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Boundaries in Mental Health Treatment
Introduction
Case Vignette
Carolyn is a 34-year-old woman with a history of sexual abuse and dissociative behaviors. She had been in treatment with Jackie O’Brien for 10 years. Jackie terminated treatment with Carolyn because she considered Carolyn to be too dependent. Carolyn has been seeing Nina Black for the past year. Nina is working with Carolyn on the abuse issues, with the primary goal of empowering Carolyn to manage her own symptoms. She has encouraged Nina to learn grounding skills. This goal has been derailed due to Carolyn’s continued contact with Jackie, who will answer Carolyn’s phone calls at all times, including at night and during treatment sessions with other clients. Recently Carolyn had a flashback and instead of attempting any grounding, she called Jackie for reassurance. Nina is frustrated, and Carolyn is angry. She sees Nina as “mean” and feels she is trying to separate her from Jackie.
As the vignette above illustrates, the ability to establish and maintain therapeutic boundaries is an important competency for mental health professionals. “Boundaries”delineate the personal and the professional roles and the differencesthat characterize interpersonal encounters betweenthe client and the mental health professional (Sarkar, 2004). Boundaries are essentialto client and therapist safety. Although setting and maintaining professional boundaries seems on the surface to be a simple process, in actual practice, it can be very difficult. Our professional relationships with our clients exist for their benefit. A useful question to ask ourselves is “Whose needs are being met in this relationship, my client’s or my own?” Ironically, familiarity and trust, basic tenets of effective psychotherapy, as well as the pull to help the client, are what often lead to boundary breaches (Gabbard, 2008b).
Obtaining accurate statistics on the extent of boundary violations isdifficult. Frequently only more serious violations are reported, and minor, less physical, forms of violationare not. Even sexual boundary violations are likely underreported due to shame and guilt on the part of the client. In a 15-year study of malpractice claims against psychologists, Pope (2003) cites sexual violations as the most frequently made allegation. Self-report studies of health careprofessionals suggest a prevalence range of 1–10% (Sakar, 2004).
It is important for practitioners to be aware of issues related to boundaries, of the importance of a strong therapeutic frame, as well as common pitfalls the practitioner can experience.
After finishing this course, the participant will be able to:
- demonstrate familiarity with what often leads to boundary breaches.
- demonstrate familiarity with the most frequently made allegations of ethics
violations.
- demonstrate familiarity with conflicts of interest.
•Demonstrate familiarity with components of informed consent including HIPAA
- demonstrate familiarity with examples of multiple relationships.
- demonstrate familiarity with important areas to consider regarding
boundaries.
Defining Boundaries
Although the term “boundary” is not found in formal ethical codes, it is a key term to understand with regard to professional ethics. A simple metaphor is to think of a boundary as similar to a fence around one’s yard. As the fence marks the parameters of someone’s property, boundaries mark the parameters of a therapeutic relationship. According to Everett and Gallop (2001) “boundaries define the helping pathway — for both clients and professionals — and as such are integral to professional effectiveness (p. 229). Other authors have pointed to professional boundaries as the tool that allows therapists and clients to explore issues in a safe and neutral environment (Guthriel & Gabbard, 1993; Simon, 1999). The most important feature of a therapeutic boundary is that the focus of the relationship is on the welfare of the patient and not the treatment professional (Bennet et. al., 2006).
Boundary concerns include behaviors that span a broad rangein terms of frequency and harmfulness. Some authors make a distinctionbetween boundary violations and boundarycrossings (Guthriel & Gabbard, 1993). The National Council of State Boards of Nursing defines boundary crossings as “a decision to deviate from an established boundary for a therapeutic purpose. These are brief excursions across boundaries with a return to the established limits of a professional relationship” (Peternelj-Taylor, 2003). Guthriel and Gabbard (1998) also utilize the term boundary crossing, which they define as an activity that moves the clinician from a strictly objective position with their clients. A boundary violation, on the other hand, is a harmful boundary crossing. Although boundary crossings may be minor, and there may be therapeutic usefulness of these actions, boundary crossings can have the potential of progressing to a boundary violation. In addition, it is often difficult to assess what actions could cause harm to the client, or know in all cases how a client may interpret a boundary crossing. For instance, one client may construe a small gift as a token of the work done in therapy, while another could interpret it as a therapist’s attempt to move the relationship to a more social level.
The list below provides examples of potential boundary crossings and boundary violations. Mental health professionals should discuss therapeutic boundaries early in the relationship, such as during the informed consent process. In this way boundaries are clearer. Additionally it is important to assess whether a boundary that may be acceptable for some clients may not be appropriate for others. Bennet et. al. (2006) provide the caution that otherwise benign boundary crossings may problematic for patients with “high-risk factors” such as personality disorders. In the example seen in the introduction, it may be perfectly acceptable to allow phone calls between sessions, especially for emergency situations. The fictional therapist Jackie, however, did not consider that the client’s history of sexual abuse may color her perception of the meaning of these phone calls, or that they may interfere with her former client’s current therapeutic goals.
Some examples of boundary crossings include:
• Taking phone calls between sessions (if not agreed upon)
• Small gifts (giving and accepting)
• Specialfee arrangements or bartering
• Allowing patients to run a large balance
• Excessive therapist self-disclosure/disclosure of personal information
• Extending time beyond what wasinitially agreed
• Lengthy sessions, especially last session
• Saying “yes” rather than “no”
• Making special allowances for patient
• Nonemergency meetings outside the office
Examples of boundary violations include:
• Avoidable dual or multiple relationships
• Sexual relationships
Therapists seeking consultation on suchcases often begin the request with "I don't usually do thiswith my patients, but in this case. ..." (Norris et. al., 2004)
An important consideration in terms of what causes harm to the client is not the behavior itself or even the intentions of the treatment professional but the meaning of the behavior to the client (Sarkar, 2004). Both clients and therapists enter the relationship with ideas about what constitutes care and being cared for. A strong therapeutic frame ensures that when these ideas are unconsciously triggered, they do not cause harm to the client.
In contrast boundary violations are behaviors that always result in harm to the client. Sexual relationships with clients are the most severe forms of boundary violations. Sexual boundary violations are often preceded by less extreme boundary crossings. These may include behaviors such as excessive self-disclosure by the therapist, dual roles, or touching/frequent hugs. This will be discussed in more detail later in these materials.
Why Do Boundary Violations/Crossings Occur?
Boundary violations may occur due to a number of factors related to the therapist or the client and how the conscious and unconscious mechanisms of each come together in the therapeutic relationship. As such, it is impossible to identify all the potential factors that could lead to a boundary problem. There have been some attempts, however, to explain this phenomenon. Sarkar (2004) feels that a key factor in why boundary violations occur is that treating professionals have both personal and professional identities. He states “The dutyof physicians is to address the patient’s unconsciousor pre-conscious desires to know not just their professional,but also their personal identity. Their personal identity mayaid the formation and maintenance of their professional identity,but it is for them and them alone to be aware of the distinctionbetween the two identities and to preserve it, at least withinthe therapeutic frame.”
Pilette et. al., (1995) propose a similar framework for explaining why boundary problems occur. These theorists state that the two most common problems that may lead to wearing away of therapeutic boundaries are: 1) inability to differentiate the professional relationship from the social relationship and 2) attempting to have personal needs met through the therapist-client relationship. Although the maintenance of therapeutic boundaries is within the auspices of the treating professional, there are factors that sometimes complicate this task.
One of these factors concerns the treatment environment. In some cases professionals working in a hospital or another residential facility may interact with clients in different ways, such as sharing meals or recreational activities. These may feel more “intimate” to both the client and the treating professional. Clients may come to see the therapist in other roles, such as friend, parent, or sexual object (Peternelj-Taylor, 2008). In addition these treatment environments may contain more challenging clients, such as those with personality disorders, whose presentation may be exaggerated by the anxieties of a hospital setting and the restricted freedom of these settings (Nield-Anderson et. al., 1999). Nield-Anderson (1999) and her fellow authors state that such clients may use manipulation (a word which they divorce from its negative connotation) to satisfy unmet needs for trust, security, and control. They urge treating professionals to be aware of things such as instant intimacy (disclosing information “never told to anyone else”), excessive neediness, and soliciting of personal information. These authors also note the presence of sexually provocative behaviors, such as use excessive flattery, flirting or touching. They recommend that the clinician clarify his or her role as a professional, redirect behaviors, and document these behaviors. Above all, the professional must also remember that the needs of the client are what should drive the therapeutic relationship.
Another concern that may lead to boundary issues is a clinician’s attempt to satisfy personal needs in their relationships with clients. This can be seen in many areas, including personal therapist factors, therapist difficulties with limit-setting, use of touch, caretaking/rescuing, and therapist self-disclosure. Each will be briefly discussed.
Personal Life of the Therapist. Norris et. al.(2003) have identified a number of therapist factors that have been found to precede boundary violations such as sexual misconduct. The first is midlife and late-life crises in therapists' development including difficulty establishing a practice, an excessive needto please patients, and balancing the demands of family and professionallife. Other crises such aging, careerdisappointment, or marital conflict can also result in increased vulnerability to boundary issues. They also identify transitions including retirement, job loss, or job change. Finally therapists' illness appears to increase their vulnerabilityto boundary crossings such as turning to a patient for support.
Therapist Difficulties with Limit Setting. Some patients press for boundary breaches for a variety of psychologicalreasons. A common barrier tolimit setting is the therapist's countertransference conflictsabout aggression or when the prospect of the patient'sexpected distress, discomfort, or frustration at being told"no" is unbearable to the therapist. When caught in such conflicts,therapists with issues around limit-setting may feel that they cannot refuse patients' requeststo violate a boundary (Norris et. al., 2004).
Touch. One concern connected to satisfaction of personal needs is the therapeutic use of touch. This is something that is not specifically mentioned in formal ethical codes, and research on the usefulness/harmfulness of touch has been mixed. There may be many reasons that touch is appropriate in a therapeutic relationship, such as helping clients to accept appropriate non-sexual touch. Some questions that may be helpful to consider:
How can I tell when touching will be helpful or not? Consider: incest or abuse victims, cultural differences
Is touching for the client or my own benefit?
Do I have to hold myself back from expressing affection of compassion in a physical way?
What if my touch is misinterpreted by clients?
If I feel sexually drawn to certain clients, is it dangerous to express physical affection?
Am I reaching out too soon to comfort clients due to my own sense of discomfort with clients’ pain?
Caretaking. An additional concern related to satisfaction of the therapist’s personal needs concerns caretaking. Many authors (e.g., Gabbard, 1996, Peternelj-Taylor, 2008) mention the pull of helping a client to have a rich, full life outside of therapy. This is actually a common transference enactment. Caretaking, however, can take the form of the therapist imagining what it may be like to establish a relationship outside of the treatment setting. Again, it is important that treating professionals can separate personal from professional and also have good self-care strategies and supports. This is particularly important given the potential problems with caretaker burnout.
Another issue with regard to caretaking is that excessive caretaking may limit client self-determination. The NASW code of ethics, for example, states that promoting client self-determination is a core ethical responsibility to clients: “Social workers respect and promote the right of clients to selfdetermination and assist clients in their efforts to identify and clarify their goals.”
Therapist Self-Disclosure. Lastly, some treating professionals have a need to be liked or approved of, and if they are unaware of this, it could take precedence over the needs of the client. One area in which this is seen is that of therapist self-disclosure (Peternelj-Taylor, 2008). This has been somewhat of a controversial topic. Some theoretical orientations, for example, feminist therapy, advocate the use of self-disclosure as a therapeutic medium to reduce the inherent power differential between client and therapist and to increase therapeutic connection. The Feminist Therapy code of ethics explicitly states: “A feminist therapist discloses information to the client that facilitates the therapeutic process, including information communicated to others. The therapist is responsible for using self-disclosure only with purpose and discretion and in the interest of the client.” This view is echoed by Beutler (1978), who states: “the degree of therapist disclosure precipitates a similar degree of disclosure in patients.” Strong and Clairborn (1982) disagree. They state: “therapist disclosure to encourage patient disclosure does not seem like a good use of therapist power unless some specific disclosure is needed.” Other theoretical orientations advocate a more neutral therapeutic stance, suggesting that some degree of disclosure is inevitable, and that therapists disclose indirectly anyway.
In looking at this issue, there seem to be both positive and negative aspects of self-disclosure. One concern about therapist self-disclosure is that it is often the final boundaryexcursion before sexual relations, although self-disclosuredoes not in itself lead inevitably to that outcome (Norris et. al., 2004)
Therapist self-disclosure can be positive, however. It can be used to deepen a client’s disclosures or provide modeling. What is important is that self-disclosure be planned, and be used in conjunction with a therapeutic goal. Such disclosures must be for the benefit of the patient and not for the benefit of the therapist. Even with careful planning, however, there may be some problems inherent in therapist self-disclosure. Consider the following case vignette, for example.
Case Vignette
Mary is a lesbian patient who has been seeing Dr. Liz Grady for two months. Dr. Grady is an openly lesbian therapist, and has found that this has helped her to connect with gay and lesbian clients. One of Mary’s primary issues has been her inability to establish a healthy relationship. She tells Dr. Grady that she generally meets potential partners in bars and that many of these women do not have the maturity she is seeking. Dr. Grady empathizes with Mary, and suggests that she may wish to check out a lesbian support and social group that she herself has found helpful. Mary is uncertain what she should do. Will Dr. Grady be at these meetings? Does she want to be friends with her? Mary responds by canceling her next therapy session.
In the above vignette, Dr. Grady’s degree of self-disclosure may be completely appropriate, but there are certainly aspects that some clinicians, particularly those clinicians that subscribe to less disclosure, may find concerning. Additionally, if Liz does in fact attend the same support group as Mary, this would be a dual relationship. Dual relationships often bring up similar concerns as Mary’s, and canceling sessions or premature termination of therapy may result.