How Far Is Too Far? Crossing Boundaries in Therapeutic Relationships

Gloria Umali

American Professional Agency

Risk Management Report

January 2023

While there appears to be a clear understanding of what constitutes a boundary violation, defining the boundary remains challenging as the line can be ambiguous with often no right or wrong answer. The APA Ethical Principles and Code of Conduct (2017) (“Ethics Code”) provides guidance on boundary and relationship questions to guide Psychologists toward an ethical course of action. The Ethics Code states that relationships which give rise to the potential for exploitation or harm to the client, or those that impair objectivity in judgment, must be avoided.

Boundary crossing, if allowed to progress, may hurt both the therapist and the client.  The good news is that a consensus exists among professionals in the mental health community that there are boundary crossings which are unquestionably considered helpful and therapeutic to clients. However, with no straightforward formula to delineate between helpful boundaries and harmful or unhealthy boundaries, the resulting ‘grey area’ creates challenges for most psychologists. Examining the general public’s perception and understanding of what an unhealthy boundary crossing looks like may provide additional insight on the right ethical course of action, including the impact of boundary crossing on relationships on a case-by-case basis. 

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Conclusion

Attaining and maintaining healthy boundaries is a goal that all psychologists should work toward while providing supportive therapy services to clients. Strong and consistent boundaries build trust and make therapy safe for both the client and the therapist. Building healthy boundaries not only promotes compliance with the Ethics Code, but also lets clients know you have their best interest in mind. In summation, while concerns for a client’s wellbeing can cloud judgement, the use of both the risk considerations above and the APA Ethical Principles of Psychologists and Code of Conduct, can assist in clarifying the boundary line and help provide a safe and therapeutic environment for all parties involved. 

The full information is here.

A good risk management reminder for psychologists.

Boundary Issues of Concern

Charles Dike

Psychiatric News

Originally posted 25 AUG 22

Here is an excerpt:

There are, of course, less prominent but equally serious boundary violations other than sexual relations with patients or a patients’ relatives. The case of Dr. Jerome Oremland, a prominent California psychiatrist, is one example. According to a report by KQED on October 3, 2016, John Pierce, a patient, alleged that his psychiatrist, Dr. Oremland, induced Mr. Pierce to give him at least 12 works of highly valued art. The psychiatrist argued that the patient had consented to their business dealings and that the art he had received from the patient was given willingly as payment for psychiatric treatment. The patient further alleged that Dr. Oremland used many of their sessions to solicit art, propose financial schemes (including investments), and discuss other subjects unrelated to treatment. Furthermore, the patient allegedly made repairs in Dr. Oremland’s home, offices, and rental units; helped clear out the home of Dr. Oremland’s deceased brother; and cleaned his pool. Mr. Pierce began therapy with Dr. Oremland in 1984 but brought a lawsuit against him in 2015. The court trial began shortly after Dr. Oremland’s death in 2016, and Dr. Oremland’s estate eventually settled with Mr. Pierce. In addition to being a private practitioner, Dr. Oremland had been chief of psychiatry at the Children’s Hospital in San Francisco and a clinical professor of psychiatry at UCSF. He also wrote books on the intersection of art and psychology.

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There are less dramatic but still problematic boundary crossings such as when a psychiatrist in private practice agrees that a patient may pay off treatment costs by doing some work for the psychiatrist. Other examples include a psychiatrist hiring a patient, for example, a skilled plumber, to work in the psychiatrist’s office or home at the patient’s going rate or obtaining investment tips from a successful investment banker patient. In these situations, questions arise about the physician-patient relationship. Even when the psychiatrist believes he or she is treating the patient fairly—such as paying the going rate for work done for the psychiatrist—the psychiatrist is clueless regarding how the patient is interpreting the arrangement: Does the patient experience it as exploitative? What are the patient’s unspoken expectations? What if the patient’s work in the psychiatrist’s office is inferior or the investment advice results in a loss? Would these outcomes influence the physician-patient relationship? Even compassionate acts such as writing off the bill of patients who are unable to pay or paying for an indigent patient’s medications should make the psychiatrist pause for thought. To avoid potential misinterpretation of the psychiatrist’s intentions or complaints of inequitable practices or favoritism, the psychiatrist should be ready to do the same for other indigent patients. It would be better to establish neutral policies for all indigent patients than to appear to favor some over others.

The article is here.

From the talking cure to a disease of silence: Effects of ethical violations in a psychoanalytic institute

Jane Burka, Angela Sowa, Barbara A. Baer, & others
The International Journal of Psychoanalysis (2019) 100:2, 247-271,

Abstract

This article presents an in-depth study of one institute’s efforts to recover from effects of ethical violations by two senior members. Qualitative data analysis from voluntary member interviews details the damage that spread throughout the institute, demonstrating that a violation of one is a violation of many. Members at all levels reported feeling disturbed in ways that affected their emotional equilibrium, their thinking processes, and their social and professional relationships. The aggregated interview data were reported to the institute community in large and small group meetings designed to reverse the “disease of silence” and to allow members to talk with each other. Outside consultation helped with this emotionally arduous process. The authors offer hypotheses concerning the nature of group anxieties during ethics crises. We assert that both sexual and non-sexual boundary violations break the incest taboo, as they breach the generational protection required of professional interactions. Ethical violations attack the group’s foundational ethos of care, unleashing primitive anxieties and defences that interfere with capacities for thinking, containment, collaboration, and integration. Since the full reality of what happened is unknowable, hybrid truths emerge, causing conflict and disturbances that inhibit thoughtful group discourse.

The article can be downloaded here.

Students' Ethical Decision‐Making When Considering Boundary Crossings With Counselor Educators

Stephanie T. Burns
Counseling and Values
First published: 10 April 2019
https://doi.org/10.1002/cvj.12094

Abstract

Counselor education students (N = 224) rated 16 boundary‐crossing scenarios involving counselor educators. They viewed boundary crossings as unethical and were aware of power differentials between the 2 groups. Next, they rated the scenarios again, after reviewing 1 of 4 ethical informational resources: relevant standards in the ACA Code of Ethics (American Counseling Association, 2014), 2 different boundary‐crossing decision‐making models, and a placebo. Although participants rated all resources except the placebo as moderately helpful, these resources had little to no influence on their ethical decision‐making. Only 47% of students in the 2 ethical decision‐making model groups reported they would use the model they were exposed to in the future when contemplating boundary crossings.

Here is a portion from Implications for Practice and Training

Counselor education students took conservative stances toward the 16 boundary-crossing scenarios with counselor educators. These findings support results of previous researchers who stated that students struggle with even the smallest of boundary crossings (Kozlowski et al., 2014) because they understand that power differentials have implications for grades, evaluations, recommendation letters, and obtaining authentic skill development feedback (Gu et al., 2011). Counselor educators need to be aware that students find not providing appropriate feedback because of the counselor educator’s personal feelings toward the student, not providing students with required supervision time in practicum, and taking first authorship when the student performed all the work on the submission as being as abusive as having sex with a student.

The research is here.

What This White-Collar Felon Can Teach You About Your Temptation To Cross That Ethical Line

Ron Carucci
Forbes.com
Originally posted June 28, 2016

The sobering truth of Law Professor Donald Langevoort’s words silenced the room like a loud mic-drop: “We’re not as ethical as we think we are.” Participants at Ethical Systems recent Ethics By Design conference were visibly uncomfortable…because they all knew it was true.

Research strongly indicates people over-estimate how strong their ethics are. I wanted to learn more about why genuinely honest people can be lured to cross lines they surely would have predicted, “I would never do that!”

The article is here.

Not All Multiple Relationships are Created Equal

By Ofer Zur
Independent Practitioner, 34/1, 15-22. 2014.

Introduction

Most mental health professionals have attended risk management and ethics workshops where one of the central messages was the dire warning that multiple relationships are generally unethical, inherently harmful, mostly prohibited, and should be avoided.  While the term "unethical" is thrown about liberally when it comes to multiple relationships, the fact is that none of the major professional organizations' codes of ethics prohibit all forms of dual or multiple relationships.

The entire article is here.