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How to Ethically Set Client Confidentiality Boundaries - The Gray

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w to Ethically Set Client Confidentiality Boundaries - The Gray Areas of Boundary Crossings and Violations Part I: Introduction
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Section 12
The Gray Areas of Boundary Crossings and
Violations Part I: Introduction
Question 12 found at the bottom of this page
Answer Booklet | Table of Contents
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The term "boundary violation" has become synonymous with unethical practice
in psychotherapy, prompting a "black-or-white" view among clinicians and
boards of review. But the current conceptual ambiguity about boundary
interventions subjects clinicians to after-the-fact second-guessing that can be
professionally ruinous at worst and may contribute to stultifying defensive
therapeutic rigidity at best. It is crucial to demarcate the differences between
boundary violations and boundary crossings (to be defined below) as clearly as
possible, to describe the "gray areas" of each, and to recognize the heterogeneity
of boundary violations and boundary crossings. These matters are of additional
importance to those who teach, train, and supervise the next generation of
clinicians. This paper will attempt to delineate a more clinically realistic and
useful view of boundary crossings than has been proposed before, and illustrate
the practical advantages of recognizing the spectrum of boundary interventions.
Background
For decades, there have been prominent public and professional concerns about
boundary violations in psychiatry and allied disciplines ( 1-6). The sentinel
work of Schoener et al. (7), based on observations made at the Minneapolis
Walk-in Counseling Center, provided careful documentation of the dimensions
of the problem. While the concept of boundaries had been explored in
psychoanalytic circles many years before, no broadly accepted definition had
been reached (8,p. 21). Nonetheless, as Gabbard and Lester ( 8,p. 83) point out
in their comprehensive review of the subject, "psychoanalytic pioneers had
some knowledge of the inadvisability of (boundary) transgressions."
Thus the early history of psychoanalysis was permeated by numerous examples
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w to Ethically Set Client Confidentiality Boundaries - The Gray Areas of Boundary Crossings and Violations Part I: Introduction
of what today are easily recognizable as boundary violations ( 8,pp. 83ff).
Gabbard and Lester ( 8,pp. 4, 39) define boundaries as "the demarcation
between the self and the object...the envelope within which treatment takes
place." Boundaries provide "a flexible set of conditions that...(establish) an
optimal ambience for the (therapeutic) work," and establish rules and role
expectations that the patient may rely upon for safety required for treatment.
In terms of therapeutic interventions, Gutheil and Gabbard ( 1,p. 410) describe
boundaries as "the edge of appropriate (therapist) behavior" adapted to the needs
of the individual patient "to create an atmosphere of safety and predictability"
(emphasis added). Here the distinction is drawn between "appropriate behavior"
by the therapist, and inappropriate behavior, i.e., behavior not in the patient's
best interests. In this paper, I will emphasize the patient's subjective experience
of his/her boundaries within the treatment: that personal space that may be
infringed upon, eliciting various responses and, concomitantly, presenting
therapeutic challenges and opportunities. This emphasis on the patient's
subjectivity is consistent with recent psychotherapeutic interest, illuminated by
the work of Kohut (9).
As clinicians achieved a clearer awareness of boundary theory and appreciated
the danger that violations posed to their patients, the treatment, and themselves,
Waldinger (10,p. 226) and others ( 11,p. 189) called attention to problems
engendered by this heightened awareness. They identified difficulties that could
arise from an inflexible adherence to a prescriptive black-or-white definition of
boundary constraints. They cautioned against a rigidification of technique that
could stifle creativity, impede the individualization of treatment, and obscure
subtleties in context, timing, and cultural expectations that could be critical for
optimal treatment. Waldinger ( 10) illuminates the counterintuitive effects of
waiving a fee and accepting a hug in two case illustrations.
The concept of "boundary crossings" was advanced ( 1, 8, 10) to describe
appropriate and ethical "boundary transgressions"( 1). In keeping with their
elusive nature, boundary crossings have been difficult to define; rather, authors
have described various properties that, they argue, typify boundary crossings.
Behaviorally, boundary crossings are seen as distinct discussible departures
from an established treatment framework. They are not part of a progressive
escalation of exploitative changes in the relationship ( 1, 6, 8). The
nonprogressive and discussible aspects of boundary crossings are central in
distinguishing a boundary crossing from the infamous "slippery slope" of
cascading transgressions that mark boundary violations. The goal of boundary
crossings is to enhance treatment without harm to the patient ( 1).
Despite these clarifications, clinicians and trainees often are uncertain if a given
intervention represents a boundary violation or a boundary crossing. In view of
the complexity of the interactions and the abovementioned imprecision in the
definition of boundary crossings, this is not surprising. But other elements add
to the challenge. Renik (12) emphasizes the inevitability of enactments in
psychotherapy (unconscious, mutual partial playings out of wishes in the
therapy), and points to their potential value in enhancing the exploratory process
when recognized and examined. Waldinger ( 10,p. 236) remarks that "the
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w to Ethically Set Client Confidentiality Boundaries - The Gray Areas of Boundary Crossings and Violations Part I: Introduction
intrapsychic meanings (to the patient) may be the only clues to understanding
whether a boundary violation has occurred." Note that this requires a
retrospective inquiry, i.e., one that occurs after the event in question. Gutheil
and Gabbard ( 1), commenting on the effect of interested litigators and
professional review boards, remark
The matter of context is all too often disregarded by fact finders and decision
makers in this area, although it is essential to determine, inter alia, whether a
specific behavior represents a boundary crossing or a boundary violation;
indeed, the identical behavior may constitute either a boundary crossing or a
boundary violation, depending entirely on the context in which it occurs.
(emphasis in original). (p. 411)
These uncertainties have led Epstein and Simon (13,14) to propose an
"exploitation index" to provide "early warning indicators of treatment boundary
violations." Others (15-17) have questioned the utility of such an approach,
fearing it is overly inclusive, misleading, and purports an unwarranted degree of
certainty in an area of cultural relativism. It is clear that apprehension of being
found on the wrong side of whatever is established as a definition of boundary
violations has led some to cling to a therapeutic orthodoxy that interferes with
flexible, empathic treatment.
Another reason for this problem of defensive inflexibility is that the existing
literature is marked by confusion as to what constitutes appropriate vs.
inappropriate "boundary transgressions"( n1) ( 1). To some extent this is
unavoidable, since, as noted above, context may make the same intervention
acceptable in one situation while not in another. Also, one's conception of
boundaries is rooted in the type of psychotherapy being practiced.
(Cognitive-behavioral therapists understandably will have different techniques
and appropriately different ideas of what constitutes the boundaries that pertain.
This article, and the literature it draws upon, are from a psychodynamic
perspective.)
In this vein, I will present an understanding of the concept of boundary
crossings that connects it to the familiar process of creating a therapeutic
alliance. Viewed in this light, boundary crossings will be recognizable as a
continuing elaboration of the therapeutic setting. As such, these "actions at the
boundary" can be understood to be part and parcel of psychotherapeutic work: a
standard element in technique with its unique place and potentials for use and
misuse. This perspective is intended to clarify the concept of boundary
crossings, securely placing them in the familiar array of reasonable therapeutic
interventions. Also, I will attempt to illustrate the clinical utility of recognizing
that boundary interventions (violations and crossings) each have gray areas that
span ethical practice and malpractice. In addition, a fundamental but overlooked
distinction between boundary violations and boundary crossings that will be
illustrated below is that boundary crossings relate to the therapist's attempts to
enhance the treatment, while boundary violations, which more grossly breach
the patient's physical and/or psychological subjective space, often do so in the
service of the therapist's interests.
- Glass, Leonard; The gray areas of boundary crossings and violations;
American Journal of Psychotherapy; 2003; Vol. 57; Issue 4.
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w to Ethically Set Client Confidentiality Boundaries - The Gray Areas of Boundary Crossings and Violations Part I: Introduction
Personal Reflection Exercise #5
The preceding section contained information about the gray areas of boundary
crossings and violations introduction. Write three case study examples
regarding how you might use the content of this section in your practice.
QUESTION 12
According to Glass, what are the costs of rigidification of technique? Record the letter
of the correct answer the Answer Booklet
Answer Booklet for this course
Forward to Section 13
Back to Section 11
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