BOUNDARIES AND BOUNDARY VIOLATIONS

1. BOUNDARIES AND BOUNDARY VIOLATIONS In the Therapeutic Setting Elizabeth M. Wallace, MD, FRCPC

2. 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.

3. 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

4. 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)

5. 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

6. 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)

7. 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.

8. 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

9. 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

10. 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

11. 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

12. 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

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

14. 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

15. 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

16. 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?

17. 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?