Rule of Abstinence Definition
There are a number of basic, overlapping principles that form the underpinning for the establishment of boundary guidelines. One of the foremost principles is the rule of abstinence, which states that the therapist must refrain from obtaining personal gratification at the expense of the patient.
A corollary of the principle of abstinence states that the therapist's main source of personal gratification arises from the professional gratification derived from the psychotherapeutic process and the satisfactions gained in helping the patient. The only material satisfaction directly received from the patient is the fee for the therapist's professional services. Treatment boundaries are violated when the primary source of the therapist's gratification is receivedfrom the patient directly rather than through engagement in the therapeutic process with the patient. The principle of abstinence underlies virtually all boundary guidelines.
The rule of abstinence attempts to secure a position of neutrality for the therapist's interactions with the patient. Therapeutic neutrality is not defined here in the psychoanalytic sense of equidistance between the patient's ego, superego, id, and reality. Rather, it means knowing one's place and staying out of the patient's personal life.
Therapeutic neutrality allows for the patient's agenda to be given primary consideration. The relative anonymity of the therapist ensures that self disclosures will be kept at a minimum, thus maintaining therapist neutrality. Also, the law independently recognizes the therapist's duty of neutrality toward patients.
The concept of relative neutrality refers to the limitations imposed upon psychotherapists from interfering in the personal lives of their patients. Life choices such as mamage, occupation, where one lives, and with whom one associates, while grist for the therapeutic mill, are fundamentally the patient's final choice." Nor should the personal views of the therapist concerning politics, religion, abortion, and divorce, for example, be aired in the treatment situation.
If an otherwise competent patient is contemplating making a decision that appears foolish or even potentially destructive, the therapist's role is limited primarily to raising the questionable decision as a treatment issue. For example, the therapist can appropriately explore the psychological meaning of the decision as well as its potential adverse consequences on the patient's treatment and life situation. On the other hand, situations do arise with patients when the psychotherapist must intervene directly. If a patient's decisionmaking capacity is severely compromised by a mental disorder, the therapist may need to actively intervene to protect the patient or others.
As an obvious example, a psychotically depressed, suicidal patient who refuses to enter a hospital voluntarily will likely require involuntary hospitalization. Under these conditions, the therapist is intervening in the patient's life for valid clinical, not personal, reasons.
Patient Autonomy and Self Determination
Fostering the autonomy and selfdetermination of the patient is another major principle underlying treatment boundary guidelines. Sustaining patient separateness through the process of separation individuation follows as a corollary. Of the over 450 psychotherapies currently available, none state as their longterm treatment goal that patients should remain dependent and psychologically fused with their therapists or others. Obtaining informed consent for proposed procedures and treatments also preserves the autonomy of the patient.
Patient selfdetermination requires that the therapist's clinical posture toward the patient should be expectant. That is, the patient basically determines the content of his or her sessions. Generally, this does not apply in cognitive behavioral therapies or even with some forms of interpersonal therapy. Moreover, the stricture that physical contact with patients be essentially avoided and that the therapist stay out of the persons personal life (no past, current, or future personal relationships) derive in large measure from the principle of autonomy and selfdetermination.
Progressive boundary violations invariably limit the patient's freedom of exploration and choice. Properly maintained treatment boundaries foster the separateness of the patient from the therapist while also maintaining the psychological relatedness of the patient to others.
Washington also has characterized the relationship between physician and patient as fiduciary: "The physicianpatient relationship is of fiduciary nature. The inherent necessity for trust and confidence requires scrupulous good faith on the part of the physician" (citations omitted).
The knowledge and power asymmetries that exist between therapist and patient require the therapist not to use the patient for his or her personal advantage.'' This responsibility is "implicit" in the therapistpatient relationship and is a fundamental aspect of the general "duty of care." The special vulnerabilities of the patient rather than the special powers of a profession give rise to a fiduciary duty.
A fiduciary relationship arises, therefore, whenever confidence, faith, and trust are reposed on one side, and domination and influence results on the other." Not only psychiatrists but all mental health professionals have a fiduciary responsibility to their patients. The maintenance of confidentiality, privacy, a stable fee policy and consistent time and treatment settings are derived in large measure from the fiduciary duties of the therapist.
Respect for Human Dignity Moral, ethical, and professional standards require that psychiatrists as well as nonmedical professionals treat their patients with compassion and respect. The dedication of physicians to their patients has a long and venerable tradition so artfully expressed in the Hippocratic oath. The Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry1*states: "A physician shall be dedicated to providing competent medical service with compassion and respect for human dignity." On clinical grounds alone, the competent therapist always must strive to maintain the patient's healthy selfesteem during the course of therapy. Exploitative therapists, however, relate to patients as part objects to be used for their own personal gratification. Frequently, such therapists attack the selfesteem of their patients in order to gain control over them. All of the boundary guidelines are substantially based on the principle of respect for human dignity.
Therapist Ethics Violations
In the course of therapy, it may be necessary for the sake of the patient or the welfare of others for the psychiatrist to cross accepted treatment boundaries. Boundary violations may be driven by crises in clinical care, and by intervening, superseding ethical or legal duties. For example, an agoraphobic patient may be incapacitated and unable to come to the psychiatrist's office. Home visits may be required initially. The potentially violent patient who threatens others places the psychiatrist in a conflicting ethical position regarding maintaining confidentiality. Professional and legal duties to warn and protect endangered third persons, however, may necessitate a breach of the patient's confidentiality. In the latter example, if the patient can be brought into the process of issuing a warning, treatment boundaries may be stretched but not necessarily violated. Engaging patients in the decision to readjust treatment boundaries as a result of treatment exigencies may permit salutary boundary reshaping that actually facilitates the treatment process.
Impaired therapists usually experience great difficulty in establishing and maintaining acceptable treatment bondaries . Deviant, idiosyncratic boundary setting forms the groundwork for patient exploitation. Therapists who suffer from severe character disorders tend to repeat boundary deviations with a number of their patients. The predatory, exploitative therapist also belongs to this group. Other therapists who establish deviant boundaries may be merely incompetent, impaired by alcohol, drugs, and mental illness, situationally distressed by personal crises, or suffering from a paraphilia, particularly frotteurism. Frotteurs consistently fail to maintain appropriate physical distance from patients, becoming involved in inappropriate touching.
Qualities of a Good Therapeutic Relationship
Well, not everyone knows that having a bond with the psychologist who is trying to help you is crucial. Relationships between the patient and the therapist are vital because they define the success of future therapy. A lot of experts expressed their viewpoints when describing a “good relationship,” and a vast majority agreed that it is vital to build a trusting relationship with the patient. There should be respect and agreement on the common goals. Only in such a way is it possible to reach the best possible result with ease.
What are the characteristics of the therapeutic relationship?
- mutual confidence and respect;
- agreement on the key goals of the therapy;
- making decisions only after discussing all the crucial points;
- engagement in the process because only in such a way the outcomes will be easy-to reach;
- the ability to talk about the things that are essential and need to be mentioned now and here;
- not being afraid to show your real emotions even if they are negative;
- the ability to deal with some challenges that may arise.
Both a psychologist and a client need to be genius with each other because it helps to make the relationship stronger. When we say about geniusness, we mean being not only open when talking about your real feelings but a non-verbal communication like gestures, eye contact, and expressing real emotions without any fear.
When a patient trusts his therapist, it will be easier to get rid of painful emotions and fears bothering each and every day. Trust brings hope. Hope for a better future, hope that everything will be alright if you have such a strong backup regardless of the difficulties that may be faced on the path.
Being empathic is also crucial for a good relationship because it is vital to see that a therapist cares for your problems and tries to offer an optimal solution. Empathy helps promote reflection and analysis.
Therapy is interaction, and every session differs from the previous one providing new experience and offering challenges that need to be overcomed.
Without a doubt, every relationship is full of daily challenges, and the therapeutic relationship is no exception as well. But the way a therapist and a patient treat each other is crucial for future success and a positive outcome. Only by being bound by the same goal, two individuals can reach the goal and be satisfied with the final result.
Therapy will be rewarding only if you recognize the mentioned above qualities and can freely talk to the specialist without a need to pretend and hide your inner fears and worries.
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