Patient-Therapist Boundary Issues

Psychiatric Times

October 2005

Vol. XXII

Issue 12

Patient-Therapist Boundary Issuesby Glen O. Gabbard, M.D.

Sponsored by CME LLC for 1.5

Category 1 credits.

Original release date 10/05. Approved for CME credit through 9/30/06.

Educational Objectives:

Upon completion of this educational activity, the reader will be familiar with:

• The difference between boundary violations and boundary crossings.
• Community standards involving professional boundaries in the practice of psychotherapy.
• The historical background that led to problems with boundary violations in psychotherapeutic practice.

Who will benefit from reading this article?

Psychiatrists, primary care physicians, neurologists, nurse practitioners, psychiatric nurses and other mental health care professionals. Continuing medical education credit is available for most specialties. To determine if this article meets the CE requirements for your specialty, please contact your state licensing board.

Dr. Gabbard is Brown Foundation Chair of Psychoanalysis and professor in the Menninger department of psychiatry at the Baylor College of Medicine. He is also training and supervising analyst at Houston-Galveston Psychoanalytic Institute.

Dr. Gabbard has indicated he has nothing to disclose.

Professional boundaries are components that constitute the therapeutic frame. They can be considered to represent an "edge" or limit of the appropriate behavior by the psychoanalytic psychotherapist in the clinical setting (Gutheil and Gabbard, 1993). The fundamental notion inherent in the concept of professional boundaries is that attention to the basic aspects of the professional nature of the therapeutic relationship will serve to create an atmosphere of safety and predictability that facilitates the patient's ability to use the treatment. Therapists are professionals being paid for a service, and therefore they must recognize that a power differential always exists in the psychoanalytic psychotherapy of a patient. Even when therapists assert adherence to relational or intersubjective theoretical models that stress mutuality, the fact that they are paid for their service establishes a fiduciary relationship.

Much of the recent attention to professional boundary violations has stemmed from a growing awareness of the instances of sexual relations between therapists and patients and the damage related to those transgressions (Epstein, 1994; Gabbard, 1994b; Gabbard and Lester, 2003; Gartrell et al., 1986; Schoener et al., 1989). Just as incest was hidden from view for many decades until women became courageous enough to speak up, sexual boundary violations have surfaced only in recent years as women have felt empowered to make complaints to licensing boards and ethics committees. Other significant boundaries that do not involve physical contact are such things as the time and place of an appointment, the length of the appointment, confidentiality, the avoidance of social or financial relationships with a patient that might interfere with the therapist-patient relationship, excessive self-disclosure by the therapist, and the declining of lavish gifts from patients. While these parameters are generally considered the architecture of the therapeutic frame (Gabbard and Lester, 2003; Gutheil and Gabbard, 1993; Langs, 1977), a set of human qualities that define the interaction also comprise the frame. Psychoanalytic psychotherapists attempt to be helpful and nonjudgmental, understanding rather than critical, and willing to forego their own gratification in the interest of assisting their patients with what brought them to treatment.

History

Although professional boundary violations have only recently been given the attention they deserve, Sigmund Freud was significantly concerned about transgressions among his disciples from the beginning of psychoanalysis (Gabbard, 1995b). Sandor Ferenczi was analyzing Elma Palos (the daughter of his mistress Gizella Palos) and fell in love with her. Whether or not Ferenczi had sexual relations with the daughter is unclear, but he certainly professed his love for her and was physically affectionate with her (Dupont, 1995). Carl Jung was clearly overinvolved with Sabina Spielrein. Wilhelm Stekel was well known as a seducer of women. Ernest Jones indicated in a letter to Freud that his common-law wife, Lo Kann, had been a patient of his as well.

Freud was sufficiently concerned about the devastating impact of transference and countertransference on his disciples that his early papers on technique often sound like a version of the Ten Commandments designed to warn his students about potential transgressions of professional boundaries. A good example can be found in the following passage from Freud's 1912 paper "Recommendations to Physicians Practising Psycho-Analysis" (Freud, 1958):

I cannot advise my colleagues too urgently to model themselves during psychoanalytic treatment on the surgeon, who puts aside all his feelings, even as human sympathy, and concentrates his mental forces on the single aim of performing the operation as skillfully as possible.

This stern prohibition may have led his supervisees and many analysts in subsequent generations to feel they must conceal feelings they were developing rather than discuss them actively with supervisors or consultants. Freud himself was anything but an anonymous or neutral figure. According to accounts from his patients who have reported their experiences, his personal presence was very much in evidence to his patients (Lohser and Newton, 1996). He made no effort to disguise his own personal judgments about issues that arose. He often was quite dogmatic and would express strong feelings toward his patients. Despite his own behavior, he was worried that wild countertransference enactments could sink his fledgling profession before it established credibility.

In the last three decades, more and more ethics committees and professional licensing boards have seen clear examples of the damage inflicted on patients by various types of boundary violations. As a result, the professions are now much more alert to the problem, and the veil of secrecy has been lifted. A modest body of literature has accumulated on the subject of boundary violations, with numerous case examples that suggest some of the psychodynamic themes involved in these transgressions.

Boundary Violations and Crossings

As a result of the recent emphasis on the damage done by boundary violations, some beginning therapists assume a posture of rigidity and remoteness in their relationship with their patients to assure that boundaries are intact. This approach to the patient is a serious misunderstanding of the role of boundaries in practice. The frame must always be sufficiently flexible so that it accommodates individual differences among patients and among therapists. Boundaries in no way imply coldness or aloofness. They are structural characteristics of the relationship that allow the therapist to interact with warmth, empathy and spontaneity within certain conditions that create a climate of safety. The external boundaries of the treatment are established so that the psychological boundaries between patient and therapist can be crossed through a number of means, such as empathy, projection, introjection and projective identification (Gabbard and Lester, 2003).

Each therapist-patient dyad creates its own particular way of interacting with one another through a negotiation process. With some patients the therapist will use humor to help foster the therapeutic alliance. With other patients, who feel that humor is at their expense, the therapist refrains from humorous comments. Similarly, some patients may require a somewhat more self-disclosing therapist than others. Still other patients can tolerate frustration only if some gratification is also provided. Therapists are constantly adjusting the frame so that it is somewhat different with each patient. Similarly, some therapists are by nature private while others are more open so that some components of the frame, such as self-disclosure, may be influenced by the therapist's inherent subjectivity as well (Gabbard and Lester, 2003; Greenberg, 1995; Mitchell, 1993).

The need for flexibility in conceptualizing and implementing professional boundaries leads to a useful distinction between boundary violations and boundary crossings (Gabbard and Lester, 2003; Gutheil and Gabbard, 1998, 1993). Boundary violations involve transgressions that are potentially harmful to or exploitative of the patient. They can be either sexual or nonsexual. They are usually repetitive, and the therapist usually discourages any exploration of them. By contrast, boundary crossings are benign and even helpful breaks in the frame. They are generally attenuated so that they are not egregious in nature, they usually occur in isolation, and they are typically discussable in the therapy (Table).

The emphasis on differentiating crossings from violations stems in part from the inevitability of human responses in unusual situations during the course of therapy. After the death of a close family member, a patient may reach to the therapist while sobbing and expect an embrace. If the therapist fails to return the embrace, the patient may be devastated and never return for another appointment. The failure to be human in extraordinary situations may be a more grievous error than viewing the boundary on touch as a flexible one. On the other hand, if a therapist begins initiating hugs and repeatedly embracing the patient, this may be a harbinger of progressively damaging boundary transgressions. Not all nonsexual boundary violations lead to sexual misconduct, but there is a well-known phenomenon--often referred to as the slippery slope--that involves the gradual progression of boundary violations from the most subtle and nonsexual to frank sexual involvement (Gabbard and Lester, 2003; Gutheil and Gabbard, 1993; Strasburger et al., 1992).

While much is made of the progression of small breaks in the frame to sexual relations between therapist and patient, there are also damaging types of boundary violations that stop short of any physical contact.

Nonsexual Boundary Violations

The fact that nonsexual boundary violations can be highly damaging to the patient demands a careful monitoring of one's countertransference as a way to discern early steps down the slippery slope. Countertransference enactments today are generally considered to be some form of a joint creation involving the therapist's own conflicts as well as the evocation of certain responses in the therapist that reflect the patient's internal object world (Gabbard, 1995a). Hence, when there is a particular fit between the patient's and the therapist's internal object world, the therapist may be prone to enacting something damaging to the patient as a result of projective identification. For example, patients with early childhood trauma have internalized an object relations scenario involving a victim and abuser. The therapist may identify with the projected abuser introject and unwittingly victimize the patient. While some nonsexual boundary violations involve unscrupulous and exploitative therapists, most represent the confluence of clinical error and ethical misconduct based on countertransference enactments. Even though flexibility is needed in the management of professional boundaries, guidelines can still be useful around a number of specific boundary issues.

Time. When clinicians find themselves regularly extending the session well beyond the end of the hour, they should wonder about their motives. Early in therapy, patients should have the time frame explained to them in terms of time as well as the therapist's rationale for ending the session more or less on time rather than continuing when the patient is upset. Another area to monitor involves the scheduling of late evening sessions. Patients who have erotic transferences or who are extraordinarily demanding should probably be seen during regular working hours when office personnel and colleagues are at work in the building. Investigating ethics committees raise questions when patients are seen late in the evening after everyone else has gone home. Therapists must carefully think about what message they are sending to patients if they see them at 8 or 9 p.m.

Location of contact. Psychoanalytic psychotherapy is generally conducted in a hospital unit or in one's professional office. Scheduling a session in other than one of those locations may raise questions in the patient's mind about the purpose of the meeting. There may be unusual circumstances when different meeting places are necessary. A patient who is dying of cancer may be visited in the home, for example. But meetings outside of the office for unclear reasons should alert the therapist to the potential for serious boundary violations. As a general principle, any meeting in an unusual location should be part of a carefully designed treatment plan that has been developed with the assistance of a consultant or supervisor.

Money and gifts. Patients pay therapists for their treatment because psychotherapy is hard work. Therapists who allow large bills to accumulate without asking for payment or who discontinue charging a fee may send a problematic message to the patient. If one is not expected to pay for treatment, patients may wonder if they are expected to give the therapist something in return. Patients who are given free treatment may also feel they have no right to express anger or disappointment with the therapist because the treatment is free. Hence, failure to collect payment or charge a fee should serve as warning signals of potential boundary problems.

A large gift of money or an extremely expensive gift to the therapist may also herald a potential boundary violation. Therapists who accept such gifts may be colluding with their patient's wish to suppress anger or aggression. Small gifts, especially ones the patient has made or ones that cost the patient very little money, may be graciously accepted under some circumstances. However, even small gifts should probably be discussed in terms of their meaning to the patient. Wealthy patients who attempt to give the therapist something of great value may then expect that treatment should be under their control.

Vignette 1 illustrates how therapists may at times be uncertain about whether accepting the gift is in the patient's best interest or not. Therapists should always feel free to postpone a decision until they have sought out consultation or supervision.

Self-disclosure. As previously noted, self-disclosure may be damaging to the patient if it shifts the asymmetry of the therapeutic relationship. Rigid guidelines are difficult in this regard because all psychotherapists disclose things about themselves all the time. They display information about themselves in their offices by virtue of the way they decorate the walls, the photographs that are placed on shelves and the artwork they choose. They also make self-disclosures when they choose to comment on certain topics and not others that the patient brings to the hour. Many countertransference disclosures about the here-and-now situation with the patient may be useful and advance the therapy. If a patient with borderline personality disorder, for example, asks an obviously angry therapist if they are upset, the therapist may wish to validate the patient's observation and try to explore it with the patient to figure out what sort of interaction irritated the therapist. Other countertransference feelings, such as sexual longings for the patient, should probably not be disclosed.

As a general consideration, therapists should refrain from sharing material about their private lives that may burden the patient. Some superficial information may be useful at times. For example, a therapist treating an adolescent may talk about sporting events that they both witnessed or a movie they both have seen. Material about the therapist's family or children should probably not be shared. In addition, therapists should avoid talking about their personal problems to the patient. Vignette 2 illustrates how self-disclosure may ultimately destroy the therapy.

In Vignette 2, the therapist took advantage of the patient's vulnerability by using the time to ventilate about his own struggles in his personal life. He lost track of the fundamental feature of the frame that the focus is on the patient's problems rather than the therapist's. By design, the therapeutic relationship is asymmetrical. Even though the initial break in the frame did not progress to sexual misconduct, the misuse of the therapy by disclosing his personal problems was itself a boundary violation that had damaging effects on the patient and the therapy.

Nonsexual physical contact. In routine office psychotherapy, the extent of physical contact should probably be limited to handshakes. However, one is hard-pressed to generalize and say that a hug is never acceptable. As noted above, when tragedies occur in the lives of patients, a human response may be to return a hug initiated by a patient. These boundary crossings can be discussed in terms of their meaning for the patient later. The problem, though, when the therapist initiates a hug or a kiss with the patient is that one can never know in advance how the patient will experience the overture. The impact on the patient may be quite different from the therapist's intent (Gabbard, 1996; Gutheil and Gabbard, 1998, 1993). Patients who have a history of sexual trauma, for example, may experience a hug or even a touch as assaultive. Moreover, therapists cannot be certain of their unconscious wishes when initiating a hug even if they consciously believe that there is no sexual connotation. Hence any form of physical contact outside of a handshake should be an extraordinary event in the course of a psychotherapy process. It should be initiated in most cases by the patient, discussed in terms of its meaning, and not repeated.

Therapist Profiles

While the vast majority of the cases of sexual misconduct occur in a dyad characterized by a male therapist and a female patient, about 20% of cases involve a female therapist who engages in sexual relations with either a female or male patient (Schoener et al., 1989). In addition, 20% of cases involve same-sex dyads. In my clinical experience, I have seen over 150 therapists who have been involved in serious boundary violations with patients, both sexual and nonsexual. I have served in the role of evaluator, consultant and therapist for these colleagues, and I have identified four psychoanalytically based categories that I have found useful in my own work (Gabbard, 1999; Gabbard and Lester, 2003).

Psychotic disorders. This group is an extremely small category that involves therapists whose sexual behavior with patients grows out of frank delusional thinking secondary to mania, schizophrenia or other psychotic disorder. I mention it only in passing here for the sake of completeness because it only infrequently figures into the origins of severe boundary violations committed by therapists.

Predatory psychopathy and paraphilias. This category of therapists who engage in sexual boundary violations is not nearly as rare as the psychotic group. While some therapists who fit this category have DSM-IV antisocial personality disorders, others have severe narcissistic personality disorders but still engage in psychopathic behavior for which they feel no remorse or guilt. Paraphilias are included in this category, not because all clinicians with sexual perversions are predatory psychopaths, but because those who enact their perversions with patients they are treating tend to have the same underlying character pathology and superego deficits that typify the predatory psychopathy group. Therapists in this category, usually male, have sometimes risen to positions of leadership within professional organizations and begin to think that the ethics codes of their professions no longer apply to them. They take advantage of their position as a transference object and sadistically and exploitively abuse their power. They may have histories of corrupt or unethical behavior in other areas as well. They generally have multiple victims, and they lack the capacity to empathize with the patients they have exploited, so they typically deny that any harm was done to the patient. They may argue that a sexual relationship, for example, was entirely consensual between the therapist and patient and that the patient actually benefited from it. The therapists who fall into this category are unlikely to be amenable to rehabilitative efforts, and they often have their licenses to practice revoked because they are seen as a persisting danger to the public.

Lovesickness. This group includes a wide range of diagnostic categories. Some therapists may be neurotically organized, many have mild narcissistic disturbances, and others are in a state of personal and/or professional crisis. They may have no history of acting unethical in any other area, and they are generally involved with only one patient. They may profess that they are "in love" with the patient and rationalize their behavior on that basis. While the presence or absence of love is, of course, ultimately irrelevant to ethics considerations, therapists who are infatuated with a patient may argue that they are soul mates and would have been married if they found each other under any other circumstance so that no harm is being done. This category is the one found most commonly in female therapists. However, many male therapists also fit this category.

Psychodynamic themes often found in this group include a desperate need to be validated, idealized and loved by patients as a way of regulating the therapist's self-esteem. These therapists also may have difficulties anticipating the consequences of their actions and a loss of the "as if" quality of the ordinary experience of countertransference. The therapist hence may be unable to see that something from the patient's and/or the therapist's past is being repeated in the present and that understanding is necessary to make sense of it. Many of the relationships between therapist and patient that are lovesick in nature involve re-enactments of incestuous longings or actual incestuous relationships from the past of either therapist or patient. In addition, the clinicians who become lovesick often mistake their own needs for the patient's needs. They may feel they are providing love for the patient while actually trying to obtain love for themselves. Aggression figures prominently in the dynamics of many lovesick therapists (Celenza, 1998; Celenza and Gabbard, 2003; Gabbard and Lester, 2003). Many of these therapists are deeply conflicted by their aggression, and they increasingly disavow hatred and anger toward the patient when their therapeutic efforts are thwarted. They may attempt to "love" the patient as a reaction formation to their aggression and unwittingly retraumatize the patient through sexual boundary violations under the guise of "love." When the therapist is female, she often hopes to transform a personality-disordered male patient by thinking of him as "a baby" who needs love. She may think that the male patient will "settle down" if she can treat him like a loving mother, only to become increasingly sexualized in her interactions with him.

Masochistic surrender. Therapists who fit this category have often been highly ethical throughout their careers. They may be regarded as expert in treating "difficult" or "impossible" patients. They may take special pride in taking the cases that no one else will treat. What they often discover is that they are repeating an object relationship from the past in which they allowed themselves to be intimidated and controlled by a demanding and tormenting object, such as a parent. They also may believe that by sacrificing themselves, they are somehow saving a patient from suicide. Unable to set limits on the patient or to confront the patient's aggression, they find themselves repeatedly giving in to the patient's demands and rationalizing their capitulation. In a typical scenario, the therapist first stops charging the patient because the patient claims that the therapy is no longer affordable. Phone calls are often accepted in the middle of the night as the therapist tries to talk the patient out of suicide. Eventually, the therapist responds to patient demands to be held by embracing or holding the patient during therapy hours. If none of these extraordinary measures seem to work, the therapist may proceed down the slippery slope to frank sexual contact.

Several recurring themes are found in the therapists who fall into this category. They are often desperately trying to disavow any connection with an internal bad object that torments the patient (Gabbard and Lester, 2003). They may have great empathy for the patient's suffering at the hands of an abusive parent and wish to convince the patient that they will not follow the same sadistic pathway as the parent. They may be frantic about the patient's potential to commit suicide and be deeply concerned about their narcissistic vulnerability to losing the patient. As a result, omnipotent strivings to heal may be activated to the point where they no longer recognize the ordinary professional boundaries. There may be a failure of mentalization as well, where they can no longer differentiate what is happening inside the patient from what is happening in their own mind (Gabbard and Lester, 2003). Psychodynamic therapy or psychoanalysis with these therapists often reveals a secret fantasy that they might be loved by tormenting internal parental objects if they simply submit to them and allow themselves to be controlled by them. Some may even have Christ identifications and assume that by sacrificing themselves, they will save their patient.

Posttermination Relationships

Nonsexual relationships between therapist and patient that occur after termination are difficult to classify in terms of ethics considerations. Therapists must keep in mind that the patient may return for further treatment, and if they become involved in a business or social relationship with a former patient, they deprive the patient of the opportunity of returning for further treatment. Moreover, therapists must also be mindful of the potential to exploit the patient's vulnerability in posttermination relationships. Sexual contact with former patients is generally regarded as unethical by the American Psychiatric Association.

All studies of transference following termination show that it is instantly re-established years after termination if the therapist and patient meet again (Gabbard, 1994a). Another compelling argument is that as long as there is the possibility of a future romantic or sexual relationship, therapy itself is profoundly contaminated. Neither party can speak freely about their observations if they want to preserve a positive image in the eyes of the other. It is only by virtue of the fact that the therapist-patient relationship will never be anything but professional that patients can speak freely about all of their problems. While some argue that marriage sanctifies the relationship as nonexploitative, marriage in no way removes the possibility of abuse of power. History has shown that marriage has been used as an excuse for rape, assault and a host of other sins. Even if marriages between therapists and former patients are reasonably happy, ethics codes commonly develop restrictions based on the potential for harm, even if harm is difficult to document in every single case.

Assessment and Rehabilitation

Most therapists who have been involved in severe boundary violations come to the attention of licensing boards, ethics committees or professional organizations when a complaint has been filed by the patient or other interested party. Reports to such a body set in motion an investigation of the allegations that determines whether the therapist should receive discipline or punishment. It is also useful to have the therapist independently evaluated regarding suitability for rehabilitation. The evaluations are best conducted by disinterested parties who are outside the same city as the therapist. Local evaluators often lack the necessary objectivity to provide a worthwhile psychiatric evaluation.

Evaluations of transgressing therapists must have collateral information about the accused therapist so that the evaluating clinician does not have to rely exclusively on the therapist's own self-report. Often, investigative reports are available as well as the patient's account of the transgression. The evaluator must assess the causes of the boundary violation, the character of the accused clinician and the basic psychodynamic conflicts within the clinician. Psychological testing may be of help as well.

If the therapist denies the boundary violation, there may be very little value in conducting such an evaluation. Therapists who deny their guilt will present themselves as having no reason to be there. Going through the motions of an evaluation in those circumstances is a waste of time, money and effort.

When an evaluator is assessing a therapist who has acknowledged the transgression, the suitability for rehabilitation hinges more on the attitude of the therapist than on objective facts provided to the evaluator (Celenza and Gabbard, 2003). If the therapist is genuinely remorseful and deeply committed to avoiding future transgressions, this attitude is a good prognostic sign. Similarly, therapists who can take full responsibility for what happened and empathize with the patient's experience of having been damaged are also good candidates for rehabilitation. If only one patient is involved, this too is a positive prognostic factor. Remorse, though, must be rigorously differentiated from narcissistic mortification (Celenza and Gabbard, 2003). Some therapists may speak of shame, but they are merely referring to the damage to their own reputations and self-regard. As a general principle, those therapists who fit in the categories of lovesickness and masochistic surrender are the best candidates for rehabilitation. The predatory types who are repeat offenders should probably not be allowed to return to practice. A caveat is in order, however. Some therapists do not fit neatly into the four categories outlined, and there are some who are in love with the patient who are not amenable to rehabilitation because they see nothing wrong with what they have done. They invoke "true love" as a rationalization for their behavior and see no point in being rehabilitated.

When rehabilitation is indicated because the therapist is deeply motivated to change and to avoid future problems, several components of a rehabilitation plan are useful.

Personal psychotherapy. In most cases of serious boundary violations, the transgressing therapist will need to be in a long-term psychoanalytic psychotherapy process to understand the reasons for the boundary violation and the relevant dynamics. The treating therapist, however, should not be selected by the boundary-violating therapist. Special expertise is needed because of the considerable countertransference difficulties encountered by therapists treating colleagues who have violated boundaries. Ethics committees and licensing boards may be in a better position to identify therapists with this skill and experience and assign the therapist who has been charged with the boundary violation to one of those clinicians with special expertise in the area.

Assignment of a rehabilitation coordinator. In addition to a psychotherapist, the transgressing therapist should be assigned to a rehabilitation coordinator in charge of the overall rehabilitation plan. This mental health professional may work with a licensing board or other body but should not be the same person as the psychotherapist. By using a coordinator separate from the psychotherapist, confidentiality within the psychotherapy can be preserved. The rehabilitation coordinator can merely ask the therapist for information about whether or not the transgressing therapist is attending their appointments. The rehabilitation coordinator can also be in contact with supervisors and other individuals engaged in the rehabilitation process. Generally, a rehabilitation coordinator meets with the boundary-violating therapist quarterly to keep in touch with how the program is going.

Practice limitations. Various kinds of stipulations are often attached to the boundary-violating therapist's rehabilitation arrangement. Some therapists are discouraged from doing long-term psychoanalytic psychotherapy and are steered toward other forms of practice. In other cases, certain types of patients, such as those with backgrounds in sexual trauma, are considered off limits to the therapist's practice. The rehabilitation coordinator may be of assistance in setting up these limitations with the accused therapist.

Supervision.Weekly supervision should be built in to the accused therapist's schedule. The supervisor should be assigned by the body handling the investigation and complaint so the accused therapist does not simply select a friend. The supervisor should be fully informed about the nature of the boundary violations, and the supervised therapist must be open about countertransference temptations that arise in the course of clinical work. Typically, the supervisor reports to the rehabilitation coordinator.

Continuing education. Because many analytic therapists have limited training in boundary violations and in the management of erotic transference and countertransference, education may be a helpful part of rehabilitation plans. Workshops and readings on relevant subjects may be extremely useful.

In addition to the rehabilitation plan outlined above, mediation between the therapist and the patient with whom the boundary violations were committed may also be useful (Gabbard and Lester, 2003; Margolis, 1997; Schoener et al., 1989). A third party, usually another therapist with knowledge about boundary violations, sits down with the therapist and the patient to allow the patient to express feelings about the damage done by the therapist. For therapists who have a difficult time acknowledging the harm done, hearing the patient in this setting may break through the denial. The mental health professional conducting the mediation may also facilitate an apology by the therapist, which is often highly meaningful to the victim. Sometimes the mediator will also arrange for money to be refunded to the patient by the therapist as a form of restitution. Typically a mediation process only lasts for two or three sessions.

Rehabilitation plans, such as the one outlined above, may go on for as long as three to five years with yearly assessments of how the boundary-violating therapist is progressing. Sometimes other measures will become important in the course of the plan, and the overall program may need to be revised. If there is a question about whether the individual is ready to re-enter practice without further rehabilitative efforts, another evaluation may be conducted to determine the therapist's readiness. In most cases the returning therapist is well advised to continue supervision voluntarily even though the rehabilitation has been successful.

Preventive Strategies

A number of measures can be taken to prevent boundary violations. However, because psychoanalytic psychotherapy requires a radical form of privacy, we must acknowledge that it will be impossible to ever completely eradicate boundary violations. What can be done is to prepare psychiatrists, psychologists and other mental health professionals in their training programs by offering courses on ethics, boundaries, and the management of erotic transference and countertransference. This educational background at least provides a conceptual framework so they can think about the risk of boundary transgressions and carefully monitor countertransference as they notice deviations occurring from their standard way of practicing.

Education will not stop unscrupulous individuals who have antisocial tendencies, but training programs can screen such individuals more carefully and identify dishonest or corrupt behavior during the training period. Psychoanalytic psychotherapists should also have a personal treatment experience to help them understand their own internal world and specific countertransference vulnerabilities. However, some severe boundary violations have occurred even when the therapist has had years of adequate analysis, so we cannot expect personal treatment to be a panacea.

Documentation of what one does and why is essential. Unusual deviations from standard professional boundaries can be useful in some cases. However, the clinician must document how those deviations fit into a rational and sensible overall treatment plan. In addition to protecting the therapist from liability, documentation forces the clinician to think through the reasons for any departures from community standards.

Perhaps one of the greatest risk factors for the development of boundary violations is the isolation of one's practice. Regular consultation on difficult patients should be built in to every psychoanalytic psychotherapist's practice. The omnipotent feeling that one can manage all difficult situations by oneself is a setup for the enactment of countertransference blind spots. Peer supervision groups are another form of getting help for countertransference vulnerabilities. Groups of colleagues will meet once a week to enlist each other's help with complicated cases. The advantage of the group, of course, is that the individuals begin to know each other well enough to spot early deviations from one's usual practice.

Regular consultation cannot be overemphasized as a preventive measure. A good rule of thumb for self-monitoring is the following: If there is anything you are doing with a patient that you feel you can't tell a consultant, this should raise serious questions. In fact, the very issue you are concealing is exactly what you should be sharing with a consultant.

Some psychotherapists practice in institutions. Psychiatric facilities can check an applicant for a position by doing a screening for a history of criminal behavior or previous ethics violations in their last position. Each psychiatric hospital should have clearly written policies that prohibit all sexual contact between employees and patients. Outpatient clinics can develop similar policies. Other potentially problematic boundary violations can also be spelled out in policies. Educational meetings about boundaries and boundary violations should also be routine in psychiatric institutions.

Colleagues should take responsibility for their profession by monitoring the behavior of one another. If one has evidence that a colleague's practice is questionable, two colleagues may sit down with the individual and share their concerns. At the very least, the colleague is informed that others are aware of what is going on. Moreover, if the rumors being circulated are false, at least the colleague has the opportunity to offer a defense. Too often rumors are ignored until it is too late.

The final preventive measure is one that should be obvious, but is not. Psychotherapists are not always attentive to their own self-care. They need to be sure that their personal lives are reasonably satisfying so they do not look for emotional gratification from patients. A lifeguard cannot save a drowning victim if he himself is drowning.

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Psychiatric Times - Category 1 Credit

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