Psychotherapy and Clinical Boundaries




Many forms of psychotherapy are known to be quite efficacious in the treatment of a variety of clinical disorders. Several pooled analyses indicate that 75 to 80% of psychotherapy patients have a positive response. Prochaska and Norcross indicate that there are four indicators that account for much of the positive impact: 1) clients realize that have more choices; 2) they have an opportunity to experiment, as a result, they are capable of changing their feelings, thoughts, and behaviors; 3) psychotherapy is cathartic; and, 4) enhanced awareness. Further, the therapeutic alliance along with specific client factors, accounts for 85% of the positive impact in psychotherapy. In this article, I focus more on the therapeutic alliance and the importance of fidelity to maintaining proper boundaries with psychotherapy patients.

Clinicians have a responsibility to adhere faithfully to their ethical boundaries. Some of the more important ones are, first of all, do no harm; be consistent in acting in the best interest of the patient; and when clinically justifiable, do the least amount of hurt possible. It is frame of reference that defines the relationship between a behavioral health practitioner and patient with respect to parameters of sound ethical practice. It is designed to protect the clinician and patient from harm. They define and clarify treatment/service roles and expectations (standards of care), they enhance treatment/service efficiency and effectiveness, and they offer safety/protection of patients first and staff second. I fully acknowledge the inherent power imbalance in the clinical relationship.

Boundary crossings are uncommon steps over the ethical line that has the potential to hurt a patient. In clinical consultations with providers, I found a number of crossings like touching or hugging a client without asking permission first; extending sessions longer than clinically indicated; and prolonging service longer than clinically indicated.

In comparison to boundary crossings, Violations are steps over the prudent ethical line that actually harms the patient. Examples include a few of the following: touching clients in inappropriate body places; kissing clients anywhere and in any location; and then of course, engaging in any sexual behavior with the client or their significant others.

The training module that I have developed illustrates, in depth, these critical issues. I use them with psychotherapy providers, and in my advanced clinical courses at the undergraduate and graduate levels. I’ve developed a survey to walk clinicians and students through a varied number of situations. I use this survey to educate targeted care managers, therapeutic staff support (TSS) clinicians, mobile therapists, and outpatient clinicians.

Note: The following are some examples. All items are arranged on a Likert scale ranging from “very comfortable” to “very uncomfortable”, and responses will vary depending on the clinician’s primary role and treatment plan:

  • Do home visit
  • Meet in community
  • Transport agency vehicle
  • Transport own vehicle
  • Meet in own home
  • Spend 1 to 2 hours with clients
  • Spend 2 to 4 hours
  • Spend 4 to 6 hours
  • Spend 6 to 8 hours
  • Loan $5
  • Loan $10
  • Loan $20
  • Loan $20 or more
  • Receive gift $2 or less
  • Receive gift $5
  • Receive gift $10
  • Receive gift $20

Reveal personal info:

  • Age
  • Marital status
  • Have child or not
  • Recreational interests
  • Weekend activities
  • Vacation plans
  • Love life details
  • Relationship problems
  • Family mental illness
  • Sexual orientation
  • Sexual preferences
  • Sexual practices
  • Suicidal attempts

In total, this survey consists of 106 items, and takes about an half hour to complete. This exercise and subsequent discussion arouses a great deal of feelings, opinions and disagreements. Participants find it extremely valuable and relevant. Throughout the training, we refer back constantly to our essential ethical obligations andresponsibilities to our patients. I suspect the readers here will also have a lot of commentary in this regard.

References

Anderson EM, & Lambert MJ (2001). A survival analysis of clinically significant change in outpatient psychotherapy. Journal of clinical psychology, 57 (7), 875-88 PMID: 11406801

Gutheil, T. G., & Brodsky, A. (2008). Preventing boundary violations in clinical practice. N. Y.: Guilford Press.

Hubble, M. A., Duncan, B. L., Miller, S. D., & Wampold, B. E. (2010). The heart and soul of change: delivering what works in therapy. (2nd Ed., pp 23-46). Wash. DC: American Psychological Association.

Prochaska, J. O. & Norcross J. C. (2010). Systems of Psychotherapy. (7th Ed.). Belmont CA: Brooks/Cole.

The above survey and its items are proprietary, and may not be reproduced or used without the expressed permission of the author.

Image via basketman23 / Shutterstock.

  • R McCormick

    Great post, this information is paramount in keeping clinitians on an ethical level. Thanks,

  • Thanks so much, Richard, for detailing your survey! I see many potential boundary violations listed here that I believe are NOT uncommon.

    Any opportunity to discuss these is invaluable to mental health professionals. Many of these seem unlikely to occur during one stage of professional development but . . . a decade later may certainly surface unexpectedly.

    With so many choice points along our career paths, your survey presents an excellent opportunity for self-examination.

    I’m happy to find your blog and will be dropping back in to learn from you.

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Richard Kensinger, MSW

Richard Kensinger, MSW, has over forty years of clinical experience in behavioral healthcare as a psychotherapist, trainer, consultant, and faculty member in the Psychology Department, Mount Aloysius College. He has also taught at Penn State, University of Pittsburgh, and Temple University. He is also a lover of "football", known in the USA as soccer. He is currently associated for over 30 years with youth "football", 26 as a referee.
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