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Ethics - 1. Boundary Crossings per se
Clearly many of these actions arise seamlessly (and unremarkably) out of the culturally expected human dimension of therapy, sometimes referred to as "the real relationship." It is apparent that boundary crossings are therapist-initiated elements in the ongoing unfolding and adaptation of the treatment frame, often appropriate and useful efforts at developing the therapeutic alliance, which evolves over the course of therapy (18) and is a crucial support of the work of treatment. The appreciation that boundary crossings represent a natural extension of standard psychotherapeutic practice is crucial to recognizing their logical place in therapeutic technique.
Introducing a boundary crossing jars the safety and predictability of the mode of relating that has been established between therapist and patient. Inescapably, boundary crossings carry a risk of disrupting that working alliance, despite their goal of improving it. With the crumbling of such icons of therapeutic orthodoxy as "neutrality" and "opacity" (i.e., therapist non-self-disclosure) (19,20), greater therapeutic flexibility and creativity have become enhanced, but at some increased risk of rationalized idiosyncratic practice.
Further, while boundary crossings may be viewed as distinct moments in a treatment, they create a new modus vivendi, altering the tone and parameters of the therapeutic (or "working") alliance. Though generally written about as single events, it is more realistic to see them as part of a pattern meant to adapt a conventional treatment to the needs of a particular patient. The fact that boundary crossings, again by definition, arise later, i.e., in an established treatment, mean that they will be experienced as novel, have distinct meanings, and carry the potential for misunderstanding that any new element, enactment or event possesses. The therapist's attunement to the patient's reactions, openness to own his/her responsibility and role in the boundary crossing(s), readiness to explore the patient's subjective experience of the impact and meaning of these interventions, and willingness to discuss the process in the treatment, supervision or through consultation, are the hallmarks of the conscientious use of boundary crossings.
Implicit in the above is that boundary crossings may arise from the therapist's unconscious motivations in addition to being planned (and are often a combination of the two.) Patients may be the first in the dyad to recognize this. The therapist's capacity to explore and understand these events when they reflect his/her enacted motivations can be crucial to enhancing their utility and minimizing the possibilities of harm.
As one moves across the spectrum of boundary crossings, points are reached which may be perceived by the patient or third parties as extraordinary and/or suspect deviations in technique. For example, the Massachusetts Board of Registration in Medicine promulgated guidelines for "the maintenance of boundaries in the practice of psychotherapy" (21). The Board cautioned physicians when their treatments evolve "outside the guidelines," which specify appropriate treatment settings, billing practices, handling of gifts, parameters for therapist self-disclosure, rules for contact with the patient outside of therapy and contact with the patient's family, and "circumstances in which termination should be considered because boundaries cannot be maintained." The detailed guidelines were developed after some highly publicized cases of boundary violations by prominent psychiatrists in the state.
We are now in a position to define boundary crossings more precisely. Boundary crossings are the therapist's attempts to adapt an existing therapeutic alliance to foster the patient's capacity to work in therapy. These interventions affect the patient's experience of his/her boundaries in the treatment, are discussible and nonexploitative. They may be disturbing to the patient, could be experienced as intrusive or seductive, and could become a step down the "slippery slope," but are not intrinsically so.
2. The "Gray Area" of Boundary Crossings
Here again, while these interventions adapt or modify the boundary of an established therapeutic relationship (and are further along the spectrum than minimal boundary crossings), and also may be experienced by the patient as seductive or intrusive, they are not inherently steps down the "slippery slope." If the therapist initiates or subsequently recognizes that a boundary crossing has occurred, and the patient is given the opportunity to explore its impact on the therapeutic relationship and its meaning to him/her, the chances of misunderstanding are minimized, and the opportunities for enhanced collaboration can be optimized.
3. Aggregated Boundary Crossings
In practice, it may be difficult to distinguish such a dead-ended treatment from bona fide long-term supportive treatments that actually sustain isolated, depressed, and paranoid patients (among others) and enable them to function and even survive in their difficult lives. Such treatments can be deeply meaningful and even heroic, and should not be peremptorily dismissed or devalued. The treator's openness to consultation and peer review can help clarify the value of these extensively individually tailored supportive therapies. Consultation may help avoid unfairly caricaturing extended potentially life-sustaining treatments. Such a consultation may provide reassurance to the clinician who has labored in relative isolation and developed a unique and possibly unconventional treatment environment. It can also afford useful ideas that refresh the therapist's thinking about the treatment, restore a more balanced approach, or suggest needed changes.
Long-term (especially supportive) treatment relationships almost always include an accumulation of boundary crossings that shape the unique relationship that evolves.
While individual boundary crossings can be identified (e.g., going to the patient's poetry recital), the cumulative and ongoing effect of the boundary crossings in total led to an individualized treatment methodology.
But a more objective assessment in peer supervision concluded that the aggregation of boundary crossings had uniquely tailored the treatment to the patient. Despite the open-ended and mutually enacted paternal transference, there was much of value and little need to defend the unorthodox elements in this treatment.
Ethics - 4. Boundary Violations per se
Financial support for the treatment has become much more complex in recent years. The traditional mix of fee-for-service and hands-off indemnity insurance has receded as managed care, third-party payers who demand progress reports, mental health "carve-outs," and fourth-party reviewers have become ascendant. The issues raised go far beyond the more familiar problems of exorbitant fees or idiosyncratic barter arrangements. A full discussion of this topic is beyond the scope of this paper, but it is important to recognize that boundaries are challenged when, for example, intimate details of a patient's treatment are proffered to others to secure the treater's reimbursement. Often this exceeds the patient's awareness or truly voluntary informed consent. Conscientious clinicians may hold different and respect-worthy opinions about privacy, confidentiality, privileged communication, and, indeed, whether bona fide psychotherapy can occur when unseen financial stakeholders are undeniably an dement of the treatment.
These complex considerations around the therapist's financial interests logically lead us to consider other matters where boundaries may be violated, but not in as gross or unmistakable manner as with boundary violations per se.
5. The "Gray Area" of Boundary Violations
Wallwork (unpublished manuscript, used with permission) suggests that case reports that are "thickly disguised" do not require the patient's consent. But, however worthy the intent, this is a form of boundary violation, and one which may be discovered by the patient in a manner unanticipated by the therapist and embarrassing and disturbing to the patient. It is an example of a conscientious boundary violation in the gray area that is noteworthy because it serves the interest of the therapist (his/her career and science), but, unlike a boundary crossing, is not based on an attempt to modify the treatment relationship to meet the patient's needs. Other examples include accepting significant patient gifts to the therapist's teaching institution, his/her research program, or even to the therapist's favorite charity.
Also belonging in the "gray area" is some non-sexual touching of the patient, such as an encouraging pat on the patient's shoulder or even a hug, perhaps uninvited but possibly welcome, possibly threatening.
So the "gray area" of boundary violations includes a gamut of moderate to substantially significant interventions which impact the patient's boundaries and sometimes are motivated by the therapist's needs. These gray areas are inevitably subject to differing professional opinions. Yet I would argue that if these actions are initiated with benign or even businesslike intent, and occur under circumstances in the treatment which make a point of recognizing of their occurrence, exploring their significance and, where fitting, having the treator honestly owning his/her role, many can be worked through and actually strengthen the therapeutic alliance.
6. "PseudoBoundary Violations"
Notice that these are generally public (i.e., far from secret) actions taken to preserve the patient's safety (or that of a vulnerable other). They are discussible and nonprogressive. Rooted in concerns for the patient's safety, these extraordinary measures share their premise with that of boundary theory itself: to provide a safe and predictable environment for the patient's treatment. I believe it is worth including these interventions in a discussion of boundary violations (even though they are quite unlike boundary violations per se), because they often elicit the subjective experience of intrusion and betrayal in the patient that are akin to bona fide boundary violations. Also, they may lead to the patient's terminating the treatment, and even taking formal action against the therapist. In addition, when teaching boundary theory, this permits us to demonstrate a kind of gradation and symmetry across the spectrum.
Second, boundary crossings are best understood as simply one type of adaptation of an established treatment alliance. As such, they can be seen as continuations of the early work to establish a treatment alliance, which emerges from the "real relationship." Thus, we have been able more precisely to define boundary crossings as the therapist's attempts to adapt an existing therapeutic alliance to foster the patient's capacity to work in therapy. These interventions affect the patient's experience of his/her boundaries in the treatment, are discussible and nonexploitative. They are often not just single events, but are part of a pattern meant to adapt a conventional treatment to the needs of a particular patient. The fact that boundary crossings, by definition, arise later, i.e., in an established treatment, mean that they will be experienced as novel, have distinct meanings, and carry the potential for misunderstanding that any new element, enactment or event possesses.
The therapist's intention to adapt his/her technique to the perceived needs of the patient, attunement to the patient's reactions, openness to own and explore the patient's subjective experience of the impact and meaning of these interventions, and willingness to discuss the process (in supervision or through consultation) are the hallmarks of the conscientious use of boundary crossings. These elements enable us to more clearly differentiate boundary crossings from boundary violations: we have noted how boundary crossings are initiated to enhance the treatment, while boundary violations (even those in the gray areas) often are motivated by the therapist's personal interests. In addition, I have also described how certain treatments, marked by aggregated, unexamined and nontherapeutic boundary crossings may verge on malpractice, though it is difficult to reach this conclusion with certainty in any given case. A thorough evaluation by a consultant may be useful. Consultations are not defensive, but they may be proposed defensively, as in the first clinical vignette.
I also argue that certain forthright and powerful therapeutic interventions at the boundary may by subjectively experienced by the patient as though they constituted a boundary violation. I have termed these "pseudoboundary violations" for heuristic and forensic reasons. Such actions should be recognized as the logical, ethically proper, and clinically responsible opposite end of the spectrum of interventions that only shares some external elements with boundary violations, most particularly with regard to the patient's subjective experience of a violation of the patient's sense of his/her boundaries. While it is important and consistent to acknowledge the emotional impact of these interventions, we view them as wholly appropriate, responsible and necessary therapeutic actions.
Thus one may discern a symmetry to boundary theory, taken as a whole, which can help clinicians and trainees more clearly conceptualize this complex area.
Clinicians should be conscious of when and how their technique is affecting the boundaries of treatment, but not be paralyzed by that awareness. A more distinct, comprehensive conceptual understanding of the variety and nature of boundary interventions will enable therapists to adapt treatments consciously and confidently, rather than fitting technique into prescribed procrustean beds to safeguard the therapist's reputation or livelihood. Increased conceptual clarity will also assist teachers of trainees in learning to maximize the opportunities and mitigate the damages such interventions may carry.
Potential litigators and professional board fact finders ( 1, 11) should hesitate to draw presumptive conclusions about specific clinical practices simply because the interventions involve activity that crosses a therapeutic boundary. Such therapeutic "actions at the boundary" are clinically necessary to deal with individual patients' unique modes of relating. As such, the full spectrum of these interventions deserves appreciation and careful study as necessary components of therapeutic technique; all the more because they are complex, subtle, controversial, interrelated, variably subjectively experienced, and double-edged.
Reflection Exercise #6
Ethics CEU QUESTION 13
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