Healthcare Training Institute - Quality Education since 1979
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The term "boundary violation" has become synonymous with unethical practice in psychotherapy, prompting a "black-or-white" view among clinicians and boards of review. But the current conceptual ambiguity about boundary interventions subjects clinicians to after-the-fact second-guessing that can be professionally ruinous at worst and may contribute to stultifying defensive therapeutic rigidity at best. It is crucial to demarcate the differences between boundary violations and boundary crossings (to be defined below) as clearly as possible, to describe the "gray areas" of each, and to recognize the heterogeneity of boundary violations and boundary crossings. These matters are of additional importance to those who teach, train, and supervise the next generation of clinicians. This paper will attempt to delineate a more clinically realistic and useful view of boundary crossings than has been proposed before, and illustrate the practical advantages of recognizing the spectrum of boundary interventions.
Thus the early history of psychoanalysis was permeated by numerous examples of what today are easily recognizable as boundary violations ( 8,pp. 83ff).
Gabbard and Lester ( 8,pp. 4, 39) define boundaries as "the demarcation between the self and the object...the envelope within which treatment takes place." Boundaries provide "a flexible set of conditions that...(establish) an optimal ambience for the (therapeutic) work," and establish rules and role expectations that the patient may rely upon for safety required for treatment.
In terms of therapeutic interventions, Gutheil and Gabbard ( 1,p. 410) describe boundaries as "the edge of appropriate (therapist) behavior" adapted to the needs of the individual patient "to create an atmosphere of safety and predictability" (emphasis added). Here the distinction is drawn between "appropriate behavior" by the therapist, and inappropriate behavior, i.e., behavior not in the patient's best interests. In this paper, I will emphasize the patient's subjective experience of his/her boundaries within the treatment: that personal space that may be infringed upon, eliciting various responses and, concomitantly, presenting therapeutic challenges and opportunities. This emphasis on the patient's subjectivity is consistent with recent psychotherapeutic interest, illuminated by the work of Kohut (9).
As clinicians achieved a clearer awareness of boundary theory and appreciated the danger that violations posed to their patients, the treatment, and themselves, Waldinger (10,p. 226) and others ( 11,p. 189) called attention to problems engendered by this heightened awareness. They identified difficulties that could arise from an inflexible adherence to a prescriptive black-or-white definition of boundary constraints. They cautioned against a rigidification of technique that could stifle creativity, impede the individualization of treatment, and obscure subtleties in context, timing, and cultural expectations that could be critical for optimal treatment. Waldinger ( 10) illuminates the counterintuitive effects of waiving a fee and accepting a hug in two case illustrations.
The concept of "boundary crossings" was advanced ( 1, 8, 10) to describe appropriate and ethical "boundary transgressions"( 1). In keeping with their elusive nature, boundary crossings have been difficult to define; rather, authors have described various properties that, they argue, typify boundary crossings. Behaviorally, boundary crossings are seen as distinct discussible departures from an established treatment framework. They are not part of a progressive escalation of exploitative changes in the relationship ( 1, 6, 8). The nonprogressive and discussible aspects of boundary crossings are central in distinguishing a boundary crossing from the infamous "slippery slope" of cascading transgressions that mark boundary violations. The goal of boundary crossings is to enhance treatment without harm to the patient ( 1).
Despite these clarifications, clinicians and trainees often are uncertain if a given intervention represents a boundary violation or a boundary crossing. In view of the complexity of the interactions and the abovementioned imprecision in the definition of boundary crossings, this is not surprising. But other elements add to the challenge. Renik (12) emphasizes the inevitability of enactments in psychotherapy (unconscious, mutual partial playings out of wishes in the therapy), and points to their potential value in enhancing the exploratory process when recognized and examined. Waldinger ( 10,p. 236) remarks that "the intrapsychic meanings (to the patient) may be the only clues to understanding whether a boundary violation has occurred." Note that this requires a retrospective inquiry, i.e., one that occurs after the event in question. Gutheil and Gabbard ( 1), commenting on the effect of interested litigators and professional review boards, remark
The matter of context is all too often disregarded by fact finders and decision makers in this area, although it is essential to determine, inter alia, whether a specific behavior represents a boundary crossing or a boundary violation; indeed, the identical behavior may constitute either a boundary crossing or a boundary violation, depending entirely on the context in which it occurs. (emphasis in original). (p. 411)
These uncertainties have led Epstein and Simon (13,14) to propose an "exploitation index" to provide "early warning indicators of treatment boundary violations." Others (15-17) have questioned the utility of such an approach, fearing it is overly inclusive, misleading, and purports an unwarranted degree of certainty in an area of cultural relativism. It is clear that apprehension of being found on the wrong side of whatever is established as a definition of boundary violations has led some to cling to a therapeutic orthodoxy that interferes with flexible, empathic treatment.
Another reason for this problem of defensive inflexibility is that the existing literature is marked by confusion as to what constitutes appropriate vs. inappropriate "boundary transgressions"( n1) ( 1). To some extent this is unavoidable, since, as noted above, context may make the same intervention acceptable in one situation while not in another. Also, one's conception of boundaries is rooted in the type of psychotherapy being practiced. (Cognitive-behavioral therapists understandably will have different techniques and appropriately different ideas of what constitutes the boundaries that pertain. This article, and the literature it draws upon, are from a psychodynamic perspective.)
In this vein, I will present an understanding of the concept of boundary crossings that connects it to the familiar process of creating a therapeutic alliance. Viewed in this light, boundary crossings will be recognizable as a continuing elaboration of the therapeutic setting. As such, these "actions at the boundary" can be understood to be part and parcel of psychotherapeutic work: a standard element in technique with its unique place and potentials for use and misuse. This perspective is intended to clarify the concept of boundary crossings, securely placing them in the familiar array of reasonable therapeutic interventions. Also, I will attempt to illustrate the clinical utility of recognizing that boundary interventions (violations and crossings) each have gray areas that span ethical practice and malpractice. In addition, a fundamental but overlooked distinction between boundary violations and boundary crossings that will be illustrated below is that boundary crossings relate to the therapist's attempts to enhance the treatment, while boundary violations, which more grossly breach the patient's physical and/or psychological subjective space, often do so in the service of the therapist's interests.
Reflection Exercise #5