In serving as an expert or consulting witness throughout the United States in more than 250 cases of boundary violations, up to and including sexual misconduct, I have observed some common pitfalls into which clinicians fall with distressing frequency. There are a variety of reasons for boundary problems; some may stem from the practitioner’s ignorance or exploitative character, others from moral weakness or emotional vulnerability, and so on. But what makes the matter even more distressing is the fact that some of the pitfalls I repeatedly observe, that often result in litigation or board complaints, could have been avoided with relative ease.
I have written extensively about this problem, but books and articles take time to read and grasp and are not always available when you need them. To aid the practitioners confronting these pitfalls, a handy short list is offered—a kind of conceptual wallet card—of extremely simple but effective risk management tips to aid in staying out of trouble. Consider this list a highly distilled summary of a spectrum of potential boundary problems. Note that there may well be context-driven exceptions to each of these points (eg, in some forms of behavior therapy), but that does not preclude keeping these points in the forefront of one’s clinical work.
Here, then, is a “pocket guide” for clinicians drawn from actual cases. With some modification, the list could become a patient information sheet or office policy.
• Stick to the therapeutic contract. When invited to do something unusual, ask yourself: “Is this what a therapist/psychiatrist does?” Also ask yourself: “Is this for me or for the patient?” An amazing number of treatments go forward without a contract (ie, an agreement by both parties as to what they are there for or what they will work on and how). Not having a contract is a very bad idea. Requests by patients to stray from the therapeutic contract (hold hands, sit on lap, take trips, etc) should be explored and almost always resisted.
• Work in the office. As a rule, do not take patients outside the office. There are exceptions to the rule: Some programs do use chaperoned home visits, and there are behavior therapy protocols that include outings; however, these must always be within standard practice (eg, treatment of agoraphobia).
• Never worry alone. Consult with a colleague, supervisor, or mentor before questionable actions can occur or after something questionable has occurred. Always remember to document your consultation sessions about patients.
• Be emotionally present. You may be emotionally present (but not unconditionally) when in session, barring ordinary human distractions. But do not promise to “always be there” for the patient; it is not a promise that you can keep. Someday your treatment of the patient will come to an end, either by mutual agreement or because of unforeseen circumstances (eg, you may fall ill or you may have a family emergency)—all of which will seem to some patients and, later, to some decision-making bodies, like a betrayal and an abandonment.
• Do not avoid personal questions from the patient. As a rule, explore therapeutically a patient’s personal questions about you rather than either giving the requested information or responding in a rejecting or punitive manner.
• Know the protocol for gift giving and receiving. Treat a patient’s gift as an opportunity to explore. Document your reasoning for accepting or not accepting a gift, and discuss the reasoning with the patient. Avoid giving gifts to adult patients. Boards of registration and licensure often practice “concrete thinking” about gifts and other boundary issues and equally often ignore context; they seem to operate out of a “list of forbidden acts” schema rather than a model based on context, clinical variability, and discretion.1 You have to supply the context in your notes. If you give a patient a relevant book or article, write it down with your reasons.
• When communicating with patients, be cordial and polite. Do not sign letters, cards, or e-mails “Love,” even if you do so with everyone else in your life. It is, of course, a standard, common, supposedly harmless and perhaps mildly hypocritical closing, but the very patients who are most likely to misconstrue it are the very ones to whom you should not be writing it.
• Do not use terms of endearment. Communicate your caring and concern by always keeping your focus on the patient’s needs and issues first. Do not tell a patient that you love him or her, even if you do. You may mean divine, abstract love, but the patient may hear (and the board may assume you meant) eros.
• Do not forget to document. Thoroughly document the incidents that seem questionable to you regarding boundaries; not to do so suggests a cover up. Use the 3 D’s: demeanor, documentation, and debriefing. If you give a patient a ride to the bus station in a blizzard, for example, keep a professional demeanor in the car; document the situation and your reasoning; and debrief it with the patient at his or her next session.
Such a concentrated summary as this pocket guide cannot be comprehensive, but the points summarized here recur repeatedly as problems for practitioners. For further analysis and discussion, see “Additional Reading,” below. Thoughtful, knowledgeable practice is always best for patients and the best avoidance of trouble for clinicians.
Dr Gutheil is professor in the department of psychiatry, Program in Psychiatry and the Law, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston. E-mail: [email protected]. Dr Gutheil reports no conflicts of interest concerning the subject matter of this article. Acknowledgment: The author thanks members of the Program, Shannon Woolley, EdD, and Kenneth Pope, PhD, for critical review.
1. Gutheil TG, Brodsky A. Preventing Boundary Violations in Clinical Practice. New York: Guilford Press; 2008.
Gutheil TG, Gabbard GO. The concept of boundaries in clinical practice: theoretical and risk-management dimensions. Am J Psychiatry. 1993;150:188-196.
Gutheil TG, Gabbard GO. Misuses and misunderstandings of boundary theory in clinical and regulatory settings. Am J Psychiatry. 1998;155:409-414.
Gutheil TG, Simon RI. Non-sexual boundary crossings and boundary violations: the ethical dimension. Psychiatr Clin North Am. 2002;25:585-592.
Norris DM, Gutheil TG, Strasburger LH. This couldn’t happen to me: boundary problems and sexual misconduct in the psychotherapy relationship. Psychiatr Serv. 2003;54:517-522.