Boundary violations and psychotherapy

Current Opinion in Psychiatry

Volumn 9, Issue 3, 1996, Pages 204-208

  Margison, Frank ^a  

^a MANCHESTER ROYAL INFIRMARY   (United Kingdom)

Author keywords

[No Author keywords available]

Indexed keywords

ATTITUDE; COUNTER TRANSFERENCE; MALPRACTICE; PROFESSIONAL PRACTICE; PSYCHOTHERAPY; SHORT SURVEY; TRAINING; TRANSFERENCE;

EID: 0029979916     PISSN: 09517367     EISSN: None     Source Type: Journal    
DOI: 10.1097/00001504-199605000-00007     Document Type: Short Survey

References (66)

1. Freud S: Observations on transference love. In Standard Edition Vol. 12. Edited by Strachey J. London: Hogarth Press, 1975:157-168.
2. Gabbard GO: Sexual excitement and countertransference love in the analyst. J Am Psychoanal Assoc 1994, 42:1083-1106. A clinical paper from an analyst whose professional career has focused on work with therapists who have become sexually involved with patients.
3. Gabbard GO: Love and lust in erotic transference. J Am Psychoanal Assoc 1994, 42:385-403. Powerful longings for love elicit corresponding roles in the analyst. Acting out is on a continuum from actual affairs to subtle forms of partial transference manifestations.
4. Gabbard GO: Therapists who transgress sexual boundaries with patients. Bull Menninger Clin 1994, 58:124-135.
5. Gabbard GO: Transference and countertransference in the psychotherapy of therapists engaged in boundary violations. Psychiatr Ann 1995, 25:100-105. Countertransference feelings include having to 'police' the profession, and becoming a 'rescuer/absolver'. Transference is often experienced by the therapist as a 'corruptible object', or as an alternative love object. Disturbing feelings of curiosity, specialness and being a voyeur affect the therapist.
6. Fawcett J: PSM: 'To err is human' - but then what? Psychiatr Ann 1995, 25:88-89. An introductory editorial to the special issue of Psychiatric Annals dealing in depth with professional sexual misconduct. The issue as a whole cites many papers published on this topic in the last twenty years.
7. Simon RI: The natural history of therapist sexual misconduct: identificalion and prevention. Psychiatr Ann 1995, 25:90-94. An excellent summary including principles: the rule of abstinence, duty to neutrality, fiduciary relationship, and respect for dignity and autonomy. Guidelines for neutrality, psychological separateness, consent, style of verbal and non-verbal interaction, avoiding personal relationships, minimizing physical contact, anonymity of therapist, stability of arrangements, consistent and private professional setting, defined session time and length, and boundaries set by and remaining the responsibility of the therapist. Key self-monitoring questions include: 'is this intervention for the patient's benefit or mine?', and 'is this part of progressive boundary shifts?'. These can form a therapist and supervisor checklist and 'early warning' system. Particular attention is needed at the end of session boundary as the patient leaves the room.
8. Schoener GR: Assessment of professionals who have engaged in boundary violations. Psychiatr Ann 1995, 25:95-99. Discusses rehabilitation compared with discipline and an assessment algorithm. A tentative classification of therapists includes (1) those with psychosis, mania and borderline states, (2) sociopaths, (3) therapists with impulse control disorders, (4) chronic neurotic isolated therapists, (5) situational offenders, and (6) naive therapists. He suggests ruling out the severe diagnostic categories (1-3), then performing a detailed assessment of the situation and dynamics prior to rehabilitation.
9. Frick DE; McCartney CF; Lazarus JA: Supervision of sexually exploitative psychiatrists. APA District branch experience. Psychiatr Ann 1995, 25: 113-117. A salutary discussion of the dependence on supervisor motivation, even in well-regulated compulsory supervised practice, as part of disciplinary procedures.
10. Abel GG, Osborn CA, Warberg B: Cognitive-behavioral treatment for professional sexual misconduct Psychiatr Ann 1995, 25:106-112. Severe offenders and their treatment are discussed. This paper contains a useful section on cognitive distortions which support the 'rhetoric of justification'. It suggests group approaches to offenders and rating scales to use with patients and colleagues to assess the degree of boundary violation. Changes in the practice of therapy are used to help reduce risk.
11. Jorgensen LM: Rehabilitation of sexually exploitative therapists: a risk management perspective. Psychiatr Ann 1995, 25:118-122. A disturbing paper discussing not just risks to patients, but also the liability of supervisors and employing agencies if therapists are rehabilitated and re-offend.
12. Simon RI: Transference in therapist-patient sex: the illusion of patient improvement and consent. Part I. Psychiatr Ann 1994, 24:509-515. See [13••]
13. Simon RI: Transference in therapist-patient sex: the illusion of patient improvement and consent, Part II. Psychiatr Ann 1994, 24:561-565. Two important articles drawing attention to the way that therapists distort their view of the patient. First, the therapist selectively perceives improvement in the patient and, second, avoids the complex issues of consent. The review carefully disentangles the rationalizations used by therapists (and their attorneys) to claim that consent is a defence against any legal action. Simon demonstrates the fundamental issue of transference relationships and the difference from consenting sexual relationships, and the importance of the 'fiduciary relationship' (a relationship founded on a particular type of trust which considers in advance that the patient will become vulnerable during any regression). An important distinction between levels of consent is given, distinguishing 'simple consent', which merely requires the communication of choice having understood the basic situation, from 'competent informed consent', which requires an appreciation of the risks and benefits in the situation.
14. Lindsay G: Values, ethics and psychology: presidential address. Bull Br Psychol Soc 1995, 8:493-498. An overview of many ethical issues in psychotherapeutic practice including empirical studies of boundary violations.
15. Pope KS, Tabachnick BG, Keith-Spiegel P: Ethics of practice: the beliefs and behaviours of psychologists as therapists. Am Psychol 1987, 42:993-1006.
16. Haas LJ, Malouf JL, Mayerson NH: Ethical dilemmas in psychological practice. Am Psychol 1986, 41:316-321.
17. Lindsay G, Colley A: Ethical dilemmas of members of the British Psychological Society. Bull Br Psychol Soc 1995, 8:448-453
18. Garrett T: Epidemiology in the USA. In Jehu D. (Ed) Patients as victims. Chichester: John Wiley, 1995. A review of several US studies of psychologists, psychiatrists and social workers. This suggests prevalence rates of 2-7% with a median of 6%.
19. Garrett T, Davis J: Epidemiology in the UK. In Jehu D. (Ed) Patients as victims. Chichester: John Wiley, 1995. The most thorough study to date in a UK context, based on 1000 members of the British Psychological Society. The response rate was 58% overall (60.7% female and only 37.6% male); mean age 39 years and mean length of post-qualification practice 11 years. Twenty (3.4%) respondents admitted sexual contact with current or past clients. Of these, 12 were men, seven women, and was one of unstated sex. Thirteen of the 20 cases were with discharged patients only, one female respondent being involved with three former clients with whom she had 'long-term relationships'. One male therapist was involved sexually with five current clients and one discharged client. Several were concerned about the effects of this involvement, but others minimized the chance of any harmful effects. Sixteen had already mentioned the sexual contact to friend, partner, colleague or manager.
20. Bachmann KM, Ziemert B: Sexual abuse in psychotherapy: epidemiological quantification, i.e. pooling the therapists as a suggested approach [In German]. Nervenarzt 1995, 66:550-553. A methodological paper which acknowledges the difficulties in estimating the frequency of boundary violations when using nonconvergent methods of estimation (asking therapists, asking clients and, finally, asking current therapists about their patients' past experience with other therapists.).
21. Gonsiorek J (ed): Breach of trust-sexual exploitation by health care professionals and clergy. London: Sage, 1994. An extensive book on professional sexual misconduct, covering familiar ground regarding prevalence and warning features in professionals but with interesting contributions on boundary issues when therapist and client are gay, and on systemic approaches. The latter topic has been developed very little to date and the relevant chapter in this book covers crucial issues regarding abusive organizational cultures, which are known to be of particular relevance to child clients.
22. Bajt TR, Pope KS: Therapist-patient sexual intimacy involving children and adolescents. Am Psychol 1989, 33:445.
23. Glaser RD, Thorpe JS: Unethical intimacy: a survey of sexual contact and advances between psychology educators and female graduate students. Am Psychol 1986, 41:43-51.
24. Pope KS, Keith-Spiegel P, Tabachnick BG: Sexual attraction to clients: the human therapist and the (sometimes) inhuman training system. Am Psychol 1986, 41:147-158.
25. Gartrell N, Herman J, Olarte S, Feldstein M, Localio R: Psychiatrist-patient sexual contacts-results of a national survey, I: prevalence. Am J Psychiatry 1986, 143:1126-1131.
26. Holroyd JC, Brodsky AM: Attitudes and practices regarding erotic and non-erotic contacts with patients. Am Psychol 1977, 32:843-849.
27. Williams MH: How useful are clinical reports concerning the consequences of therapist-patient sex? Am J Psychother 1995, 49:237-243. The author describes the tension for therapists who may feel outraged and betrayed by colleagues who have become sexually involved with clients, while trying to maintain objectivity in attributing causality to the adverse sequelae of sexual abuse by the therapist. He acknowledges that this can come dangerously close to 'blaming the victim', but does raise some crucial issues: is the likelihood of boundary violations determined, at least in part, by the patient's past history (particularly of early abuse)? Do the adverse consequences persist? Are the prevalence estimates systematically biased by the sampling process and lack of a denominator to calculate rates of adverse effects? Are the adverse effects related to the absence of therapeutic input rather than the direct consequences of the sex itself? The paper reviews, but does not resolve, some of the methodological problems in determining rates and causality in phenomena which vary with time, and where base rates for the relevant clinical population are not known.
28. Pages KP, Maxim PE, Wasch H: An in-patient team's response to alleged sexual misconduct by an outpatient psychotherapist. Hosp Community Psychiatry 1994, 45:1231-1 232. A brief but informative account of the extra professional boundary involved in treating an inpatient who is sexually involved with an outpatient psychotherapist. The authors argue that the inpatient team may be well situated to help a patient manage her conflict of loyalties and split feelings towards the other therapist. They suggest that the patient may have become 'enmeshed' in a complex system with the therapist. In this case the abusive dynamics become clearer when, after initially cooperating with his own supervision and disclosing 'personal pressures', the therapist then becomes intimidating to the patient. The authors point out the characteristic 'loosening' of boundaries which frequently precedes sexual contact: 'increasing the frequency of sessions, becoming lax about fees, moving chairs to different positions to make it easier to be supportive, and holding hands in the hope of being reassuring (p 1231).
29. Hankins GC, Vera MI, Barnard GW, Herkow MJ: Patient-therapist sexual involvement: a review of clinical and research data. Bull Am Acad Psychiatry Law 1994, 22:109-126.
30. Field N: Listening with the body: an exploration in the countertransference. Br J Psychother 1989, 5:512-522.
31. Stoller RJ: Sexual excitement: dynamics of erotic life. New York: Pantheon, 1979.
32. Hill D: The special place of the erotic transference in analysis. Psychoanal Inquiry 1994, 14:483-498.
33. Bergmann MS: The challenge of eroticized transference to psychoanalytic technique. Psychoanal Inquiry 1994, 14:499-518.
34. Bollas C: Aspects of the erotic transference. Psychoanal Inquiry 1994, 14:572-590. Bollas makes a useful distinction between erotic (which implies 'private imaginative use of the object of desire') and sexualized transference (in which these experiences are defensively dealt with through the wish to actually have intercourse with the analyst). A helpful clinical account which demonstrates that recounting erotic material to the analyst has already involved the therapist in a form of sexual enactment.
35. Siegal EV: Clinical observations of sexual and sensual aspects of the transference in women. Psychoanal Inquiry 1994, 14:591-603.
36. Lachmann FM: How can I eroticize thee? Let me count the ways. Psychoanal Inquiry 1994, 14:604-621.
37. Blum HP: Discussion on the erotic transference: contemporary perspectives. Psychoanal Inquiry 1994, 14:622-635.
38. Gould E, Rosenberger J: Erotic transference: contemporary perspectives: prologue Psychoanal Inquiry 1994, 14:477-482. An introduction to this special issue which reviews erotic transference from several perspectives, concentrating on challenges to technique, but raising the issue of possible boundary violations.
39. Goldberger M: The couch as a defense and as a potential for enactment Psychoanal Q 1995, 64:1-22.
40. Myers WA: Addictive sexual behaviour. J Am Psychoanal Assoc 1994, 42:1159-1182. Examines the difficult countertransference feelings in working with impulsive sexuality, but also takes a biochemical view examining serotonin function.
41. Mann D: The psychotherapist's erotic subjectivity. Br J Psychother 1994, 10:344-354. Mann examines the importance of awareness of one's own subjective erotic experience as an important source of clinical data. He claims that the absence of such experience is potentially more damaging than to be aware because of the possibility of the experience 'going underground' and being manifest in actual abuse of the patient.
42. Chiesa M: Some thoughts on erotic transference. Psychoanal Psychother 1994, 8:37-48. Further clinical examples of working with intense erotic material.
43. Colman W: Boredom in the therapist: countertransference issues. Br J Psychother 1995, 11:536-545.
44. Hill DH: The special place of the erotic transference in psychoanalysis. Psychoanalytic Inquiry 1994, 14:483-498. A thorough review of an important clinical phenomenon which may be particularly important in some boundary violations.
45. Cantlie A: The non-lover: desire and discourse in the psychoanalytic session. Free Associations 1993, 4:210-240.
46. 46' Rosenberg V: On touching a patient Br J Psychother 1995, 12:29-36. A clinical account from a therapist who moves her orientation from a bioenergetic perspective to become a psychoanalytic therapist. She analyses the need for touch in terms of 'autistic-contiguous' anxiety based on Ogden's concept of anxiety predating Klein's paranoid-schizoid position.
47. McLaughlin JT: Touching limits in the analytic dyad. Psychoanal Q 1995, 64:433-465. This paper explores the metaphoric relation between touch and human contact generally, and includes a discussion of boundary issues.
48. Levenson EA: Beyond countertransference: aspects of the analyst's desire. Contemp Psychoanal 1994 30:691-707.
49. Kumin I: Erotic horror: desire and resistance in the psychoanalytic situation. Int J Psychoanal Psychother 1985, 11:3-20.
50. Coen SJ: Barriers to love between patient and analyst. J Am Psychoanal Assoc 1994, 42:1107-1135. Analysts avoid the full range of feelings in themselves and others, particularly of love and hate. Coen analyses the barriers to experiencing loving feelings to his analysands.
51. Kernberg OF: Love in the analytic setting. J Am Psychoanal Assoc 1994, 42:1137-1157. 'Normal' love is distinguished from transference, Oedipal and neurotic love. This paper explores the conditions under which countertransference love is most intense and the importance of the analyst's ability to explore his or her feelings and fantasies without constraint. The use of these feelings in formulating interpretations is exemplified.
52. van Deurzen-Smith E: Letting the client's life touch yours. Changes: J Psychol Psychother Assoc 1995, 13:293-298.
53. Roughton RE: Useful aspects of acting out: repetition, enactment and actualization. J Am Psychoanal Assoc 1993, 41:443-472.
54. Owen IR: Power, boundaries, intersubjectivity. Br J Med Psychol 1995, 68:97-107. A useful discussion of the role of interpersonal power and boundary issues, analysing Masson's critique of psychotherapy; also includes Lang's concept of the therapeutic 'frame'.
55. van Deurzen-Smith, E: Questioning the power of psychotherapy. Is Jeffrey Masson onto something? J Soc Existential Anal 1994, 5:36-44.
56. Greenberg J: Self-disclosure: Is it psychoanalytic? Contemp Psychoanal 1995, 31:193-246. A practical discussion of apparently trivial boundary transgressions making the point that self-disclosure (and, for that matter, interpretations) can be experienced by the patient as invasive and unhelpful rather than increasing trust and rapport as the therapist expected.
57. Harris DR: What are the boundaries of psychoanalytic work? Panel report from the 1993 Annual meeting of the American Psychoanalytic Association chaired by SJ. Cohen. J Am Psychoanal Assoc 1994, 42:1209-1224.
58. Fonagy P, Target M: Understanding the violent patient. Int J Psychoanal 1995, 76:487-501.
59. Klimovsky G, Dupetit S, Zysman S: Ethical and unethical conduct in psychoanalysis. Correlations between logic, ethics and science. Int J Psychoanal 1995, 76:977-990.
60. Schachter J: The analyst under stress: issues of technique. J Am Psychoanal Assoc 1995, 43:11-14.
61. Colsen DB: An analyst's multiple losses: countertansference and other reactions. Contemp Psychoanal 1995, 31:459-478. A moving paper which deals with the boundary difficulties faced by a therapist whose wife is dying.
62. Clark RW: The Pope's confessor: a metaphor relating to illness in the therapist. J Am Psychoanal Assoc 1995, 43:137-149.
63. Sussman MB (ed): A perilous calling: the hazards of psychotherapy practice, New York: Wiley Interscience, 1995. A mixed book with some highly relevant chapters on boundary issues. Some of the ramifications of boundaries covered in this book confront our assumed composure: the feeling of intense shame and failure in a group therapist; the bodyshame of an overweight therapist seeing her anorexic patient by chance at the gym; the 'pathologization of everyday life' by therapists who become totally immersed in their work role.
64. Wolf ES: How to supervise without doing harm: comments on psychoanalytic supervision. Psychoanal Inquiry 1995, 15:252-267.
65. Feiner AH: First do no harm. Contemp Psychoanal 1994, 30:661-690.
66. Margison FR: Learning to listen: teaching and supervising basic psychotherapeutic skills. In Textbook of psychotherapy in psychiatric practice. Edited by Holmes J. London: Churchill Livingstone; 1991:165-185.