Clinical Concerns in Boundary Issues

It is relatively recent that boundary issues in clinical practice have attained professional awareness, although some early concepts portended the issue. Several decades ago, for example, the term boundary violations referred almost exclusively to what we now term sexual misconduct. Within psychoanalysis existed the notion of parameters (e.g., actions, interventions or responses that lay outside the fundamental analytic terrain of verbal free association)-a term that embraced some of the boundary issues we identify today, though in slightly different conceptual terms.

Moreover, Gabbard and Lester (1998) have pointed out that the developmental notion of ego boundaries, a term relevant to the understanding of psychotic thought among other things, may have been an early expression of boundary theory; however, the sense of "where 'you' leave off and 'I' begin" has a more intrapersonal focus compared to the dyadic context in which we now think of boundary issues (Simon, 1989).

As the mental health professions expanded their knowledge and understanding of trauma and its effects, victims of therapist sexual misconduct began to come forward in increasing numbers. Clinicians who assessed, treated or testified for such patients began to observe that sexual relations between these patients and their therapists were almost inevitably preceded by, accompanied by and surrounded by a nimbus of behaviors that constituted either encroachment on patients' personal space in some way or transgressions by the professional of some stated or unstated limits of professional conduct.

Since emergence of these early nebulous perceptions, a more systematic vision of boundary theory has emerged-if only in the last decade (Epstein and Simon, 1990; Gutheil, 1989; Gutheil and Gabbard, 1998, 1993; Simon, 1992, 1989). Since problems with boundaries still seem to bedevil our field and our patients, the time may be ripe for a review and update of this topic.

What is a boundary? While the term is easier to intuit than to explicate, a boundary is the edge of appropriate behavior in a given situation (Gutheil and Gabbard, 1993). But modern boundary theory goes beyond behavior to matters of language, time, place and space, money, self- disclosure, and receptivity to input from outside the dyad.

Therapists breach boundaries in one of two major ways (Gutheil and Gabbard, 1993): boundary crossings and boundary violations. In a boundary crossing, the therapist steps out of the usual framework in some way, but this action neither exploits nor harms the patient; indeed, it may advance the therapeutic alliance or the therapy itself. Examples that clearly fit this description include offering a crying patient a tissue; helping up a patient who has fallen; disclosing some facts about oneself (e.g., that one is a psychiatrist rather than a psychologist); and, under some circumstances, giving a patient a ride to safety in a blizzard.

None of these actions would constitute ordinary psychotherapy; moreover, the examples involve physical action, physical contact, self-disclosure and extra-office encounters, respectively-all issues that could, with slight alterations, represent boundary breaches. However, none of these particular events, as described, harms or exploits the patient.

Boundary violations, in contrast, are defined by their exploitative or other harmful effects on the patient. In a boundary violation, the therapist inappropriately takes advantage of the dynamics and potential dynamics that are present naturally in the therapy situation: transference, intimacy, dependency, idealization, rapport, empathy and the closeness one feels with a confidant. Rather than serving as essential elements of the therapeutic alliance for therapeutic goals, these natural elements of therapy are, in a boundary violation, put to the service of the therapist's gratification rather than the patient's welfare.

Note that patients, too, may breach or attempt to breach boundaries, but the responsibility for maintaining and defining boundaries always belongs to the therapist.

Robert I. Simon, M.D., and I (1995) suggested that boundary breaches may first manifest themselves in the transition zone "between the chair and the door," i.e., when the session appears to be over. If put to use as risk management, this interval may serve as an early warning system of boundary problems if carefully scrutinized by the therapist.

This is an opportune moment to stress one of the most commonly misunderstood aspects of boundary theory: the centrality of context in assessing boundary issues in general and, most importantly, in distinguishing a boundary crossing from a boundary violation. In parallel with the examples above, giving gifts to a patient, erotic physical contact, highly personal self-disclosure and planned meetings outside the office might well constitute boundary violations, but context is always determinative. For example, a psychiatrist might give an impoverished patient a medication sample; a patient might have an unexpected erotic reaction to an inpatient physical examination, even with a chaperone present; a therapist might have to explain that a recent absence was for needed surgery; and a case manager might have to drive a patient to a welfare office.