Book Review

Preventing Boundary Violations in Clinical Practice

N Engl J Med 2008; 359:2074-2076November 6, 2008

Article

Preventing Boundary Violations in Clinical Practice
By Thomas G. Gutheil and Archie Brodsky. 340 pp. New York, Guilford Press, 2008. $38. ISBN: 978-1-59385-691-5

Psychotherapists endeavor to help people bear the burdens of their lives and become more fulfilled in their relationships and societal roles. Modern approaches to psychotherapy take many forms and use many different techniques, ranging from motivational methods in the treatment of addiction to exposure therapy in the treatment of specific phobias. Longstanding skepticism about the value of “talking cures” has more recently been replaced with extensive evidence that validates the effectiveness of specific therapies for the treatment of remarkably diverse and often severe conditions.

As a unique interpersonal process, psychotherapy has many mysteries. One certainty, however, is the primacy of the clinician's professionalism — his or her expertise, trustworthiness, and unwavering commitment to the well-being of the patient — as the basis of the therapeutic relationship. In the 1999 book Psychiatric Ethics (3rd ed. Bloch S, Chodoff P, Green SA, eds. New York: Oxford University Press, 1999), Glen O. Gabbard defined boundaries as the “`edge' or limit of appropriate behavior by the psychiatrist in the clinical setting.” Len Sperry, in Dictionary of Ethical and Legal Terms and Issues: The Essential Guide for Mental Health Professionals (New York: Routledge, 2006), classifies this term further: “Because of a power differential between client and practitioner, and because clients are in a vulnerable position, adequate boundaries serve to protect the client's welfare.” Boundary violations, meaning actions of the psychotherapist that place the wishes, gratification, and material gains of the therapist above the interests of the patient, thus represent breaches of professionalism. When they engage in boundary violations, clinicians take advantage of their fiduciary role to exploit patients for sexual, financial, or other personal gain.

In Preventing Boundary Violations in Clinical Practice, Thomas Gutheil and Archie Brodsky have written what they call “a supervisor on a bookshelf,” providing a conceptual framework, practical advice, and numerous examples to help therapists avoid unprofessional actions in their care of patients. Most simply, the authors recommend that therapists engage in careful self-observation and ask themselves for whose benefit (Cui bono?) a particular action may be motivated. On one hand, unexploitative and harmless departures from the usual distance maintained in therapy, such as accepting a hug from a sobbing patient who has just learned of the death of a loved one, are seen as boundary “crossings” that may be ethically acceptable. On the other hand, actions that are driven by the therapist's loneliness (such as seeking greater closeness or a physical relationship with a patient) or by the therapist's need to feel special or important (such as boasting or engaging in excessive self-disclosure) would fail to meet the Cui bono? “test.”

The book is clearly written and neatly organized in three sections. The focus is first on definitions and evolving perspectives on professionalism; next, on the ways in which various boundary issues arise in clinical care; and last, on practical implications for clinicians. The authors characterize key theoretical issues but devote welcome attention to helping therapists understand the nitty-gritty and often nonintuitive considerations in clinical care. Examples include how the therapist's clothing and appearance may affect professional boundaries, how clinicians may best manage issues related to overlapping roles and out-of-office contacts with patients, and the proper limits of self-disclosure by therapists in their care of patients. The book contains numerous anecdotes taken from the authors' experiences, describing, for example, the “slippery slope” along which therapists sometimes progress from boundary crossings to minor boundary violations and ultimately to serious sexual and financial misconduct. Gutheil and Brodsky also address differences in therapeutic boundaries between various forms of psychotherapy, including the very strict rules of conduct in long-term psychoanalytic treatment as compared with cognitive-behavioral or supportive therapy, in which clinicians may justifiably be more actively involved in patients' lives outside the standard treatment setting — for example, by going shopping with a patient who has agoraphobia.

The book has two principal limitations. It is heavily focused on traditional clinical practice and does not give sufficient attention to the special issues that arise in the maintenance of professional boundaries and behavior for psychotherapists who serve different kinds of communities, such as a rural or frontier community or a distinct cultural, religious, ethnic, racial, or organizational community. And the text overemphasizes very strict, dynamically oriented (“Freudian”) psychotherapy over other treatment approaches.

Thirty-seven years ago, psychiatrist Martin Shepard asserted in The Love Treatment: Sexual Intimacy between Patients and Psychotherapists (New York: Peter H. Wyden, 1971) that physical “intimacy with a therapist can indeed be useful,” a statement that is completely contradicted by the present-day consensus that sexual relationships between therapists and patients are never permissible. Gutheil and Brodsky's book is thus valuable in that it provides great clarity on the importance of strict professionalism and the avoidance of exploitative behavior in clinical practice. Moreover, it offers down-to-earth guidance in an accessible and interesting format, making theoretical notions come to life for use in everyday practice.

Laura Weiss Roberts, M.D., M.A.
Joseph B. Layde, M.D., J.D.
Medical College of Wisconsin, Milwaukee, WI 53226
jlayde@mcw.edu