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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
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
Absence of dual relationships outside the treatment
Confidentiality and limits of confidentiality
Clothing and language (mostly implicit) THERAPEUTIC FRAME
5. Boundarycrossings vs. violations CROSSINGS VIOLATIONS Benign and even helpful breaks in the frame
Usually occur in isolation
Minor and attenuated
Ultimately cause no harm to patient, clinician, or treatment Exploitive breaks in the frame
Egregious and often extreme e.g. sexual
Clinician discourages discussion
Typically cause harm to patient, clinician or treatment
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
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
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
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
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
13. Therapeutic context is an imbalanced structure with respect to
NONRECIPROCAL MODES OF RELATING
IMBALANCES ARE CONTEXTUALIZED AND IRREDUCIBLE THERAPEUTIC CONTEXT
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
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
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