Principles Underlying Boundary Guidelines
Rule of Abstinence Definition
There are a number of basic, overlapping principles that form the underpinning for the establish-ment of boundary guidelines. One of the foremost principles is the rule of absti-nence, which states that the therapist must refrain from obtaining personal gratification at the expense of the pa-tient.8 Extra-therapeutic gratifications within treatment must be avoided by both therapist and ~ a t i e n t . ~
A corollary of the principle of absti-nence states that the therapist’s main source of personal gratification arises from the professional gratification derived from the psychotherapeutic process and the satisfactions gained in helping the patient. The only material satisfaction directly received from the patient is the fee for the therapist’s professional services. Treatment bound-aries are violated when the primary source of the therapist’s gratification is receivedfrom the patient directly rather than through engagement in the thera-peutic process with the patient. The prin-ciple of abstinence underlies virtually all boundary guidelines.
The rule of abstinence attempts to secure a position of neutrality for the therapist’s interactions with the patient. Therapeutic neutrality is not defined here in the psychoanalytic sense of equidistance between the pa-tient’s ego, superego, id, and reality. Rather, it means knowing one’s place and staying out of the patient’s personal life.9 Therapeutic neutrality allows for the patient’s agenda to be given primary consideration. The relative anonymity of the therapist ensures that self-disclo-sures will be kept at a minimum, thus maintaining therapist neutrality. Also, the law independently recognizes the therapist’s duty of neutrality toward pa-tients. l o
The concept of relative neutrality re-fers to the limitations imposed upon psychotherapists from interfering in the personal lives of their patients. Life choices such as mamage, occupation, where one lives, and with whom one associates, while grist for the therapeutic mill, are fundamentally the patient’s fi-nal choice.” Nor should the personal views of the therapist concerning poli-tics, religion, abortion, and divorce, for example, be aired in the treatment situ-ation.
If an otherwise competent patient is contemplating making a decision that appears foolish or even potentially de-structive, the therapist’s role is limited primarily to raising the questionable de-cision as a treatment issue. For example, the therapist can appropriately explore the psychological meaning of the deci-sion as well as its potential adverse con-sequences on the patient’s treatment and life situation. On the other hand, situa-tions do arise with patients when the psychotherapist must intervene directly. If a patient’s decision-making capacity is severely compromised by a mental disorder, the therapist may need to ac-tively intervene to protect the patient or others.12 As an obvious example, a psy-chotically depressed, suicidal patient who refuses to enter a hospital voluntar-ily will likely require involuntary hospi-talization. Under these conditions, the therapist is intervening in the patient’s life for valid clinical, not personal, rea-sons.
Patient Autonomy and Self Determination
Fostering the auton-omy and self-determination of the patient is another major principle un-derlying treatment boundary guidelines. Sustaining patient separateness through the process of separation-individuation follows as a corollary. Of the over 450 psychotherapies currently available, none state as their long-term treatment goal that patients should remain de-pendent and psychologically fused with their therapists or others. Obtaining in-formed consent for proposed procedures and treatments also preserves the auton-omy of the patient.I3
Patient self-determination requires that the therapist’s clinical posture to-ward the patient should be expectant. That is, the patient basically determines the content of his or her sessions. Gen-erally, this does not apply in cognitive behavioral therapies or even with some forms of interpersonal therapy. More-over, the stricture that physical contact with patients be essentially avoided and that the therapist stay out of the persons personal life (no past, current, or future personal relationships) derive in large measure from the principle of autonomy and self-determination.
Progressive boundary violations in-variably limit the patient’s freedom of exploration and choice. Properly main-tained treatment boundaries foster the separateness of the patient from the ther-apist while also maintaining the psycho-logical relatedness of the patient to oth-ers.
Fiduciary Relationship As a matter of law, the physician-patient relationship is fiducial. In Omer v. Edaren,14 a law-suit was brought against a psychiatrist for alleged sexual exploitation of a pa-tient. The Washington Court of Appeals noted that:
Washington also has characterized the rela-tionship between physician and patient as fi-duciary: “The physician-patient relationship is of fiduciary nature. The inherent necessity for trust and confidence requires scrupulous good faith on the part of the physician” (citations omitted).
The knowledge and power asymmetries that exist between therapist and patient require the therapist not to use the pa-tient for his or her personal advantage.” This responsibility is “implicit” in the therapist-patient relationship and is a fundamental aspect of the general “duty of care.” The special vulnerabilities of the patient rather than the special pow-ers of a profession give rise to a fiduciary duty.16 A fiduciary relationship arises, therefore, whenever confidence, faith, and trust are reposed on one side, and domination and influence results on the other.” Not only psychiatrists but all mental health professionals have a fidu-ciary responsibility to their patients. The maintenance of confidentiality, privacy, a stable fee policy and consistent time and treatment settings are derived in large measure from the fiduciary duties of the therapist.
Respect for Human Dignity Moral, ethical, and professional standards re-quire that psychiatrists as well as nonmedical professionals treat their pa-tients with compassion and respect. The dedication of physicians to their patients has a long and venerable tradition so artfully expressed in the Hippocratic oath. The Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry1*states: “A physician shall be dedicated to providing competent medical service with compassion and respect for human dignity.” On clinical grounds alone, the competent therapist always must strive to maintain the pa-tient’s healthy self-esteem during the course of therapy. Exploitative thera-pists, however, relate to patients as part objects to be used for their own personal gratification. Frequently, such therapists attack the self-esteem of their patients in order to gain control over them. All of the boundary guidelines are substantially based on the principle of respect for human dignity.
Therapist Ethics Violations
In the course of therapy, it may be necessary for the sake of the patient or the welfare of others for the psychiatrist to cross accepted treatment boundaries. Boundary violations may be driven by crises in clinical care, and by interven-ing, superseding ethical or legal duties. For example, an agoraphobic patient may be incapacitated and unable to come to the psychiatrist’s office. Home visits may be required initially. The po-tentially violent patient who threatens others places the psychiatrist in a con-flicting ethical position regarding main-taining confidentiality. Professional and legal duties to warn and protect endan-gered third persons, however, may ne-cessitate a breach of the patient’s confi-dentiality. In the latter example, if the patient can be brought into the process of issuing a warning, treatment bound-aries may be stretched but not necessar-ily violated. Engaging patients in the decision to readjust treatment bounda-ries as a result of treatment exigencies may permit salutary boundary reshaping that actually facilitates the treatment process.
Impaired therapists usually experi-ence great difficulty in establishing and maintaining acceptable treatment bo~ndaries . ‘~Deviant, idiosyncratic boundary setting forms the groundwork for patient exploitation. Therapists who suffer from severe character disorders tend to repeat boundary deviations with a number of their patients. The preda-tory, exploitative therapist also belongs to this group. Other therapists who es-tablish deviant boundaries may be merely incompetent, impaired by alco-hol, drugs, and mental illness, situation-ally distressed by personal crises, or suf-fering from a paraphilia, particularly frotteurism. Frotteurs consistently fail to maintain appropriate physical distance from patients, becoming involved in in-appropriate touching.