Prevention of Boundary Violations
The Role of Education, Self-Monitoring, and Consultation
By Glen O. Gabbard, MD |
April 1, 2008
Dr Gabbard is Brown Foundation Chair of Psychoanalysis and professor of psychiatry at the Baylor College of Medicine in Houston. He reports no conflicts of interest concerning the subject matter of this article.
A myriad of reasons can be marshaled to avoid consultation. It is expensive. It takes time away from one's practice. A consultant cannot possibly understand the full complexity of a particular patient. The confidentiality of the patient might be breached if the consultant figures out who the patient is. Many of these excuses are fueled by a wish to have an exclusive "one and only" relationship with the patient, uncontaminated by outside interference.5
As valuable as consultation can be, it is by no means a panacea. Consultation or supervision can be corrupted. The corruption can begin with the selection of a consultant. Therapists who wish to continue their descent down the slippery slope can pick friends whose opinion can be anticipated in advance. Therapists select such consultants because they know that nothing they are doing will be challenged. Therapists can also corrupt the consultation process by concealing details from the consultant. I am aware of one situation in which a therapist was having regular sexual relations with a patient but confined what he told the consultant to "struggles with countertransference."
Two basic axioms of prevention can be gleaned from these concerns4:
• Anything you are doing with a patient in psychotherapy should be something that can be freely shared with a consultant; if you feel you cannot share what is going on in the psychotherapy with the consultant, then you have already started your descent down the slippery slope.
• Anything you feel that you must keep secret from a consultant is exactly what you should be sharing with the consultant.
Sexual boundary violations often involve a compartmentalized sector of the psyche. Forbidden and otherwise unacceptable activities operate only within this split-off area of the self, while more acceptable professional conduct holds sway with the other patients in the therapist's caseload. The beginning of this compartmentalization process is characterized by concealing certain kinds of interventions or behaviors from a consultant or supervisor.
Different models of consultation exist. Some therapists prefer to meet in groups, where the group itself serves as a consultation process. Each therapist in turn presents at a regular meeting of the group, often at breakfast or dinner. Some colleagues prefer a one-to-one relationship with another colleague, where they alternate presenting cases so that the vulnerability of feeling embarrassment or shame is lessened. An asymmetrical consultation relationship, in which one person always presents, is preferred by some for whom the shame issue is not as relevant, or where there are substantial differences in terms of experience. When therapists are extremely concerned about confidentiality because their patients may be in the mental health profession or otherwise well-known, they can seek consultation with a colleague from another city over the telephone while keeping the identity of the patient confidential.
Psychotherapists who work in institutional settings must be carefully screened before being hired. Letters of recommendation are often generic and rarely useful in screening out seriously corrupt behavior. Screening persons for a history of criminal behavior or previous ethics violations must be undertaken through appropriate Internet sources, such as the National Practitioner Data Bank for physicians.
Psychiatric institutions must also have clearly written policies that demarcate appropriate professional boundaries and identify problematic dual relationships. Educational meetings must occur on a regular basis with institutional therapists. Finally, administration must be able to make appropriate interventions early in the process of a boundary transgression rather than waiting until the damage has been done.2
Personal therapy or analysis
Psychotherapists must have a working knowledge of their own conflicts, defenses, schemas, internal object relations, and vulnerabilities. Without this knowledge they are at risk for enacting their own needs and wishes with their patients. Hence, most therapists seek out personal therapy or analysis at some point in their professional development. No amount of treatment is foolproof as a form of prophylaxis against boundary violations, but at its best, the therapist's personal treatment experience sets in motion a process of self-analysis that becomes part of his or her professional life.
The foregoing discussion reflects the inherent problem in all preventive efforts—namely, much of the prevention of professional boundary violation relies on rigorous self-monitoring by psychotherapists themselves. This self-scrutiny involves balancing one's life so that one's emotional needs are met in the context of personal relationships in one's private life. While there are a variety of gratifications in doing psychotherapeutic work, they cannot take the place of valued intimate relationships outside the therapeutic setting. Another part of the monitoring must be systematic questioning of oneself: Is what I am doing part of a carefully thought-out treatment plan within the community standards of psychotherapeutic practice? Is anything I am doing potentially exploitative of the patient's vulnerability? Is there anything I am doing that I could not share with a colleague? If we expect our patients to look unflinchingly into the darkest recesses of their psyches, then we must be willing to do so ourselves. At the end of the day, therapists are there to help their patients, and that unassailable ethical principle must be the beacon that guides us.
1. Gabbard GO, Gabbard KE. Psychiatry and the Cinema. 2nd ed. Washington, DC: American Psychiatric Press; 1999.
2. Gutheil TG, Brodsky A. Preventing Boundary Violations in Clinical Practice. New York: Guilford; 2008.
3. Gutheil TG, Gabbard GO. Misuses and misunderstandings of boundary theory in clinical and regulatory settings. Am J Psychiatry. 1998;155:409-414.
4. Gabbard GO. Consultation from the consultant's perspective. Psychoanalytic Dialogues. 2000;10: 209-218.
5. Gabbard GO, Lester E. Boundaries and Boundary Violations in Psychoanalysis. Arlington, Va: American Psychiatric Publishing, Inc; 2003.
FROM PHYSICIANS PRACTICE
Five Steps to Improving Patient Access Judy Capko,
May 21, 2013
Patient access is getting increased attention through reform initiatives. Here are five steps you can take to make sure patients get appropriate access to care in your office.
SearchMedica SEARCH RESULT
Find peer-reviewed literature and websites for practicing medical professionals