Sexual boundary violations reflect the most egregious of boundary violations in psychotherapy, yet they comprise the minority of all such abuses of the privileged therapy relationship. Trainees in psychiatry and psychotherapy are quick to identify sexual relations with patients as a major ethical and legal transgression. As described elsewhere, many mental health professionals who engage in such behavior have severe narcissistic or masochistic characterological pathology (Gabbard, 2005).
Yet, many therapists fail to recognize that some other types of boundary violations exist, are detrimental to the healing process of psychotherapy, and can lead to future violations of a sexual nature. Some uninformed or psychologically unfit therapists attempt to justify their actions as being therapeutic in their intent or result. Others recognize them as inappropriate conduct but engage in them nevertheless. From my experience as a psychotherapist, these types of violations are more prevalent than commonly believed.
I have outlined below some of the common boundary violations encountered in psychotherapy, their significance, and ramifications on the treatment process.
Communications outside of the therapy hour: The patient begins to call or email the therapist outside of the therapy hour. It may be due to a perceived emergency, to provide an update, or to engage in casual conversation. Perhaps the patient asks to see the therapist at a neutral location, or even at their home. With very few exceptions, all communications outside of the allotted psychotherapy hour constitute boundary violations on the part of the therapist. The patient should be made aware, at the outset of treatment, that they are contracting for the therapist’s time and that the therapist is allotting a predetermined amount of time each week to see the patient in the office. If the therapist is to communicate with the patient outside of the therapy hour, they are violating the therapeutic contract. The patient should be informed that there is a reason why they are reaching out to the therapist between sessions, and this should be analyzed as part of the transference reaction. The goal of any ethical psychotherapy is to assist the patient in becoming more autonomous and self-determining, and this is not possible with extra-therapeutic communication. Such activities usually only serve to worsen the patient’s underlying condition. These boundary violations may also occur when therapists occasionally or routinely spend more than the allotted session length with certain patients, schedule patients at unusual hours, or see patients more frequently than is clinically necessary.
Befriending the patient and giving advice: There is significant overlap between communications outside of the established therapy hour and befriending the patient. Elements of this type of boundary violation include unnecessary, excessive, or self-serving personal disclosure or providing direct advice or guidance to patients about their personal lives. These types of therapists typically have an unmet need for power or control, and the patient becomes an object of such need. Alternatively, these therapists may be in emotional turmoil and turn to their patients as sources of emotional support, turning the table in psychotherapy. Some may accompany their patients to public or private events. Some may even attempt to coerce them out of relationships. Attempts on the part of patients to become friends with their therapists should not be dismissed in a disapproving fashion, but again should be made sense of in psychotherapy. Usually, these patients are playing out past themes and reliving them in the therapy relationship. Therapists who use the therapy relationship to insert themselves into their patients’ personal lives may also be acting out what Freud called the “rescue fantasy,” an unconscious belief on the part of the therapist that they are needed or able to save another person from perceived harm.
Giving or receiving gifts: If the patient brings you a gift, large or small, it likely signifies that the patient feels they owe you something—other than the money they are paying you for psychotherapy. They may feel they are paying you too little, that the value of your work exceeds the money they are paying. Alternatively, it may indicate that the patient is seeking to exert control or power over the therapeutic relationship, or to suppress feelings of anger or hostility. Small gifts (those worth less than ten or so dollars) can be graciously accepted under certain circumstances, but even these exchanges should be discussed in terms of their meaning. Under very few circumstances is it appropriate for a therapist to give a gift to the patient, even something as seemingly trivial and inexpensive as a book. The only “gift” that you are giving to the patient is an empathic and emotionally-attuned psychotherapy.
Physical touch: Psychoanalysts of years past viewed physical touch to be something to be avoided entirely within the therapy relationship. Even a handshake was deemed by some to muddy the waters of the transference. As a rule of thumb, a handshake is the only physical interaction that should take place between therapist and patient. Anything beyond a handshake, such as a pat on the back, a caress of the arm, a hug, or a kiss, is inappropriate under virtually all circumstances. It could be argued that a grieving elderly woman who lost her husband of many years and seeks a hug from her therapist on one occasion might be harmed by the therapist’s rejection. However, this situation is a rare exception to the rule. The therapist should never initiate such physical contact. Those who do may be unaware or dismissive of the sexual connotation of their conduct. In some cases, it advances to sexual activity. Such desires for physical contact on the part of the patient warrant investigation in psychotherapy.
This list of nonsexual boundary violations is not exhaustive, and many other types of violations can and do routinely occur. While some professionals may take somewhat different approaches to these matters, there is widespread agreement amongst theoretically-informed therapists that these practices constitute boundary violations. It is not uncommon for these seemingly minor violations to develop into a sexual relationship, although it is now accepted that not all nonsexual violations are covertly sexual in their nature or progress to sexual intercourse.
If you are a patient involved in a therapeutic relationship with a therapist who engages in these nonsexual boundary violations, it may make sense to consult a different psychotherapist. For therapists who find themselves engaging in this type of conduct, psychoanalytic consultation and supervision is warranted.
Gabbard, G. O. (2005). Patient-therapist boundary issues. Psychiatric Times. Retrieved from http://www.psychiatrictimes.com/schizophrenia/patient-therapist-boundary-issues