Essay Example on Therapist-Client Relationship Boundaries

Vulnerable Patients

Every patient, by virtue of being a patient, is vulnerable to psychological damage from therapists who commit boundary violations. Psychotic and borderline patients are particularly at risk for psychic injury." Frequently, these patients have been physically and sexually abused as children. Their sense of what constitutes appropriate relationships and boundaries may be seriously impaired. Treatment boundaries are frequently tested by the patient through repetition of early childhood relationships where personal boundaries were not respected. Highly dependent patients or patients recently experiencing a personal loss also are vulnerable to exploitation.

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Patients with Borderline Personality Disorder (BPD) present special problems for therapist." These patients frequently attempt to manipulate and draw the therapist out of the treatment role. Therapists frequently find themselves making exceptions in the treatment of such patients. Patients with BPD often induce the greatest countertransference trap of all: the desire to do better than or to undo the damage done by, previous parental figures. Thus, a high level of vigilance for treatment boundary violations must be maintained by therapists who treat BPD patienk2* From a litigation perspective, suicide and sexual misconduct are the most common claims in malpractice suits against therapists treating patients with BPD.

Although the therapist sets the treatment boundaries, patients will question or test these boundaries repeatedly and in various ways. Thus, boundary issues invariably arise in every therapy as grist for the therapeutic mill. Generally, healthier patients are able to stay within acceptably established treatment boundaries, using the treatment framework provided to progress psychologically. More disturbed patients often act out their conflicts surrounding boundary issues. For example, a patient who was sexually abused as a child may actively repeat sexually seductive behavior toward the therapist who is attempting to maintain relative anonymity and neutrality. With many of these more disturbed patients, a considerable portion of the therapy is devoted to examining the psychological meaning of the patient's efforts to gain exceptions to established treatment boundaries. Patients who are consistently unable to tolerate limit setting by the therapist may be untreatable.

Severely disturbed patients frequently present daunting treatment and management problems for therapists who are willing to undertake their care. The patient's psychiatric condition with the associated vicissitudes in the therapeutic alliance may necessitate utilizing innovative treatment techniques that cross customary treatment boundaries without necessarily creating deviant boundaries. The strict application of the usual boundary guidelines to these patients could prove inimical to their treatment.

Examples of boundary violations

Sexual Exploitation Invariably. in cases of therapist-patient sex, progressive boundary violations precede and accompany the eventual sexual acts. 22 Patients are psychologically damaged by the precursor boundary violations in addition to the ultimate sexual exploitation. Even if the therapist and patient stop short of an overt sexual relationship, precursor boundary violations interfere with the adequate diagnosis and treatment of the patient. Thus, therapists may be sued for negligent psychotherapy in addition to sexual misconduct. Under either circumstance, patients are not provided essential psychiatric care. The patient's original mental disorder is often exacerbated and other mental disorders are iatrogenically induced.

Sexual misconduct cases usually demonstrate boundary violations in the extreme. Thus, their study can be very instructive. The following clinical vignette will be used as an introduction to the discussion of basic boundary guidelines. It illustrates the progressive, increasingly flagrant violation of treatment boundaries that often precede therapist-patient sex:

A 38yearold single woman with previously diagnosed Borderline Personality Disorder and drug abuse seeks treatment for severe depression following spontaneous abortion. The psychiatrist is 49 years old. and recently divorced by his wife. His ex-wife is very attractive. a talented artist who ran off with a concert pianist. The psychiatrist is increasingly relying on alcohol to deal with his feelings of loss.

The patient is quite bright and attractive. She talks continually about her feelings of isolation and emptiness. Clear vegetative signs of depression are present. The patient had hoped for a child as a way of assuaging her loneliness. The psychiatrist is struck by the patient's resemblance to his ex-wife. He becomes quickly enamored of the patient, overlooking and minimizing her major depression. His clinical judgment is further distorted by the appearance of improvement in the patient's depression as the psychiatrist shows a personal interest in her. The psychiatrist looks forward to seeing the patient for her twice-a-week appointments, finding solace and relief from his own sense of desolation. For the first two months, the treatment boundary remains relatively intact. Then gradually, the sessions take on a conversational, social tone.

Psychiatrist and patient begin to address each other by their first names. The psychiatrist discloses the facts surrounding his divorce. talking at length about his wife's infidelity and his feelings of betrayal. He also confides in the patient intimate details about his other patients. treating her as a confidant. The patient is distressed at the psychiatrist's unhappiness and feels guilty that she cannot be of more assistance. Initially. the psychiatrists sits across from the patient but gradually moves his chair closer. Ultimately doctor and patient sit together on the sofa. occasionally the psychiatrist with his arm around the patient when she tearfully describes extensive childhood physical and sexual abuse. Treatment sessions are extended in time. some lasting as long as three hours. The patient feels grateful that she is receiving such special treatment.

Because the extended sessions disrupt the psychiatrist's other appointments, the patient is scheduled for the end of the day. Whenever possible. therapist and patient also meet for brief periods of time at a nearby park or bar for a drink. Because the patient complains of sleeping problems, the psychiatrist prescribes barbiturates. He has not kept up with developments in psychopharmacology. having used medications very sparingly in his practice over the years. The psychiatrist is unaware of her prior addiction to narcotics. He does not explain the risks of taking barbiturate medications. The patient requires higher doses of barbiturates over time that interfere with her ability to function independently. The psychiatrist begins to make day to day decisions for the patient. including balancing her checkbook.

During sessions. therapist and patient begin to embrace and kiss. The psychiatrist finds the patient more compliant to his advances when she has had a few drinks. During one session when the patient drinks too much, sexual intercourse takes place. The psychiatrist stops billing the patient as their sexual relationship continues.

A few months later, the psychiatrist takes an extended vacation. While he is away, the patient learns from another patient that the psychiatrist revealed details of her childhood sexual abuse. The patient becomes extremely depressed and takes a near-lethal overdose of barbiturates. While hospitalized. she is weaned from barbiturates. She discloses the fact of her sexual involvement with her outpatient psychiatrist. The patient is successfully treated for major depression with antidepressants. The diagnosis of Borderline Personality Disorder also is made that is severely aggravated due to the sexual exploitation by her therapist. The exploiting psychiatrist attempts to see the patient upon his return. She refuses. One year later, the patient brings a malpractice suit against the psychiatrist for sexual misconduct.

Neutrality and Self-Determination

The rule of abstinence and the therapist position of relative neutrality empower patient separateness, autonomy, and self-determination. In the vignette, the psychiatrist abandons a position of neutrality and undercuts the patient's independence through numerous boundary violations that promote fusion between psychiatrist and patient. He gradually gains control over the patient's life, making basic life decisions for her. Whether done consciously or subconsciously, boundary violations cut short a patient's options for recovery and independent psychological functioning. The achievement of psychological independence is a goal of treatment. Maintaining patient separateness that permits pursuit of this goal is a boundary issue.