Must Some Boundaries Be Crossed?

Recent discussions on the Division 42 listserv have focused on the very complex and, for many, very troubling issue of multiple relationships. The question was raised about the appropriateness of providing home visits to patients. The ensuing discussion was expanded to include other therapist behaviors such as driving in a car with a phobic patient or other outside the office meetings, the use of touch or self-disclosure, and the exchange of small gifts. These behaviors were discussed in the context of multiple relationships and the fear was expressed that they may be viewed as harmful, exploitative, inappropriate, or below the standard of care of our profession. The concern is expressed that these behaviors would be difficult to justify in the context of a malpractice suit or ethics investigation.

One reaction described is a strict avoidance of all multiple relationships. But are all multiple relationships harmful? Are the behaviors described above all "multiple relationships" so therefore they should be avoided at all costs? Or does such a strict stance detract from the richness of the psychotherapy relationship and as Zur (2000) asks, even harm patients? In our attempt to comply with ethical standards and to protect against malpractice claims are we actually hurting ourselves and our patients?

To answer these questions it is proposed that a clear and concise use of certain words and concepts must first occur. Rather than lump all the behaviors described above in the catch-all category of "dual relationships" or "multiple relationships" we must first think in terms of "boundaries." Smith and Fitzpatrick (1995) discuss boundaries in terms of "a therapeutic frame which defines a set of roles for the participants in the therapeutic process" (p. 499). They describe this frame as including structural elements such as time, place, and money, and the content of psychotherapy or what Gutheil and Gabbard (1993) describe as "role." Issues such as space, gifts, language, self-disclosure, and physical contact are viewed as boundary issues.

Gutheil and Gabbard (1993) raise for us the specific dilemma psychologists are grappling with. First, available data indicates that inappropriate and exploitative behaviors are often preceded by relatively minor boundary crossings. Yet, not all boundary crossings or even boundary violations lead to more inappropriate or harmful behaviors by the practitioner. One way of avoiding patient exploitation is to never cross any of these widely agreed upon boundaries, but, in reality, this attempt at risk management is excessive, it actually may be harmful to patients, and it really just isn’t possible.

A boundary crossing is not the same as a multiple relationship and it most definitely is not necessarily harmful or exploitative. It also does not necessarily lead one down the "slippery slope" toward other boundary incursions of increasing magnitude that will invariably lead to sexual intimacies or other forms of exploitation with our patients. While this may occur, it may, in fact be due to other therapist factors such as a tendency toward exploitation or other pathology (Zur, 2000).

Psychologists must differentiate between boundary crossings, which are not harmful and which may not only be appropriate at times, but even necessary for providing effective and caring treatment; and boundary violations, which are harmful and should be avoided. The distinction may at times be a difficult one to make, but it is the patient’s perception, not ours, that dictates this. Also, as Zur (2000) points out, professional isolation is our enemy. When unsure on these matters, consultation with colleagues is of great importance. There also may be a great difference between various therapist actions and behaviors along the dimensions of intent, impact on the patient, relevance to the patient’s treatment needs and treatment plan, outcome for the patient, and the view of others such as colleagues, ethics committees, licensure boards, and the courts.

For example:

Self-disclosure: Sharing with a patient who has suffered a great loss about a personal tragedy you overcame with assistance despite initially feeling this couldn’t be possible vs. sharing with an attractive patient about the difficulties you’re having in your marriage and how unsympathetic your spouse is to the many stresses you are under.

The use of touch: Responding to a patient’s outstretched hand with a handshake or touching a grieving patient on the forearm vs. hugging a patient at the end of each session or having a patient sit on your lap during a session and stroking her or his hair as descriptions of past abuse are described.

Location: Providing psychotherapy sessions at a patient’s home for a homebound individual or driving with a phobic patient while conducting systematic desensitization vs. having lunch with a patient at a local restaurant or going to movies or out dancing with a patient.

Time: Allowing a session to run over the allotted time for a patient who is clearly in crisis and in need of immediate assistance and intervention vs. spending increasing amounts of time with a patient who is particularly attractive to you and even scheduling these sessions at the end of the day so you won’t be disturbed by other patients arriving for their sessions.

Role: Providing psychotherapy to a member of your church or synagogue when refusing to do so would result in the person not receiving needed treatment because the nearest other mental health professional is several hours away vs. providing psychotherapy to your spouse’s employer when there are other qualified clinicians in the local community who could easily provide this treatment.

Post-termination relationships: Providing a patient with four sessions of stress management training with treatment successfully being completed, meeting by chance 10 years later, and entering into a personal relationship vs. providing a patient with ongoing intensive long term psychotherapy, feeling attracted to this patient, and ending the treatment so you may enter into a personal relationship with this individual.

It is hoped that these examples highlight the rich diversity of boundary issues and multiple relationships. Certainly, one's theoretical orientation is of great relevance and we should always be sensitive to the role of transference and counter transference reactions. We should also be mindful of the potential impact of our actions on patients and the psychotherapy process. All of our actions as psychotherapists should be consistent with a written treatment plan that we can justify as in the patient’s best interest. We should also attempt to include such issues in our ongoing informed consent process with patients so they are active participants in the decision making process that leads to the use of these techniques or actions. Consultation with experienced colleagues is also an important step in ensuring our actions are in each patient’s best interest and not self-serving for us or in some other way exploitative or harmful. Additionally, as Lazarus (1998) recommends "…we need to employ carefully measured, case-by-case, nondogmatic evaluations of boundary questions. Individual client differences should be emphasized rather than subjugated to rigid standards" (p. 24). Thus, the use of a formal, structured decision-making model or process (see Yes, but is it ethical?; Barnett, 2000) that addresses each patient’s treatment needs and best interests and that is documented as well, will also help us to achieve the goal of providing caring, compassionate, and effective treatment that does not exploit or harm our patients or put us at increased risk for punitive action.

References

Barnett, J. E. (2000). Yes, but is it ethical? 42 Online. www.division42.org

Gutheil, T.G. & Gabbard, G.O. (1993). The concept of boundaries in clinical practice: theoretical and risk-management dimensions. American Journal of Psychiatry, 150, 2, 188-196.

Lazarus, A.A. (1998). How do you like these boundaries? The Clinical Psychologist, 51, 1, 22-25.

Smith, D. & Fitzpatrick, M. (1995). Patient-therapist boundary issues: An integrative review of theory and research. Professional Psychology: Research and Practice, 25, 5, 499-506.

Zur, O. (2000). In celebration of dual relationships: How prohibition of non-sexual dual relationships increases the chance of exploitation and harm. The Independent Practitioner, 20, 2, 97-100.


	News and Views Ethics Issues		Must Some Boundaries Be Crossed?
	Ethics Table of Contents		by Jeffrey E. Barnett, Psy.D.

			Recent discussions on the Division 42 listserv have focused on the very complex and, for many, very troubling issue of multiple relationships. The question was raised about the appropriateness of providing home visits to patients. The ensuing discussion was expanded to include other therapist behaviors such as driving in a car with a phobic patient or other outside the office meetings, the use of touch or self-disclosure, and the exchange of small gifts. These behaviors were discussed in the context of multiple relationships and the fear was expressed that they may be viewed as harmful, exploitative, inappropriate, or below the standard of care of our profession. The concern is expressed that these behaviors would be difficult to justify in the context of a malpractice suit or ethics investigation. One reaction described is a strict avoidance of all multiple relationships. But are all multiple relationships harmful? Are the behaviors described above all "multiple relationships" so therefore they should be avoided at all costs? Or does such a strict stance detract from the richness of the psychotherapy relationship and as Zur (2000) asks, even harm patients? In our attempt to comply with ethical standards and to protect against malpractice claims are we actually hurting ourselves and our patients? To answer these questions it is proposed that a clear and concise use of certain words and concepts must first occur. Rather than lump all the behaviors described above in the catch-all category of "dual relationships" or "multiple relationships" we must first think in terms of "boundaries." Smith and Fitzpatrick (1995) discuss boundaries in terms of "a therapeutic frame which defines a set of roles for the participants in the therapeutic process" (p. 499). They describe this frame as including structural elements such as time, place, and money, and the content of psychotherapy or what Gutheil and Gabbard (1993) describe as "role." Issues such as space, gifts, language, self-disclosure, and physical contact are viewed as boundary issues. Gutheil and Gabbard (1993) raise for us the specific dilemma psychologists are grappling with. First, available data indicates that inappropriate and exploitative behaviors are often preceded by relatively minor boundary crossings. Yet, not all boundary crossings or even boundary violations lead to more inappropriate or harmful behaviors by the practitioner. One way of avoiding patient exploitation is to never cross any of these widely agreed upon boundaries, but, in reality, this attempt at risk management is excessive, it actually may be harmful to patients, and it really just isn’t possible. A boundary crossing is not the same as a multiple relationship and it most definitely is not necessarily harmful or exploitative. It also does not necessarily lead one down the "slippery slope" toward other boundary incursions of increasing magnitude that will invariably lead to sexual intimacies or other forms of exploitation with our patients. While this may occur, it may, in fact be due to other therapist factors such as a tendency toward exploitation or other pathology (Zur, 2000). Psychologists must differentiate between boundary crossings, which are not harmful and which may not only be appropriate at times, but even necessary for providing effective and caring treatment; and boundary violations, which are harmful and should be avoided. The distinction may at times be a difficult one to make, but it is the patient’s perception, not ours, that dictates this. Also, as Zur (2000) points out, professional isolation is our enemy. When unsure on these matters, consultation with colleagues is of great importance. There also may be a great difference between various therapist actions and behaviors along the dimensions of intent, impact on the patient, relevance to the patient’s treatment needs and treatment plan, outcome for the patient, and the view of others such as colleagues, ethics committees, licensure boards, and the courts. For example: Self-disclosure: Sharing with a patient who has suffered a great loss about a personal tragedy you overcame with assistance despite initially feeling this couldn’t be possible vs. sharing with an attractive patient about the difficulties you’re having in your marriage and how unsympathetic your spouse is to the many stresses you are under. The use of touch: Responding to a patient’s outstretched hand with a handshake or touching a grieving patient on the forearm vs. hugging a patient at the end of each session or having a patient sit on your lap during a session and stroking her or his hair as descriptions of past abuse are described. Location: Providing psychotherapy sessions at a patient’s home for a homebound individual or driving with a phobic patient while conducting systematic desensitization vs. having lunch with a patient at a local restaurant or going to movies or out dancing with a patient. Time: Allowing a session to run over the allotted time for a patient who is clearly in crisis and in need of immediate assistance and intervention vs. spending increasing amounts of time with a patient who is particularly attractive to you and even scheduling these sessions at the end of the day so you won’t be disturbed by other patients arriving for their sessions. Role: Providing psychotherapy to a member of your church or synagogue when refusing to do so would result in the person not receiving needed treatment because the nearest other mental health professional is several hours away vs. providing psychotherapy to your spouse’s employer when there are other qualified clinicians in the local community who could easily provide this treatment. Post-termination relationships: Providing a patient with four sessions of stress management training with treatment successfully being completed, meeting by chance 10 years later, and entering into a personal relationship vs. providing a patient with ongoing intensive long term psychotherapy, feeling attracted to this patient, and ending the treatment so you may enter into a personal relationship with this individual. It is hoped that these examples highlight the rich diversity of boundary issues and multiple relationships. Certainly, one's theoretical orientation is of great relevance and we should always be sensitive to the role of transference and counter transference reactions. We should also be mindful of the potential impact of our actions on patients and the psychotherapy process. All of our actions as psychotherapists should be consistent with a written treatment plan that we can justify as in the patient’s best interest. We should also attempt to include such issues in our ongoing informed consent process with patients so they are active participants in the decision making process that leads to the use of these techniques or actions. Consultation with experienced colleagues is also an important step in ensuring our actions are in each patient’s best interest and not self-serving for us or in some other way exploitative or harmful. Additionally, as Lazarus (1998) recommends "…we need to employ carefully measured, case-by-case, nondogmatic evaluations of boundary questions. Individual client differences should be emphasized rather than subjugated to rigid standards" (p. 24). Thus, the use of a formal, structured decision-making model or process (see Yes, but is it ethical?; Barnett, 2000) that addresses each patient’s treatment needs and best interests and that is documented as well, will also help us to achieve the goal of providing caring, compassionate, and effective treatment that does not exploit or harm our patients or put us at increased risk for punitive action. References Barnett, J. E. (2000). Yes, but is it ethical? 42 Online. www.division42.org Gutheil, T.G. & Gabbard, G.O. (1993). The concept of boundaries in clinical practice: theoretical and risk-management dimensions. American Journal of Psychiatry, 150, 2, 188-196. Lazarus, A.A. (1998). How do you like these boundaries? The Clinical Psychologist, 51, 1, 22-25. Smith, D. & Fitzpatrick, M. (1995). Patient-therapist boundary issues: An integrative review of theory and research. Professional Psychology: Research and Practice, 25, 5, 499-506. Zur, O. (2000). In celebration of dual relationships: How prohibition of non-sexual dual relationships increases the chance of exploitation and harm. The Independent Practitioner, 20, 2, 97-100.

	Return to Top