Personal boundaries

During the first week of my neurology outpatient placement I was treating a male patient with left hemiplegia due to a stroke which occurred 15 months ago. A fellow female student was observing the treatment session.

As I was doing the foot mobilisations (with the patient sitting on the plinth with his foot on my thigh while I was kneeling) the patient remarked to the student observing the session, “She must be used to begging to her boyfriend.”
I continued with the foot mobilisations and a few seconds past in silence. The patient then looked me in the eye and said, “That was the wrong word wasn’t it?”
“Yes, that was the wrong thing to say.” I replied.
“Oh well, you have to have a sense of humour.” He responded.

I believe the patient had made a comment with a derogatory sexual connotation that was inappropriate. The fact the patient recognised that his remark was inappropriate led me to suspect that similar behaviour would not occur in the future. However, the incident made me feel a little uncomfortable and on guard with the patient throughout the remainder of the session. Although uncomfortable, I did not feel threatened by the situation. My feeling of safety was due to the gym being open and busy with other people and the decreased physical function of the patient.

I can not say for sure why the patient made the comment he did. Perhaps due to behavioural disturbance resulting from his stroke, or maybe such conduct is an inherent part of his personality. Maybe it was a reaction to emotional issues regarding his impairments or a response to the stress posed by the huge challenge of rehabilitation and living with disability.

The situation prompted me to consider where my personal boundaries are and where formal legal boundaries lie regarding the issue of sexual harassment and verbal abuse by a patient. Is it acceptable for a therapist to refuse treatment? Is it acceptable to terminate a treatment session? When is it appropriate to do so? Are certain pathologies such as frontal lobe disturbances or other causes of impairment of socially acceptable conduct exceptions for tolerating inappropriate behaviour? These were some questions guiding my consideration.

The APA code of conduct which states that “physiotherapists have the right to refuse to provide a service where there are reasonable grounds for doing so especially when, in their opinion, it is not in the best interests of the client.” This did statement does not specify what the reasonable grounds for refusal of services are. Would

The Equal Opportunity Act states that sexual harassment can be “unwelcome conduct of a sexual nature” and can take the form of “suggestive comments or jokes” and “insults or taunts based on sex”. It also states that “The behaviour must be such that the harassed person has reasonable grounds to believe if they reject the advance, refuse the request or object to the conduct they will be disadvantaged.”
The act says there is legal protection against sexual harassment in the workplace through laws that make harassment from colleagues and employers illegal but nothing is mentioned about harassment from a patient in a patient clinician interaction.

I appreciate that my view on the issue may change as I gain more experience with physio, but for now I have a better idea of where my boundaries regarding this kind of issue lie and am therefore more confident to deal with and respond to similar circumstances in the future:

If I felt personally threatened by a patient’s comments and behaviour I would not hesitate to terminate the treatment session and believe this would be reasonable grounds on which to do so. Even if I did not feel threatened, but felt uncomfortable with a patient and their behaviour to the point where this uncomfortable feeling was impeding my ability to deliver the most effective treatment I would also refuse to treat the patient and ensure they received treatment by a colleague who was comfortable to do so.

I feel I did the right thing by continuing the treatment session with the patient in the above scenario as I did not feel threatened or feel very uncomfortable with the situation.