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1. Describe components and functions of the therapeutic frame2. Differentiate boundary crossings from boundary violations.3. Describe common characteristics of physicians who commit sexual boundary violations.4. Appreciate the inherent power imbalance in the therapeutic relationship.5. List ele

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1. BOUNDARIES AND BOUNDARY VIOLATIONS In the Therapeutic Setting Elizabeth M. Wallace, MD, FRCPC

2. 1. Describe components and functions of the therapeutic frame 2. Differentiate boundary crossings from boundary violations. 3. Describe common characteristics of physicians who commit sexual boundary violations. 4. Appreciate the inherent power imbalance in the therapeutic relationship. 5. List elements in the prevention of sexual boundary violations. LEARNING OBJECTIVES

3. Define the relationship with the patient Establish a framework for treatment Set expectations Major factor in establishing trust Make possible evaluation of deviations from the frame PURPOSE OF THERAPEUTIC BOUNDARIES

4. Setting, duration, frequency, procedures, policies e.g. cancellation policy Clinician is paid to deliver a service Absence of unnecessary physical contact Limited self-disclosure Absence of dual relationships outside the treatment Confidentiality and limits of confidentiality Clothing and language (mostly implicit) THERAPEUTIC FRAME

5. Boundary crossings vs. violations CROSSINGS VIOLATIONS Benign and even helpful breaks in the frame Usually occur in isolation Minor and attenuated Discussable Ultimately cause no harm to patient, clinician, or treatment Exploitive breaks in the frame Usually repetitive Egregious and often extreme e.g. sexual Clinician discourages discussion Typically cause harm to patient, clinician or treatment

6. DEFINITION: Any kind of physical contact occurring in the context of a therapeutic relationship for the purpose of erotic pleasure (Many affectionate gestures made by clinicians are misconstrued at the time they occur or at some later point e.g. hug) SEXUAL BOUNDARY VIOLATIONS

7. 7-12% of practitioners in the U.S. (anonymous self-report, all disciplines) Gender: Male practitioners account for 80+% of incidences 7-9% of male practitioners (most with female patients) 2-3% of female practitioners (most with female patients) Least frequent: Male practitioner ? male pt., Female practitioner ? male pt. PREVALENCE OF SEXUAL BOUNDARY VIOLATIONS

8. Middle-aged male In solo practice Sexual dual relationship with one female patient Female transgressors 70% same sex Practitioner views herself as heterosexual Love and tenderness in relationship drifts to sexual relationship Male patient: may feel triumphant rather than victimized TYPICAL TRANSGRESSOR

9. Gabbard (1994) proposed 4 underlying psychological profiles: 1. Psychotic disorders 2. Predatory psychopathy and paraphilias 3. Lovesickness ? on a continuum with 4. 4. Masochistic Surrender PSYCHOLOGICAL PROFILES OF TRANSGRESSORS

10. These cases have attracted media attention, but not the most prevalent Typically refuse to be evaluated Persistently lie about their conduct despite multiple complaints Blame the patient(s) Dynamics involve sadism, need for power or control PSYCHOPATHIC PREDATORS

11. Most prevalent category ? usually one-time offenders Seek help, display genuine remorse Can be effectively rehabilitated Typical scenario: Heterosexual male, isolated in practice, treating a difficult patient, in a highly stressful time in his life Relationship usually intense, may last several years and fell like ?true love? Ethical complaint most likely filed by pt. when MD ends the relationship LOVESICK ? MASOCHISTIC SURRENDER PROFILE

12. Longstanding narcissistic vulnerability Grandiose (covert) rescue fantasies Intolerance of negative feelings of pt. Childhood: emotional deprivation and sexualization Family history of covert and sanctioned boundary violations Unresolved anger towards authority figures Limited awareness of inner world PRECURSORS TO SEXUAL MISCONDUCT: CLINICAL FINDINGS


14. EDUCATION ? about boundaries, power differential, transference/countertransference, ethics CONSULTATION ? with colleagues on all intense feelings towards patients (love and hate) SELF-CARE ? work/life balance, satisfying relationships, support network, personal therapy if needed PREVENTING TRANSGRESSION

15. Awareness of clinician risk factors ? personal history, current stressors Awareness of patient risk factors Challenging patients ? personality disorder Suicidality History of sexual abuse Awareness of vulnerability at ?edges? of treatment i.e. moments of transition ? end of appointment, between chair and door, outside the office PREVENTING TRANSGRESSION

16. Why am I thinking of doing/saying this? Would I do this with all my patients? Why with this particular patient? Why at this particular time? EVALUATING DEVIATIONS FROM THE FRAME: QUESTIONS

17. How much do I know about how this will be received by the patient? Is there a safer way of achieving the same goal? Why do I think I can do this without harm? Would I hesitate to tell a colleague what I have done? Would I worry if my patient told someone? EVALUATING DEVIATIONS FROM THE FRAME: QUESTIONS

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