Preventing Boundary Violations in Clinical Practice

Preventing Boundary Violations in Clinical Practice

by Thomas G. Gutheil, MD, and Archie Brodsky, BA. Guilford Press, New York, NY, 2008, 340 pages, $40.00.

In the afterword to this excellent treatise, Gutheil and Brodsky, both noted scholars and practitioners in the field of forensic psychiatry, express the hope that their book serves its readers as "a supervisor on a bookshelf" (p 301). They have accomplished their mission!

In Preventing Boundary Violations in Clinical Practice, which is divided into 3 sections—"Foundations," "Explorations," and "Implications," the authors take the reader carefully through the morass of understanding and analyzing boundary issues in the therapeutic encounter, whether one is a psychiatrist or any other mental health professional. In providing this 360-degree look at boundaries, beginning with the theoretical underpinnings and moving to the "on the ground" examples of a wide array of considerations about patient interactions that are, or could become, boundary crossings or violations and on to explicating the potential consequences for both patient and practitioner, the reader comes to appreciate these concepts from every angle. The chapters included in the "Explorations" section leave few stones unturned. They discuss the following: "Role, Time, Place"; "Money, Services, Gifts"; "Self-Disclosure"; "Communication and Out-of-Office Contacts"; "Clothing and Physical Contact"; and, of course, "Sexual Misconduct." On the basis of their extensive review of the literature as well as their own clinical and consulting experiences, the authors have many sordid stories to tell—not always easy reading—providing important cautionary tales that will help readers think through the ways patients, ethics committees, state medical boards, and juries might interpret an interaction. Every chapter closes with "Key Reminders," bullet points emphasizing the most important elements discussed.

Gutheil and Brodsky readily acknowledge that there are few absolutes in this nuanced area of ethics and practice. Except for prohibiting sexual encounters with current patients, all other patient interactions fall on a wide spectrum of "gray zones" requiring context and intent to tease out whether a boundary violation has actually occurred.

A classification system is provided that groups offenders into categories ranging from the naive to the sociopath, including clinical descriptions as well as recommendations regarding their rehabilitation potential. Also included is a section on factors that make even the best practitioners vulnerable at times, reminding us that self-care is crucial as we do this challenging work.

A brief section on education and training is included that makes general recommendations for principles that should inform training and provides an exhaustive reference for further reading and curriculum content.

It is possible that one might criticize this work for being "too analytical" in its approach. Repeatedly, the authors concede that various schools of psychotherapy such as cognitive-behavioral therapy, Gestalt therapy, and others may need to extravasate beyond the usual limits of the more traditional models of psychodynamic therapy in order to achieve their goals. For example, a therapist working with a patient with a social phobia that includes extreme anxiety about eating in public may need to accompany that patient to a restaurant as part of the treatment plan. The authors point out that this kind of activity needs to be a part of an agreed-upon therapeutic contract, one in which the patient has provided informed consent and one that is designed with the patient’s best interest in mind. Regardless of the type of therapy employed, the authors conclude, "All, however, are subject to the ethical standard that the therapist must always act in the interest of the patient. Every legitimate form of therapy accepts this fiduciary responsibility" (p 252). This elemental concept continually reverberates, keeping the reading audience focused on the understanding that all therapists must maintain their professional stance—that therapy is about the relationship, and, as a result, some knowledge of relational dynamics is required for all therapeutic endeavors.

Every reader is likely to close this book thinking "There, but for the grace of God, go I." Preventing Boundary Violations in Clinical Practice will give pause—and probably cause anxiety, but, in the end, it will provide an incredible amount of useful information to therapists for practicing, teaching, and making careful and reasoned judgments about therapist behavior, whether their own or someone else’s .

Susan J. Stagno, MD

susan.stagno@UHhospitals.org

Author affiliation: Case Western Reserve University School of Medicine, Cleveland, Ohio. Potential conflicts of interest: None reported.

doi:10.4088/JCP.09bk05667whi

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