers. There will be elements of your professional practice where the ‘rules’ are created entirely by you. When I first set myself up as an independent OT I had some firm ideas on ‘acceptable’ professional behaviour and some wishy-washy ones. A few years down the road I’ve adapted some of those and kept others the same. Some of my personal policies are very different to the ‘usual’ ones. I frequently follow clients on twitter, for some of my clients, twitter DM is the preferred contact method and I’m happy to adapt to that. Like so much in clinical practice, you simply need to be able to justify your actions and explain your reasoning. The growing evidence base for more diverse forms of therapy certainly helps too!
Working in diverse and trend setting areas of practice is certainly a steep learning curve. I’ve found my own ways of doing things, but I’ve also learnt from others. The inner workings of someone elses brain is a priceless resource when it comes to challenging your own beliefs. I don’t remember who said this to me the first time but the idea has always stuck with me.
“One of the most dangerous phrases in healthcare is ‘this is how we’ve always done it”
So, long live, life long learning and please do challenge or comment on my thoughts with your own. I’d love to get some discussion going.
Apologies if none of this makes any sense at all, I started thinking about this at 4am as a distraction from back pain and just couldn’t let the idea go without writing something.