boundaries and boundary violations

In the Therapeutic Setting

Elizabeth M. Wallace, MD, FRCPC

1. Describe components and functions of the therapeutic frame

2. Differentiate boundary crossings from boundary violations.

3. Describe common characteristics of physicians who commit sexual boundary violations.

4. Appreciate the inherent power imbalance in the therapeutic relationship.

5. List elements in the prevention of sexual boundary violations.

◦ Define the relationship with the patient

◦ Establish a framework for treatment

◦ Set expectations

◦ Major factor in establishing trust

◦ Make possible evaluation of deviations from the frame

◦ Setting, duration, frequency, procedures, policies e.g. cancellation policy

◦ Clinician is paid to deliver a service

◦ Absence of unnecessary physical contact

◦ Limited self-disclosure

◦ Absence of dual relationships outside the treatment

◦ Confidentiality and limits of confidentiality

◦ Clothing and language (mostly implicit)

CROSSINGS VIOLATIONS

◦ Benign and even helpful breaks in the frame

◦ Usually occur in isolation

◦ Minor and attenuated

◦ Discussable

◦ Ultimately cause no harm to patient, clinician, or treatment

◦ Exploitive breaks in the frame

◦ Usually repetitive

◦ Egregious and often extreme e.g. sexual

◦ Clinician discourages discussion

◦ Typically cause harm to patient, clinician or treatment

◦ DEFINITION: Any kind of physical contact occurring in the

context of a therapeutic relationship for the purpose of erotic pleasure

(Many affectionate gestures made by clinicians are misconstrued at the time they occur or at some later point e.g. hug)

◦ 7-12% of practitioners in the U.S. (anonymous self-report, all disciplines)

◦ Gender: Male practitioners account for 80+% of incidences

7-9% of male practitioners (most with female patients)

2-3% of female practitioners (most with female patients)

Least frequent: Male practitioner – male pt., Female practitioner – male pt.

◦ Middle-aged male◦ In solo practice◦ Sexual dual relationship with one female

patient

◦ Female transgressors 70% same sex Practitioner views herself as heterosexual Love and tenderness in relationship drifts to

sexual relationship Male patient: may feel triumphant rather than

victimized

◦ Gabbard (1994) proposed 4 underlying psychological profiles: 1. Psychotic disorders

2. Predatory psychopathy and paraphilias

3. Lovesickness – on a continuum with 4.

4. Masochistic Surrender

◦ These cases have attracted media attention, but not the most prevalent

◦ Typically refuse to be evaluated

◦ Persistently lie about their conduct despite multiple complaints

◦ Blame the patient(s)

◦ Dynamics involve sadism, need for power or control

◦ Most prevalent category – usually one-time offenders

◦ Seek help, display genuine remorse

◦ Can be effectively rehabilitated

◦ Typical scenario: Heterosexual male, isolated in practice, treating a

difficult patient, in a highly stressful time in his life Relationship usually intense, may last several years and

fell like “true love” Ethical complaint most likely filed by pt. when MD ends

the relationship

◦ Longstanding narcissistic vulnerability◦ Grandiose (covert) rescue fantasies◦ Intolerance of negative feelings of pt.◦ Childhood: emotional deprivation and

sexualization◦ Family history of covert and sanctioned

boundary violations◦ Unresolved anger towards authority figures◦ Limited awareness of inner world

◦ Therapeutic context is an imbalanced structure with respect to

◦ POWER◦ NONRECIPROCAL MODES OF RELATING

◦ IMBALANCES ARE CONTEXTUALIZED AND IRREDUCIBLE

◦ EDUCATION – about boundaries, power differential, transference/countertransference, ethics

◦ CONSULTATION – with colleagues on all intense feelings towards patients (love and hate)

◦ SELF-CARE – work/life balance, satisfying relationships, support network, personal therapy if needed

◦ Awareness of clinician risk factors – personal history, current stressors

◦ Awareness of patient risk factors Challenging patients – personality disorder Suicidality History of sexual abuse

◦ Awareness of vulnerability at “edges” of treatment i.e. moments of transition – end of appointment, between chair and door, outside the office

◦ Why am I thinking of doing/saying this?

◦ Would I do this with all my patients?

◦ Why with this particular patient?

◦ Why at this particular time?

◦ How much do I know about how this will be received by the patient?

◦ Is there a safer way of achieving the same goal?

◦ Why do I think I can do this without harm?

◦ Would I hesitate to tell a colleague what I have done?

◦ Would I worry if my patient told someone?