Boundary Concerns in Clinical Practice

In the historical context of American psychiatry, the concept of boundaries is a relatively recent development.¹ Freud reportedly analyzed some patients while walking along the river Danube, gave patients gifts, and was known to share a meal with a patient. Jung was said to have had an affair with his patient, Sabina Spielrein, who later became a therapist herself. Ferenczi took the daughter of his mistress into analysis, and both women knew the role the other played in his life.² There were no negative consequences for these founders of the analytic movement.

The picture has changed remarkably for today's practitioners. Not only actual boundary transgressions but even perceived or misperceived ones can cost therapists their licenses, their reputations, and their professional standing.³ How did this all come about?

Let us begin by attempting to define a boundary in the therapeutic context. A boundary is a line in the sand that represents the edge of professional conduct at a certain point in the therapy and in relation to the therapeutic context and contract. This edge has been referred to by Langs⁴ as part of the therapeutic frame. Therapists who cross the line risk vitiating the therapy, harming the patient, and violating their own standards.

A common error made in discussions about boundaries is to consider boundaries to be bright lines, subject to clear and unambiguous observation and understanding. Instead,

Where the boundary line actually falls, or is perceived to fall, depends on the type and stage of therapy and may be subject to judgment and interpretation. Therapeutic boundaries are not hard and fast. Rather, they are movable and context-dependent, and their placement depends on a number of factors in the clinical situation.²

Countless clinical consultations, as well as the role of experts in lawsuits and complaints to professional boards and ethics committees, attest that major misunderstandings, misjudgments, errors, and anxiety stem from a failure to adequately consider the centrality of context in evaluating a particular incident or behavior.

As an extreme example, consider the following situation: a therapist directly and intentionally follows a patient into a public restroom. Such conduct would be highly questionable for a classical psychoanalyst, but it would be fully appropriate if this occurred in line with informed consent from the patient and as a late stage of a behavioral therapy paradigm for the treatment of paruresis.²

As this example illustrates, the therapeutic paradigm, the role of informed consent, and the subject of treatment may all represent relevant contextual factors, along with the stage of therapy, the patient's diagnosis, the external social setting, as well as many other considerations.²

Historically (eg, in the middle of the past century), boundary violations were defined narrowly to mean sexual intercourse with a current patient. Over time, clinicians realized that other interactions short of intercourse posed similar problems for the value or efficacy of the therapy and posed the clear risk of harm to patients; these other interactions are the focus of the present article. Before analyzing this development in so emotionally charged a subject, it will be useful to establish some axioms.^2,5

Three axioms
First, mental health professionals must abide by a professional code of ethics and regulations, whether formed by a professional organization or as statutes from the legislature; patients have no such constraints. This represents a significant asymmetry: it is the professional, not the patient, who is ultimately responsible for setting and maintaining the professional boundaries.

Thus, although the majority of boundary transgressions are initiated by patients, only the therapist can be held liable for the transgression and considered unethical or (in some jurisdictions) criminal.² An extension of this axiom eliminates controversy over who is at fault: it is always the professional's duty to refrain from initiating and being a party to a boundary violation.

Second, because in most cases both patient and therapist are competent adults, each may be held accountable for his or her conduct; as in any dyad, the actions of both persons contribute to the result. However, according to the first axiom, this cannot be parsed to mean that the patient is blamed or the therapist should be exonerated. This accountability may or may not prove relevant in the patient's subsequent therapy.

Third, to study the therapeutic dyad as a 2-person psychodynamically interactive field—to understand how boundary issues and problems arise with the aim of averting harm—is neither to blame the victim (the patient) nor to exculpate the therapist.

Crossings versus violations The complexity of boundary transgressions other than sexual intercourse was articulated in an article by Gutheil and Gabbard in 1993.¹ A clinically and conceptually useful definition that emerged from that discussion was the distinction between boundary crossings and boundary violations—a distinction that has been widely cited and used by decision makers such as courts and professional boards.

Boundary crossings are minor deviations from traditional psychotherapy that neither harm nor exploit the patient and may even advance the alliance or the therapy. Examples include offering a tissue to a weeping patient or helping a patient who has fallen get up. Neither of these interventions constitutes classic psychotherapy but clearly the effect, in most circumstances, is benign.

In contrast, boundary violations do harm the patient, usually by some form of exploitation, whether it be psychological, sexual, financial, emotional, or based on the patient's dependency needs. In any case, the violation serves the therapist's wishes, goals, and desires, not the welfare of the patient.

Both these concepts are fundamentally defined and influenced by the context in which they occur. Identical behaviors in one context might represent a benign crossing and in another, a harmful violation.

Although some behaviors can occur as actual or incipient boundary issues (phone calls or use of first names), decision-making bodies—often the professional boards—take the approach described as the "list of forbidden acts" paradigm. Without attention to context, the regulatory agency automatically decides that certain behaviors are violations and punishes accordingly. This empirical observation prompted a follow-up article in 1998, "Misuses and Misunderstandings of Boundary Theory in Clinical and Regulatory Settings."³ Indeed, a significant portion of forensic work in this area can be described as going around explaining to various agencies the difference between crossings and violations.

Boundary crossings
A boundary crossing constitutes a benign departure from the structures and procedures of traditional psychotherapy (dialectical behavioral therapists may identify these crossings as "in-session behaviors"). This departure is often defined in terms of the physical, verbal, and psychological distances between the parties.² Both this term and its management can be visualized most clearly in the following example.

Case Vignette
Having spent the entire day indoors, a therapist leaves his office for the day and notes that during the day a heavy but unexpected blizzard has dropped a large amount of snow on the city. Taking comfort in his high-riding sports utility vehicle with 4-wheel drive and winter tires, the therapist begins the drive home. A short distance away he sees his last patient of the day, apparently caught unawares by the sudden snowfall, slogging gamely on foot through deep drifts that the wind has thrown up on the roadside.

The therapist ponders whether to stop and give his patient a ride, either home or to public transportation but worries that to do so is to create a problem with boundaries. However, having the patient possibly die of exposure is not in the service of the therapeutic alliance; thus, the therapist offers the patient a ride and the patient accepts.