Boundary Violations
in the Professional Relationship
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
This is a portion of a talk entitled "Boundary Violations in the
Professional Relationship: With Special Focus on Sexual Abuse of Clients - Ethics,
Damage, & Prevention" presented at the Department of Psychology, University of
Oslo, Norway, 5 September 1997. Edited by AdvocateWeb, with permission
from the author.
Boundary Violations
Long before inappropriate intimacy or sexual contact occur in a helping
relationship, a variety of boundary crossings or violations often occur. (Simon, 1995)
Inappropriate touch is only one variable, and is not the most common. We are not
simply talking about erotic touch. These represent breakdowns in the professionalism of
the relationship and, as such, often undermine the therapy.
Enmeshment of the client in a relationship characterized by
unidentified or unresolved erotic transference & counter-transference may be at times
more harmful and confusing than having sexual contact with them. The same can be
true with intense friendships which confuse the counseling or make the client
unnecessarily dependent on the helper. Even romantic "game playing" can be
quite distracting and harmful. Even without overt sexual contact, boundary breakdowns can
lead to damages similar to those seen when the relationship becomes sexual (Schoener et.
al., 1989, pp. 133-147; Simon, 1991):
The failure to render needed therapy -- undermining what good work
may have been done;
Failure to refer for other services -- the psychotherapist
"hanging on" to the client and trying to provide for all of his or her needs;
Creation of unhealthy dependency which is difficult to resolve;
Confusing the client about what is therapy and what is personal;
Breach of trust -- client distrusting professionals as a result of
the corruption of the therapy;
In some instances, interference in family relationships, friendships,
etc.
Anger, loss of self esteem, depression, and other psychological
distress.
Practice Styles
The research has failed to show that practice style per se is the major
issue in boundary breakdowns, boundary crossings, and whether or not the relationship is
sexualized. Psychoanalysts become sexually involved with clients despite the fact that
they don't do much touching, and many body-therapists (e.g. Reichian) do not have
difficulties in this area.
Even separating psychotherapists along lines of boundary
conservativeness versus risk taking does not clearly separate those who have sexual
contact with clients from those who do not. Borys (1988) compared those 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 expect would have caused high scores 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
There is considerable variability in the psychotherapy fields, as well
as within any given field (e.g. psychology), as to what is acceptable in some boundaries
areas. Borys (1988) found, for example, in a national survey of psychologists,
psychiatrists, and social workers:
| 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 |
As regards attitudes towards erotic touch, or touch in general, the
Norwegian study cited earlier found the same thing as American studies have: you cannot
clearly differentiate offenders from non-offenders on these dimensions.
Excessive Self Disclosure by the Psychotherapist
Therapist self-disclosure is by far the most common boundary violation
which precedes sexual involvement with clients as well as a number of other therapeutic
mistakes. Therapist self-disclosure is problematic when it involves:
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.
Self-Reflection & Supervisory Oversight
From the organizational perspective, several references focus on
organizational issues: Psychotherapists'
Sexual Involvement With Clients: Intervention & Prevention (Schoener et. al.,
1989, pp. 451 -516), The Incestuous Workplace: Stress & Distress in the
Organizational Family (White, 1997), and Breach
of Trust (Gonsiorek, 1994, pp. 176-192, 284-316).
At the level of the individual psychologist, Epstein's (1994) Keeping
Boundaries: Maintaining Safety and Integrity in the Psychotherapeutic Process and
Gabbard & Lester's (1996) Boundaries and
Boundary Violations in Psychoanalysis are excellent. In the area of sexual
feelings, Rutter's (1989) Sex in the
Forbidden Zone. In the area of sexual misconduct, Pope, Sonne, &
Holroyd's (1993) Sexual Feelings
in Psychotherapy, and Edelwich & Brodsky's (1991) Sexual Dilemmas for the
Helping Professional are useful. So is Marilyn Peterson's (1993) At
Personal Risk. Epstein & Simon (1992) have developed an
"Exploitation Index" for clinicians to use to evaluate their own boundary
maintenance.
Some areas which require self-awareness and watchfulness by ones'
supervisors or consultants, 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 or unwillingness to refer
for other types of 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
Dynamics Which Make Psychotherapy a Potential Setting for Boundary
Violations and Exploitation
It involves a fiduciary relationship with unequal power,
especially early in the relationship. The therapist sets all the rules and the therapy is
conducted in private so there is little accountability.
A variety of common dynamics seen in cases of exploitation
(e.g. see Gabbard, 1994):
Unconscious re-enactment of incestuous longings;
Wishes for nurturance can emerge & be quite powerful;
Rescue fantasies -- the countertransference trap of doing a better
job than someone's parents or previous therapist/counselor;
Fantasy that love, or sex, are curative in and of themselves;
Repression or disavowal of rage at client's persistent thwarting of
your therapeutic efforts;
It is a fertile ground for acting out anger at organization,
supervisor, etc.
Defense against grief and mourning at termination;
It is an unreal world -- the "exception" fantasy;
A "safe" ground to experiment -- e.g. sorting out identity
confusions:
Cultural myth that the "right woman" can fix the most
disordered man
Prevention Aids -- Training
A. BOUNDARIES EXERCISES (see Jeanette Milgrom's [1992] BOUNDARIES
IN PROFESSIONAL RELATIONSHIPS)
B. PRACTICE WITH CLIENT CHALLENGES TO BOUNDARIES -- Lisa Steres'
videotapes and role plays [Lisa Steres, Ph.D. Scripps Clinic Rancho Bernardo, 15025
Innovation Drive, San Diego, Calif. 92128(619) 487-1800]
C. WORK ON THE TASKS INVOLVED IN TERMINATION WITH A CLIENT AND ON
POST-TERMINATION ISSUES
D. VIDEOTAPE PACKAGES: There are a number aimed at clergy &
pastoral counselors, but recently Hazelden has produced one entitled SUBTLE BOUNDARY
DILEMMAS. [Available from Hazelden, Box 176, Center City, Minn. 55012-0176. Phone
orders from US & Canada: 1(800) 328-9000 with credit card.] The Assn. of State &
Provincial Psychology Boards has one on ETHICAL DILEMMAS FOR PSYCHOLOGISTS [ASPPB,
P.O. Box 4389, Montgomery, Alabama 36103. Call 1(800) 448-4069 -- hope to be able to take
phone orders with credit cards soon.]
References
Borys, D. (1988) Dual relationships between therapists and
client: A national survey of clinicians attitudes and practices. Unpublished doctoral
dissertation, UCLA.
Committee on Physician Sexual Misconduct (1992). Crossing the
Boundaries. Vancouver, British Columbia: College of Physicians and Surgeons of British
Columbia.
Dawson, E. (1994). Professional misconduct in psychiatry: sexual
behavior with patients. A report of recent New South Wales findings. Australian & New
Zealand J. of of Psychiatry, 28, pp. 197-204.
Edlewich, J. & Brodsky, A. (1991) Sexual dilemmas for the
helping professional. N.Y., N.Y.:Brunner/Mazel
Epstein, R. (1994). Keeping boundaries: Maintaining safety and
integrity in the psychotherapeutic process. Washington, DC: American Psychiatric Press.
Epstein, R . & Simon, R. (1992) The exploitation index.
Bulletin of the Menninger Clinic, 56, pp. 1 - 21.
Fromm-Reichmann, F. (1989). Reminiscenses of Europe. In A.
Silver (Ed.) Psychoanalysis and Psychosis pp.469-481. Madison, Conn.: International
Universities Press, pp. 469-481.
Gabbard, G. (1995). The early history of boundary violations in
psychoanalysis. J. of the American Psychoanalytic Assn., 43, pp.1115 - 1136.
Gabbard, G. & Lester, E. (1995). Boundaries and Boundary
Violations in Psychoanalyisis. New York: Basic Books.
Gay, P. (1988). Freud: A Life for Our Times. New York, N.Y.:
Norton.
Gonsiorek, J. (Ed.) (1995). Breach of Trust: Sexual Exploitation
by Health Care Professionals and Clergy. Thousand Oaks, Calif.: Sage.
Grosskurth, P. (1986). Melanie Klein: Her World and Her Work.
New York: Alfred Knopf.
Grosskurth, P. (1991). The Secret Ring: Freud's Inner Circle and
the Politics of Psychoanalysis. Reading, Mass.: Addison - Wesley.
Jehu, Derek. (1994). Patients as Victims: Sexual Abuse in
Psychotherapy and Counselling. Chichester, England: John Wiley & Sons.
Jones, E. (1957). The Life and Work of Sigmund Freud, Vol. 3.
New York, N.Y.: Basic Books.
Kerr, J. (1993). A Most Dangerous Method. New York, N.Y.: Alfred
A. Knopf.
Mason, J.(1984). The Assault on Truth. New York, N.Y.: Farrar,
Straus & Giroux.
Milgrom, J. (1992) Boundaries in professional relationships.
Mpls., Minn.: Walk-In Counseling Center.
Paris, B. (1994). Karen Horney: A Psychoanalyst's Search for
Self Understanding New Haven: Yale University Press.
Person, E. (1988). Dreams of Love and Other Fateful Encounters:
Romance in Our Time. New York, N.Y.: Norton.
Peterson, M. (1993) At Personal Risk. NY, NY: W.W. Norton
Pope, K., Sonne, J., & Holroyd, J. (1993). Sexual Feelings
in Psychotherapy. Washington, DC: American Psychological Association.
Rachman, A. (1993). Ferenczi and sexuality. In L. Aron & A.
Harris (Eds.) The Legacy of Sandor Ferenczi, pp. 81 - 100, Hillsdale, N.J.: The Analytic
Press.
Rutter, P. (1989). Sex in the Forbidden Zone. Los Angeles, CA:
Jeremy Tarcher.
Schoener, G., Milgrom, J., Gonsiorek, J., Luepker, E., &
Conroe, R. (1989). Psychotherapists' Sexual Involvement With Clients: Intervention and
Prevention. Minneapolis, MN: Walk-In Counseling Center.
Schwebel, M., Skorina, J., & Schoener, G. (1994). Assisting
Impaired Psychologists.Revised Edition Washington, D.C.: American Psychological Assn.
Simon, R. (1991). Psychological injury caused by boundary
violation precursors to therapist-patient sex. Psychiatric Annals, 21, pp. 614-619.
Simon, R. (1995). The natural history of therapist sexual
misconduct: Identification and prevention. Psychiatric Annals, 25(2), pp. 90-94.
Stepansky, P. (Ed.). (1988). The Memoirs of Margaret Mahler. New
York, N.Y.: Free Press.
Steres, L. (1992). Therapist/Patient sexual abuse and sexual
attraction in therapy: A professional training intervention. Unpublished doctoral
dissertation, Calif. School of Professional Psychology -- San Diego.
Swenson, Carol (1994) Freud's "Anna O.": Social work's
Bertha Pappenheim. Clinical Social Work Journal 22(2), pp. 149-163
White, W. (1997) The incestuous workplace: Stress and distress
in the organizational family. Center City, Minn.: Hazelden Foundation
White, W. (1993) Critical incidents. Bloomington, Ill.: Lighthouse. [available
from Lighthouse Training Inst., 702 W. Chestnut, Bloomington, Illinois 61701. (309)
827-6026]
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