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9 Tips to Maintain Boundaries in Clinical Practice

9 Tips to Maintain Boundaries in Clinical Practice


  • Thoughtful, knowledgeable practice is always best for patients and the best avoidance of trouble for clinicians. The points summarized here recur repeatedly as problems for practitioners. It is a “pocket guide” for clinicians drawn from actual cases.



  • When invited to do something unusual, ask yourself: “Is this what a therapist/psychiatrist does?” Also ask yourself: “Is this for me or for the patient?” An amazing number of treatments go forward without a contract (ie, an agreement by both parties as to what they are there for or what they will work on and how). Not having a contract is a very bad idea. Requests by patients to stray from the therapeutic contract (hold hands, sit on lap, take trips, etc) should be explored and almost always resisted.



  • As a rule, do not take patients outside the office. There are exceptions to the rule: Some programs do use chaperoned home visits, and there are behavior therapy protocols that include outings; however, these must always be within standard practice (eg, treatment of agoraphobia).



  • Consult with a colleague, supervisor, or mentor before questionable actions can occur or after something questionable has occurred. Always remember to document your consultation sessions about patients.



  • You may be emotionally present (but not unconditionally) when in session, barring ordinary human distractions. But do not promise to “always be there” for the patient; it is not a promise that you can keep. Someday your treatment of the patient will come to an end, either by mutual agreement or because of unforeseen circumstances (eg, you may fall ill or you may have a family emergency)—all of which will seem to some patients and, later, to some decision-making bodies, like a betrayal and an abandonment.


  • As a rule, explore therapeutically a patient’s personal questions about you rather than either giving the requested information or responding in a rejecting or punitive manner.

     


  • Treat a patient’s gift as an opportunity to explore. Document your reasoning for accepting or not accepting a gift, and discuss the reasoning with the patient. Avoid giving gifts to adult patients. Boards of registration and licensure often practice “concrete thinking” about gifts and other boundary issues and equally often ignore context; they seem to operate out of a “list of forbidden acts” schema rather than a model based on context, clinical variability, and discretion. You have to supply the context in your notes. If you give a patient a relevant book or article, write it down with your reasons.


  • Do not sign letters, cards, or e-mails “Love,” even if you do so with everyone else in your life. It is, of course, a standard, common, supposedly harmless and perhaps mildly hypocritical closing, but the very patients who are most likely to misconstrue it are the very ones to whom you should not be writing it.


  • Communicate your caring and concern by always keeping your focus on the patient’s needs and issues first. Do not tell a patient that you love him or her, even if you do. You may mean divine, abstract love, but the patient may hear (and the board may assume you meant) eros.


  • Thoroughly document the incidents that seem questionable to you regarding boundaries; not to do so suggests a cover up. Use the 3 D’s: demeanor, documentation, and debriefing. If you give a patient a ride to the bus station in a blizzard, for example, keep a professional demeanor in the car; document the situation and your reasoning; and debrief it with the patient at his or her next session.


  • For more information, see “Boundary Concerns in Clinical Practice” and “A ‘Pocket Guide’ to Avoiding the Most Common Boundary Pitfalls,” by Thomas G. Gutheil, MD, on which this slideshow is based.

View slides in PDF format.

Disclosures: 

Dr Gutheil is Professor of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School. He is an editorial board member of Psychiatric Times.

References: 

READING LIST

Gutheil TG, Brodsky A. Preventing Boundary Violations in Clinical Practice. New York: Guilford Press; 2008.

Gutheil TG, Gabbard GO. The concept of boundaries in clinical practice: theoretical and risk-management dimensions. Am J Psychiatry. 1993;150:188-196.

Gutheil TG, Gabbard GO. Misuses and misunderstandings of boundary theory in clinical and regulatory settings. Am J Psychiatry. 1998;155:409-414.

Gutheil TG, Simon RI. Non-sexual boundary crossings and boundary violations: the ethical dimension. Psychiatr Clin North Am. 2002;25:585-592.

Norris DM, Gutheil TG, Strasburger LH. This couldn’t happen to me: boundary problems and sexual misconduct in the psychotherapy relationship. Psychiatr Serv. 2003;54:517-522.
 

Comments

A note from the author:

My forensic consultative experience indicates without a doubt that these basics need to be reviewed, and practitioners reminded, on a regular basis. I did not invent this problem; I merely comment on the passing scene. It is my impression—and I would welcome some observations—that the topic of boundaries is still insufficiently explored in training programs; political correctness, taboos, claims that "it's obvious," fears—as with suicide—that discussing it may provide an incentive, may all be to blame.

Thomas G. Gutheil, MD

PsychTimes @

OK....
All this is very correct , but who out there is so professionally untrained to need this low level advice? Has medical training become so politically correct and Californiated that there are actually psychiatrists who need to be advised not have the pt "sit in their lap" or tell them "you love them?"
If any practicing psychiatrist is out there doing any of these things , then, yes, for God's sake, STOP.

Alan @

Again, If you are shocked people need this advice, maybe you are the one who is having difficulties with boundaries... Practioners with poor boundaries makes it difficult for the rest of us.

Gia @

Sorry
Pardon me, is what I should have written first.

Gia @

There very definitely are practicing psychiatrists and other psychotherapists doing "these things," not from lack of training but more likely from their inability to control their own compulsions, etc. The statement, "for God's sake, STOP" falls into the realm of "Just Say No." Ideal but not real. The word "If" at the beginning of that sentence falls into the longest river, denial.
A significant problem victims of this kind of exploitative behavior have is finding good subsequent treaters who do not immediately assume that this is about the patient's pathology and not about the trauma that has been inflicted on them. Tom Gutheil's slides, at the least, should serve as a reminder that these things do happen, that when they do, patients are likely to suffer serious trauma, and that the acknowledgement to a victim that this is a very real phenomenon is generally palliative.
J

Janet W @

Then again, sometimes it's very much about the patient's pathology. An ASP (or sociopath or "malignant/covert narcissist") is an expert at convincing people that the reason the boundary is there in the first place doesn't apply in *this* case, so there's no purpose in upholding the boundary itself - and, in fact, to do so would be counterproductive.

Then there's the myth that all therapists are codependent. Perhaps I should have put ironic quotes around it: "myth". I know of a couples' therapist who broke every rule in the book, in the mistaken belief that she was protecting one patient from the other - that is, from his spouse. In reality, his spouse was very much the victim of the patient the therapist got involved with. (One of many victims, it turned out.) And, of course, so was the therapist, although she didn't realize it at the time. The level of denial this experienced therapist allowed herself, while genuinely believing that this case was "the exception", was amazing, as evidenced by such statements as "Women are supposed to be the strong ones, so I felt I had to protect him; of course, it's not really true, but that's what I was thinking" and "I knew [his wife] had a therapist, so she would be OK when she found out". All of this based on the private, shall we say, "between sessions", word of the perpetrating patient, without the therapist witnessing any confirmation whatsoever in session. This is a therapist who usually earns high praise, because she is (normally) very insightful and effective. But in this case, she ignored her own boundaries, and the professional ethics rules for every therapist, left and right. This was at the behest of a patient who knew exactly what he was doing; and what he was doing was manipulating the therapist in order to manipulate his wife further: in other words, while believing she was "protecting" this patient, the therapist was actually assisting him in further abusing his wife.

How could such an insightful and effective therapist not see what was happening? Was this pathological patient really that much *more* insightful and effective than the therapist was? I don't believe so. I think that therapists do *not* generally recognize serious pathologies (including, but not limited to cluster B personalities), instead assuming that "Statistically, it's vanishingly rare - I'm not likely to ever come across one", and to make the problem a great deal worse, tend to assume that anything that any patient says to them is completely truthful. (From the patient's point of view, of course.) "I provide a safe place to be honest, and the patient knows that, and the patient wants my help, so naturally, the patient will be honest with *me*." (In a similar vein, many therapists, when counseling an addict, will assume that anything the patient says to them actually is truthful. A baffling blind spot in a therapist; a kind of institutional hubris.)

So what tripped up this therapist? The simple confusion of the "usual" for the "always" - which is so easily exploited by a patient who wants to manipulate the therapist. If one member of a patient couple says the other is lying, the patient making the accusation is believed, because *usually* that patient is the more aggrieved party (and as the codependent, usually also the one trying to save the marriage). Repair of the marriage, or the decision to split, depends on whether the spouse indulging in the worst behavior is willing to work on the marriage, too. But in the case of a cluster B patient, for instance, the exact opposite could be true, and in that case, the cluster B patient will appear exactly like the truthful patient in a "usual" couple. And the truthful spouse may appear to be emotionally disregulated, particularly if the cluster B spouse had been gaslighting him/her.

I have heard innumerable therapists proclaim, "That would never happen to me. I'd recognize a psychopath / narcissist / manipulator within a few minutes after the first session began." But it actually seems to be very rare indeed, when a therapist even recognizes a deliberate lie told by *any* patient. Perhaps this is because of the very common belief that the therapist's main duty is to "relieve the pain" of the patient. The problem with this approach is that it can quite easily lead to enabling the patient to inflict pain on others - regardless of the type of patient. (No serious pathology required, although the enabling by the therapist certainly increases the possibility of serious pathology developing during the course of therapy.)

Perhaps along with teaching good ol' basic boundaries, it would be helpful to do some very thorough teaching about how to recognize the type of manipulations used by various types of patients *upon* their therapists. (And as a necessary complement, how to tell the difference between a real borderline personality, and the BPD-like behavior of a victim of an ASP or NPD).

Tati @

Thanks Dr Gutheil, this is very helpful. I wonder if you could follow up with some guidance for psychiatrists who work in academic centers that increasingly depend on philanthropic gifts from patients and families? This situation raises boundary issues, and though we work with our professional development offices, their job is to raise money, often from our patients.

Deirdre @

May I use your slides to teach in an ethics class for masters level therapists?

Thank you

A. Lucas MA LMHC

Anne @

Dear A. Lucas,
Dr. Gutheil and Psychiatric Times give you permission to use the slides in a class, as long as full attribution is given as follows:

Gutheil TG. 9 Tips to Maintain Boundaries in Clinical Practice. Psychiatric Times. March 31, 2017. http://www.psychiatrictimes.com/forensic-psychiatry/9-tips-maintain-boun.... Accessed [xx/xx/xxxx].

If you have further questions, feel free to contact me. Thank you.

Laurie Martin
Digital Managing Editor
Psychiatric Times
Email: Editor@PsychiatricTimes.com

PsychTimes @

Just a tidbit of semantic humor. By debriefing you mean talk about it next time. I like to think of a cardinal rule of "always keeping your pants on". I have always thought of the word "debriefing" as a tricky word.

A couple of adages I learned in my life as a social worker before medical school.
1) Don't get laid where you get paid (don't sleep with or flirt heavily with co-workers, much less patients)
2) Never work harder than your client
3) I care..... but not that much (meaning, at the end of the day, it is still THEIR Journey and they must walk it... we accompany them on part of the path as it goes through the forrest, but when we reach a clearing, they must go on without us.)

Also, I wanted to mention Irvin Yalom's great book, "The Gift of Psychotherapy" as one of the best sources on the art of non-eros love for the patient, and the value of this love in the therapeutic relationship.

I ask of the universe that I be given the capacity to freely move within the realms of my profession so that I can be in some moments deeply and calmly empathic, and at other moments quite firm, as the individual patient situation calls for. I pride myself for having been fired by some of the best benzo-seeking manipulators in the business, and at the same time one of the most accepting and life changing psychiatrists some of my patients tell me they have ever met. When one of my resident colleagues tells me they have been rejected or fired by a patient for one thing or another, I like to point out that it goes with tha job, and that I have, in my career, been called "[expletive *** COMMENT EDITED]" who doesn't care and doesn't understand. I've learned to feel an ironic sense of pride in this, and yet to know that the ability to move, as needed, between both ends of the spectrum (with "[expletive *** COMMENT EDITED]" on one end and "transcendent life changing spiritual coach/ the first person who ever understood me and helped me to accept myself as I truly am" on the other end of the spectrum)... this is the art of love and the dance of the work itself.

Lisa E @

About gifts, a: 'Manual for Inquisitors', by Nicolau Eimeric, XIII century, pointed, regarding if the inquisitor may request that the inquired pay the expenses: 'To them -inquisitors- extend the indications of saint John the Baptist: 'Don't hurt no one, don't slander no one, be satisfied with your salary'.

Moderate gifts, spontaneously offered, can be accepted. So, in: De.eulogiis.de.offic.procons, discussing if it's acceptable for a judge receiving gifts, said:
“Never, is inhumane; many times, vile; always, is pure and simple greed”.
However, he personally thought that no spontaneous gifts from litigants should be accepted, in order to avoid suspicions.

Jose @

An old Spanish medical proverb said: 'Encounter visit yields no money nor reputation',

In a fight between two practitioners in a medical meeting, the shorter of them, who was losing, shouted: 'Beat, beat, but don't prescribe!'

Jose @

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