BOUNDARIES CROSSING

2 April 2010RANZCP CongressAukland, NZ

Gary R. SchoenerClinical Psychologist & Executive Director

Walk-In Counseling Center

Minneapolis, Minnesota

WHAT ARE BOUNDARIES?

“Professional boundaries in medical practice are not well defined. In general, they are the parameters that describe the limits of a fiduciary relationship in which one person (a patient) [or client] entrusts his or her welfare to another (a physician) [or professional], to whom a fee is [usually] paid for the provision of a service.”*

*(Taken from Gabbard & Nadelson, “Professional Boundaries in the Physician-

Patient Relationship” JAMA, May 10, 1995-Vol. 273, No. 18).

BOUNDARIES ALWAYS DEPENDENT ON CONTEXT

• Type of Therapy/Therapeutic Frame• Treatment Contract• Organizational Rules• Setting – small town, rural vs.

urban• Cultural differences/expectations 

CONTEXT:Other Situational Factors

• Faith Group or Faith – Based• Gay/Lesbian/Transgender• Military• Ethnic Group• Small College• Institute (Therapist treating Therapist)

• Age/Health Status (e.g. homebound)

Changed Perception of Relationship

• Can lead to a positive or negative interpretation by patient;

• Impact on perception of patients, relatives, others in community

Self-Disclosure by Practitioner

• Role Reversal• Changed perception by patient

Social Contact w/ Patients

Commonwealth of Massachusetts Board of Registration in

Medicine Policy 94-001, January 12,

1994 • General Guidelines related to the

maint. of boundaries in the practice of psycho-therapy by physicians (adult pts.)*

• Appointment place and time • Billing practices• Other economic relationships• Physical contact• Self disclosure

• General Guidelines continued…

• Gifts• Non-sexual social relations• Patients’ families• Changes in behavior regarding

boundaries• Circumstances in which

termination should be considered because boundaries cannot be maintained

* Developed in conjunction with the Mass. Psychiatric Society, the Boston Psychoanalytic Institute and the Mass. Medical Society)

“Self-disclosure, in general, should be kept to a minimum in psycho-therapy. There are, however, a few circumstances in which self-disclosure may be appropriate …

Example: Self Disclosure

... First, patients have a right to know the physician’s training and qualifications when deciding whether to establish a physician-patient relationship. Second, in the treatment of addictions, disclosure of the psychotherapist’s own history of substance abuse treatment has become common…

... Finally, there are infrequent occasions when self-disclosure can have an important therapeutic impact. These situations need to be well thought out, and it must be clear that these disclosures serve the patient, not the therapist…

... It is never appropriate for physicians practicing psychotherapy to discuss their own current emotional problems or to disclose details of their sexual lives.”

Commonwealth of Mass. Board of Registration in Medicine, General Guidelines

related to the maint. of boundaries in the practice of psychotherapy by

physicians (adult patients), January 12, 1994.

BOUNDARY CROSSINGS

• Myth of the Slippery Slope: There is not good evidence that one boundary crossing leads to another – however, if boundaries are being broken down there may be a succession of crossings.

• Myth of the Small Violation: Some times a seemingly minor crossing is ignored – it could be the beginning of a major breakdown or simply the one visible sign of it.