Grand Rounds-Boundary Issues in Clinical Practice

Author(s):

Psychotherapists have fiduciary power and-from a risk management perspective-the clinician must act in a manner in which misconduct cannot be inferred. In terms of boundary violations, some preventative measures (like psychodynamic education) can be taken.

The Yale School of Medicine Department of Psychiatry was host to Dr Thomas Gutheil, Professor of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School in Boston.

Among Dr Gutheil’s key points:
• When there is a boundary issue, the therapist is culpable, even though both the therapist and patient may be responsible.
• Ultimately, the therapist has “fiduciary” power and-from a risk management perspective-the clinician must act in a manner in which misconduct cannot be inferred.
• There are 2 types of boundary breaches:
    – Boundary crossings
    – Boundary violations
• Some preventative measures against boundary violations:
    – Psychodynamic education
    – Alerting to “exceptions”
    – Didactic teaching explicitly on clinical and legal pitfalls
    – Teaching on patient management
    – Presenting case of erotized transference to supervisor