Boundary crossings vs. boundary violations. (CE Credit for APA Diplomates, Counselors, Psychologists and Social Workers).
Subject: Psychotherapist and patient (Ethical aspects)
Therapist and patient
Psychiatrists (Practice)
Psychiatrists (Ethical aspects)
Author: Lazarus, Arnold A.
Pub Date: 03/22/2003
Publication: Name: Annals of the American Psychotherapy Association Publisher: American Psychotherapy Association Audience: Academic; Professional Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 2003 American Psychotherapy Association ISSN: 1535-4075
Issue: Date: Spring, 2003 Source Volume: 6 Source Issue: 1
Topic: Event Code: 290 Public affairs; 200 Management dynamics Advertising Code: 91 Ethics
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 99514093
Full Text: Abstract

Boundary crossings can often be extremely helpful, whereas boundary violations are usually harmful. Many therapists confuse the two. Therapy is often shortchanged by the tendency to practice defensively, to allow the fear of attorneys and licensing boards to dictate how we treat our clients, it is imperative not to exploit, disparage, abuse or harass a client, and to steer clear of any sexual contact. We must also appreciate the significance of confidentiality, integrity, respect and informed consent. All the rest of the ethical rules, codes, and regulations are negotiable. Thus, contrary to the opinions of most therapists, non-sexual dual relationships can often enhance the process and outcome of psychotherapy.

Key Words

Boundary crossings, ethical codes, dual relationships, predatory therapists, non-psychoanalytical therapies, better selection procedures

A few minutes before noon, my client, whom I am scheduled to see from 11 a.m. to noon, is focusing on some highly significant issues. I say to him: "What's your program like for the rest of the afternoon?" He says he must attend a 4 p.m. meeting, I say, "I have nothing scheduled until 1:30. Should we pick up some sandwiches from the local deli, come back here, and continue for another hour at no extra cost to you?" He enthusiastically agrees. As a psychotherapist, my largesse could land me in hot water.

Licensed psychologists, psychiatrists, social workers, and counselors have been denounced for engaging in a boundary crossing of this kind--that are often mistakenly called "dual relationships." Some have even lost their licenses. (I should underscore that the invitation to extend the session and "break bread" was not issued capriciously. Boundary crossings should occur only when they are likely to be helpful to the client, and potential benefits, drawbacks, and probable risks have been considered beforehand [see Lazarus & Zur, 2002]. As I had anticipated, the client in question seemed to be more relaxed and open while munching sandwiches and sipping iced tea, so that pertinent information emerged much sooner than might have been the case had we adhered to the traditionally accepted therapist/client relationship.)

A dual relationship in psychotherapy refers to virtually any association outside the "boundaries" of the standard client-therapist relationship--for example, lunching, socializing, bartering, or mutual business transactions (other than the fee-for-service). Yet none of the codes of ethics of any major professional association states that non-sexual dual relationships are unethical. Nevertheless, many counselors and clinicians resolutely avoid entering in to what have come to be called "multiple relationships," and lecturers who conduct risk-management seminars warn that therapists open themselves up to potentially serious negative consequences if they cross the threshold of professionalism into something less formal. Sexual activities are obviously and appropriately forbidden. But the absolute ban on "dual relationships" so prevalent in most circles, draws no distinction between "boundary violations" that can harm a client, and "boundary-crossings," that produce no harm and often prove extremely helpful (see Fay 2002). Strictly speaking, it is not a boundary that gets "violated" but a client--e.g., when exploited for the therapist's personal gain, or when confidentiality is breached.

My interest in debunking the rigid boundaries that are widely imposed by many ethics committees and licensing boards came about in 1993 when two of my colleagues were severely censured for transcending minor limits. One had accepted an invitation to a client's wedding and had also agreed to propose a toast. This displeased the groom's father (a school psychologist) who lodged a complaint with the state licensing board. My other colleague had given a part time job at his clinic to a client with an MSW degree, and one of his assistants asked a licensing board member if this was ethical. In addition, it came to my attention that several students had been reprimanded by authoritarian supervisors for having gone beyond the call of duty on behalf of some of their clients--despite the fact that this had proved quite helpful.

It is the mandate of the state licensing boards and professional ethics committees to oversee that no client is harassed, exploited, or harmed. There is almost universal agreement, for example, that a therapist should not enter into a client-therapist sexual relationship of any kind. Clinicians who do not follow these rules can face severe consequences, including state investigation, public humiliation, loss of their licenses and livelihoods, civil liability and even criminal indictments. Many of these regulations are necessary and sensible, especially those that enforce strict consequences for sexual or other forms of exploitation, but over the years, the rulebook has become needlessly stringent and rigid, and so inflated that, at times it undermines effective therapy. Let us also realize that some clients pose as victims but are, in fact predators themselves--they level false accusations and trump up groundless charges (Williams, 2000).

It seems to me that some members of regulatory boards and ethics committees are imbued with a risk adverse mentality and administrative zeal. They are apt to impose extreme penalties for minor infractions. Even worse, they have labeled various benevolent acts "unethical" and have chastised clinicians for engaging in them (e.g., driving a client to a railroad station during a taxi cab strike, accompanying an anxious client to a dental visit, or helping a client acquire a better sense of self by socializing with him or her). One is warned to eschew "dual relationships" and never to step outside the bounds of a sanctioned healer.

In my opinion, too many members of our profession compromise and undermine their true healing potential by forfeiting the benefits that selected clients can gain from a dual relationship. Here are two examples:

(1) Justin, aged 17, required help with some potentially serious drug problems. His parents had tried to find a therapist who could help him, but to no avail. Justin had initial meetings with four different therapists over a six-week interval but declared each one "a jerk" and refused to go back. He then reluctantly consulted a fifth therapist (who had been one of my recent post-doctoral students) who quickly sized up the situation and challenged Justin to shoot some baskets with him later that day at a nearby basketball court. It took several weeks of basketball playing, informal chatting, and a trout fishing expedition, before adequate rapport and trust was established, at which point Justin was willing to engage in formal office visits and seriously address his problems.

(2) Susan, aged 32, consulted me for help with what appeared to be an agitated depression. She had seen a therapist for almost three years who had successfully assisted her in resolving numerous family issues, relationship problems, panic attacks, and work-related difficulties. The therapy ended by mutual agreement a few months after Susan met a man, became engaged to him, and the two of them saw her therapist for a few successful sessions of premarital counseling. "We invited Dr. M. to the wedding but she declined the invitation on the grounds that she considered it inadvisable to socialize with clients or former clients." Susan said that she felt humiliated, demeaned, and invalidated by this rejection and added that she now questioned whether her therapist ever really cared about her. Suffice it to say that it took several months of therapy before I was able to help Susan overcome this needless and unfortunate setback. (I do not consider out-of-office activities designed to establish rapport a "dual relationship," and nor do I regard going to a client's wedding as a "dual relationship." However, too many therapists do look upon them as dual or multiple relationships, and they strongly oppose any interaction beyond the confines of the office. As the foregoing examples indicate, such thinkers may, at the very least, shortchange their clients.)

Most psychotherapists have a negative knee-jerk reaction to the idea of entering into any association with a client beyond the formal therapist-client relationship. I have stressed that it can be extremely beneficial, with selected clients, to dine together, play tennis, or socialize in other capacities (see Lazarus & Zur, 2002). Responses from many colleagues, both in private and in the correspondence columns of journals and periodicals, have been extremely critical of these contentions. Here's a case in point. Rita, a young woman who had graduated from a prestigious law school felt inferior, considered herself "a loser," and generally belittled herself. She had received years of traditional insight therapy, and whatever gains may have accrued, self-confidence was not one of them. I was using a cognitive-behavior therapy approach and we were making headway. Then a few fortunate events came together. She obtained a position with a law firm in which the senior partner was very supportive. She developed an intimate relationship with a man who helped bolster her faulty ego. She prepared a legal brief that enabled her firm to win an important case. Nevertheless, to use a football analogy, she was still not in the end zone. She felt that I and I alone really understood her "decrepitude." If her boss, her boyfriend, or anyone else were privy to the information she had shared with me, they would demean and reject her. (She was referring to a bout with drugs and a serious suicide attempt two years before she consulted me.) So when she volunteered to critique a rather lengthy book chapter I was working on at the time, I decided to cross a boundary and accepted her offer. (I had mentioned this project en passant when she was discussing the rigors of preparing legal briefs.) My sense was that had I played by the rules and declined her offer--no matter how politely and graciously--this would only have reinforced her self-denigration. When the page proofs subsequently arrived, I made a point of showing her how many of her excellent literary suggestions had been incorporated. A few months later, I crossed another boundary. When one of my associates needed an attorney with expertise in Rita's domain I referred him to her. This proved to her that despite knowing about her previous shortcomings, I nevertheless had respect for her and held her in high regard. This was a turning point. "If you believe in me, there's every reason for me to believe in myself," she declared.

Many who uphold strict boundaries practice psychoanalytic or psychodynamic forms of therapy. Indeed, according to their precepts, one should: (1) never socialize with current or former clients; (2) never have financial dealings beyond the fee for service; (3) avoid first name forms of address; (4) avoid physical contact beyond a handshake or an encouraging pat on the shoulder; (5) never treat relatives or friends; (6) never ask for or accept favors from a client; (7) never see a client outside the office; (8) never self-disclose personal information; and (9) never have contact between sessions except for emergencies. But therapists of non-psychoanalytic persuasions such as Gestalt, Humanistic, Cognitive-Behavioral and Feminist Therapists subscribe to different rules. This is also true for many small communities, such as the military, deaf, church, physically handicapped, university counseling centers, gays and certain ethnic minorities where dual relationships are not only unavoidable but in fact increase trust and are often essential for therapeutic effectiveness (see Lazarus & Zur, 2002 for details). The rural practitioner often has no choice but to establish multiple relationships with clients through involvement in community activities, committees, and informal networks.

On the other hand, there are indeed predatory psychotherapists whose clients may suffer grievously at their hands. It seems that we all pay the price for the immoral, illegal, and unethical acts that these depraved practitioners perpetrate. There are therapists who display poor social judgment, disordered thinking, and impaired reality testing. Some are socio-pathic or have narcissistic or borderline personalities. But in my opinion, many of these unscrupulous practitioners will not be cowed or deterred by facing longer and more stringent rules and regulations. What we need are far more careful selection criteria so that we weed out these people before they enter into our graduate schools and training programs.

Virtually all agree that the client-therapist relationship is the soil that enables growth to occur. Often, an integral part of maintaining rapport centers on the issue of when and when not to enter into dual relationships. Those who allow an overriding fear of attorneys and boards to determine the course of therapy are inclined to neglect important clinical concerns. Therapists are not paid to act defensively. For example, a positive outcome is unlikely when therapists provide further detachment to clients whose problems stem from familial-childhood isolation (see Lazarus & Zur, 2002). Barricades between a "professional" and a "patient" do not promote the type of working alliance that fosters emotional growth. As Greenspan (1995) eloquently underscored, the genuine meeting of persons is the sine qua non of healing. She urges us not to allow the boundary police turn authenticity into a bad and dangerous thing. There are certain rules that are worth upholding--never exploit, disparage, abuse or harass a client, and steer clear of any sexual contact. Appreciate the significance of confidentiality, integrity, respect, and informed consent. All the rest of the rules, codes, and regulations are negotiable (Lazarus & Zur, 2002).

References

(1.) Fay, A. (2002). The case against boundaries in psychotherapy. In A. A. Lazarus & O. Zur (Eds.), Dual relationships and psychotherapy. New York: Springer. Pp. 146-168.

(2.) Greenspan, M. (1995). Out of bounds. Common Boundary Magazine. July/August, 51-58.

(3.) Lazarus, A. A., & Zur, O. (Eds.), Dual relationships and psychotherapy. New York: Springer.

(4.) Williams, M. H. (2000). Victimized by "victims." A taxonomy of antecedents of false complaints against psychotherapists. Professional Psychology: Research and Practice, 31, 75-81.

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Arnold A. Lazarus, Ph.D., ABPP, FAPA is Distinguished Professor Emeritus of Psychology, Rutgers University, and President, Center for Multimodal Psychological Services, Princeton, New Jersey. He has also served on the faculties of Stanford University, Temple University Medical School, and Yale University and is on the APA Executive Advisory Board. Dr. Lazarus has authored, co-authored, and edited 18 books and 300 professional articles. A past president of several professional associations, he has received numerous honors including two lifetime achievement awards, and the prestigious Cummings PSYCHE Award.
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