Preventing Boundary Violations in Clinical Practice

Preventing Boundary Violations in Clinical Practice

by Thomas G. Gutheil

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What do you do when you run into a patient in a public place? How do you respond when a patient suddenly hugs you at the end of a session? Do you accept a gift that a patient brings to make up for causing you some inconvenience? Questions like these—which virtually all clinicians face at one time or another—have serious clinical, ethical, and legal


What do you do when you run into a patient in a public place? How do you respond when a patient suddenly hugs you at the end of a session? Do you accept a gift that a patient brings to make up for causing you some inconvenience? Questions like these—which virtually all clinicians face at one time or another—have serious clinical, ethical, and legal implications. This authoritative, practical book uses compelling case vignettes to show how a wide range of boundary questions arise and can be responsibly resolved as part of the process of therapy. Coverage includes role reversal, gifts, self-disclosure, out-of-office encounters, physical contact, and sexual misconduct. Strategies for preventing boundary violations and managing associated legal risks are highlighted.

Editorial Reviews

Doody's Review Service
Reviewer: Christopher J Graver, PhD, ABPP-CN(Madigan Healthcare System)
Description: Having sexual relations with a patient is an obvious boundary violation for clinicians, but what about accepting a gift, receiving a hug, or saying hello in the supermarket? This book explores potential boundary violations that occur commonly in clinical practice and discusses the ways in which clinicians can address them in a therapeutic context.
Purpose: The main purpose is provide clinicians with very practical information about boundary violations and how to handle them from legal, ethical, and professional standpoints.
Audience: This book is appropriate for anyone working in a patient care role, such as psychologists, other mental health professionals, social workers, occupational and physical therapists, physicians, and many others. For students and those supervising trainees, this will be a particularly helpful book. The authors are involved in this area in their scholarly work.
Features: An introduction to boundaries begins the book, followed by a discussion in the second chapter of the limits of therapy and the therapist's role. The book presents a multitude of situations that emphasize clinician/patient boundaries and the potential for violating those boundaries. Some of these situations include gifts/services, self disclosure, public meetings, physical contact, and sexual misconduct. These situations are discussed within the framework of ethical guidelines, as well as contextual factors relevant to the ethics of the situation. The book eschews a black-and-white perspective gleaned from rules and regulations, instead embracing the complexity and ambiguity of these situations. This is especially helpful for clinicians to truly understand the need for rational and ethical problem-solving, rather than relying on a strict memorization of ethical codes. Case examples illustrate the ambiguity and decision-making process that might underlie such behaviors related to boundaries. The final section addresses the importance of boundaries in clinical practice and the liability associated with violations. The final chapter offers important suggestions for the prevention of boundary violations, such as documentation, consultation, peer support, education, and training. The references are current and the index is detailed.
Assessment: This book gets to the heart of boundary violations in a sensible manner. The most valuable attribute of the book is that it helps clinicians engage in rational thought about potential violations before they occur and prepare ways to handle such situations when they arise, rather than just regurgitating ethical standards. It is refreshing to see a sincere discussion of this critical yet deficient area of clinical training.
Journal of Psychiatric Practice

"This excellent book will appeal to novice and veteran therapists alike....It is convenient and extremely useful to have such a comprehensive and well referenced treatment of the subject available in a single volume....Therapists will ignore the wisdom of this book at their—and their patients'—peril."
Journal of Pastoral Care and Counseling

"It is detailed without being tedious. Occasional bits of humor give the text a welcome sparkle....Written in a lucid, unadorned style, with a minimum of technical language. It is easy to read, easy to understand, eminently practical, and comprehensive in its scope. The book is organized so that each topic leads naturally into the next. By the end of the book the reader will have a good foundational knowledge of how and why therapeutic frames are created, what boundaries are and why they are needed, how to avoid crossing or violating boundaries, what to do when such crossings or violations occur, how to deal with the aftermath of such crossings and violations, and how to protect both the patient and oneself from the repercussions that often ensue from such events. If you can make it through this book without recognizing some of your own mistakes, you haven't been reading closely....While the book is written primarily for psychiatrists, psychologists, and other types of counselors who operate within a well-defined therapeutic frame, it is also a valuable resource for anyone whose vocation involves pastoral care, pastoral counseling, or simply making rounds as a hospital chaplain....This book deserves a close and attentive reading. Individual portions of the book should be read more than once. It would be a valuable resource for anyone in both the therapeutic or pastoral fields. Given its accessibility, it would make an excellent addition to any therapist's or pastoral caregiver's library. The authors deserve thanks and praise for their achievement."
Journal of Clinical Psychiatry

"Excellent....The authors take the reader carefully through the morass of understanding and analyzing boundary issues in the therapeutic encounter, whether one is a psychiatrist or any other mental health professional. In providing this 360-degree look at boundaries, beginning with the theoretical underpinnings and moving to the 'on the ground' examples of a wide array of considerations about patient interactions that are, or could become, boundary crossings or violations and on to explicating the potential consequences for both patient and practitioner, the reader comes to appreciate these concepts from every angle. The chapters included in the 'Explorations' section leave few stones unturned....Will provide an incredible amount of useful information to therapists for practicing, teaching, and making careful and reasoned judgments about therapist behavior, whether their own or someone else's."
From the Publisher

"At last, therapists have a clear, comprehensive, practical guide to the boundary decisions facing each of us throughout every course of therapy. Two foremost authorities discuss the full range of boundary issues--time, place, fee, gifts, self-disclosure, touch, documentation, causes and responses to false complaints, avoiding problems and misunderstandings, and so on--in light of the patient's condition and needs, benefits and risks, research, legal standards and liabilities, and varying theoretical orientations. No practicing therapist, training program, or expert witness should be without this essential resource."--Kenneth S. Pope, PhD, ABPP, coauthor of Ethics in Psychotherapy and Counseling: A Practical Guide, Third Edition

"Gutheil and Brodsky have provided mental health professionals of all persuasions with a marvelous guide to navigating the minefield of professional boundaries. What is refreshing and exemplary about this superb book is that the authors appreciate the pervasive ambiguity and uncertainty that are inherent in clinical decisions involving boundaries. A gesture that saves the therapy in one context can destroy the therapy in another context. Each chapter of this rich volume is filled with clinical wisdom and thoughtful risk management strategies that will be of great assistance to both mental health trainees and experienced psychotherapists."--Glen O. Gabbard, MD, Brown Foundation Chair of Psychoanalysis and Professor of Psychiatry, Baylor College of Medicine
"Gutheil and Brodsky have done an outstanding job. Reading this book is like taking a course with the authors, who demonstrate great wisdom and perspicacity as they build the reader's awareness, elucidate what constitutes a boundary violation, and provide strategies for prevention. In today's litigious climate, in which clinical practitioners need to remain so mindful of their professional role, this book is a welcome contribution. I highly recommend this resource to everyone from students to seasoned professionals."--Frank M. Dattilio, PhD, ABPP, Department of Psychiatry, Harvard Medical School and University of Pennsylvania School of Medicine

"This is an excellent volume. I'm pleased to see that it immediately addresses 'transference atheists,' psychotherapists whose theoretical models allow them to pretend that a therapist holds no special power or responsibility in the relationship. The authors' willingness to make clear that clinical practice of mental health occurs within boundaries--whether one practices CBT, prescribes medication, is covering for the treating provider, or does in-depth, transference-based work--is wonderful to encounter. The clarity of the writing makes this book accessible both for beginning therapists and for those of us who are more experienced and think we know better--but often don't."--Laura S. Brown, PhD, ABPP, Director, Fremont Community Therapy Project, Seattle

Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry

"This book is a scholarly and comprehensive approach to the subject of boundary violations....The authors are both very well versed on the subject, write in a clear and engaging style, and invite the reader to continue the exploration of their discourse beyond the knowledge possessed by the reader. It will appeal to the novice differently than to the seasoned professional, but it will enrich both in their knowledge of prevention of boundary violations....An excellent addition to the literature on the subject, this book is a must for the beginner and the expert. It reminds us of how challenging and meaningful our profession is, and how crucial it is to comprehend the multifaceted subject of boundaries within a fiduciary relationship."

"Two highly regarded practitioners in the field of forensic psychiatry, who also specialize in the study of ethical and legal aspects of mental health delivery systems, have brought us an illuminating and highly readable guidebook to risk management in psychotherapy. With an unflinching examination of the behaviors and practices that can result in the sexual exploitation of patients, the book lays out the .practical challenges faced by clinicians in maintaining boundaries in today's institutional, regulatory, and legal environment'....[It] is a thorough and useful guidebook and reference for the practitioner. As the most current review of the clinical, ethical, and legal requirements for good clinical practice across disciplines and theoretical orientations, this book is highly recommended for inclusion in the curricula of mental health training programs. In fact, as the authors note, boundary violations can occur in any setting; therefore, all providers of direct patient care would benefit from reading this book."
New England Journal of Medicine

"The book is clearly written and neatly organized in three sections....The book contains numerous anecdotes taken from the authors' experiences....Offers down-to-earth guidance in an accessible and interesting format, making theoretical notions come to life for use in everyday practice."

Product Details

Guilford Publications, Inc.
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Meet the Author

Thomas G. Gutheil, MD, is Professor of Psychiatry, Department of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, where he is Assistant Director of Medical Student Training and Co-Founder of the Program in Psychiatry and the Law. One of the world's leading forensic psychiatrists, he is a past president of the American Academy of Psychiatry and the Law and current president of the International Academy of Law and Mental Health. Dr. Gutheil is coauthor of the widely used Clinical Handbook of Psychiatry and the Law, which won the American Psychiatric Association's Manfred S. Guttmacher Award (an award Dr. Gutheil has shared three times). His numerous other awards and honors include the American Psychiatric Association's 2000 Isaac Ray Award for outstanding contributions to forensic psychiatry. The author of more than 250 scholarly journal articles and book chapters, Dr. Gutheil lectures worldwide and is regularly consulted by attorneys, licensing boards, and institutions on boundary questions, risk management, and malpractice prevention.


Archie Brodsky is Research Associate in the Department of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, where he is Co-Founder of the Program in Psychiatry and the Law. He is coauthor of  Sexual Dilemmas for the Helping Professional, a pioneering work on clinical and ethical boundaries in mental health treatment. Among the 15 trade and professional books he has coauthored in the mental health field are  Love and Addiction;  The Truth about Addiction and Recovery;  Medical Choices, Medical Chances; and  Clinical Supervision in Alcohol and Drug Abuse Counseling. A co-winner (with Dr. Gutheil) of the Guttmacher Award, Mr. Brodsky is a member and former chair of the Human Rights Committee at Massachusetts Mental Health Center.



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