There is ample evidence now that professional boundary transgressions are a major cause of malpractice litigation in psychiatry (1) and a primary contributor to the negative image that psychiatrists have with the public (2). These unethical enactments in psychiatric treatment occur both in psychotherapy and in other contexts and are not confined to any one theoretical model of psychotherapy. All psychiatric residents must be educated about professional boundaries in psychiatry, and preventive measures should be taught so that the psychiatrist’s relationship with the patient is one that is both ethical and clinically effective. Boundary education is best taught in the context of psychotherapeutic principles, so we will emphasize that context in this communication. However, the basic principles apply to all clinical settings in psychiatry.
A number of contributions regarding boundary education have appeared in the literature in the last several years (3–6). Some have proposed courses focused on sexual feelings toward patients (7, 8). Surveys of training directors have appeared addressing education regarding sexual boundaries (9, 10). Myers (11) developed a curriculum that specifically outlined the effects of culture on boundary maintenance for residents educated outside the United States. Pope and Keith-Spiegel (12) emphasized a practical approach to decision-making regarding boundaries. In this communication, we present a broad-based view that regards teaching on boundaries as an integral part of good psychotherapy training.
The Concept of Boundaries
One of the fundamental components of teaching boundaries must be to help psychiatric residents grasp exactly what is unethical about boundary transgressions even though many will be skeptical about the need for this education. Others will question if a personal relationship with a patient is really unethical. The notion that a patient is an adult and is free to give consent must be explored from the standpoint of the inherent power differential in a fiduciary relationship where one person trusts another to provide a service for a fee. In addition, the role that transference plays in all psychiatric treatment must be emphasized. The patient imbues the doctor with a parental role—an authority figure with knowledge and skills who is deserving of confidence and trust. Breaches of that trust are thus symbolically incestuous.
Professional boundaries must also be taught in a broad sense because they constitute far more than a prohibition against sexual or physical contact. In fact, they are the architecture of the frame and include such items as the following:
Location (hospital, office)—meeting patients outside the office or hospital (if it is essential, it should be documented in the patient’s record)
Time (length of the session)—extending the session substantially beyond its usual length without charging the patient is a common transgression
Gifts and donations—although small gifts may be accepted with gratitude, cash or expensive gifts generally are not within the professional boundaries of the psychiatrist-patient relationship
Professional role (the psychiatrist is not a friend, lover, parent, or business partner)
Clothing and language—provocative or too casual clothing, just like crude language, may cause the doctor to appear nonprofessional
Physical contact—hugs and/or kisses can be interpreted as sexual even if the doctor’s intent is otherwise
Prohibition of any sexual contact whatsoever
Avoidance of dual roles—one must avoid business relationships or other complications so that one is only the patient’s psychiatrist and nothing more
Excessive self-disclosure—some self-disclosure is useful, but personal problems and private family matters are rarely helpful and may burden the patient
Professional boundaries must also be taught in terms of the “slippery slope” (13). In other words, the most egregious forms of boundary violations, such as sexual misconduct, do not spring de novo from a therapeutic setting in which two people talk to each other about meaningful psychological matters while sitting in their respective chairs. There is usually a progressive slide from minor breaks in the frame to serious violations. On the basis of more than 200 cases of boundary violations seen by the first author (GG) in consultation, evaluation, or treatment, often the first step down the slope is excessive self-disclosure, where personal problems are shared with the patient, leading to a role reversal in which the therapist begins to use the patient as a therapist-like figure who is expected to offer support and empathy. This transgression may lead to meetings outside the office, which in turn, lead to hugs, then kisses, and finally to sexual contact. Hence a preventive approach emphasizes careful monitoring of early and minor transgressions of nonsexual boundaries.
One of the major obstacles in teaching psychiatric residents is their conviction that boundary violations will never occur in their own practices. There is a natural tendency to projectively disavow any personal vulnerability and to see it only in predatory colleagues. Hence educators must emphasize the broad spectrum of therapists and situations that lead to boundary violations rather than narrowly focus on malignant predators who serially seduce patients. It is particularly useful to provide disguised case examples (which are now widely available in the literature, e.g., 14) to illustrate how the psychiatrist’s personal situation may contribute to a specific vulnerability that is not normally present. For example, a middle-aged male psychiatrist who was mourning the death of his wife was feeling increasingly beleaguered and felt that his female patients were eager to provide solace to him. One of his female patients hugged him at the end of the session, and the psychiatrist noted that he held the hug a bit too long because he felt needy. He immediately sought consultation and told his consultant, “For the first time in my life, I can understand why a colleague might engage in a sexual relationship with a patient. I am so needy of love and affection, and my patients sincerely care about me and want to comfort me.”
This model of the “lovesick therapist” can be contrasted with sexual predators, those who masochistically surrender to the demands of a bullying patient who is suicidal, who engage in sexual misconduct during a manic episode, and who may have severe narcissistic personality and need love and validation on an ongoing basis from their patients (14).
Professional boundary management cannot be taught as a list of rules. It must be intrinsic to good clinical teaching about the therapeutic alliance, transference and countertransference, professionalism, and the sense of altruism that is inherent in the practice of psychiatry. The clinician is there to provide help to the patient; the problems of the patient are always the paramount focus of the treatment. Everything else is secondary.
Because good psychotherapy is inherently flexible rather than rigid (15), educators must point out the risk of approaching boundary maintenance as the establishment of a rigid frame that is unyielding to human aspects of the interaction. The clinician must be free to vary the frame within reason to reach patients who may be idiosyncratic in their needs. Some patients may require more humor or more verbal activity than others. Adolescents and some adult patients may need some “chit-chat” about movies, pets, sports, or current events to develop a trusting therapeutic alliance. If a patient falls down getting up from a chair or coming into the office, the clinician may need to help the patient up. One must not construe boundaries as an admonition against being human with the patient. In teaching one must differentiate between benign boundary crossings, that can be usefully discussed, and boundary violations, which are destructive by definition (13, 14, 16).
Culture must also be taken into account in teaching boundaries. Patients from different ethnic backgrounds and different countries of origin may come to see a psychiatrist with different expectations about the boundaries of the treatment contract. In some countries, for example, it may be entirely expected that the therapist will accept gifts. A clinician working in a North American setting may need to verify the nature of the boundaries within the context of this geographic area.
Gender considerations must be actively taught because there are frequently specific boundary issues involved in different gender constellations. For example, a male patient with a female psychotherapist may experience a sense of humiliation because a woman is in a position of power over him. As a result, he may push boundaries by flirting or sexualizing the relationship. His fantasy may be that by taking a seductive posture, he will restore the power differential in his direction rather than in the fiduciary direction, where the clinician is imbued with power and the patient is in a “one-down” position. Similarly, female psychotherapists may be much more vulnerable to aggression simply because men are often physically stronger than women (17, 18).
Supervision is essential to teach psychiatric residents about the regulation of professional boundaries. Although seminars can use case vignettes, weekly supervision over a long time period provides the kind of nuanced and complex approach that is not possible in a seminar. The key to supervision that will effectively teach boundaries to residents is to establish an atmosphere of complete honesty and openness. Supervisors need to spend some time with the resident at the beginning of the process to form a supervisory alliance. The supervisor should convey a nonjudgmental attitude in which all of the supervisee’s feelings are acceptable and welcome in the process. The supervisor may wish to say, “If there is anything at all that you feel like concealing from me, that is probably the most important thing to discuss.” This frank statement conveys that compartmentalizing certain kinds of material as outside the scrutiny of a consultant or supervisor is the beginning of the creation of an “off-limits” sector of the therapy (22, 23). Complete disclosure provides a model that trainees will carry into consultation following completion of their training.
Didactic education has its limits in prevention. Powerful feelings may override any cognitively based knowledge that has been accumulated in the course of psychiatric residency. Hence one other priority in psychiatric education is to dispel any notion that one can solve all problems arising in psychotherapy or other clinical situations by oneself. Psychotherapy is taught in a triadic situation of patient, therapist, and supervisor. However, after training is completed, some clinicians start to believe that they can manage all situations on their own. Supervisors should inculcate a value system in which consultants are readily enlisted without any sense of failure or vulnerability. An outside perspective should be viewed as a valuable way of continuing to learn and improve one’s skills (20). In supervision one must go beyond teaching professional boundaries as a way of keeping one’s sexual or romantic feelings in check. It also provides an opportunity to help psychiatric residents learn how to maintain boundaries in the face of patients who repeatedly challenge them. These strategies may be especially helpful with the gender constellation of a female therapist and a male patient.
A systematic education regarding professional boundary maintenance must be embedded in sound principles of psychotherapeutic teaching, both in didactic seminars and in supervision. Universal vulnerability should be emphasized and practical strategies that are built around specific cases rather than generic prescriptions should be taught in supervision. Finally, the management of boundaries must include dealing with the patient’s encroachment on boundaries as well as the therapist’s avoidance of boundary violations.
At the time of submission, the authors reported no competing interests.