BOUNDARIES AND BOUNDARY VIOLATIONS

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BOUNDARIES AND BOUNDARY VIOLATIONS

• In the Therapeutic Setting
• Elizabeth M. Wallace, MD, FRCPC

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LEARNING OBJECTIVES

• 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.

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PURPOSE OF THERAPEUTIC BOUNDARIES

• 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

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THERAPEUTIC 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)

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Boundarycrossings vs. 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

• CROSSINGS

• VIOLATIONS

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SEXUAL BOUNDARY VIOLATIONS

• 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)

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PREVALENCE OF SEXUAL BOUNDARY VIOLATIONS

• 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.

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TYPICAL TRANSGRESSOR

• 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

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PSYCHOLOGICAL PROFILES OF TRANSGRESSORS

• 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

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PSYCHOPATHIC PREDATORS

• 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

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LOVESICK MASOCHISTIC SURRENDER PROFILE

• 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

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PRECURSORS TO SEXUAL MISCONDUCT CLINICAL
FINDINGS

• 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

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THERAPEUTIC CONTEXT

• Therapeutic context is an imbalanced structure
  with respect to
• POWER
• NONRECIPROCAL MODES OF RELATING
• IMBALANCES ARE CONTEXTUALIZED AND IRREDUCIBLE

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PREVENTING TRANSGRESSION

• 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

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PREVENTING TRANSGRESSION

• 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

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EVALUATING DEVIATIONS FROM THE FRAME QUESTIONS

• 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?

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EVALUATING DEVIATIONS FROM THE FRAME QUESTIONS

• 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?