Boundary Concerns in Clinical Practice

Thomas G. Gutheil, MD;

Boundary Concerns in Clinical Practice

April 1, 2008

Thomas G. Gutheil, MD

Publication

Article

Psychiatric TimesPsychiatric Times Vol 25 No 4

Volume 25

Issue 4

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.

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.^2,5Three 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 VignetteHaving 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.

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."⁷Conclusion
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.