A vast array of diverse authors have contributed to our understanding of boundaries in psychotherapy. A literature search shows that the topic (boundaries, dual relationships, etc.) has served as the title of over 1,500 books, articles, or dissertations.

It seems worth highlighting a frequently-cited key article that helped transform the framework for what seems to be the predominant view of boundaries today.

The 15 years or so running from the 1980s through the mid 1990s saw non-sexual boundary issues emerge from a period in which they were rarely talked about -- almost as if they were taboo (Pope, Sonne, & Greene, 2006) -- into a creative focus of exploration, argument, research, publication, and changing standards of care. Those years saw a virtual explosion of healthy controversy over dual relationships, bartering, nonsexual touch, meeting therapy clients outside the office for social visits, and other nonsexual boundary issues.

Professionals wrote thoughtful articles during these years challenging basic assumptions, questioning traditional practices, and arguing over virtually every aspect of nonsexual boundaries -- Should all prohibitions be abolished? Was it possible to tell which boundary crossing were therapeutically indicated as helpful, which were therapeutically contra-indicated as harmful, which might be necessary or unavoidable in certain communities or cultures? For citations of works published during this period representing the full spectrum of views on these issues, please see Pope and Vasquez (2007) and Pope and Wedding (2007); see also Pope and Keith-Spiegel (in preparation).

Research during this period revealed how theoretical orientation, size of the local community, therapist gender, client gender, profession (psychologist, psychiatrist, social worker, etc.), and other factors affected both the degree to which therapists engaged in crossing various boundaries and therapists’ beliefs about the nature and appropriateness of boundary crossings.

A landmark 1993 article drew these evolving viewpoints and research findings into a useful framework that continues to shape our current understandings and practices: “The Concept of Boundaries in Clinical Practice” by Tom Gutheil and Glen Gabbard.

Gutheil and Gabbard cast a new light on the historical context of boundaries. Pointing out that many who endorsed inflexible boundaries relied on Freud as an authority, they described how Freud himself sometimes sent postcards to his patients, lent them his books, gave them gifts, talked with them about his own family members, shared meals with an analytic client while on vacation, conducted an analysis while walking through the countryside, and analyzed his own daughter. (It is worth noting for those who love animals that he routinely brought his beloved dog Jofi into the consulting room with him while he conducted analyses.)

Gutheil and Gabbard emphasized that “crossing certain boundaries may at times be salutary, at times neutral, and at times harmful.” In their initial “explorations” of this notion they suggest a framework of “boundary crossings” and “boundary violations” in which our professional judgments must be made on a case-by-case basis in light of context and specifics:

If this exploration is to be useful, we should adopt the convention that “boundary crossing” in this article is a descriptive term, neither laudatory nor pejorative. An assessor could then determine the impact of a boundary crossing on a case-by-case basis that takes into account the context and situation-specific facts, such as the possible harmfulness of this crossing to this patient. A violation, then, represents a harmful crossing, a transgression, of a boundary.

These two innovative therapists discussed examples and implications of this basic framework in such diverse areas of boundaries as “role; time; place and space; money; gifts, services, and related matters; clothing; language; self-disclosure and related matters; and physical contact. While broad guidelines are helpful, the specific impact of a particular boundary crossing can only be assessed by careful attention to the clinical context.”

Gutheil and Gabbard also started a discussion of how some regulatory boards have had difficulty addressing boundary issues in disciplinary actions in a way that takes account of theoretical orientation and other contexts, is consistent with the research, and is fair to the therapist.

They addressed their concerns about the ways in which some licensing boards and other regulatory agencies address boundary issues in much more detail in their subsequent widely-cited and influential 1998 article: “Misuses and misunderstandings of boundary theory in clinical and regulatory settings.”

“The Concept of Boundaries in Clinical Practice” was a turning point for the field in 1993 and continues to help us engage in critical thinking about boundaries and find our way through the sometimes daunting complexity of some of the choices our work brings our way. It is a wonderful resource for thinking through and challenging beliefs, for providing thoughtful explorations, for learning from and arguing against, for understanding the history and development of this area, and for sorting our way through difficult decisions in our day-to-day clinical work.

I believe that this article (along with its follow-up on misuses and misunderstandings of boundary theory in clinical and regulatory settings) is one of those essential works that every clinician, supervisor, expert witness, and member of a licensing board or ethics committee should read, be familiar with, and keep handy. Students in any course on boundaries, ethics, clinical standards of care, clinical judgment and decision-making, or related topics should encounter it on the reading lists.

NOTE: THOSE WHO WOULD LIKE AN ELECTRONIC OR HARDCOPY REPRINT OF EITHER OF THESE ARTICLES MAY SEND A REQUEST TO: Thomas J. Gutheil at Harvard Medical School and the Massachusetts Mental Health Center or -- easier and faster -- at his email address: GutheilTG@cs.com.

For those interested in these issues, I’ve put up some free resources on one of my web sites: <http://kspope.com>. These resources include:

1. standards for dual relationships & other boundary issues quoted from the codes of over 25 professional associations (with links to the complete codes), showing how different organizations take different approaches;
2. quotes & research findings about boundaries in therapy from articles, books, & studies;
3. complete articles (those for which I was able to obtain copyright permission from the publisher to post on the web) addressing boundaries from American Psychologist, Professional Psychology: Research &
Practice, etc.;
4. widely-used decision-making guides for boundary issues (by Jeff Younggren; by Mike Gottlieb; & by Janet Sonne), which meet 3 criteria -- (a) each is free so that those who may be struggling to make ends meet or with limited funds can obtain them without adding to their expenses; (b) each was written by a psychologist who has been recognized by peers as having expertise in ethics through election to serve on the American Psychological Association’s Ethics Committee, and has experience in working with the ethics code as it impacts the lives -- sometimes in decisive and lasting ways -- of individual psychologists; and (c) each is available on the internet so that that clinicians, graduate students, interns, supervisors, and others anywhere in the world can access them as long as an internet connection is available, even in the absence of access to a professional library; and
5. related resources.

That section of the web site begins at: http://kspope.com/dual/index.php

References

Gutheil, Thomas G., & Gabbard, Glen O. (1998). Misuses and misunderstandings of boundary theory in clinical and regulatory settings. American Journal of Psychiatry, 155, 409-414.
Gutheil, Thomas G., & Gabbard, Glen O. (1993). The concept of boundaries in clinical practice. American Journal of Psychiatry, 150, 188-196.
Pope, K.S., & Keith-Spiegel, Patricia C. (in preparation). Nonsexual boundary crossings and boundary violations in psychotherapy.
Pope, K.S., Sonne, Janer L., & Greene, Beverly G. (2006). What therapists don’t talk about and why: Understanding taboos that hurt us and our clients. Washington, DC: American Psychological Association.
Pope, K.S., & Vasquez, Melba J.T. (2007). Ethics in psychotherapy and counseling: A practical guide (3rd edition). San Francisco, CA: Jossey-Bass/John Wiley.
Pope, K.S., & Wedding, Danny. (2007). Contemporary challenges and controversies. Chapter in Corsini, R. & Wedding D. (Eds.) Current Psychotherapies, 8th Edition. Belmont, CA: Thomson Brooks/Cole, 2007.