Every patient, by virtue of being a patient, is vulnerable to psychological damage from therapists who commit boundary violations. Psychotic and bor-derline patients are particularly at risk for psychic injury." Frequently, these patients have been physically and sex-ually abused as children. Their sense of what constitutes appropriate relation-ships and boundaries may be seriously impaired. Treatment boundaries are fre-quently tested by the patient through repetition of early childhood relation-ships where personal boundaries were not respected. Highly dependent pa-tients or patients recently experiencing a personal loss also are vulnerable to ex-ploitation.
Patients with Borderline Personality Disorder (BPD) present special prob-lems for therapist." These patients fre-quently attempt to manipulate and draw the therapist out of the treatment role. Therapists frequently find themselves making exceptions in the treatment of such patients. Patients with BPD often induce the greatest countertransference trap of all: the desire to do better than or to undo the damage done by, previous parental figuies. Thus, a high level of vigilance for treatment boundary viola-tions must be maintained by therapists who treat BPD patienk2* From a liti-gation perspective, suicide and sexual misconduct are the most common claims in malpractice suits against ther-apists treating patients with BPD.
Although the therapist sets the treat-ment boundaries, patients will question o r test these boundaries repeatedly and in various ways. Thus, boundary issues invariably arise in every therapy as grist for the therapeutic mill. Generally, healthier patients are able to stay within acceptably established treatment bound-aries, using the treatment framework provided to progress psychologically. More disturbed patients often act out their conflicts surrounding boundary is-sues. For example, a patient who was sexually abused as a child may actively repeat sexually seductive behavior to-ward the therapist who is attempting to maintain relative anonymity and neu-trality. With many of these more dis-turbed patients, a considerable portion of the therapy is devoted to examining the psychological meaning of the pa-tient's efforts to gain exceptions to estab-lished treatment boundaries. Patients who are consistently unable to tolerate limit setting by the therapist may be ~ntreatable.~'
Severely disturbed patients frequently present daunting treatment and man-agement problems for therapists who are willing to undertake their care. The pa-tient's psychiatric condition with the associated vicissitudes in the therapeutic alliance may necessitate utilizing inno-vative treatment techniques that cross customary treatment boundaries with-out necessarily creating deviant bound-aries. The strict application of the usual boundary guidelines to these patients could prove inimical to their treatment.
Examples of boundary violations
Sexual Exploitation Invariably. in cases of therapist-patient sex, progressive boundary violations precede and accom-pany the eventual sexual acts.22Patients are psychologically damaged by the pre-cursor boundary violations in addition to the ultimate sexual e ~ p l o i t a t i o n .25~ ~ . Even if the therapist and patient stop short of an overt sexual relationship, precursor boundary violations interfere with the adequate diagnosis and treat-ment of the patient. Thus, therapists may be sued for negligent psychotherapy in addition to sexual misconduct. Under either circumstance, patients are not provided essential psychiatric care. The patient's original mental disorder is often exacerbated and other mental dis-orders are iatrogenically induced.
Sexual misconduct cases usually dem-onstrate boundary violations in the ex-treme. Thus, their study can be very instructive. The following clinical vi-gnette will be used as an introduction to the discussion of basic boundary guide-lines. It illustrates the progressive, in-creasingly flagrant violation of treatment boundaries that often precede therapist-patient sex:
A 38-year-old single woman with previously diagnosed Borderline Personality Disorder and drug abuse seeks treatment for severe depres-sion following a spontaneous abortion. The psychiatrist is 49 years old. and recently di-vorced by his wife. His ex-wife is a very attrac-tive. talented artist who ran o f fwith a concert pianist. The psychiatrist is increasingly relying on alcohol to deal with his feelings o f loss.
The patient is quite bright and attractive. She talks continually about her feelings o f isolation and emptiness. Clear vegetative signs o f depression are present. The patient had hoped for a child as a way o f assuaging her loneliness. The psychiatrist is struck by the patient's re-semblance to his ex-wife. He becomes quickly enamored o fthe patient, overlooking and min-imizing her major depression. His clinical judgment is further distorted by the appear-ance o f improvement in the patient's depres-sion as the psychiatrist shows a personal inter-est in her. The psychiatrist looks forward to seeing the patient for her twice-a-week ap-pointments, finding solace and relief from his own sense o f desolation. For the first two months, the treatment boundary remains rel-atively intact. Then gradually, the sessions take on a conversational, social tone.
Psychiatrist and patient begin to address each other by their first names. The psychiatrist discloses the facts surrounding his divorce. talking at length about his wife's infidelity and his feelings o f betrayal. He also confides in the patient intimate details about his other pa-tients. treating her as a confidant. The patient is distressed at the psychiatrist's unhappiness and feels guilty that she cannot be o f more assistance. Initially. the psychiatrists sits across from the patient but gradually moves his chair closer. Ultimately doctor and patient sit to-gether on the sofa. occasionally the psychia-trist wuts his arm around the ~atientwhen she tearfully describes extensive childhood physi-cal and sexual abuse. Treatment sessions are extended in time. some lasting as long as three hours. The patient feels grateful that she is receiving such special treatment.
~ecause-theextended sessions disrupt the psy-chiatrist's other appointments, the patient is scheduled for the end o f the day. Whenever possible. therapist and patient also meet for brief periods o f time at a nearby park or bar for a drink. Because the patient complains o f sleeping problems, the psychiatrist prescribes barbiturates. He has not kept up with devel-opments in psychopharmacology. having used medications very sparingly in his practice over the years. The psychiatrist is unaware o f her prior addiction to narcotics. He does not ex-plain the risks o f taking barbiturate medica-tions. The patient requires higher doses o f barbiturates over time that interfere with her ability to function independently. The psychi-atrist begins to make day-to-day decisions for the patient. including balancing her check-book.
During sessions. therapist and patient begin to embrace and kiss. The psychiatrist finds the patient more compliant to his advances when she has had a few drinks. During one session when the patient drinks too much, sexual in-tercourse takes place. The psychiatrist stops billing the patient as their sexual relationship continues.
A few months later, the psychiatrist takes an extended vacation. While he is away, the pa-tient learns from another patient that the psy-chiatrist revealed details o f her childhood sex-ual abuse. The patient becomes extremely de-pressed and takes a near lethal overdose o f barbiturates. While hospitalized. she is weaned from barbiturates. She discloses the fact o f her sexual involvement with her outpatient psy-chiatrist. The patient is successfully treated for major depression with antidepressants. The diagnosis o f Borderline Personality Disorder also is made that is severely aggravated due to the sexual exploitation by her therapist. The exploiting psychiatrist attempts to see the pa-tient upon his return. She refuses. One year later, the patient brings a malpractice suit against- the usychiatrist-- for sexual misconduct.
Neutrality and Self-Determination
The rule of abstinence and the therapist position of relative neutrality empower patient separateness, autonomy, and self-determination. In the vignette, the psychiatrist abandons a position of neu-trality and undercuts the patient's inde-pendence through numerous boundary violations that promote fusion between psychiatrist and patient. He gradually gains control over the patient's life, mak-ing basic life decisions for her. Whether done consciously or subconsciously, boundary violations cut short a patient's options for recovery and independent psychological functioning. The achieve-ment of psychological independence is a goal of treatment. Maintaining patient separateness that permits pursuit of this goal is a boundary issue.
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