The points summarized in this pocket guide-drawn from actual cases-recur repeatedly as problems for practitioners.
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.
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.