Boundary Concerns in Clinical Practice

What principle should govern this interaction? The 3 critical principles here can be generalized to many otherwise problematic interactions relating to boundaries. First, although the vehicle is a confidential environment, the therapist resists the temptation to convert it into an office for finishing or extending the just-completed session. Instead, the therapist continues to behave in a professional manner and refrains from continuing the therapy. The therapist also avoids allowing the informality of the situation to prompt extensive self-disclosure.

Second, at the next scheduled session, the patient is debriefed on his feelings about the event. An extensive panoply of possible reactions may be evoked by the ride, all of which replay therapeutic attention according to the agreed-on modality (the contract). If the context involves exploratory therapy, deep exploration of the patient's feelings and fantasies may be appropriate; more cognitive- behavioral models might lead to attention to the patient's thoughts and subsequent behaviors, and so on. These approaches ensure that the maximum utility of this accidental occurrence is realized.

Finally, the therapist documents not only the details of the event but also the reasoning, judgment, and decision-making that governed the choice of intervention. Failure to document the event raises damaging questions about concealment or cover-up of a deviation from traditional psychotherapeutic practice; the simple act of recording the use of clinical judgment documents the antithesis of negligence. In addition to using documentation, it may be profitable to report the incident to a consultant or supervisor.

These 3 approaches—professional conduct, debriefing, and documentation—may be used whenever the therapist notes that some form of boundary crossing has occurred. Their combined effect is to safeguard the therapy from distortion or derailment by the boundary crossing.

Why should such pains be taken with this essentially lifesaving maneuver whose value cannot be seriously questioned? The answer harks back to the possibility of misunderstanding by agencies whose "list of forbidden acts" may include meetings outside the office. While in some cases extra-office meetings may indeed be precursors to more serious boundary problems, the approach outlined above will usually successfully avert this misperception.

Regulatory agencies are not the only ones capable of misconstruing a boundary issue. For example, a patient who had recently experienced a series of personal and family losses begins uncontrollably sobbing in her doctor's office. Later that evening the doctor calls the patient at home to inquire if she is all right. She indicates she is but later complains to the Board of Medicine about the boundary transgression involved because the doctor had called her at home.

We might dismiss this incident as a layperson's minor misconception of what constitutes a boundary problem. However, it illustrates the observation that members of the public have their own formulations of what is and what is not a professional boundary.

Boundary violations
In contrast to benign boundary crossings, boundary violations are the harmful and exploitative form of deviations from standard therapeutic procedures. In violations, the therapist departs from the therapeutic role, which places the patient's needs first; most boundary violations place the therapist's needs, wishes, and goals ahead of the patient's. From this viewpoint, a sexual relationship with a patient would constitute the ultimate boundary violation, not only because of its exploitative nature and departure from all professional codes but because it almost always is harmful to the patient and to the therapy itself.

The violation may or may not be intentional; one can do harm by accident. Although the distinction between the benign and the noxious would seem to be straightforward, the opposite is true: depending on the context, the identical behavior may be a crossing or a violation. For example, the therapist's self-disclosure of unmarried status may be an important part of alliance support with an extremely ill, concrete patient; or an initial gambit of seduction—again, depending on context.

As noted, an additional complexity here is the fact that some crossings may be benign in intent but harmful in effect. To modify an earlier example, helping a patient who has fallen may trigger traumatic abuse memories in a particular case. In such a situation, the 3 responses noted earlier —professionalism, debriefing, and documentation—should probably be supplemented by tactful apology.

Boundary violations challenge a suitably neutral view of the dyad and its asymmetry of responsibility.

A patient may initiate behavior that presents a serious threat of a boundary violation, such as disrobing in the office or im- pulsively kissing the therapist. However, since the therapist retains responsibility for maintaining boundaries, whether the provocative behavior leads to a boundary violation actually depends on the therapist's response.²

A pitfall seen in consultative practice is the therapist's rationalization that if he or she has been persuaded by a patient to commit one boundary violation there is no option but to go on to more extensive violations, because to stop treatment is to risk retaliatory reporting and punishment for the violation already committed. In reality, it is always possible to acknowledge one's error, apologize, and attempt to get back on a professional footing, preferably with the aid of supervision and consultation. Some form of consequence, of course, may yet occur, but at least the patient is spared additional harm.

Areas of controversy In a number of areas the crossing/ violation distinction can become especially cloudy. If a patient gives a therapist a small gift in gratitude for good work, has the relationship been exploited? On the other hand, if the patient gives a therapist of the opposite sex an erotic device or seductive article of clothing, what context might justify that? Under what circumstances might excursions outside the office or hospital be appropriate or inappropriate? How much and what kind of self-disclosure is a cross- ing or a violation?

In considering these dilemmas clinicians themselves and regulatory forces must not only consider context but must resist the temptation to revert through anxiety and uncertainty to the "list of forbidden acts" paradigm that seems to offer illusory clarity. The 2 sovereign pathways to clarity remain documentation and consultation.⁶

Consultation especially offers a view from outside the intensity of the dyad, as well as offering reassurance of protection of the patient and avoidance of negligent conduct. The therapist who finds himself reluctant to obtain consultation about a boundary problem has been given involuntary insight into a likely countertrans- ference resistance that makes a consultation all the more essential. Equally significant to the same effect is the therapist's rationalization, "It couldn't happen to me."⁷

Conclusion
The concept of boundaries poses many challenges for the clinician and for the patient, as well as for later evaluators of the conduct involved. Beyond careful documentation and maintenance of a low threshold for consultation, increasing awareness and understanding of the underlying issues, as may be provided by this Special Report section, may aid the clinician to maintain the necessary level-headed perspective to avoid the clinical, legal, and ethical problems that can occur in this charged area.