Boundaries in
Professional Relationships
by Gary Richard Schoener
Gary Schoener is a licensed psychologist and Executive Director of the Walk-In
Counseling Center in Minneapolis, MN. He is the senior author of "Psychotherapists'
Sexual Involvement with Clients: Intervention and Prevention", co-author of
"Assisting Impaired Psychologists", and has written many
articles on this topic. Schoener has consulted in more than 3000 cases of sexual
misconduct by professionals and was a member of the Task Force on Sexual Impropriety of the
American Psychological Association and its Advisory Committee on the Impaired
Psychologist. The Walk-In Counseling Center was the recipient of the 1977 Gold
Achievement Award in Hospital and Community Psychiatry from the American Psychiatric
Association.
This article has been reproduced with permission from the
Walk-In Counseling Center. Copyright © 1998 WICC.
Preface
Presented to the Norwegian Psychological Association in Oslo,
Norway - 3 & 4 September 1997. Edited by AdvocateWeb, with permission from
the author.
Introduction & Background
The concept of boundaries is not limited to professional relationships
-- nations, tribes, families, and individuals all have boundaries. Poet Robert Frost once
wrote "good fences make good neighbors." Cultures have widely differing
understanding of boundaries, and when someone from one culture moves to a new environment
their sense of boundaries may evolve, more closely mirroring the beliefs of the place
where they now live.
Authored between the 3rd and 2nd Century BC, the Oath of Hippocrates
was part of a great body of medical writings collected by the Library of Alexandria in
Egypt, the great library of the ancient world. Historians have called this collection the
Corpus Hippocratum. In the Oath, the promise is made that "In purity and holiness I
will guard my life and my art" and that the physician will treat the sick and
"will keep them from harm and injustice." It includes a promise to provide the
mentor who taught him medical skills with money if he is in need and to hold him equal to
his parents, and to train his sons in the medical arts. By way of some professional
boundaries, the physician agrees:
To not train anyone in the medical arts who hasn't taken an oath and
signed the covenant [equivalent today to not collaborating in the practice of
unqualified people]
"Whatever houses I may visit, I will come for the benefit of
the sick, remaining free of all intentional injustice, of all mischief and in particular
of sexual relations with both female and male persons, be they free or slaves."
[a broader standard than usually in use today, forbidding sex with even slaves in the
household]
"What I may see or hear in the course of the treatment or even
outside of the treatment in regard to the life of men, which on no account one must spread
abroad, I will keep to myself holding such things shameful to be spoken about."
[a
broader standard than our current concept of confidentiality in that it includes things
"outside of treatment"-- this promises to not be a gossip, something very
important given that doctors were travelers and thus potential sources of
"news"]
Political & Philosophical Underpinnings
Professional boundaries are relevant to the delivery of professional
services in that the degree to which they are necessary or produce some predictable
outcome, the professional is obligated to be concerned about them. While Freud originally
believed that the psychotherapist could simply serve as a "tabula rasa" (blank
slate) on which the client's feelings were projected, and which could then be analyzed, he
came to understand the power of "countertransference," or the therapist's
feelings and needs.
As regards the boundaries of confidentiality, political and societal
issues are very important. There has always been a debate and changing view of the rights
of the individual versus rights of the society, or of third parties. This has to do with
the establishment of conventions, rules, and laws concerning the reporting of various
types of abuse, or the need to warn persons who may be injured by a client.
Any treatment, or any practice or decision concerning a professional
boundary can be evaluated based on the ethical premises:
-
Beneficence -- the likelihood that it will do good
-
Non-malfeasance -- the likelihood that it will not cause harm
-
Client autonomy -- the likelihood that it will foster client
independence
-
Fidelity -- the degree to which it reflects what was promised and
is true to the articulated goals of the professional service
The psychotherapist (or other professional) is a fiduciary -- a
person in whom trust is invested by the client. The professional relationship
represents a fiduciary contract -- that is, an agreement between unequals in which one
person has more power, and therefore more responsibility. Thus, while both have duties
and responsibilities, it is the professional who has greater duties and responsibilities.
Remembering Our Own History
The maintenance of professional boundaries has always been a
problem in our field. While we might prefer to see people with boundary maintenance
problems as a handful of poorly trained or ethically limited persons, this ignores our
history. The early analytic circle in Vienna was rife with dual relationships, violations
of confidentiality, and poor boundaries. Grosskurth's book The Secret Ring: Freud's
Inner Circle and the Politics of Psychoanalysis and Kerr's A Dangerous
Method are among the many works which detail some of this history.
Melanie Klein, who psychoanalyzed her own children,
encouraged patients to come away with her on holiday and then provided therapy while they
lay on her bed in her hotel room. Ernest Jones had Klein analyze his children and
wife. Certainly many in the early analytic circles analyzed each others family members,
mistresses, etc. Sigmund Freud analyzed his own daughter, Anna Freud, who
later indicated she felt exploited by many aspects of this process, especially his use of
her clinical material for teaching well after she had herself become a professional in the
field.
Many key contributors to the fields of psychotherapy and psychoanalysis
have had a romantic or sexual involvement with a current or former client --- in some
cases a client who was in training or already in the field him or herself. Carl Jung
had a romantic involvement with Sabina Spielrein, a young medical student who came
to Jung struggling with serious emotional problems and then went on to a brilliant career
in psychoanalysis, cut short by her murder by the Nazis on 27 July 1942. The historical
record suggests that Jung helped her considerably, although doubtless also injured her.
During a now famous interchange of letters with Freud, Jung acknowledged his misdeeds,
only to have Freud blame Spielrein. The involvement between June and Spielrein was not a
singular one in early analytic circles:
Jung was scarcely the only person to become involved with a patient.
Gross's exploits were legendary, Stekel had long enjoyed a reputation as a
"seducer," Jones was paying blackmail money to a former patient, the even good
Pastor Pfister was lately being entranced by one of his charges. Indeed, the most
extraordinary entanglement was Ferenczi's, the amiable Hungarian having taken into
analysis the daughter of the woman he was having an affair with and then fallen in love
with the girl. Freud in fact was then currently seeing the younger woman at Ferenczi's
request in an attempt to help rescue the situation. That Spielrein had once been Jung's
lover would have disturbed Freud not at all.
(Kerr, 1993, p.379)
Freud's reference was to Ferenczi's involvement with Elma
Palos (the daughter of his future wife Gisella Palos), whom both he and Freud had treated,
in the now famous letter from Freud to Ferenczi of 13 December, 1931 containing Freud's
criticism of Ferenczi's kissing of patients. Although this exchange is often used to
suggest that Freud was a stickler on boundaries, the historical record shows otherwise
Furthermore, Freud was providing private information to Ferenczi in an apparent attempt to
influence his choice of a mate. In addition, for many years the extent of Ferenczi's
misconduct was not widely known because Ernest Jones' widely-read translation of this
letter, significantly, omitted Freud's attempt to connect the kissing of patients with
what he termed Ferenczi's "old misdemeanors", "...the tendency to sexual
playing about with patients...". For his part Ferenczi replied to Freud in a letter
dated 27 December 1931:
"The sins of youth," misdemeanors if they are overcome and
analytically worked through, can make a man wiser and more cautious than people who never
even went through such storms...Now, I believe, I am capable of creating a mild,
passion-free atmosphere, suitable for bringing forth even that which had been previously
hidden. (Masson, 1984, p. 160)
While at the University of Toronto, Ernest Jones became the
subject of an allegation of sexual involvement with a client. He had not only initially
denied the involvement but attacked the woman's general practitioner who had assisted her
in making the complaint. However, his defense was seriously undermined by revelations that
he had attempted to pay money to the former patient to stay quiet about the matter.
Another example of the problems in maintaining professional boundaries
is provided by the experience of famous psychotherapist Margaret Mahler:
...my almost three-year analysis with Aichhorn, while helpful in
many respects, was far from "classical." For the fact is that Aichhorn and I
were, by this time, very much in love with one another, making impossible the classical
relationship between analyst and analysand. In taking me under his wing and vowing to see
me restored to the good races of the Viennese psychoanalytic establishment, Aichhorn only
buttressed my self-image as an "exception" -- now in an entirely positive sense
as opposed to the negative sense inculcated by Mrs. Deutsch. Under Aichhorn's analytic
care, I became a sort of Cinderella, the love object of a beautiful Prince (Aichhorn) who
would win me the favor of a beautiful stepmother (Mrs. Deutsch). At the same time, my
analytic treatment with him simply recapitulated by oedipal situation all over again...
By the time Aichhorn intervened and secured my readmittance to the
institute training program some six months after our analytic work began, I was his
favorite pupil. As our personal relationship blossomed, I became his lover as well.
(Stepansky,
1988, pp. 68-69)
Famous women analysts were also at times in charge and their male
trainees or clients were the subject of their personal interests. Frieda
Fromm-Reichmann has written that her husband, Erich Fromm, was a patient when
they became romantically involved, noting that at least they had the "common
sense" to terminate the therapy before marrying. Even today, it is widely known but
rarely discussed, that a number of key figures in the various psychotherapy fields are
married to former patients.
Karen Horney is alleged to have had sexual relationships with
candidates at the analytic institutes with which she was associated in both New York and
Chicago, "including supervisees and analysands" such as "Leon Saul, who was
traumatized by the experience"(Paris, 1994, p.142). She has been described at times
as behaving much like the stereotype of the "dirty old man" who plays
"sexual politics. "Horney's lovers sometimes became favorites to whom she gave
power, until, to their pain and bewilderment, she turned against them. She then replaced
them with other favorites.(Paris, 1994, p. 143)
Otto Rank reportedly became sexually involved with a former
patient. Freud himself encouraged Horace Frink, a young analyst whom he was
treating, to follow his desires and divorce his wife so he could marry a patient. Freud
may have had financial motives in this case, hoping for a donation to the psychoanalytic
movement from the patient's wealthy family, and that the outcome had some very negative
consequences for those involved.
Perhaps this should not surprise us. Reviewing even the earliest
fumbling in the evolution of psychotherapy -- Joseph Breuer's treatment of Anna O.--
which Freud felt led to the development of the "talking cure" or psychotherapy,
leads one to believe that clients often find their own way to health. According to Ernest
Jones, Anna O. developed a hysterical pregnancy. For his part, Breuer became entranced
with this interesting client, leading his wife to become both angry and depressed. One
night Anna O. went into a false labor and Breuer was obliged to visit her. According to
Jones, he left her home in a cold sweat, went home, and the next day he and his wife left
for Venice to spend a second honeymoon. What happened to the young woman? She grew up to
be Bertha Pappenheim, a leading feminist, social reformer, and a pioneer in the
field of social work in Germany. True, the relationship with Breuer did not involve sexual
activity, but it certainly involved heavy transference and countertransference, probably
left unresolved.
Even today a small group of writers is challenging the cultural and
professional zeitgeist about professional boundaries. Rev. Carter Heyward, in her book When
Boundaries Betray Us, argues that her psychotherapist "betrayed" her by
not being willing to be involved in a post-therapy friendship or intimate relationship.
Psychotherapist and author Miriam Greenspan, in her article "Out of Bounds,"
argues that rigid therapist-patient boundaries are consequences of a patriarchal society
and can encourage abuse.
Some Notes on the Dual or Multiple Relationship
Featured in many codes of ethics, the the term dual relationship,
or more current term of multiple relationships can be over-used. There has
been a tendency to equate this with inappropriate intimacy.
Sonne (1994) has argued that the Ethics Code of the American
Psychological Association, despite many revisions, still does not clearly define multiple
relationships or define when they are harmful. However, contacts with clients
outside of the professional psychotherapy relationship are not limited to true dual or
multiple relationships where there is a conflict of interest and the professional
relationship can be undermined. On the other hand are also overlapping relationships
where there is not really a significant role conflict, and also encounters
with clients outside of the treatment setting. Even encounters vary as to significance,
and our own experience as well as some of the research suggests that professionals are far
more concerned about encountering clients than are current or former clients. In fact, we
have ourselves made the mistake of "processing" an outside contact with a client
in a fashion which caused her to simply be angry at us for intruding on the treatment with
"our hangups." For example:
"I ran into a client in a church parking lot and said
'hello.' [encounter] I noticed that the
client, although she rarely attended, was a parishioner in the same church as our family
[encounter, but with the possibility of an overlapping
relationship]. The client signed up for the same Sunday school class, one
which involved simply hearing lectures and occasionally discussing readings about the
gospel. [overlapping] The pastor announced
the formation of a marital support group designed to improve marital relationships and my
spouse and I signed up, but in the first session we discovered that the client and her
spouse were members, something of great concern since participants were to be talking
about their marital life." [multiple relationship]
Can You Classify Psychotherapists Based on Conservativeness About
Boundaries?
Borys (1988) compared who admitted to sex with clients to those who
didn't on a number of self-reported boundaries issues. Despite the fact that 40 of her 44
offenders had a post-termination sexual relationship (which one would have expected
to have brought about agreement on a number of items on her scale), she could only
correctly classify 55% of the erotic practitioners and 79.4% of the non-erotic when
comparing them on her Social Involvement Scale, which included the following
items:
-
Became friends with client after termination
-
Disclosed details of your current personal stresses to a client.
-
Invited clients to an office/clinic open house
-
Went out to eat with a client after a session
-
Invited clients to a personal party or social event
Borys (1988) also found considerable variability within the
psychotherapy fields (psychology, social work, psychiatry) as to what is deemed acceptable
in a number of areas. For example, therapists' responses to the following boundaries
questions yielded the following very varied opinions:
Accept a gift under $ 10: 19.5% never, 53% several, 10.4% all
clients
Accept invitation to client's special event: 50% never, 22% few,
3.4% some
Becoming friends after termination: 65% never, 23% few, 3.3%
several clients
Treating an employee: 57% never, 12.8% few, 3% some clients
Disclose own stresses to client: 59% never, 26.8% few, 9.7% some,
1.3% many
Invite to open house: 50% never, 5.7% few, 6.7% some, 2.7% many,
3.4% all
Depending on the school of therapy one belongs to a particular boundary
may be more or less important. For a behaviorist to visit a client's home to perform an
en-vivo desensitization may be quite proper, whereas for a psychoanalyst to make a home
visit might be a boundary crossing.
The Zone of Helpfulness
In the 1950's and 1960's concern was about genuineness, warmth, and
"connecting with the client." Researcher's studied these things and their impact
on therapy and counseling. By the mid-1970's into the 1980's the concerns were about
intrusiveness, exploitation, and abuse -- all seen as a consequence of over-involvement.
Studies have shown that either extreme can be harmful.
The key is to be somewhere in the Zone of Helpfulness,
whether one tends to be more formal, or one tends to be more emotionally involved or in
greater physical contact.
Excessive self-disclosure is the single most common precursor to
therapist-client sex:
-
Disclosing current personal needs or problems;
-
Disclosure as common, rather than rare event, during sessions;
-
Disclosing things not clearly connected to client's problems or
experiences; or not clearly things which would be likely to encourage or support client;
-
Self-disclosure not only frequent, but uses up more than a few
minutes in a session;
-
Self-disclosure occurs despite apparent client confusion or
romantization.
For Colleagues or Supervisors
Some areas which require watchfulness are:
Obvious therapist distress or upset
Therapeutic drift -- shifting style and approach to a given client
Lack of goals and reflection on progress in therapy
Therapy which exceeds normal length for a client of that type in
the particular therapist's practice.
Exceeding areas of competence, reluctance to refer for other
therapy, assessment, etc.
Unwise techniques
Routine hugs
Face to face, intimate hugs
Excessive touch
Sessions in non-traditional setting when this isn't necessary
Adult clients on lap
Routine or common socializing with clients
Excessive self-disclosure by therapist
Direct intervention in client's life
Becoming enmeshed in client's life -- treating close friends or
family members
Unique vulnerabilities:
Attraction
Over-identification with client
Uniquely similar family dynamics
Divorce or loss in therapist's life
Identity disturbance in therapist
References
Borys, D. (1988). Dual relationships between therapists and client:
A national survey of clinicians attitudes and practices. Unpublished doctoral
dissertation, UCLA.
Greenspan, M. (July/August 1995). Out of bounds. Common Boundary,
pp. 51 - 57.
Heyward, C. (1993). When Boundaries Betray Us: Beyond What Is
Ethical in Therapy and Life. New York, NY: HarperCollins.
Kerr, J. (1993) A Most Dangerous Method. New York, NY: Knopf.
Masson, J. (1984). The Assault on Truth. New York, NY: Farrar,
Straus, & Giroux
Paris, B. (1994). Karen Horney: A Psychoanalyst's Search for Self
Understanding . New Haven, Conn: Yale University Press.
Sonne, J. (1994) Multiple relationships: Does the new ethics code
answer the right questions? Professional Psychology: Research and Practice, 25, pp.
336 - 343.
Stepanski, P. (Ed.) (1988). The Memoirs of Margaret Mahler. New
York, NY: Free Press.
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