Treatment Boundary Violations:
Clinical, Ethical, and Legal Considerations
Robert I. Simon, MD
What is a therapeutic relationship
The observance of treatment boundaries maintains the integrity of the therapist-patient relationship. It is the therapist's professional duty to establish appropriate treatment boundaries. Basic boundary guidelines are reviewed. The principles underlying these boundary guidelines are explored. A clinical vignette describing the sexual exploitation of a patient by her therapist dramatically illustrates progres-sive boundary violations. Boundary violations involving money are particularly com-mon. Double agent roles also are likely to lead to the establishment of dissonant treatment boundaries with patients. The clinical, ethical, and legal issues surround-ing the maintenance of treatment boundaries are discussed.
The concept of treatment boundaries developed during the twentieth century from outpatient psychodynamic psycho-therapy. Treatment boundaries have been a continuing issue since the begin-ning of psychoanalysis, reflected in Freud's disputes, for example, with Fer-enzi and Reich. Ethical principles devel-oped by the mental health professions and the legal duties imposed by courts and statutes have further defined treat-ment boundaries. For example, the cli-nician's duty to maintain confidentiality derives from three distinct origins: professional (clinical), ethical, and legal.
Treatment boundaries are set by the therapist that define and secure the ther-apist's professional relationship with the patient for the purpose of promoting a trusting, working alliance. The bound-ary guidelines listed below are generally applicable to the broad spectrum of psy-chiatric treatments. Nevertheless, con-siderable disagreement exists among psychiatrists concerning what consti-tutes treatment boundary violations. The therapy techniques of one therapist may be anathema to another therapist who considers such practices as clear boundary violations. Much variability in defining treatment boundaries appears to be a function of the nature of the patient, the treatment and the status of the therapeutic alliance. For example. notable exceptions do occur in alcohol and drug abuse programs, in inpatient settings and with certain cognitive-be-haviorally based therapies. Regardless of the therapy used, every therapist must maintain basic treatment boundaries with all patients. If boundary exceptions are made, they must be made for the benefit of the patient. Every effort must be exerted to therapeutically restore breached boundaries. Brief boundary vi-olations that are quickly recognized and rectified can provide important insights into conflictual issues for both the ther-apist and patient. The danger to treat-ment arises when boundary violations progress in frequency and severity over time.
Since boundary guidelines maintain the integrity of therapy and safeguard both the therapist and the patient, pro-ponents of therapies that breach gener-ally accepted boundary guidelines risk harming the patient and suffering the legal consequences.' Psychiatry contin-ues to be highly receptive to innovative treatments that offer the hope of helping the mentally ill. The maintenance of basic treatment boundaries, by itself, should not be an impediment to thera-peutic innovations. On the contrary, conducting innovative therapies in gen-eral accord within accepted treatment boundaries should provide added credi-bility.
Professional boundaries in health care relationships
Psychotherapy as an Impossible Task
All psychiatric therapies, regardless of their philosophical or theoretical orien-tation, are based upon the fundamental premise that interaction with another human being can alleviate psychic dis-tress, change behavior, and alter a per-son's perspective of the world.* Psycho-therapy can be defined as the application of clinical knowledge and skill to the dynamic psychological interaction be-tween two people for the purpose of alleviating mental suffering. This defi-nition of psychotherapy also applies to biological and behavioral therapies. But psychotherapy is an impossible task.' There are no perfect therapists nor per-fect therapies.
Psychotherapy also has been defined as a mutually regressive relationship with shared tasks but different roles.3 Boundary violations are therapist role violations that inevitably occur to a de-gree in every therapy. Although main-taining boundaries is a major psycho-therapeutic imperative, the competent psychotherapist must recognize when he or she has erred. Often, the real work of psychotherapy involves the therapeutic restitution of breached boundaries. Treatment boundaries usually can be reestablished if the therapist can raise the boundary violation as a treatment issue. Since therapists use themselves as a therapeutic tool, sensitivity to bound-ary violations must be maintained at a high level.
From a clinical perspective. the ther-apeutic alliance is considered by most practitioners to be the single most criti-cal factor associated with successful treatment.4 The maintenance of treat-ment boundaries sets the foundation for the development of the therapeutic alli-ance and the subsequent work of ther-apy. Trust is the essential basis for a secure therapeutic relationship that per-mits patients to reveal their innermost yearnings and fears. The patient's trust is based upon the belief that the therapist is acting professionally and using skills
Violations of the Boundaries in Therapy
in a competent manner for the benefit of the patient. The maintenance of con-sistent, stable, and enabling treatment boundaries creates a safe therapeutic en-vironment for the patient to risk self-revelation. At base, the therapist's professional concern and respect for the patient ensures that treatment bounda-ries will be preserved.
Treatment boundary violations occur on a continuum that may interfere with the provision of competent clinical care to the patient. Boundary violations fre-quently are a consequence of the thera-pist acting out personal conflicts. As a result, the patient's diagnosis may be missed. Inappropriate treatment may be rendered. Moreover, the patient's origi-nal psychiatric condition may be wors-ened. Boundary violations may repre-sent deviations in the standard of care that are alleged to have harmed the pa-tient, forming the basis of a malpractice claim. Boundary violations as an inte-gral part of negligent psychotherapy are inevitably present in claims of sexual misconduct as in well as other types of suits alleging exploitation of patients.
Boundary violations also encourage malpractice suits by creating a misalli-ance between therapist and patient. Boundary violations, usually reflecting the personal agenda of the therapist, set patient and therapist against one an-other. Langs5 notes that the failure to maintain treatment boundaries may lead to autistic, symbiotic, and parasitic relationships with patients. Langs ob-serves that autistic relationships (severed link) between therapist and patient dam-age meaningful relatedness, symbiotic (fusional) relationships pathologically gratify the patient, and parasitic (de-structive) relationships exploit the pa-tient. As frequently happens, bad results combined with bad feelings set the stage for a malpractice s u k 6
Characteristics of Therapeutic Relationship
Treatment boundaries are set by the therapist according to accepted profes-sional standards. It is the therapist's professional duty to establish and main-tain appropriate treatment boundaries in the provision of good clinical care. This duty cannot be delegated to the patient. Once treatment boundaries are established, boundary issues inevitably arise in working with the patient that form an essential aspect of treatment. Boundary violations,on the other hand, arise solely from the therapist and are often inimical to treatment, particularly if unchecked and progressive. Therapists who establish idiosyncratic boundaries or set no boundaries at all are likely to provide negligent therapy that harms the patient and invites a malpractice suit. A major continuing task for therapists is the maintaining of constant vigilance against boundary violations and imme-diately repairing any breaches in a clin-ically supportive manner.
Observing the following boundary guidelines for psychotherapy will help maintain the integrity of the treatment process:
Maintain relative therapist neutral-ity
Foster psychological separateness of patient
Obtain informed consent for treat-ments and procedures
Interact verbally with patients
Ensure no previous, current, or fu-ture personal relationship with the pa-tient
Minimize physical contact
Preserve relative anonymity of ther-apist
Establish a stable fee policy
Provide consistent, private, and professional setting
Define time and length of sessions. These guidelines will be discussed more fully later in connection with a clinical vignette.
Some of these guidelines have been considered by Langs7 to form a neces-sary treatment frame for the conduct of psychodynamic psychotherapy. Al-though additional boundary rules can be elaborated, a consensus generally exists concerning the basic rules listed above. Other rules concerning the management of transference and countertransference could be included but might not find ready acceptance among some behavior-ists, biological psychiatrists, and "here and now" treatments such as Gestalt therapy. Nevertheless, regardless of the-oretical orientation, all therapists must recognize that transference and counter-transference plays an important role in any therapy.
An absolutist position concerning treatment boundary guidelines cannot be taken. Otherwise, it would be appro-priate to refer to boundary guidelines as boundary standards. Effective treatment boundaries do not create walls that sep-arate the therapist from the patient. Instead, they define a fluctuating, reason-ably neutral, safe space that enables the dynamic, psychological interaction be-tween therapist and patient to unfold. Since treatment boundaries have a certain variability, unanimity of profes-sional opinion does not exist on a number of boundary issues. Moreover, practitioners may place a different em-phasis on certain boundary guidelines. Although the static listing of boundary guidelines serves an important heuristic purpose, clinicians must remain vigilant to the process of gradual, progressive boundary violations. Progressive bound-ary violations are almost invariably the consequence of an exploitative relation-ship established by the therapist with the patient
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