Boundary violations
Although sexual activities with patients are clear boundary violations, what about the second case when the therapist gave the patient stuffed animals and cards and hugged her? Progressive boundary violations often precede and accompany sexual misconduct.10
Five risk factors have been associated with therapist boundary violations:3
- life crises—effects of aging, career disappointments, unfulfilled hopes, or marital conflicts
- transitions—job changes or job loss
- medical illness
- arrogance—the belief that a boundary violation couldn’t happen to him or her and not recognizing the need for consultation
- common stress points with the patient
Although the list is not exhaustive, these factors may be associated with a psychiatrist turning to the patient for solace, gratification, or excitement.
Drawing boundary lines
Not all boundary issues are the same, and Gutheil et al2 suggest 2 categories:
- Boundary crossings—a benign variant where the deviation may advance therapy in a constructive way that does not harm the patient, such as discussion of countertransference.
- Boundary violations—the transgression harms or exploits the patient.
Although some boundary issues may appear benign, even theoretically harmless boundary crossings can be misrepresented or misconstrued by the patient.11 Also, boundary transgressions that do not involve erotic touch might harm the treatment process and the patient.2
When examining “minor” boundary issues that may seem innocuous, ask yourself if the action is for your benefit rather than to advance the patient’s therapy. Also, determine if the intervention is part of a series of progressive boundary violations. If the answer to either question is “yes,” desist immediately and take corrective action.10
The psychiatrist has a professional code of ethics to follow and can be held responsible for failing to set or adhere to boundaries.11 If a patient initiates a boundary violation, you must refuse and then explore the patient’s underlying psychological issues, perhaps aided by consultation with a peer or mentor (Table). Repeated patient demands to breach boundaries requires prompt consultation to determine if you can continue treating the patient or if you should transfer the patient to another clinician. Document the patient’s demands to breach boundaries and your actions when seeking consultation.3
Table 1
How to maintain integrity of the treatment process
| Maintain relative therapist neutrality |
| Foster psychological separateness of the patient |
| Protect confidentiality |
| Obtain informed consent for treatments and procedures |
| Interact verbally with patients |
| Ensure that you do not have any previous, current, or future personal relationships with the patient |
| Minimize physical contact |
| Preserve the therapist’s relative anonymity |
| Establish a stable fee policy |
| Provide a consistent, private, and professional setting |
| Define the time and length of sessions |
| Source: Reference 10 |