Therapists’ Experiences of Maintaining Boundaries in the Therapeutic Process
CHAPTER I: INTRODUCTION
Though traditionally associated with health care and medical personnel, psychotherapy, in fact, seems to be a part of social service. Originated as a branch of medicine, initial psychoanalysis was performed by medically trained professionals (Holmes & Lindley, 1998). As an integral part of medicine, psychotherapy emerged due to the inability of traditional medicine to explain some health-related issues with its physiochemical grounding. In the early 19th century, US physicians faced a challenge of multiple cases of physical pain complaints in the absence of any physical injury or trauma (Whitaker & Malone, 2014).
That psychosomatic tendency became the first precursor to psychotherapy followed by a frequent diagnosis of neurasthenia disorder. The disease characterized by anxiety, neuralgia, fatigue, headache, depression, and importance affected many in the US society, while revealing the failure of identifying its nature through physical medicine (Bateman, Drown, & Pedder, 2010). Finally, a rapid technological development equipped the physiochemical medicine with a range of advances. In contrast to the increased medicine capabilities, people demonstrated a need in mind-healing practices, initially sought in the New Thought movement and Christian Science (Wampold & Imel, 2015).
Initially, traditional medicine deliberately ignored that tendency regarding it as an unscientific attempt to cure either mental or physical illness and attributing it to relics of the past religious practices. With the time, psychochemical medicine recognized the value of mind-oriented treatment in the face of frequent declaration of physical symptoms in the ultimate absence of the cause (Whitaker & Malone, 2014). In addition, a common tendency to refer to mental healers instead of physicians aroused the need to impose a medical authority on the practice. As a result, mental treatment was integrated in the scope of public medicine, which obliged a person to obtain necessary medical education and training to become eligible for providing mind-related cure (Bateman, Brown, & Peddler, 2010).
Further psychoanalysis theory developed by Sigmund Freud equipped this healthcare branch with the sought theoretical coherence. “Psychoanalysis appeared to be more proper and civilized than mind cure, more scientific than Christian Science and positive thinking, and more medical that advertising” (Wampold & Imel, 2015, p. 18). Freud’s theoretical foundation created a firm ground for psychodynamic psychotherapy delivered by physicians and psychology specialists. However, the pioneer of the traditional psychotherapy, Sigmund Freud, emphasized the therapeutic process as the instrument of mental treatment rather than the healer’s medical qualifications. His advocacy for the healer’s personality gave the ground for further expansion of the list of those eligible for the service delivery (Whitaker & Malone, 2014).
Today, psychotherapy may be delivered by a range of stakeholders, including doctors, clinical psychologists, marriage guidance counselors, priests, and social workers. Thus, both medical specialists and non-qualified individuals may serve as psychotherapists (Holmes & Lindley, 1998). The state of affairs produces a negative impact on the profession, the existence of which is not a guarantee of a good service. In psychotherapy, the healer performs two roles simultaneously being the main coordinator of the process and its primary instrument. The task of serving as an integral part of the therapeutic process is complex, requiring a healer to commit to foster client’s happiness, while following professional guidelines (Dewane, 2010).
In some life domains, standardized training and adherence to the established procedures may be regarded as uniformity and mediocrity in the area that depends on a variety of human situations, thus, requiring diversity (Holmes & Lindley, 1998). In the case of psychotherapy, regulated training is fundamental to prescribe a therapist with various scenarios of the therapeutic process and accepted conducts. The prevailing position that psychotherapy is only for clinicians, since therapy can harm a client either negatively though not reinforcing a desired change or positively by worsening a patient’s mental or emotional condition (Moodley, Gielen, & Wu, 2013).
Though representatives of psychology, psychiatry, social work, and nursing professions are subject to basics of psychotherapy, only psychotherapists ponder in the depth of the psychotherapeutic content through sophisticated training and workshops (Holmes & Lindley, 1998). As a discipline, psychotherapy combines elements of medicine and education, providing its clients with a route to a happy living. An efficient clinician is to possess a range of skills and a long-term orientation. This implies acquiring a scope of broad strategies and techniques within a consistent theoretical framework along with an ability to choose clinical skills most suitable for each case (Wedding & Corsini, 2013).
This ability to recognize appropriate moments for using particular psychotherapeutic strategies enables a clinician to customize coherent treatment plans for an individual patient who refers to the assistance with hope and anxiety (Wampold & Imel, 2015). In addition, a skillful therapist needs a therapeutic personality to cope with various frustrations, stresses, and failures inherent to the profession, where not every relationship reaches the intended outcomes. In line with professional ethics, psychotherapists are required to deal within professional boundaries, but with respect to needs and preferences of each client. Therefore, psychotherapy requires knowledge and understanding of cognitive science, social psychology, developmental psychology, cultural anthropology, psychopedagogy, and hermeneutics (Wedding & Corsini, 2013). These competences enable psychotherapists to adopt a multidimensional approach when building trustworthy but professional relationships with their clients to facilitate their mental health and sought assistance in overcoming some life events.
Social changes have affected multiple life domains, including psychotherapy that has become brief, intermittent, time-limited, and recurrent. These changes evoked criticism of the professional as whole. While advocates of the profession underline its address of emotional autonomy, self-esteem, and productive social function, its critics claim it an instrument of diverting attention from the social inequality in terms of racism, class, and sexism that is the true cause of unhappiness (Hilmes & Lindley, 1998). The major critical point concerns vulnerability of both psychotherapists and clients to the effects of former’s capacity to provide quality service, while coping with adverse consequences of the profession. In other words, the need to repair one’s personality regularly influences therapist’s professional choice, capacity to handle rigors of the profession, and therapeutic empathy (Mander, 2007).
An unconscious connection between a clinician and a client underpins any therapeutic relationship with a potential for both positive and negative outcomes. This underlines a need for a responsible management of the therapeutic process and relationship to focus the cooperation of two strangers on the purpose of therapy through a fixed frame, comprehensive training, and supervision (Mander, 2007). The emergence of psychotherapy as a branch of medicine was a response to the need to establish limits to the relationship between a therapist and a client. That decision of outlining therapy boundaries sought to benefit both parties of the therapeutic process. Fixed therapy guidelines protected a client from adverse therapeutic effects, while maintaining a positive and reputable image of the practice as a whole (Wampold & Imel, 2015).
Dedicated to fostering client’s treatment progress, a therapist seeks to build a productive relationship with a client based on trust and confidence. However, this may result in either conscious or unconscious development of a secondary relationship. This mostly unplanned, unexpected, and inadvertent connection is typically perceived as a minor withdrawal from the established ethical guidelines (Mander, 2007). Such nonsexual secondary relationship is a frequent consequent or companion of legitimate interactions between the parties of the therapeutic process. Because of the inoffensive nature, dual relationships are not perceived as a threat to patient’s well-being and mental state as well as a violation of the professional ethics. In contrast to advocates of this boundary crossing, there is an opposite position in the industry with therapists calling dual relationships harmful for patients and manifestation of unprofessional conduct (Dewane, 2010).
The issue of whether psychotherapists should strictly adhere to traditional profession’s boundaries has been subject to the debate since the 1980s. Thus, for over three decades, the industry has experienced a range of rises and falls on the controversy of developing dual relationships in the process of psychotherapy and counseling (Strauss, Barber, & Castonguay, 2015). In the 1980s, the question of the appropriateness of expanding the frames of the therapist-client relationship shook the entire psychotherapeutic community. The debate engaged both industry clinicians and scholars provided evidence to controversial effects of dual relationship on the practice as a healthcare discipline, value system, and approach to treatment (Pope & Vasquez, 2011).
The major point of those advocating development of dual relationship concerns psychotherapy service in small-scale communities of faith and rural areas that might experience a lack in therapy professionals (Cohn & Hastings, 2013). As a result, professional and personal life of psychotherapists may overlap, forcing them to serve their family members, neighbors, friends, or public housing acquaintances (Zur, 2015). In support of dual relationship, its proponents emphasize its non-sexual nature, which significantly reduces its potential for producing harm to a client. Thus, it is reasonable to evaluate the situational context to identify expected benefits along with negative outcomes to determine whether treatment benefits overweigh risks posed to the therapeutic process and profession as a whole (Pope & Vasquez, 2011).
The relationship-based process of psychotherapy is subject to diverse and multi-dimensional ethical considerations to address all aspects of human nature. This complexity nourishes the enduring debate on the appropriateness of developing dual relationship in therapy. Those focused on potential harm to client argue for its entire avoidance in the therapeutic practice, while those citing evidence to the contribution to the treatment progress claim its suitability in certain circumstances (Mander, 2007). In the context of its current popularity and multi-channel delivery through clinicians, social workers, or public counselors, psychotherapy seems to benefit from dual relationship as a strategy for reinforcing patient’s engagement in the treatment process and its success (Dewane, 2010).
The observed inconsistency in positions concerning adherence to the standard ethical guidelines found reflection in two opposite ethical frameworks. Absolutist or deontological ethics advocates the ultimate reliance on the professional boundaries and principles when making therapeutic decisions. Relativist or utilitarian ethics allows minor ethical deviations driven by treatment enhancement motives (Conway, 2013). Therefore, the former focuses on the therapeutic process as the essence of the profession, while the latter emphasizes outcomes as the key purpose of therapy. In addition, there is an argument that sometimes, therapists are unable to prevent development of dual relationships because of specific patient’s intentions or desires. Thus, such unavoidable relationships should not be clarified for their violation natures in the industry’s code of conduct, provisions of which follow the American Psychological Association’s (APA) Code of Ethics (Dewane, 2010).
Problem Statement
As indicated above, psychotherapy is a relationship-based process that requires a fixed ethical framework, while calling for diversity. Since therapy produces a direct impact on client’s well-being and happiness, it is subject to strict guidelines, establishing boundaries for the professional conduct. The most comprehensive and authoritative source of therapeutic boundaries is the APA’s Code of Ethics that prescribes psychotherapist’s response to various scenarios of the therapeutic process (Welfel, 2015). Advocates of dual relationships and minor boundary deviations point out that APA’s dispositions are too vague and broad, providing a general direction rather than an action plan for any specific situation. The situational context of therapy may force a clinician to adjust the treatment process to certain patient’s needs in reliance on his or her professional judgment. Contrary to this viewpoint, proponents of a strict adherence to ethical standards claim that APA’s framework establishes boundaries for the therapist-client relationship to ensure its compliance with the therapeutic purpose and focus on achieving treatment targets (Barnett & Hynes, 2015). This position implies a ban on any withdrawal from the determined regulations and rules, including dual relationship.
In fact, the APA’s Code of Ethics prohibits multiple or dual relationships unless they contribute to the treatment progress or are unavoidable and harmless (APA, 2010). However, the main source of therapeutic ethics does not provide clarifications on parameters, when dual or multiple relationships are regarded as unavoidable or harmless. As a result, the APA’s Code of Ethics fails to handle the dispute of the acceptability of dual relationship and to foster consensus on the issue among psychotherapy researchers and practitioners. In the pursuit of handling the point, Pope and Vetter (1992) suggested the industry’s ethical code had to integrate a precise definition of dual relationships and to determine therapeutic conditions, making it an integral and valuable part of the treatment process.
In addition, they underlined the need of making a specific point concerning psychotherapeutic service in small towns, rural communities, religious communities, and remote locations that made dual relationship almost unavoidable (Pope & Vetter, 1992). Authors recommended drawing a line between intentional dual relationship and accidental encounters between a therapist and a client in public housing facilities. The research of Freud and Krug (2002) echoed ideas of Pope and Vetter (1992) in relation to the needed careful and detailed address of multiple and dual relationships within the APA’s Code of Ethics. Pointing out to their concurrent or consecutive nature, scholars asserted that the existing ethical guidelines were unable to solve the dilemma of dual relationship.
In their argument, Freud and Krug (2002) defined three issues of concern in relation to enhancing boundaries for the professional conduct. In terms of the appropriateness of dual relationship, authors emphasized that the ethical code needed changes to ensure protection of the therapeutic process, client protection from exploitation or harm, and practitioner protection from liability. In other words, efficient boundaries for the therapeutic practice should prescribe the overall scope of accepted behavior patterns for a therapist in the therapeutic process, prevent any cases of client hurt or exploitation, and mitigate possible lawsuits against practitioners (Earle & Barnes, 2013).
While arguing for boundary strengthening, Freud and Krug (2002) admitted that some therapeutic situations required going beyond the traditional therapist-client relationship framework in favor of improved communication and confidence. In that vein, scholars asserted that in some instances, development of dual relationship was crucial for “successful entry, professional legitimacy, and knowledgeable intervention” (Freud & Krug, 2002, p. 486). As a process based on human interactions, psychotherapy posed a challenge to a practitioner to assess all risks and negative consequences when making a therapeutic decision outside the established boundaries. In their analysis, Reamer (2000) and Johner (2006) outlined the need of a careful risk management for cultivation of dual relationship. However, the ultimate avoidance of it was a solution as well (Dewane, 2010).
The viewpoint that dual relationship is acceptable upon a thorough consideration of multiple contributing factors and solid evidence to the overweight of expected treatment benefits over potential risks seems to prevail in the contemporary psychotherapeutic community. The APA’s Code of Ethics indicates boundaries for the following parameters of the therapeutic process: time, location, space, touch, gifts, and self-disclosure (Barnett & Hynes, 2015). In a nutshell, a therapist is permitted to meet with a client only in therapy office setting in prescribed hours and days without any breakages of the initial arrangement. Personal communication, meeting, gifts, manifestations of friendship or other feelings are a ban for both participants of the therapeutic process (APA, 2010). These dispositions of the Code of Ethics serve to prescribe a general scenario for therapy to ensure its focus and pursuit of treatment goals and expectations.
In addition, these boundaries of the therapeutic process are to protect the profession as a whole, maintaining its positive image in the public. Freud and Krug (2002) pointed out that when decision on the engagement in dual relationship, a therapist should consider one’s own professional risks of being misunderstood, disqualified, or revoked of license. The point seems valuable in light of the recent statistics on increased rates for lawsuits issues against therapists for professional misconduct (Dewane, 2010). The tendency for blaming one’s therapist for boundary crossing or dual relationship is common today. Thus, a therapist’s intention to facilitate the treatment progress through deepening the relationship with a client may be either appreciated by the latter or perceived as an intrusion in one’s personal life or exploitation.
In order to prevent such cases of misunderstanding, critics of dual relationship appeal for maintaining and strengthening therapeutic boundaries (Mander, 2007). In support of the argument, Younggren (2002) claimed, “all dual relationships are unethical or at least run the risk of getting you into trouble with your licensing board” (n.p.). In their justification on the ultimate prohibition of dual relationships in the therapeutic process, Ramsdell and Ramsdell (1993) emphasized a threat of sexual contact between a therapist and a client as a consequence of dual relationship. Stressing upon a tendency of transforming emotional closeness to physical interactions, scholars alerted unacceptance of dual relationship as detrimental for treatment and the therapeutic discipline.
In response to these anti-dual-relationship claims, advocates of a flexible application of therapeutic boundaries suggested the existence of cases when dual relationship were not a violation of professional ethics, but an integral part of the therapeutic process. Kagle and Giegelhausen (1994) conducted a nationwide survey to prove that friendship, business, or educational relationship prevailed physical contacts. As a subject to preliminary risk assessment, client awareness and consent, and specific training, dual relationship seems suitable for psychotherapy ethical guidelines (Kagle & Giegelhausen, 1994). Hence, there is no clarity and uniformity in relation whether the existing boundaries are applicable to any specific therapeutic situation or whether dual relationship is acceptable upon a thorough risk assessment and precaution management. While some continue the dispute on the subject, others engage in dual relationship that may either result in treatment benefits or cause harm to both a client and a therapist, which signifies the need for the issue clarification.
Purpose of the Study
Psychotherapy is a socio-medical discipline regulated by a set of regulations, policies, and procedures that establish standards for acceptable behavior of therapists in the therapeutic process. These boundaries create a frame for the therapist-client relationship to ensure the pursuit of the treatment goals and needs. The key source of therapeutic boundaries – the APA’s Code of Ethics – provides a general guidance and indicates exceptions for some boundary deviations under the ultimate condition that this departure from boundaries does not cause harm or exploitation of a client. The issue of dual or multiple relationships regarded as therapeutic boundary crossing, which is typically non-exploitative, non-offensive, and non-sexual, is one of such cases. The problem concerns unclear APA’s dispositions in relation to what particular situations allow cultivating dual relationship.
As a result, while some industry representatives urge the importance of maintaining boundaries without any exceptions to protect clients from harm, therapists from liability, and profession from a negative public image, others point out cases when dual or multiple relationships are unavoidable due to location constraints, treatment benefits, or client intentions. The latter group argues that it is inadequate and unreasonable to prohibit minor boundary crossing and dual relationship without consideration of potential treatment benefits. Simultaneously, they recognize the need of a thorough risk assessment to identify adverse effects of boundary crossing or dual relationship and to ensure overweight of positive outcomes.
Given evidence cited above, this study seeks to investigate the scope and importance of maintaining established boundaries in therapy. Upon a precise analysis of APA’s provisions pertaining to boundary crossing, boundary violations and dual or multiple relationships, the researcher expects to determine whether departures from boundaries are acceptable and beneficial in certain clinical situations. Since the APA’s Code of Ethics does not establish a ban on emotional, non-exploitative boundary crossing or dual relationship, this inquiry focuses on the examination of non-sexual dual relationship and non-physical boundary crossings. Through an in-depth literature review and analysis of primary data provided by psychotherapy practitioners, the researcher expects to achieve credible findings and to conclude whether the industry boundaries prescribe behavioral patterns for various clinical situations, including required or unavoidable boundary crossing or dual relationship, and thus, should be strictly maintained.
The present study is dedicated to investigating therapeutic boundaries and their address of various boundary departures, such as boundary violations, boundary crossings, and dual or multiple relationships. This extensive examination is likely to shed light onto appropriateness and applicability of boundaries to each particular clinical situation. In line with the pursued research objective, the researcher has formulated the following research questions to provide orientation for the overall research process:
What procedures should therapists follow to maintain boundaries?
What are benefits in boundary maintenance?
What are challenges in maintaining boundaries as a therapist?
What is the role of APA’s Code of Ethics in maintaining therapy boundaries?
What therapeutic situations imply boundary violations?
Conceptual Framework
Psychotherapy is an interactive treatment process based on regular communication sessions between a therapist and a client. The widespread term of “psychotherapy” implies a range of psychoanalysis forms, such as client-centered therapy, group psychotherapy, psychodynamic psychotherapy, existential psychotherapy, and others. All types share a set of common features that establish standards for the therapist-client relationship to make it focused on the clinical process of treatment (Novalis, Rojcewicz, & Peele, 1993). The list of these elements includes therapeutic neutrality, transference, countertransference, free association, and resistance (Goldstein & Goldberg, 2006).
Therapeutic neutrality implies the therapist’s stay within boundaries of professional relationship and communication with a client. It is the core premise of the therapeutic practice that a practitioner is not a friend or a family member, but a professional, whose task is to listen and analyze (Jackson & Greene, 2000). In this vein, a therapist must maintain a certain therapeutic distance, acting in compliance with the practice’s standards. There is no place for a therapist’s personal motivation or desire in the treatment process. Instead, each clinician’s word and action should be deliberately focused on the treatment needs and the healing process (Goldstein & Goldberg, 2006).
The psychotherapeutic relationship that presupposes trust and closeness between two parties evokes a transference reaction of a client when he or she experiences some feelings for the practitioner. In its broad definition, transference is “the process that leads to attitudes, assumptions, and feeling in the patient that are outgrowths of the patient’s earlier relationships with significant others, especially parents” (Novalis, Rojcewicz, & Peele, 1993, p. 24). This process is commonly unconscious and results in the patient’s recreation of past emotional relationship with the therapist as a new object. Regardless of the restored feelings – either negative or positive, transference requires a thorough consideration and management on behalf of the practitioner, since it reenacts emotional connections from the past in the present (Jackson & Greene, 2000). In addition to actual or imagined thoughts and feelings, transference includes patient’s mental defenses against them. In the therapeutic process, it is essential to establish and address transference along with other symptoms of client’s pathological and non-pathological personality traits (Goldstein & Goldberg, 2006).
Like patients, therapists may develop unconscious emotional reactions to their patients as well, which is called countertransference. Initially defined as the therapist’s tendency to perceive a client through the prism of his or her previous relationships, countertransference is an emotional reaction directed from the practitioner towards the client (Sommers-Flanagan & Sommers-Flanagan, 2011). Immediately upon recognizing countertransference, the therapist is obliged to overcome its emotional, behavioral, and attitudinal responses, since their duration, intensity, and frequency are inappropriate in the therapeutic practice. In other words, allowing countertransference means integrating the therapist’s internal resistance and complexes in the treatment process, which is unacceptable in therapy (Sommers-Flanagan & Sommers-Flanagan, 2011). Traditionally perceived as separate and distinct phenomena, transference and countertransference are intertwined and mostly inseparable. As a rule, countertransference is an unconscious reaction of the therapist to the client’s transference (Goldstein & Goldberg, 2006).
In psychotherapy, free association entails a mental process that brings to mind some words and images in response to a certain word or image. This technique is highly beneficial for the therapeutic process, when a patient reports what comes to his or her mind to allow the therapist to interpret individual’s psychological defenses (Corey, 2009). Free association is the central therapeutic technique used to uncover and obtain preconscious material for further therapist’s interpretation as a part of the healing process. The task implies drawing connections between “events at the time of speaking and what us spoken about” (Jarvis, 2004, p. 168).
The final element of the therapeutic process concerns resistance that refers to any interruption of the analytic progress, such as missing communication session, coming late, avoiding discussion of a particular issue, and the like. Typically, patient’s resistance is a result of one’s fear to face the problem. In terms of the therapeutic treatment, resistance requires the therapist to convince the patient to recognize the issue and overcome the tendency of lying to oneself (Goldstein & Goldberg, 2006). To sum up, therapy requires a certain therapeutic distance of a therapist from a client, identification and work with patient’s transference, deterrence and mitigation of practitioner’s countertransference, proactive use of free association technique, and overcome of resistance.
Definitions of Key Terms
Psychotherapy. Sommers-Flanagan and Sommers-Flanagan (2011) defined psychotherapy and counseling as a process, where a specifically trained person “practices application of scientifically derived principles for establishing professional helping relationships with persons who seek assistance in resolving large or small psychological or relational problems. This is accomplished through ethically defined means and involves, in the broadest sense, some form of learning or human development” (n.p.). The key purpose of psychotherapy is to cause a behavioral change by reorganizing mental structures. The process implies the presence of a qualified healer, a sufferer, and a series of structured contacts between the both (Cameron, Ennis, & Deadman, 1998).
Therapeutic process. Therapeutic process is viewed through two domains – as a change process and as a treatment process. The former refers to changes provoked by the therapist-client interactions that occur within a client in the therapy service setting and beyond. Treatment process concerns the overall scope of events occurred during a therapy session as a result of therapist-client encounters. This in-session process implies actions, thoughts, perceptions, feelings, and intentions of a therapist and a client in conjunction with the relationship between the both (Greaves, 2006). Another definition regards therapeutic process as a combination of interpersonal and intrapsychic processes. The former is emotional and relational based on interactions between a therapist and a client. The latter is a planned process aimed at achieving treatment targets (Elzer & Gerlach, 2014).
Psychotherapy components. A client is a person who suffers from emotional or mental problem and seeks assistance and relief in therapy. Psychotherapy professional is a qualified, trained, and socially acceptable healer, whose clinical skills and abilities are sought by a sufferer and his community or social group (Cameron, Ennis, & Deadman, 1998). The third component of the therapeutic process is a series of structured communication sessions between the therapist and the patient through which the therapist managed to force changes in the patient’s emotional state, behavior, and attitudes. Thus, words, rituals, and acts constitute the core of the treatment process (Cameron, Ennis, & Deadman, 1998).
Psychotherapy boundaries. Boundaries are a set of regulations that predefine parameters of the therapist-client relationship, aligning therapy expectations with standards of professional conduct. Framing the overall therapeutic process, boundaries ascribe roles to its participants. Determining acceptable therapeutic actions in reference to treatment expectations, boundaries draw a line between interactions appropriate in the therapeutic process and those considered inappropriate (Sommers-Flanagan & Sommers-Flanagan, 2011). Boundaries are crucial for the therapist-client relationship, since they facilitate a sense of safety, trust, and confidence in patients (Barnett & Hynes, 2015). Boundaries regulate two domains of the therapeutic process – logistical (time, location, fee, and privacy policy arrangements) and conceptual (clothing, self-disclosure, language, gifts, non-sexual physical contact, and proximity) (Zur, 2015).
Boundary violations. These are “a departure from accepted practice that places the client or the therapeutic process at serious risk” (Smith & Fitzpatrick, 1995, p. 500). Boundary violations refer to cases of professional ethics’ breaches that involve client exploitation, harm, or sexual intercourse. Boundary violation may be a rapid act of offensive treatment or a consequence of long-term deepening of the relationship between a therapist and a client (Sommers-Flanagan & Sommers-Flanagan, 2011). Boundary violations are immediately associated with harm, evoking in clients a sense of betrayal, confusion, and exploitation, which discourages one’s participation in the treatment process and causes serious damage to well-being and mental state. Boundary violations are strictly prohibited as posing a threat to the profession as a whole (Barnett & Hynes, 2015).
Boundary crossing. It is a withdrawal “from commonly accepted clinical practice that may or may not benefit the client” (Smith & Fitzpatrick, 1995, p. 500). In essence, boundary crossing implies a non-violent harmless departure from the established boundaries motivated by the therapist’s intention to facilitate treatment. Non-exploitative boundary crossing executed in the pursuit of treatment needs is likely to support the therapeutic process and meet treatment expectations (Barnett & Hynes, 2015). There is no clear prohibition of boundary crossing in the Code of Ethics, which nourishes the long-standing dilemma of their acceptance in certain situational context in favor of therapeutic needs.
Dual relationship. It is a kind of boundary crossing and refers to cases when either a therapist, a client, or both initiate another relationship in addition to the therapeutic one. This secondary relationship may take form of an employer-employee, a teacher-student, or a friendship one. Additional connections between a therapist and a client are regarded as dual relationship whenever they occur – prior, during, or after therapy (Burgard, 2013). Though mostly associated with business or professional encounters, dual relationship includes sexual contacts as well. The industry standards of ethics permit cultivation of dual relationship if they are unavoidable, treatment supporting, and harmless. However, dual relationship may damage client’s mental state and well-being, destroying the sense of autonomy and confidence, while evoking a sense of exploitation and abuse (Wright & Cummings, 2013).
Harm to psychotherapy client. Boundaries in therapy serve to define accepted behavioral patterns and kinds of interactions between a therapist and a client for the purpose of treatment success. Any boundary violation, even minor crossing, may do harm to a patient. Instead of a relief from the suffered emotional or mental problem, a patient gets confused, feeling betrayal and losing confidence in therapy (Wright & Cummings, 2013). In case of serious boundary violation, a patient experiences anxiety, depression, cognitive dysfunction, guilt, sexual confusion, and even suicidal inclinations (Loue, 2015).
Preview of Literature
Being a relationship-based process, psychotherapy needs rules, establishing standards for this relationship to make it acceptable and successful for both a professional and a client. Boundaries constitute the agreement on regulations and expectations to shape the therapist-client relationship. Hence, boundaries are a frame for the therapeutic process, defining certain roles for its participants (Barnett & Hynes, 2015). Moreover, Smith and Fitzpatrick (1995) ascertained that boundaries laid the ground for the therapist-client relationship though facilitating a sense of safety and trust between participants complemented by a belief in the clinician’s performance always in favor of the client’s best interest (in Barnett & Hynes, 2015).
Developed in the account for expectations and acceptable actions, boundaries in therapy produce a “distinction between the expectations and interactions that would be considered appropriate within the relationship and those that would be considered inappropriate within the relationship” (Sommers-Flanagan, Elliot, & Sommers-Flanagan, 1998, p. 38). In general, boundaries in therapy address two dimensions of the clinician-client relationship – administrative aspects and ethical standards. The first sort of boundaries regulates issues of session’s time and place, fees, and privacy or confidentiality policy. The second sort of boundaries concerns elements of the relationships between a professional and a client, such as language, clothing, gifts giving and receiving, self-disclosure, non-sexual physical contact, and proximity between two parties (Zur, 2015).
Though each clinician has to accept and adhere to the established industry boundaries, when entering psychotherapy, avoidance, violation, or crossing of boundaries is a frequent case. Any departure from boundaries in therapy is associated with a high risk of harm for a client. For instance, it is inappropriate for the profession and moreover, unbeneficial for the treatment success, if a clinician uses touch with a person overcoming a sexual trauma or assault (Barnett & Hynes, 2015). There are two kinds of the boundaries’ withdrawal in psychotherapy – boundary crossing and boundary violation. While boundary violations are “a departure from accepted practice that places the client or the therapeutic process at serious risk”, boundary crossing refers to “departures from commonly accepted clinical practice that may or may not benefit the client” (Smith & Fitzpatrick, 1995, p. 500).
Given the evidence above, boundary violations are harmful for clients, evoking a sense of being exploited and betrayed. Instead of building and developing trustworthy relationship with a client and providing him or her with emotional support, a psychotherapist exercising boundary violations confuses a client and discourages engagement in the treatment process (Zur, 2015). Boundary crossings, taking place in a non-harmful and non-exploitative manner, produce a sense of consistency with treatment needs. As a rule, boundary crossing serves in support of the therapeutic process to foster achievement of treatment goals (Barnett & Hynes, 2015). Therefore, boundary violations are subject to unified prohibition, while boundary crossing is an omnipresent dilemma.
Boundaries in psychotherapy were developed and adopted to establish a guideline for practitioners in framing treatment sessions and building professional relationships with clients. However, contextual parameters of a particular situation may require boundary crossing to facilitate treatment progress. Prior to making thoughtful decisions concerning boundaries, it is crucial for a clinician to identify and assess a number of factors to ensure prevention of any harm to a client (Barnett & Hynes, 2015). In terms of contextual perspective on ethical decision-making, psychotherapy needs address of four main aspects, such as client, therapy setting, therapy process, and a practitioner (Zur, 2015). The major client factor concerns his or her clinical history that describes the type, nature, and extent of trauma, including indication of physical and/or sexual abuse (Smith, 2008). It is essential to evaluate client’s presentation of a problem, mental state, mental disturbance severity, personality type, personality disorder, sexual orientation, prior therapy experience, and physical health. In addition, the overall scope of client-related factors covers age and gender, socio-economic status, social support, cultural background, religious beliefs, and spiritual practices (Zur, 2015).
Similar to client factors, the spectrum of setting parameters affecting the therapeutic process and treatment progress is extensive. Main setting factors seek a distinction between inpatient and outpatient, individual sessions and group practice, and the presence or proximity of other professionals or clinical staff in therapy (O’Connor & Ammen, 2012). Various setting characteristics also influence the treatment plan and success, ranging between medical building office, home office, and private setting; hospital-based clinic and free-standing one; and publicly owned hospital and a private clinic. Locality features contribute to the therapeutic context as well (O’Connor & Ammen, 2012). Practitioners point out a fundamental difference between service and ethical standards in large metropolitan area in contrast to low-scale communities, rural towns, and Indian reservations. Another inconsistency concerns university counseling centers opposed to poor neighborhood and suburban settings. Besides, context of urban settings contrasts remote settings of a military base, police department, or prison (Zur, 2015).
Therapy factors are another relevant point of consideration for clinician’s ethical decision-making. They include two major categories of factors, such as therapeutic features and therapeutic relationship elements. Therapeutic factors address aspects of therapy modality, intensity, population, and theoretical orientation. Modality aspect implies difference between individual sessions, couple counseling, family practice, and group meetings. Besides, it indicates therapy duration, such as short-term, longitudinal, or intermittent long-term treatment (O’Connor & Ammen, 2012). Therapy intensity refers to the frequency of professional-client sessions like monthly consultations or regular weekly meetings. The aspect of population emphasizes therapy differences related to client’s age – a child, adolescent, or adult. In compliance with the trauma experiences, therapy applies various approaches, such as psychoanalysis, group therapy, eclectic therapy, humanistic therapy, or body psychotherapy (Zur, 2015).
Therapeutic relationship factors encompass nature, quality, length, period, kind, out-of-the-office interactions, and other aspects of the therapeutic alliance. The expected therapeutic relationship should be a secure, safe, trusting, fearless, and well-planned connection (O’Connor & Ammen, 2012). An effective therapeutic alliance is intense and involved in comparison to neutral or casual interactions that produce little effect on client’s treatment. Other parameters of the therapeutic connection comprise new and longitudinal relationships, newly started, experienced, or those going toward termination (O’Connor & Ammen, 2012).
The kind of therapeutic relationships may be either professional and transferencial or egalitarian and familiar. Besides, the place of clinician-client interactions – only in the office, community familiarity, and distanced relations – produces an impact on the outcome (O’Connor & Ammen, 2012). Finally, the list of therapist factors comprises age, gender, cultural background, sexual orientation, and practical scope achieved through training and experience (Zur, 2015). Therefore, the meaning of boundaries along with the appropriateness of departure from them needs a thorough analysis of the multidimensional context of therapy. Boundary crossing executed on the ground of such a contextual evaluation is not the only possible kind of boundary deviation; dual relationships are another frequent case.
In order to clarify kinds of interactions between therapists and clients applicable to therapy to foster achievement of treatment goals, it is crucial to analyze them in detail. The list of non-sexual connections encompasses social, professional, special treatment-professional, business, communal, institutional, forensic, digital/online/internet, and supervisory (Zur, 2015). A social dual relationship refers to cultivation of a friendship or another type of social communication between a therapist and a client. This kind of additional interactions may take place both in person and online through various social media channels, such as Facebook, Twitter, blogs, chats, and so on (Weiner & Craighead, 2010).
In this vein, social media and digital communication between a therapist and a client also fall under the domain of dual relationships. It is reasonable to point out that online communication through professional networking sites like LinkedIn or Facebook may be professional and within therapy boundaries (Zur, 2015). A professional dual relationship is another popular type of the matter and refers to situations when therapy participants collaborate in the professional field like colleagues in institutions, students in training courses, co-authors of scientific publications, or presenters in professional meetings and conferences (Zur, 2015).
A special treatment-professional dual relationship is when a therapist provides some extra services in health care in addition to psychotherapy and counseling. Examples may include dietary consultation, nutrition planning, or progressive muscle relaxation (Zur, 2015). A business dual relationship takes place when therapy parties have also an employer-employee connection or are business partners (Doverspike, 2008). A communal dual relationship concerns situations when a therapist and a client share locational belongings. For instance, they live in the same community, visit the same shops, or attend the same church. As a rule, communal relationships are characteristic to small communities that lack a variety of psychotherapy services (Burgard, 2013).
An institutional dual relationship may occur in specific settings, such as military, police departments, prisons, and mental hospitals, where it is inherent for an institutional setting. For instance, some detection facilities and state hospitals assign dual duties to clinicians – to perform functions of therapists and evaluators simultaneously or sequentially (Zur, 2015). Similar to institutional dual relationships, forensic interactions are subject to clinicians who practice witnessing at trials and court hearings along with exercising therapeutic counseling (Doverspike, 2008). Furthermore, a treating clinician might manage supervisory functions as well, overseeing responsibilities, performance, and treatment plans for other professionals. As a result, a therapist supervisor is associated with professional relationship not only with subordinate colleagues, but also with supervisee’s clients (Zur, 2015).
Given above, there is a wide array of roles for a professional to take up in the therapeutic process. While some dual relationships are cultivated intentionally to contribute to the treatment progress, others develop due to unforeseen factors. Accordingly, dual relationships may be avoidable, unavoidable, unexpected, and mandated. Avoidable interactions are possible in metropolitan areas and large cities, where there is enough space for a clinician and a client not to cross (Weiner & Craighead, 2010). In contrast, unavoidable dual relationships occur in rural areas and small communities that are limited in space and psychotherapist services (Burgard, 2013).
Mandated dual relationships are subject to institutional and forensic connections exercised in prisons, jails, military, and police settings. Finally, unexpected dual relationships refer to any kind of interactions between a client and a therapist occurred unintentionally. Examples include cases when a professional is initially unaware of locational, professional, or relative belongings with a client (Zur, 2015). Another parameter for dual relationships implies the level of parties’ involvement, ranging from minimal to intense. Hence, occasional encounters are hardly associated with dual relationships, while regular socialization, cooperation, or services are a subject for ethical consideration in therapy (Zur, 2015).
Preview of Methodology
As outlined above, this research inquiry seeks to investigate the APA’s provisions for ethical conduct, establishing boundaries for the therapist-client relationship to identify appropriateness of cultivating dual relationship in therapy. The study intends to provide evidence to the comprehensiveness of boundaries that admits cases of harmless and beneficial or unavoidable boundary crossings. Thus, this research aims at proving that therapist decision-making in a particular clinical situation should rely entirely on boundary provisions to eliminate possible harm to clients, lawsuits against therapists, and discrimination of the profession at large. The task requires a thorough literature review to determine some themes for their later testing through personal experiences of therapy participants.
In accordance with the industry’s privacy and confidentiality policies, patient-related data is not subject to public disclosure. In account for privacy and confidentiality, it seems challenging and highly impossible to reach clients of psychotherapy and counseling and receive their perceptions of industry boundaries and boundary crossings. Hence, the issue should be clarified through ideas, attitudes, and positions of another participant of the therapeutic process – therapists. Through engaging treating clinicians, the researcher expects to produce a general picture of boundaries’ perception and to discover justifications and rationales underlining boundary crossings and dual relationship initiated by therapists. The researcher has decided to recruit 15 therapy professionals for personal interviews,
In order to acquire personal experiences and perceptions of therapist in relation to boundary crossings and development of dual relationship, this study deploys qualitative methodology to interview the study participants. The naturalistic and interpretive nature of qualitative research design fit the current research purpose. As a situation-focused activity, placing the researcher within the observed context, qualitative research methodology encompasses a range of interpretive strategies and techniques to investigate the reality through human observations, perceptions, and experiences (Merriam & Tisdell, 2015). A diversity of research practices available for qualitative researchers allows depicting, decoding, translating, and representing a studied phenomenon. Thus, the researcher is an integral part of the research process, which enables him or her to identify and interpret social meanings produced by people throughout their experiences with various world’s phenomena. To sum up, qualitative research is dedicated to the meaning generation through gaining an in-depth understanding of a situation, while analyzing different people’s perceptions, ideas, and attitudes towards the examined phenomenon (Anzul et al., 2003).
For the present study, qualitative research methodology is suitable and beneficial for providing answers to the formulated research questions. It is fundamental for fulfilling the posed research goal to reveal therapists’ rationalizations underpinning their initiations of dual relationship or minor boundary crossings. Serving as a direct instrument of data collection, the researcher executes a series of communication sessions with therapists to identify their views on the issue of boundary maintenance. A precise literature review enables the researcher to design an interview guide, addressing most relevant issues that affect clinicians’ decision-making about adhering or going beyond therapeutic boundaries. Therefore, the study intends to generate a shared understanding that the existing boundaries already prescribe situations for possible boundary crossings and dual relationship’s development, recognizing that these departures from boundaries in favor of the treatment process are meaningful, ethical, and appropriate.
Significance of the Study
The contemporary industry of psychotherapy and counseling lacks consensus on whether therapeutic boundaries should be maintained to the maximum or boundary crossing and dual relationship are eligible for cultivation in certain situational contexts, where they serve in interest of the treatment plan. This psychotherapy dilemma is of a high value, since the practiced provisions of the APA’s Code of Ethics neither clarifies when exactly multiple relationships may be developed, nor prohibits them entirely. In terms of the current social and industry changes with an expanded range of therapy deliverers, an appropriateness of boundary crossing is of an increasing tendency. Emphasizing its non-exploitative, non-sexual nature, many therapists advocate cultivation of dual relationship as a valuable instrument in strengthening cooperation between a therapist and a client and increasing participation of the latter in the treatment process. Focused on treatment outcomes, these therapists regard dual relationship as ethical, legitimate, and acceptable.
However, proponents of absolutist ethics, attorneys, and boards of psychotherapy and counseling organizations argue for the importance of following the established boundaries with no exceptions made. In addition to reasons of client-expected harm and exploitation, they emphasize a high risk of malpractice suits issued against therapists by patients who have experienced boundary crossing or violations. An increased amount of lawsuits spoils the public image of the profession, posing the discipline’s existence at stake. Hence, arguments for and against boundary crossing and dual relationships are solid and reasonable. The present study aimed at examining the issue from multiple dimensions is expected to provide an insight and contribute to the existing body of knowledge through synthesizing prior empirical evidence and narrow-focused findings of the current primary research.
Besides, this study is likely to produce implications for the therapeutic practice by giving a guideline for therapists in making decisions concerning boundary crossings and dual relationship’s development. Indeed, the study points out the entire scope of risks for clients, therapists, and practice posed by even a minor boundary crossing. In particular, this inquiry analyses, whether industry boundaries influence therapist’s ethical reasoning in comparing potential treatment benefits and threats to client’s well-being and mental health. Without manipulating the practiced ethical principles, the study illustrates that the required risk management for any boundary crossing should be integrated in the APA’s Code of Ethics framework. In respect for the existing ethical guidelines, the study seeks to facilitate policymaking by outlining the necessary amendments to ensure efficient protection of clients and therapists in terms of boundary crossings and dual relationship.
Limitations of the Study
Though the selected qualitative research methodology favors achievement of the established research objectives, it produced some methodological limitations as well. The major critical point of the chosen research design concerns high subjectivity of the research product. In qualitative studies, the researcher serves as a direct instrument of data collection, which is beneficial in terms of the human-instrument ability to adjust to changing situational contexts to acquire the maximum of the required data (Klenke, 2008). However, this characteristic implies a heavy impact of the researcher’s identity on data collection and analysis procedures. As a result, the researcher’s subjective perception and interpretation of the observed reality lead to a highly descriptive research product (Merriam & Tisdell, 2015).
This limitation poses a threat to generalization of findings and their applicability to other similar populations and settings. One more limitation refers to a small sample size of research participants (Munhall & Chenail, 2008). The selected number of 15 therapists is not representative for the overall US population of psychotherapy and counseling professionals. In the context of the present study, these shortages of qualitative research methodology do not diminish the value of findings because of the taken precaution measures. First, the researcher develops an interview guide for the data collection orientation based on a thorough review of prior research findings and other academic publications concerning the current research subject. Second, this study does not seek to simply discover, whether therapists support or oppose development of dual relationships through a nation-wide survey. Instead, it is dedicated to identify rationalization of boundary crossings and dual relationship’s cultivation to determine, whether boundaries address these cases.
Another delimitation technique concerns this research’s orientation on meeting trustworthiness criteria for credibility, dependability, and transferability of study findings. Research credibility represents the overall study quality through accurate data collection, interpretation, and presentation (Klenke, 2008). This research employs a holistic approach to data collection and processing through reviewing the existing body of scholarly literature to create an interview guide, recording both verbal and non-verbal information provided during personal interviews with therapists, and triangulating all obtained data. Research transferability refers to applicability of achieved research findings to other populations, settings, and contexts (Klenke, 2008). The designed interview guide may be utilized in other qualitative studies in the field of psychotherapy and its ethical guidelines. Finally, research dependability implies the ability of others to achieve the same results in the studied reality (Klenke, 2008). Building conclusions on the ground of an in-depth literature review and therapists’ personal ideas and experiences, data collation and analysis procedures are duplicable for other researchers. Therefore, this research meets credibility, transferability, and dependability criteria, which ensures trustworthiness of its findings.
Summary
This chapter introduces the current research focus and provides a rationale for the intended inquiry. Though the professional psychotherapist ethics sets up clear boundaries on keeping the client-professional relationship in alignment with the therapy goals, the issue of boundary crossing and violations is frequent. The most typical case of boundary crossing concern dual relationship developed by any party either intentionally or not in support of the treatment process. The APA’s Code of Ethics encourages maintaining boundaries, though allowing non-offensive, non-exploitative boundary crossings in some case. The lack of clarity on this question nourishes the long-standing debate about scholars and therapists on the appropriateness of boundary crossings. This chapter establishes background to the research problem to proceed with research statement that provides a logical reasoning to the present research purpose and questions formulated to guide the overall research process. Then, the chapter introduces the key concepts and defines terms relevant for the current research subject. Next, it provides a brief overview of literature and discusses methodological aspects concerned during the research planning. Further on, the chapter outlines the expected significance of the study and limitation inherent to the selected methodology and design.
CHAPTER II: LITERATURE REVIEW
Introduction
This chapter is a detailed literature review concerning the issue of boundaries adopted in the therapeutic practice and the need for their maintenance. Therapy implies regular and productive interactions between a practitioner and a patient to foster the treatment progress and to achieve treatment goals. Dependent on human nature, behavior, and communication, the therapeutic process is subject to multiple contextual factors shaping it (Zur, 2015). This essence of the therapeutic practice frequently leads the development of additional relationships between a therapist and a patient, in addition to the professional one, or other boundary crossings. There is no consensus between scholars and practitioners on whether a non-offensive violation of therapeutic boundaries is acceptable. In addition, the ethical guideline of the American Psychological Association (APA) allows harmless boundary crossing if no other prohibitions exist (APA, 2010). The state of affairs poses a dilemma whether it is crucial to maintain and adhere to therapeutic boundaries strictly.
In the pursuit of proving the value of boundaries, this literature review is dedicated to investigating the aspect of boundaries in therapy to shed light onto its role and purpose. In addition, the chapter reviews various contextual factors cited by some scholars in support of boundaries’ violation and distinguishes different types of withdrawals from the professional ethics. Further on, the chapter points out the importance of maintaining boundaries in therapy through citing studies that demonstrate negative outcomes of boundary crossing along with legal advice that underlines a protective nature of boundaries. The overall literature review process utilizes a number of studies to provide evidence to each point covered in conjunction with academic publications and professional guidelines to set up a general overview first.
Boundaries in Therapy
The Purpose and Role of Therapy
The nature and purpose of therapy. According to the broad APA definition of psychotherapy, its role is to assist people in leading happier, more productive, and healthier lives through combating their emotional, mental, and social problems (APA, 2016). The scope is diverse to include emotional distress evoked by coping with work issues, senior illness, smoking cessation, or weight loss, mental disorders accompanied by depression and anxiety, and stress and emotional discomfort from relationship troubles, substance abuse, or loss of a beloved one. Psychotherapy implies a variety of approaches and techniques aimed to facilitate patient’s coping with the problem experienced (APA, 2016).
Craighead and Craighead (2001) claimed that the modern psychotherapy had switched its focus from a long-term to a short-term perspective to improve treatment of specific mental disorders. Their clinical study revealed psychotherapy efficiency in coping with major psychiatric disorders through different treatment sessions between a therapist and a patient. The study of Lauder et al. (2010) investigated and proved a positive impact of psychological interventions on the bipolar disorder treatment. In addition, this critical review inquiry pointed out that trustworthy communication between a patient and a professional was productive in both educational and treatment domains. Psychotherapy facilitates patient’s understanding of the disorder and adherence to the designed treatment framework and medication intake. The clinical trial study of Benjamin (2010) revealed efficacy of psychotherapy in addressing mental and emotional problems, arising in cancer patients.
Therefore, the therapeutic practice is a collaborative treatment process, relying on the relationship between a patient and a practitioner. It implies a neutral, objective, and non-judgmental performance of the latter to encourage the former for an open dialogue (Barnett & Hynes, 2015). In his qualitative analysis, Gordon (2000) emphasized two approaches to defining psychotherapy. The perspective of Holmes and Lindley (1989) explained the relationship between a patient and a therapist as a way of producing changes in patient’s “cognition, feeling, and behavior”; and the view of Smail (1987) described psychotherapy as a situation, creating an opportunity for patients to learnt the truth about themselves (Gordin, 2000, n.p.). Hence, psychotherapy relies on three elements, such as a professional with recognized expertise, an individual or a group, suffering from a mental or emotional problem, and a structured relationship between the two dedicated to healing (Frank & Frank, 1991).
Components of therapeutic relationship. Regardless of the kind of therapy, scholars and practitioners distinguish four crucial elements of the therapeutic relationship. The list includes trust, respect, power, and personal closeness (Greenhalgh & Health, 2010; College of Psychotherapists of Ontario, 2013). The issue of power concerns the inherent imbalance between a therapist and a patient in the therapeutic relationship. Because of the acquired professional knowledge and accumulated skills, psychotherapists possess authority within the healthcare system, while patient’s care and treatment achievements depend on that expertise (Pope & Vasquez, 2009; College of Psychotherapists of Ontario, 2013). A privileged access to information and the priority in making decisions about patient’s care may evoke a sense of vulnerability and distress associated with the entire treatment’s dependence on the psychotherapist’s expertise (Morgan, 2008; Norton, 2010). Thus, the primary responsibility of a psychotherapist is to use his or her authority and power to facilitate the treatment progress. In addition, a practitioner is expected to create a comfortable environment for a patient to feel safe and free to negotiate the treatment plan and ask questions (Pope & Vasquez, 2009; Sanderson, 2009).
The notion of respect implies the practitioner’s understanding and appreciation of personal characteristics, such as age, gender, socio-cultural background, sexual orientation, and marital status (College of Psychotherapists of Ontario, 2013). Other characteristics include economic status, physical condition, political, religious, and spiritual beliefs, education, and ethnic background (Pope & Vasquez, 2009; Norton, 2010). Thus, psychotherapists are responsible for acting in a respectful way to encourage their patients’ participation in the therapeutic process (Morgan, 2008; Sanderson, 2009).
The aspect of trust refers to the patient’s belief in therapist’s knowledge, expertise, and skills to provide a quality care, acting in patient’s best interests and avoiding power abuse and patient’s exploitation (Pope & Vasquez, 2007). In fact, patient’s vulnerability is inherent in the therapeutic practice, since patients share their personal, physical, and emotional experiences with practitioners in order to receive assistance in coping with the existing problems. In this vein, psychotherapists are responsible for avoiding any exploitation or harm doing to patients (College of Psychotherapists of Ontario, 2013; Sanderson, 2009). Trust is crucial for a productive therapeutic process; once breached, it is hard to re-establish it (Morgan, 2008; Pope & Vasquez, 2009; Norton, 2010).
Finally, the concept of personal closeness has nothing common with sexual intimacy. It entails physical and emotional closeness to a patient exercised as a part of the therapeutic process (Greenhalgh & Health, 2010; College of Psychotherapists of Ontario, 2013). These elements of psychological, emotional, and physical closeness are necessary to fill gaps in patient’s daily interactions with society. However, it is critical to point out that this therapeutic closeness differs from the one of sexual, romantic, and social relationships (Morgan, 2008; Norton, 2010). In therapy, closeness may take place in psychical proximity, disclosure of highly sensitive personal data, diverse degrees of undress, and manifestation of strong emotions. When cultivating closeness during the treatment process, psychotherapists should be very careful in carrying it out, ensuring patient’s consent, respecting patient’s autonomy, and avoiding feelings of vulnerability (Pope & Vasquez, 2009; Norton, 2010; College of Psychotherapists of Ontario, 2013).
Industry Standards and Ethics
APA code of conduct. The notion of respect implies the practitioner’s understanding and appreciation of personal characteristics, such as age, gender, socio-cultural background, sexual orientation, and marital status (College of Psychotherapists of Ontario, 2013). Other characteristics include economic status, physical condition, political, religious, and spiritual beliefs, education, and ethnic background (Pope & Vasquez, 2009; Norton, 2010). Thus, psychotherapists are responsible for acting in a respectful way to encourage their patients’ participation in the therapeutic process (Morgan, 2008; Sanderson, 2009). In the pursuit of its healing objective, psychotherapy needs standards and ethical guidelines to shape the relationship between a professional and a client. As a relationship-based process, therapy requires a clear framework to make interactions acceptable and successful (Barnett & Hynes, 2015). The key source of ethical principles, governing the therapeutic practice, is the APA’s Code of Conduct enacted in 2003 (APA, 2010). The APA’s ethical guideline sets up standards for the entire practice to ensure professional conduct of practitioners along with positive and desired outcomes for clients. The document clarifies cases of psychological assistance provided to individuals, families, and groups.
In underlining principles for human relations, the Code of Conduct prohibits unfair discrimination, sexual harassment, and other harassment and harm activities in relation to patients (APA, 2010). In terms of unfair discrimination, psychologists are to provide equal treatment and care to patients of different age, gender, ethnicity, race, sexual orientation, and any other personal characteristic. Under the term “sexual harassment”, APA (2010) means any physical, verbal or non-verbal behavior pattern that is sexual in nature and is performed by a psychologist during therapy.
Practitioners are accused of sexual harassment when their sexual solicitation is unwelcome, offensive, or produces harm to a patient and when their conduct with sexual coloring addresses an individual, suffering from a similar abuse. Sexual harassment may occur as a single intense or multiple acts (APA, 2010). In addition, the key ethical guidelines for psychotherapy alert practitioners about an unintentional engagement in conduct that is harassing or demeaning to clients. Such unknowingly harassment may take place because of the psychologist’s unawareness of patient’s personal characteristics. Therefore, the code of ethics suggests psychologists to foresee and avoid any potential harm to patients and other people they work with (APA, 2010).
In line with harmless psychotherapeutic service, psychotherapists are responsible for treating and respecting individuals regardless of their age, gender, sexual orientation, cultural, social, physical, spiritual, educational, economic, moral, ethical, environmental, ethnic, and political background (Zur, 2015). These requirements are essential due to practitioner’s authoritative position in the therapeutic process and awareness of patient’s information concerning one’s personal history, unique circumstances, emotional state, and mental health status. For an example , psychotherapists are accountable to avoid any conscious or unconscious power abuse reflected in behavior patterns, offensive for patients (Pope, 1990).
The accepted principles of ethical conduct in psychotherapy are general, which evokes a belief in their inability to cover all aspects of the therapeutic practice. Zur (2015) claimed that that relationship-based practice needed to deal with complex issues and contributing factors quite often. The task requires a thorough reasoning based on the code of ethics and morals. In his explanatory study, Rowson (2001) argued psychotherapy lacked a clear distinction between concepts of ethics and morals. The scholar recognized ethics as an industry-focused science of professional duty and morality, viewing morals as a system of individual values. Though notions of values and ethics are used interchangeably, Rowson (2001) emphasized the importance of differentiating them, since a practitioner made decisions in compliance with professional ethical principles and one’s personal judgment.
Deontological and utilitarian perspectives on professional ethics. In fact, the practice faces constant moral dilemmas, the resolution of which uses either deontological or utilitarian moral reasoning. Scholars and practitioners used these two contradictory approaches to therapy ethics to deal with complex issues raised by the relationship between a professional and a client. The qualitative analytical study of Conway (2013) found that deontological ethics based on the premise that any harm is acceptable for therapy provides an effective reaction to harm. In the decision-making process, deontological reasoning allows preventing or avoiding practitioner’s engagement in atypical behavior patterns.
In her analysis of demonological and utilitarian principles, shaping ethical decisions in psychotherapy, Dewane (2010) pointed out the absolutist position of deontology, prohibiting any withdrawal from ethical guidelines adopted. Thus, deontologists give a clear distinction what is ethically right and wrong in therapy, which determines the moral course for any practitioner’s action. Utilitarianism accepts a withdrawal of established ethical standards as a part of the treatment process, where expected outcomes prevail. In reference to utilitarian ethics, Conway (2013) found the parameter efficient in evaluating outcomes, which was consistent with its core theme of the harm acceptability if its outcomes overweighed the damage caused. These findings echoed the view of Dewane (2010), emphasizing flexibility of utilitarian ethics that makes decisions in relation to personal, subjective, and situational moral standards. Strengths and gaps of two approaches to therapeutic ethics. As indicated above, therapy relies on building up a dialogue between a therapist and a client. The task implies client’s openness and trust towards a professional to share one’s feelings, experiences, and grievances. Each therapeutic case is unique, requiring a precise evaluation of a particular client and situation. In his analytical study, Zur (2015) asserted that decision-making in psychotherapy needed flexibility and consideration of specific factors and circumstances. The position is similar to the one of Miller (2007) who claimed ethical reasoning entailed involvement in “authentic decision-making means deliberating about a number of options in a contentious practice situation, each option having both negative and positive elements” (p. 28).
The position fits the ethics of the care psychological construct that regards therapeutic decision-making as grounded on the core humanity capacity to provide care to people in need or vulnerable. As pointed out by Bloch and Green (2005), the ethics of care reasoning is sensitive to moral emotions, such as friendship, compassion, trustworthiness, and love. Thus, the interpersonal dimension of morality determines individual’s psychological morals and ethics. Such reasoning abilities are fundamental for thorough ethical decisions made upon practitioner’s situational evaluations, judgments, and rationales (Miller, 2007).
To sum up, deontological ethics establishes rigid moral rules reflected in ethical standards for practice, hierarchy of duties and responsibilities, adopted codes of ethics, and other professional guidelines (Playford, Roberts, & Playford, 2014; Bartels et al., 2016). Focused on the cost-benefit analysis, utilitarian ethics seeks to find the most successful and valuable solution for a client through practicing ethical problem solving, situational evaluations, and harm assessment (Bloch & Green, 2005; Dewane, 2010; Playford, Roberts, & Playford, 2014). Therefore, the established code of ethics for psychotherapy is the main resource of ethical principles. Adopted and practiced by the community of psychotherapists, the code facilitates development of professional norms and morals, identifying boundaries for the practitioner-client relationship.
Role of Boundaries
Definition and understanding of boundaries. Boundaries in psychotherapy refer to standards of the relationship between a professional and a client. These relationship standards reflect ethical principles of the practice and seek meeting client expectations. As defined by therapy practitioners Barnett and Hynes (2015), boundaries create a frame for therapeutic sessions, predefining the structure and roles for its participants. Smith and Fitzpatrick (1995), recognized psychotherapy boundaries as “a foundation for this [client-therapist] relationship by fostering a sense of safety and the belief that the clinician will always act in the client’s best interest” (in Barnett & Hynes, 2015, n.p.). Bridges (1999) also underlined the securing role of boundaries, enabling a professional to identify and evaluate patient symptomatology and to exercise symbolic communications. In addition, the scholar pointed out boundaries created a structure for patient-therapist interactions.
According to Sommers-Flanagan, Elliot, and Sommers-Flanagan (1998), boundaries are responsible for establishing a “distinction between the expectation and interactions that would be considered appropriate within the relationship and those that would be considered inappropriate within the relationship” to determine acceptable behaviors and to meet therapeutic expectations (in Barnett & Hynes, 2015, n.p.). The APA Code of Conduct claims its intention to provide standards for psychologists’ behavior in most situations encountered. Its primary goal is to ensure adequate treatment and protection of individuals and groups collaborating with psychologists. In addition to its provisions, the APA code suggests consideration of specific board regulations and applicable laws in therapy decision-making (APA, 2010). Hence, APA-established ethical principles create the core for separate organizational policies and laws to determine the scope of boundaries, shaping the client-practitioner relationship in a specific therapeutic setting.
Types and roles of therapeutic boundaries. The current boundaries that define what behavior lines should be crossed neither by a clinician nor by a client are in the power since the 1990s. Until then, therapists lacked a clear guideline for professional conduct in multiple therapy situations and conditions (Totton, 2010). Today, boundaries in therapy fall within two domains of the therapist-client relationship – conceptual (ethical principles) and logistical ones (Simon, 1992; Johnston & Farber, 1996). Logistical boundaries refer to the following therapeutic aspects: time and location of a therapy session, fees, and the adopted privacy and confidentiality policy. Conceptual boundaries concern dimensions of the relationship between a professional and a client, such as language, clothing, gifts giving and receiving, self-disclosure, non-sexual physical contact, and proximity between two parties (Zur, 2015).
Advocates of therapeutic boundaries underline their role in protecting the practice from the practitioner’s abuse of power and authority. It is a modern argument that any withdrawal from the established therapy framework, including the use of first names, is likely to lead to a sexual abuse (Totton, 2010). In fact, the pioneer of psychotherapy, Sigmund Freud, recommended young therapists to adhere to professional communication boundaries for their convenience and benefit, rather than for the patient’s protection.
“The psycho-analyst who is asked to undertake the treatment of the wife or child of a friend must be prepared for it to cost him that friendship, no matter what the outcome of the treatment may be: nevertheless, he must make the sacrifice if he cannot find a trustworthy substitute” (in Totton, 2010, n.p.).
Cases from therapeutic practice illustrating the role of boundaries. The boundary provisions discussed above are standard for the therapeutic practice, but have their exceptions as well. Bridges (1999) analyzed several cases when personal lives of a patient and a therapist overlapped to demonstrate that boundary dispositions are not only rules, but also a dynamic framework to solve boundary dilemmas. Bridges (1999) cited a case of Sam who appeared to belong to the same congregation as his therapist. The discovery and boundaries-oriented discussion revealed the need to cease this common relation to facilitate the treatment process. The therapist offered Sam a choice – either to continue attending the same church as the therapist did and terminate therapy or to seek another congregation. Initially perceived with anger and frustration, the therapist decision was beneficial with further continuation of the therapeutic process and new achievements.
The case cited by Bridges (1999) is excellent to demonstrate how boundaries work to assist therapists in making ethical decisions and acting the patient’s best interest. In fact, a prohibition against mutual church attendance is not ultimate for all clinical case. In rural areas, it is almost impossible to avoid overlaps of professional and personal activities. As revealed by Pope and Vasquez (2011), small communities lack psychotherapeutic resources to ensure the entire segregation between personal and professional lives of therapists. Being frequently the only available source of help, practitioners have to work with their neighbors, acquaintances, and even relatives. However, in large metropolitan areas, it is beneficial to segregate these life domains to keep privacy of both a therapist and a patient (Bridges, 1999).
Though arguments for minor boundary deviations seem rational, a strict adherence to boundaries is more desired and beneficial for the practice. Simon (1992) claimed that boundaries were the key means of maintaining integrity of the therapeutic process. In particular, boundaries allow maintaining psychotherapist’s neutrality and patient’s psychological separateness. In addition, boundaries protect patient’s confidentiality, facilitate patient’s informed consent for care plan and treatment procedures, and ensure no earlier, current, or further relationship with a patient. They assist psychotherapists in verbal interactions with patients, reduction of physical contact, and preservation of practitioner’s anonymity. In terms of logistics, boundaries are an asset in defining session time and length, setting up a fee policy, and creating professional, private, and consistent setting (Simon, 1992).
Violations of Boundaries in Therapy
Contextual Factors
Conditions favoring boundary violations. Though the APA’s Code of Conduct claims to equip psychotherapists with standards for most therapy-related situations, it does not take account for multiple contextual factors that might affect practitioner’s behavior and decision-making. In their analysis of therapy boundaries, Barnett and Hynes (2015) emphasized the importance for therapists to identify and evaluate situational factors to make sound decisions and to ensure avoidance of any harm toward a client. While advocates of therapeutic boundaries argue for the maintenance of behavioral standards to prevent any potential harm to patients, proponents of utilitarian reasoning claim the acceptance of minor boundary violations evoked by certain situational factors. Thus, Zur (2015) distinguished four aspects of the psychotherapeutic practice that influenced the context of ethical decisions during the treatment process, such as client factors, setting factors, therapist factors, and therapy factors. Though the present study seeks to prove the value of therapeutic boundaries and their maintenance, review of contextual factors is essential, since boundaries, in fact, are quite flexible, which will be illustrated below.
Patient-related factors. In the study of group treatment therapy against anger, Smith (2008) regarded client factors in the context of the patient’s clinical history, encompassing aspects of the trauma type, extent, and nature. In his quantitative assessment, Smith (2008) pointed out that patient’s clinical report contained sensitive information, when it concerned sexual or physical abuse of a patient. Thus, psychotherapists should pay attention and analyze patient’s presentation of the experienced problem, demonstrated mental state, reported disturbance along with medical data about the personality type, sexual orientation, personality disorder, physical health, and prior therapy experience (Smith, 2008).
Zur (2015) claimed the need to take into account patient’s age, gender, socio-cultural background, economic status, religious beliefs, social support, and spiritual practices. In fact, these contextual factors are subject to the established therapeutic boundaries with the APA’s Code prohibiting any unfair discrimination of patients and other people with which psychologists work with (APA, 2010). Practitioner’s respect to various patient-related factors and issues is a showcase of one’s professional flexibility, which has proven to be a valuable quality of a psychologist in a quantitative study of Owen and Hilsenroth (2014). Personal characteristics of a therapist are of a similar value for the therapeutic process as those of a patient. The psychotherapist’s age, sexual orientation, gender, cultural background, and practical scope acquired by professional training and experience produce an effect on practitioner’s perception of a patient and his or her problem as well as patient’s perception of the therapist’s credibility and proficiency (Zur, 2015; Schumann & Alfandre, 2008).
Setting-weighted factors. In conjunction with client-related factors, therapists should regard a number of setting parameters, shaping the overall treatment process and outcomes. In their analytical study, Pope and Keith-Spiegel (2008) indicated the following clinical factors that require consideration: inpatient versus outpatient therapy, individual, family, or group sessions, and engagement or proximity of other psychology specialists and clinical professionals in therapy planning and execution. In his appeal to the significance of the contextual assessment, Zur (2015) pointed out a range of setting features, such as healthcare building versus home office versus private setting, in-hospital therapy versus freestanding clinic, and private clinic versus publically owned one. In addition, Zur (2015) underlined locality characteristics, affecting the therapeutic process. For instance, in small rural towns, a therapist and a client are more likely to develop dual relationships or engage in another form of boundary violation due to a scarcity of therapeutic services compared to large metropolitan areas.
In their explanatory study, Cohn and Hastings (2013) asserted the challenge of delivering quality psychotherapy services in rural areas. Small-scale rural communities and Indian reservations eliminate the possibility of a strict adherence to APA’s ethical principles concerning avoidance of any common social, religious, and other belongings between a therapist and a patient. As claimed by Zur (2015), while psychotherapists of metropolitan cities are able to ensure the entire personal segregation from a client, practitioners in rural communities are frequently unable to avoid cases of serving neighbors, family members, or other acquaintances. The issue of the community size is important for various remote or separated settings like academic neighborhoods, military bases, prisons, and police departments, where staffed therapists have to serve their colleagues or other associates (Zur, 2015).
Therapy-caused factors. Therapy operates in a highly dynamic and ever-changing environment, which makes it a source of numerous contextual factors. In his analysis, Zur (2015) divided therapy-caused factors in two groups – therapeutic features and components of therapeutic interactions. The position is in line with the argument of Pope and Keith-Spiegel (2008) who distinguished therapy modality, theoretical orientation, population, and treatment intensity as the major therapeutic factors. The issue of modality refers to disparities in treatment planning and delivery to individuals, couples, families, and groups. Therapy duration implies the concept of its length – short-term, long-term, or periodical longitudinal treatment (Zur, 2015).
When defining a treatment strategy and tactics, psychotherapists are expected to conduct a thorough analysis of the patient’s personal data and clinical history to define the most appropriate theoretical framework. Ryan et al. (2011) suggested that in accordance with its nature and severity, trauma treatment might require group therapy, body psychotherapy, psychoanalysis, humanistic therapy, or eclectic therapy to achieve treatment goals. In addition to the sort of trauma experienced, therapy planning requires consideration of the patient’s age. Multiple researchers emphasized the difference in serving adolescents, adults, and elderly with each group facing a set of mental and physical challenges peculiar for it (Abeles, 1998; Weisz, 2004; Atiq, 2006; Carlberg, Eresund, & Boethius, 2008). The issue of therapy intensity concerns the frequency of therapist-patient interactions, ranging from occasional monthly consultations to regular weekly sessions (Zur, 2015).
Characteristics of the exercised therapeutic alliance predetermine treatment outcomes and fulfillment of therapy objectives as well. The list comprises the nature, length, quality, kind, and other dimensions of the therapeutic relationship. Piper and Ogrodniczuk (2004) conducted a quantitative study to show that therapeutic interactions should have been safe, secure, thoroughly planes, and fearless. The argument is supported by endeavors of other researchers, underlining that the desired neutrality of psychotherapists is not a barrier to an intense and involved therapeutic alliance. In contrast to neutral interactions, proactive therapy sessions are likely to increase the treatment effect and reinforce patient’s wellbeing (Wright & Davis, 1994; Aravind, Krishnaram, & Thasneem, 2012). The length of the therapeutic relationship is another influential factor; there is a great disparity between a new and a longitudinal relationship. A newly started therapy lacks trust, confidence, and closeness cultivated in an experienced alliance or interactions to be terminated in the nearest future (Herman, 1998; Cahill et al., 2008; Zur, 2015).
Therapist-related factors. Another parameter of therapeutic interactions concerns the balance of roles performed by a therapist and a patient. An authoritative position of a therapist is more professional in comparison to familiarity and egalitarian behavior with a client (Herman, 1998; Aravind, Krishnaram, & Thasneem, 2012). Zur (2015) pointed out that the place of therapist-patient encounters was an effect on the therapy. In particular, the scholar claimed that outcomes of psychotherapy office interactions differed from those combined with community familiarity and distanced connections. However, the APA’s Code of Conduct underlines that the psychotherapy relationship should be bound by professional counseling interactions only. There is no room for personal interactions and community belongings in psychotherapy (APA, 2010).
The context of psychotherapy is multidimensional and dependent on various factors. The illustrated complexity of the therapeutic alliance dependent on client characteristics, setting conditions, therapist identity, and therapy-related factors does not justify boundary violations. Instead, the above-discussed contextual factors indicate issues to be considered by psychotherapists in treatment planning and execution. In this case, boundaries established by the professional community are not an obstacle, but a valuable guideline, assisting practitioners in ethical reasoning and decision-making.
Cases from Therapeutic Practice of Unavoidable Boundary Violation
There are cases when boundaries are deviated in disregard of a therapist intention or desire to adhere to ethical principles. The study of Bridges (1999) analyzed a case of a woman who turned to a therapist of her colleague to cope with anger, rage, distress, and depression. Having imagined the desired level of emotional proximity with a therapist, the woman was unable to appreciate the executed treatment. Numerous attempts of the therapist to expand the space between them and to reduce woman’s acknowledgment of therapist’s personal life were ineffective and even caused a negative effect on the woman’s treatment progress. The case cited by Bridges (1999) demonstrates that sometimes a withdrawal of therapeutic boundaries in unescapable and essential for achieving treatment goals.
Another example of unintentional withdrawal from therapeutic boundaries concerns the case cited by Totton (2010). During the previous meeting, a practitioner Jodie Messler Davies had trouble in working with her client Karen because of the having a heavy cold. She was sneezing and coughing all the time. Karen brought a mug of warm milk to the next therapeutic session to demonstrate her sympathy and concern for the therapist’s health. According to therapy ethic guidelines, the mug symbolized a gift. Though the practitioner had to deny taking the mug, she felt so pleased for Karen’s care and took a gulp of the milk (Totton, 2010). The case may be viewed through both the therapist’s physical illness and emotional recall to the care expressed by the patient. These minor boundary withdrawals seem ethical and harmless unless they are recognized as seeds of later serious violations. In this vein, it is essential to discuss different types of boundary deviations and their outcomes to illustrate the importance of boundaries.
Boundary Crossing, Violations, and Dual Relationships
Different views on boundary violation. In accordance with therapist’s consideration of contextual factors and commitment to ethical principles, he or she may decide to exercise a certain withdrawal from professional boundaries. A subjective and relationship-based nature of psychotherapy is a frequent subject to boundaries’ avoidance, violation, and crossing. Developed on the ground of jurisprudence, cultural morality, and ethical framework, boundaries determine the accepted and expected social and psychological distance between therapists and patients. As defined by Aravind, Krishnaram, and Thasneem (2012), boundaries indicate an edge of the professional behavior, infringement of which implies breaching one’s clinical role. In support of the argument, Barnett and Hynes (2015) stressed upon the boundaries’ value in preventing and avoiding harm to clients.
In contrast to utilitarian scholars like Zur (2015), most practitioners and academics share a belief that contextual factors should not give a way to departures from boundaries because of the immediate association with an increased risk of harm to patients and their treatment outcomes (Simon, 1992; Johnston & Farber, 1996; Blunt, 2006; Totton, 2010). The initial purpose of therapy is to provide assistance in coping with various emotional and mental problems. The relationship between a practitioner and a patient should serve for the achievement of this objective. Whenever, the exercised relationship steps out of the presupposed clinical role, it becomes non-therapeutic due to violation of the established boundaries. Furthermore, these boundaries are a product of the consideration that longitudinal interactions between a psychotherapist and a patient might cultivate strong emotional bonds between the two. The role of boundaries is to control these bonds in compliance with the basic treatment goal (Aravind, Krishnaram, & Thasneem, 2012).
The reliance on contextual factors in clinician decision-making is risky and unprofessional. In their appeal to the importance of maintaining boundaries, Barnett and Hynes (2015) referred to the case when a clinician uses touch to foster confidence and closeness development with an individual, overcoming an assault or another sexual trauma. Such a behavior deviation is likely to create severe barriers to the treatment progress and success. The major cornerstone in the dispute, whether some withdrawals from boundaries should be acceptable, concerns their nature and extent. Scholars distinguish three types of boundary deviations, such as boundary violations, boundary crossing, and dual/multiple relationships (Miller, 2007; Dewane, 2010; Zur, 2015). In the pursuit of citing evidence to the importance of maintaining therapeutic boundaries, it is essential to clarify these boundary breaches first.
Boundary violations. Smith and Fitzpatrick (1995) defined boundary violation as “a departure from accepted practice that places the client or the therapeutic process at serious risk” (p. 500). Similarly, Aravind, Krishnaram, and Thasneem (2012) called boundary violations harmful to a patient and the therapeutic practice, since they imply patient’s exploitation. Typically, boundary violations refer to sexual contacts experienced by psychotherapists with their current clients. However, non-sexual boundary violations are also common, when therapists exploit their clients for their business goals (Simon, 1992; Zur, 2015).
Other manifestations of boundary violations include giving and receive improper gifts, inappropriate touching, ignorance of practice-established conventions and standards, excessive self-disclosure, breaches of patient confidentiality, and assuming patient’s values as those of a therapist (CPSO, 2004; Garfinkel et al., 1997). As claimed by both scholars and most practitioners, boundary violations are harmful for therapy clients, evoking feelings of vulnerability, betrayal, and exploitation (Johnston & Farber, 1996; Blunt, 2006; Barnett & Hynes, 2015). Violation of boundaries has an adverse effect for the treatment and therapy as a whole. They destroy trust and confidence, crucial for the therapeutic relationship. Instead of the sought emotional support, patients get confused and betrayed, which discourages their engagement in the treatment process (Zur, 2015).
Boundary crossings. While boundary violations are immediately associated with a severe breach of the clinical role, boundary crossing refers to minor deviations conducted in favor of beneficial outcomes. Smith and Fitzpatrick (1995) defined boundary crossing as “departures from commonly accepted clinical practice that may or may not benefit the client” (p. 500). Aravind, Krishnaram, and Thasneem (2012) regarded boundary crossing as non-exploitative, harmless, and aligned with the therapy objectives. Due to the minor breaching nature, boundary crossing are non-sexual activities, such as self-disclosure, gifts, non-sexual touch, and bartering (Zur, 2015). Some scholars claim that boundary crossing may be an integral part of the treatment process, supporting the pursued therapy goals (Garfinkel et al., 1997; Aravind, Krishnaram, & Thasneem, 2012). Thus, CPSO (2004) and Zur (2015) promote the idea that self-disclosure, common social events and experiences, hugs and friendly touching, dual relationships, and common friends are acceptable boundary crossings that are ethical and supportive for the therapy.
Dual/multiple relationships. When speaking about acceptability and possibility of boundary crossings to foster the treatment process, scholars touch upon the issue of dual/multiple relationship that has become an independent boundary issue. Similarly to boundary violations and boundary crossings, dual/multiple relationships mean a withdrawal from the established relationship’s standards through initiation and engagement in additional interactions between a therapist and a patient (Dewane, 2010). In his study, Burgard (2013) pointed out that the development of dual/multiple relationships as an additional connection between therapy participants referred to the past, present, and future.
Though the APA Code of Conduct does not differentiate boundary violations and boundary crossing, it regards a separate concept of dual/multiple relationships. According to APA ethical provisions,
“A multiple relationship occurs when a psychologist is in a professional role with a person and (1) at the same time is in another role with the same person, (2) at the same time is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relationship, or (3) promises to enter into another relationship in the future with the person or a person closely associated with or related to the person” (APA, 2010, 3.05(a)).
Dual/multiple relationships have a negative connotation as other kinds of boundary deviations, being immediately associated with a high risk for patient exploitation and sexual abuse (Smith & Fitzpatrick, 1995). Furthermore, dual/multiple relationships mean deepening and expanding connections between a therapist and a patient, breaching fundamental therapy principles of patient’s autonomy and practitioner’s separateness (Simon, 1992). The universally formulated and accepted rules of therapy expect therapists to maintain neutrality,
“foster psychological separateness of the patient… Interact only verbally with clients. Ensure no previous, current, or future personal relationships with patients. Minimize physical contact. Preserve relative anonymity of the therapist” (Wright & Cummings, 2013, p. 259).
The issue of dual/multiple relationships has become the key cornerstone in the dispute between deontological and utilitarian reasoning about ethical decisions in therapy. In particular, the absolutist position denies any possible acceptance of boundary crossing and multiple relationships. Scholars, appealing to the strict adherence to and maintenance of therapeutic boundaries, reject any possibility of boundary crossing and multiple relationships in supporting and reinforcing the treatment process (Pope, 1992; Simon, 1992; Aravind, Krishnaram, & Thasneem, 2012). Arguments against boundary crossing and multiple relationships refer to the therapeutic dogma that determines standards of the therapist-patient relationship to protect patient’s welfare from exploitation and sexual abuse (Wright & Cummings, 2013).
Arguments for and against dual relationships. In support of the viewpoint, deontologists stress upon the case of sexual contacts developed as an additional relationship between therapy participants. Studies of Galletly (2004) and Loue (2015) displayed that sexual contacts, accompanying the therapeutic relationship, are unethical, inappropriate, and unacceptable, carrying out a risk of patient’s cognitive dysfunction, sexual confusion, depression, anxiety, guilt, and suicidal inclinations. Though multiple relationships may start as an exchange of emails and other friendship manifestations, they are predecessors to future sexual contacts (Yonan, Bardick, Willment, 2011; Loue, 2015). Hence, dual/multiple relationships are regarded as increasingly harmful for psychotherapy clients and the therapy as a whole.
The opposite position of utilitarian ethics emphasizes the value of non-sexual multiple relationships cultivated in support of the therapy goals’ pursuit. The major advocate of this boundary issue – Zur (2004; 2015) – claimed that regular therapy sessions required high emotional and mental closeness between a therapist and a patient. Ergo, prolonged interactions might lead to the development of additional relationships between therapy participants, such as a teacher and a student, business associates, or an employer and an employee. In this vein, many scholars like Dewane (2010), Aravind, Krishnaram, and Thasneem (2012), or Zur (2015) considered dual/multiple relationships as sequential or concurrent as cultivated during or after the therapy. The utilitarian perception of dual/multiple relationships points out to their harmless, non-exploitative nature, having no effect on the treatment objectivity. Accordingly, advocates of this boundary issue do not recognize it as unethical and violating (Weiner & Craighead, 2010).
Dual relationships within ethical guidelines. The continuous debate over dual/multiple relationships is nourished by the APA-formulated ethical principles to guide practitioners in various therapy situations. In fact, the APA’s Code of Conduct sets up clear standards for dealing with multiple relationships. The document prohibits therapists entering any additional relationship with patients if these dual or multiple relationships are expected to pose a risk of harm of exploitation to a therapy client or to impair the professional’s objectivity, effectiveness, and competence in performing one’s psychotherapeutic functions (APA, 2010, 3.05(a)). Otherwise, when there is no reason to expect any harm risk exploitation or impaired therapy, multiple relationships are ethical (Doverpike, 2008).
In addition to the reasonably expected threats to the treatment process and patients, the APA’s code bans multiple relationships in two other cases.
“If a psychologist finds that, due to unforeseen factors, a potentially harmful multiple relationship has arisen, the psychologist takes reasonable steps to resolve it with due regard for the best interests of the affected person and maximal compliance with the Ethics Code. [And] when psychologists are required by law, institutional policy, or extraordinary circumstances to serve in more than one role in judicial or administrative proceedings, at the outset they clarify role expectations and the extent of confidentiality and thereafter as changes occur” (APA, 2002, 3.05(b)(c)).
To sum up, therapeutic boundaries based on the APA’s ethical principles prohibit unfair discrimination, harassment, and other harmful actions against clients. In terms of multiple relationships, the Code of Conduct clarifies cases when they are ethical and acceptable for the practice. When no patient-related risks are expected and no additional, either institutional, or conditional restrictions on entering multiple relationships are present, the APA ethical standards allow development of dual/multiple relationships (APA, 2010). This is another argument for maintaining therapeutic boundaries and keeping to their dispositions to make sound ethical decisions in various situations.
The Value of Any Boundary Violation
Given the evidence provided above, non-harmful and non-exploitative boundary crossing is mostly regarded as consistent with treatment needs (Barnett & Hynes, 2015). Advocates of boundary crossing as a part of the treatment program stress upon its support for the therapy and achievement of the pursued treatment objectives (Zur, 2004; Zur, 2015). While boundary violations constituting patient’s social or physical exploitation are subject to unified ban, boundary crossing and dual relationships are frequent topics of psychotherapeutic disputes. Deontologists claim that boundaries serve to provide psychotherapists with a guideline and behavioral standards for various situations. The utilitarian counter argument relies on the premise that contextual factors shape clinical decision-making that also follows conceptual and logistic guidelines of boundaries (Aravind, Krishnaram, & Thasneem, 2012).
Boundary crossing, boundary violations, and dual/multiple relationships may arise from both parties of the therapeutic relationship (Aravind, Krishnaram, & Thasneem, 2012). As pointed out by Barnett and Hynes (2015), respect for patient’s autonomy and dignity is at the core of psychotherapy ethics. Hence, practitioners are responsible for mitigating boundary crossings and violations initiated by clients. Designed in accordance with ethical principles, professional boundaries are clear in defining acceptable and non-acceptable patterns of the practitioner-client relationship. They serve to create safety and protect both patients and psychotherapists from any harm to them or the practice at large. Clear boundaries define roles for practitioners and patients that are compliant with the therapy and do not undermine the exercised interactions. Therefore, therapists are responsible for observing and maintaining boundaries to avoid any kind of boundary violations. Aravind, Krishnaram, and Thasneem (2012) underlined that any severe boundary violations starts from a minor crossing and became highly problematic with the time leading to sexual misconduct.
Maintenance of Boundaries in Therapy
Negative Outcomes of Boundary Violations
Sexual contact between a client and a therapist. Though the APA’s Code of Conduct does not ban boundary deviations entirely in relation to multiple relationships that pose no harm and risk exploitation to patients, most health organizations and associations exclude this boundary issue in their ethical policies as pointed out by Burgard (2013). The analytical endeavor of Aravind, Krishnaram, and Thasneem (2012) provided an explanation to the issue in relation to a high potential of sexual contact between a therapist and a patient. Regarded as a severe boundary violation, sexual connections start from relatively insignificant boundary deviations that may be not associated with intrusion into the client’s space. The shift from a professional relationship to a sexual one is not direct or short-term.
Typically, there is a range of minor sequencing changes in the therapeutic relationship that culminate in sexual contacts. In his study, Simon (1989) pointed out to the following precursors of future sexual misconduct: transition from last names to first names, some body contact like hugs, massage, or shoulder patting, and personal conversation irrelevant for the treatment. These initial preconditions for sexual intercourse are, then, followed by meetings outside the office, lunch sessions, evening activities like movie visits and social entertainments, common dinners, and finally, sexual contact (Simon, 1989).
The study of Simon (1992) illustrated the scenario perfectly citing a case of a 38-year old female patient diagnosed with borderline personality disorder, substance abuse, and post-abortion depression. The 49-year-old practitioner had his own problems; being recently left by his wife, he suffered from a feeling of loss and alcohol abuse. Shortly after the therapy start, the psychotherapist and his patient began to use first names instead of last ones when addressing each other. That minor boundary deviation led to some physical contact by sitting together on the sofa followed by brief meetings outside the office. A series of boundary crossings ended up with a sexual intercourse one day when both drank too much at the dinner (Simon, 1992).
Non-sexual relationships that lead to sexual contact in the end. As claimed by Aravind, Krishnaram, and Thasneem (2012), boundary crossings and non-sexual boundary violations do not necessarily lead to sexual connections or give evidence to the psychotherapist’s sexual misconduct. Nonetheless, the risks of patient exploitation, harm, and sexual abuse are too high to put the entire psychotherapeutic practice at stake. In addition to the impaired treatment and harm caused to patients, sexual misconduct discriminates and spoils the image of psychotherapy at large. Therapy boundaries establish a clear prohibition on sexual relations between a therapist and a patient, though they still take place, bringing negative consequences (Simon, 2012; Blunt, 2006). The situation seems unchanged for decades.
The analytical study of Riskin (1979) underlined the inappropriateness and unacceptance of sexual intimacies between therapy participants. The scholar asserted the need of improving the existing social controls to deter and prosecute sexual contacts. Riskin (1979) claimed that the adopted ethical principles shaped standards for professional interactions between a therapist and a patient, but failed to prevent sexual misconduct. Furthermore, reports of sexual intimacies between therapists and patients increased in the 1980s. The study of Perry and Kuruc (1993) regarded sexual misconduct as the second leading cause of psychotherapy practice litigation at the end of the 20th century.
The problem of sexual contact in therapy. The 1983 study of Bouhoutsos et al. of 704 Californian psychologists revealed a high rate for sexual intimacies between therapists and patients. Furthermore, respondents reported entering sexual contacts with 30% of patient during first few meetings, 25% of patients after three months of therapy, 22% – after six months, 19% – after a year, and 4% – within last three months before termination. In the discussed study, initiation of sexual relations was mutual with 15% of contacts initiated by therapists, 14 % – by patients, and 27% – by both. Bouhoutsos et al. (1983) indicted that sexual intimacies forced 66% of patients and 15% of therapists to terminate treatment. For nine out of ten patients, sexual intimacies with therapists appeared harmful with an adverse effect on the treatment. Harmfulness of sexual misconduct validates ethical standards for the therapist-patient relationship, aimed at preventing any boundary violations.
Analyzing criminal provisions and industry laws in relation to sexual intimacies between a therapist and a patient, Perry and Kuruc (1993) emphasized a significant expansion of legal remedies against sexual exploitation and abuse. Scholars cited various statutes, accusing psychotherapists of causing sexual abuse or emotional distress to their patients through entering sexual relations. No matter who initiates the sexual contact, patients are victims in the case due to the authority and professional responsibility imposed on therapists.
“The impacts of sexual involvement with one’s counselor are more severe than the impacts of merely ‘having an affair’ for two major reasons: first, because the client’s attraction is based on transference, the sexual contact is ordinarily akin to engaging in sexual activity with a parent and carries with it the feelings of shame, guilt and anxiety experienced by incest victims. Second, the client is usually suffering from all or some of the psychological problems that brought [her] into therapy to begin with” (Perry & Kuruc, 1993, p. 47).
The 1992 USA-wide research of Svartberg investigated studies, surveying psychotherapists across the country, to identify that most of them experienced sexual attraction to patients at least once in the career. A later study of Pope, Tabachnik, and Keith-Spiegel (2006) reported that 87% of therapists (76% of women and 95% of men) felt sexual attraction to their patients. Both Svartberg (1992) and Pope et al. (2006) pointed out that the amount of therapists expressing their feelings and developing sexual contacts with patients was relatively small. In addition, among 575 psychotherapists surveyed by Pope, Tabachnik, and Keith-Spiegel (2006), the majority (63%) felt confused, guilty, and anxious about the feeling. Engaging in sexual intimacies with patients, therapists break standards of professional ethics and are regarded as a subgroup of sexual offenders, since nine out of ten patients involved in sexual contacts are harmed. Svartberg (1992) pointed out that instead of assisting patients in overcoming their problems, psychotherapists entering sexual contacts with patients evoked or maintained their feeling of being rape and incest victims.
The research of Galletly (2004) cited results of the European and American surveys, reporting up to 10% of therapists admitting sexual contacts with their patients. The Australian anonymous survey revealed that 7.6% of psychiatrists admitted sexual misconduct with their patients during and after treatment termination. Along with self-reported therapist data, 4% of patients reported being sexually abused or exploited by their clinicians (Galletly, 2004). In fact, it is not typical for patients to report about sexual exploitation or abuse by their therapists due to feelings of guilt and shame. Sharing a belief that authoritative bodies will not adequately perceive their complaints about sexual exploitation, patients are more likely to report sexual intimacies with previous therapists and doctors to current practitioners.
The issue of boundary violations and sexual intimacies between a therapist and patient remain acute for the therapeutic practice for few decades. Almost 90% of therapists reported being sexually attracted to their clients as underlined by Drukteinis (2015). Nonetheless, the industry lacks training and guidance to assist professionals in coping with evoked feelings. Thus, Pope, Tabachnick, and Keith-Spiegel (2006) indicated that almost half of the surveyed psychotherapists reported not receiving any training on the issue. Only 9% of respondents reported being training and adequately prepared to deal with a feeling of sexual attraction toward patients.
The common concern in relation to boundary crossing and violation is potential harm to patient. The appeal to avoiding harm and exploitation of a patient is at the core of the therapy’s ethical principles outlined by APA (2010) and each study conducted in the field of psychotherapy like those of Bouhoutsos et al. (1983), Pope, Tabachnik, and Keith-Spiegel (2006), and Totton (2010). The majority of studies stressing upon the risk of harm in boundary violations touch upon the issue of sexual intercourse. In addition to dramatic outcomes for a patient, sexual intimacies among therapy participants damage practitioners and the profession as well.
Most healthcare institutions prohibit any kind of boundary crossing regardless of the potential benefit for the treatment progress with intention to protect themselves and their staff from complaints and suits of patients against psychotherapists for their withdrawal from standards of the therapeutic relationship. As pointed out by Burgard (2013), half of malpractice suits results from confusion, shame, or dissatisfaction evoked by practitioner’s boundary crossing or cultivation of dual relationships. The paper of Eddington and Shuman (2008) placed the psychotherapist’s performance outside the realm of the accepted therapeutic practice the first in the list of other situations, representing practitioner’s malpractice. Underlining the inexact scientific nature of medicine and psychotherapy in particular, scholars reasoned the profession’s prohibition to make promises about patient’s health and to develop relationships with patients. In line with the accepted therapy ethics and boundaries, health attorneys insist on the importance of prohibiting any boundary crossing and dual relationships, relying on the evidence to a high percentage of complaints issued by patients in the follow-up (Burgard, 2013).
Legal outcomes of therapeutic malpractice. Sexual misconduct when a therapist violates boundaries or allows their violation by a client is a frequent subject to current malpractice suits against psychotherapists. Drukteinis (2015) stated that 15% of all court cases against therapists concern sexual activities. In fact, sexual contacts are harmful for both parties; therapists are at a high financial and professional risk. Typically, malpractice insurance does not cover damages caused by legal cases of the therapist-patient sex. Dedicated to cease and prevent practitioner’s entry of sexual contacts with patients, licensing boards are extremely intolerant to this boundary violation, revoking professional licenses of therapist detected and accused of having sex with a client (Drukteinis, 2015).
Simon (1992), Pope, Tabachnik, and Keith-Spiegel (2006), and Totton (2010) claimed that psychotherapists physically attracted by their patients might have misperceived emotional recall of their clients. Practitioners enact their sexual feelings to patients when they believe that the feeling goes both ways. In his analysis, Drukteinis (2015) explained that love or sexual contacts between a psychotherapist and a patient were taboo because of the disparities in mutual perceptions of therapy participants. While therapists may cultivate a love feeling toward patients, the latter frequently do not even perceptive clinicians as real persons. Seeking emotional support, patients view their therapists as alive projections of care and assistance. Their feelings towards practitioners resemble those towards parents and close relatives. Hence, sexual intimacies with therapists are likely to arouse a sense of incent and guilt in patients rather than physical and emotional satisfaction (Drukteinis, 2015).
Given the evidence cited by Simon (1992), when a psychotherapist and his female patient developed multiple relationships in addition to the therapeutic one, which ended up with sexual intimacy. The story had its continuation – when the therapist went on the vacation, his sexual partner communicated with another patient to learn that details of her childhood sexual abuse had been disclosed. The situation boosted the patient’s depression to foster intake of the lethal barbiturates’ dose. After hospitalization and successful treatment, the patient issued a malpractice suit against her therapist for sexual misconduct (Simon, 1992). Initially started as manifestations of friendship closeness, boundary crossings led to a severe boundary violation that destroyed the therapeutic process, caused harm to the patient, and disqualified the practitioner.
The major negative outcome from boundary crossings and violations concerns sexual misconduct that negatively affects a patient, a practitioner, and the profession. Sexual exploitation worsens the patient’s mental condition, evoking sense of shame, guilt, betrayal, depression, suicidal thoughts, and post-traumatic stress disorder. These outcomes lead to the increased alcohol and drug use, loss of employment, and destruction of the therapeutic relationship (Galletly, 2004). The practitioner frequently becomes subject to legal prosecution, negative media image, financial losses, and loss of medical registration. Finally, media publicity of the therapist-patient sexual intimacy cases result in negative societal attitudes towards psychotherapy as a discipline. Report on patient sexual exploitation and abuse form public perception of therapy as not meeting its professional obligations (Galletly, 2004).
The Need to Maintain Boundaries
Therapists’ understanding and expertise in maintaining boundaries. Several studies cited above – Bouhoutsos et al. (1983), Svartberg (1992), Galletly (2004), Pope, Tabachnik, and Keith-Spiegel (2006), and others gave sound evidence to a frequent sexual attraction experienced by psychologists towards their patients that sometimes forced them to breach their professional boundaries and initiate a sexual contact. The tendency seems unchanged since the 1980s. However, the inability of therapists to cope with the issue was not only a result of their poor morale, but the lack of appropriate education and guidelines provided (Pope, Tabachnik, & Keith-Spiegel, 2006). As already discussed above, contextual factors are extremely influential on clinician decision-making, which requires a continuous reminder and refresh of risks and negative outcomes caused by boundary crossing. In fact, psychotherapists report respect and appreciation of professional boundaries.
The quantitative study of Johnston and Farber (1996) illustrated the actual perception of boundaries by psychotherapists. Scholars sent survey forms to 250 male and 250 female APA members to examine their establishment and upkeep of two boundary types – logistical and conceptual ones. The total amount of responses equaled 213 completed surveys, analysis of which showed that most patients felt comfortable in interacting within boundaries. Findings of Johnston and Farber (1996) made a turning point in the debate of the boundary maintenance. In opposition to the prevailing position that patients challenged accepting therapy boundaries, the research demonstrated that a proper understanding of their role and purpose and cooperation between a therapist and a patient was a successful strategy in building the therapeutic relationship within boundaries.
Therapists surveyed by Johnston and Farber (1996) reported their appreciation and inclination to adhere to the established boundaries to the most possible extent. In addition, they demonstrated their capability to establish cooperation with patients to conduct interactions within boundaries. Hence, psychologist’s personal perception of boundaries and ethical principles seems crucial for the desired compliance. In the cited above case of a female patient seeking atypically close relationship with her therapist, Bridges (1999) underlined inclinations and effort made by the therapist to maintain boundaries. Though providing the patient with the desired personal data, the therapist continued seeking ways to adhere to professional communication boundaries.
The small-scale study of Shavit and Bucky (2004) focused on investigating psychotherapists’ perception of post-treatment sexual contacts and their ban in the APA’s Code of Conduct. For their semi-structured interview research, scholars recruited six heterosexual male therapists who reported not engaging in post-therapy sexual relations with clients. All interviewed practitioners indicated a belief that their professional responsibilities were not terminated with the treatment cessation. In addition, Shavit and Bucky (2004) found a strong support among respondents to the APA’s prohibition of sexual contacts with former patients.
Sexual relationships in the APA’s code of conduct. This ethical principle is present in the 3.09 point of the APA’s code of ethics that bans sexual relationships with current and former therapy clients along with the therapy prohibition with former sexual partners. In relation to sexual relations, the APA’s guideline demonstrates its firm and clear position that “psychologists do not engage in sexual intimacies with current therapy clients/patients” (APA, 2010, 10.05). In terms post-therapy relations, the Code of Conduct points out that
“(a) Psychologists do not engage in sexual intimacies with former clients/patients for at least two years after cessation or termination of therapy. (b) Psychologists do not engage in sexual intimacies with former clients/patients even after a two-year interval except in the most unusual circumstances. Psychologists who engage in such activity after the two years following cessation or termination of therapy and of having no sexual contact with the former client/patient bear the burden of demonstrating that there has been no exploitation, in light of all relevant factors, including (1) the amount of time that has passed since therapy terminated; (2) the nature, duration, and intensity of the therapy; (3) the circumstances of termination; (4) the client’s/patient’s personal history; (5) the client’s/patient’s current mental status; (6) the likelihood of adverse impact on the client/patient; and (7) any statements or actions made by the therapist during the course of therapy suggesting or inviting the possibility of a post-termination sexual or romantic relationship with the client/patient” (APA, 2010, 10.08).
The need for maintaining boundaries. Maintenance of therapeutic boundaries is crucial for effective treatment and patient recovery, practitioner’s career development, and the practice’s positive image. As already discussed above, boundaries address both logistical and conceptual domains of the therapeutic process (Zur, 2015). In fact, boundary guidelines allow some deviations in response to contextual factors, but emphasize the importance of a thorough evaluation of all possible outcomes. Boundaries rely on principles of abstinence, neutrality, patient’s autonomy, respect for human dignity, and fiduciary relationship (Simon, 1992). These principles are fundamental for psychotherapy as a healthcare medicine, the primary responsibility of which is to treat, but not to become friends or partners.
In addition to the drastic consequences of various boundary violations, boundary maintenance is essential to cope with challenges posed by modern technologies and social media. Social networking channels and cellular phones are beneficial in easing communication and information sharing. However, in the context of psychotherapy as claimed by Yonan, Bardick, and Willment (2011), these technology advancements threaten the development of the therapeutic relationship within boundaries. Communicating with means of social networking, psychotherapists reduce the distance with clients, letting the latter learn some personal information about practitioners along with intruding in personal lives of their patients themselves. Thus, modern communication channels create a positive ground for the development of dual relationships (Yonan, Bardick, & Willment, 2011).
In their study, scholars Yonan, Bardick, and Willment (2011) analyzed two ethical dilemmas posed by these communication means and provided a ten-stage reasoning process to illustrate how practitioners could pose with a problem in reliance on ethical principles and therapeutic boundaries. Yonan, Bardick, and Willment (2011) discussed the therapist’s response to a client’s Facebook request and the acceptability of giving a phone number to a patient. Both ethical dilemmas followed the same reasoning scenario. The proposed decision-making process required to identify those affected, define ethically relevant aspects, consider personal biases, design various action courses, analyze risks and benefits, select a suitable action, act, evaluate outcomes, assume responsibility, and take actions, preventing further occurrences (Yonan, Bardick, & Willment, 2011). Cases analyzed by scholars illustrated perfectly the conceptual applicability of therapeutic boundaries to a particular situation. The prescribed decision-making process underlined by the key ethical principles provided a framework to assist practitioners staying professionals and adhering to standards of their therapist-client relationship.
The boundary maintenance seems the most effective way of preventing boundary violations and their negative outcomes. In his analysis, Galletly (2004) pointed out six aspects relevant for boundary maintenance, such as assessment measures, regulatory bodies, unprofessional colleague’s conduct, risk management, education, and rehabilitation of offenders. Practitioner’s mental health should be subject to professional evaluating and monitoring to ensure one’s capability to assist and treat others. As illustrated in the case discussed by Simon (1992), when starting therapy with a new client, the therapist experienced an emotional distress evoked by the divorce and extensive alcohol drinking. Hence, minor boundary crossings seemed suitable for the development of a productive relationship with a patient. Client’s physical resemblance with the practitioner’s ex-wife and an emotional recall transformed professional interaction into sexual contacts.
Professional preparation and development. Therefore, psychotherapists require implementation of assessment tools like doctor-doctor programs to detect early symptoms of a practitioner’s vulnerability to boundary crossing or violation and to take preventive measures (Galletly, 2004). The issue requires an improved control of psychotherapist’s conduct by the professional community. As assumed by Drukteinis (2015), psychotherapy lacks effective regulatory bodies to discourage and prevent sexual misconduct. Though being intolerant to practitioner’s sexual intimacies with a patient, the psychotherapeutic community reacts mostly to the occurred cases of sexual misconduct through a license revoke. In terms of discouragement and prevention, Pope, Tabachnik, and Keith-Spiegel (2006) underlined the importance of designing and delivering corresponding education to assist practitioners in their boundary maintenance.
As emphasized by Galletly (2004), feelings of shame and guilt prevent patients involved in sexual exploitation to report the issue to authoritative instances. Over 60% of Australian therapists report being informed by their patients about sexual misconduct of a previous clinician. In addition, about half of practitioners assume that at least two of their patients described being abused in prior therapeutic relationships. Though therapists are obliged to report such issues to a regulatory body to hold unprofessional practitioners accountable for their unethical conduct, they are unable to initiate the case investigation without a patient’s complaint (Galletly, 2004).
Svartberg (1992) claimed that psychotherapists engaging in sexual intimacies with patients should have been treated similar to other sexual offenders. Thus, sexual misconduct as a fragrant breach of professional obligations requires strict prosecution and punishment. In his analysis of the boundary maintenance, Galletly (2004) argued that practitioners violating boundaries should have received an opportunity for rehabilitation as other sexual offenders. Similar to individual and group cognitive and psychodynamic programs that facilitate coping with sexual abusive inclinations, specific educational programs for psychotherapists are likely to increase their awareness and understanding of the inappropriate, unaccepted, and unethical nature of their conduct. In addition to sessions with a colleague-therapist, the rehabilitation process should imply regular reports to a medical board (Galletly, 2004).
Given the arguments above, ethical and professional psychotherapy requires a continuous education of practitioners to maintain their awareness of risks associated with boundary crossings and violations. With the time, some therapists may overestimate their capability of making ethical decisions, while deviating therapeutic boundaries. Various scholars to include Bouhoutsos et al. (1983), Pope, Tabachnik, and Keith-Spiegel (2006), and Aravind, Krishnaram, and Thasneem (2012) illustrated by qualitative and quantitative endeavors that a slight withdrawal from boundaries might lead to severe boundary violations like sexual misconduct. Hence, regular training courses are required to maintain practitioner’s firmness and adherence to boundaries to ensure the fiduciary nature of the practiced relationship with a patient. As underlined by the Washington Court of Appeal when reviewing the malpractice suit that fiduciary nature of the practitioner-client relationship implies “the inherent necessity for trust and confidence [that] require[d] scrupulous good faith on the part of the physician” (in Simon, 1992, p. 274). Hence, trust, confidence, and faith are crucial for the fiduciary relationship between a therapist and a client to foster patient’s belief in and acceptance of the professional’s knowledge, influence, and dominance.
Chapter Summary
This literature review gives a precise examination of the therapeutic relationship to illustrate the importance of maintaining boundaries in psychotherapy. The chapter illustrates that the primary role of boundaries is to guide practitioners in ethical decision-making rather than restricting their power and authority. The accepted ethical principles address various aspects of the therapeutic process to clarify what behavior patterns are ethical and appropriate for the profession. In contrast to the ruling psychotherapeutic dogma, utilitarian reasoning allows minor boundary violations in reference to specific contextual factors, when boundary deviations seem beneficial for the treatment progress. In the pursuit of shedding light onto the acceptability of boundary violations, the chapter discusses various contextual factors that might affect clinician decisions. Furthermore, it cites particular points of the professional ethical framework that address these issues.
The subsequent overview of various forms of boundary violations gives references to the APA’s Code of Conduct and therapeutic boundaries to demonstrate that some minor deviations are allowed with an emphasis on the required evaluation of all possible outcomes. The issue of boundary deviation outcomes is crucial, since most of studies reviewed gave evidence that minor boundary crossings were likely to end up with sexual intercourse. The latter causes severe damages to a patient, a therapist, and the practice as a whole. The chapter points out that practitioner’s respect to boundary prevails breaching inclinations. In spite of their belief in the importance of maintaining therapeutic boundaries, many psychotherapists lack preparation and education to cope with the sexual attraction to patients along with other aspects discussed. The review of boundary-related studies conducted for over three past decades displayed an unchanging trend – while recognizing the purpose of boundaries, many practitioners engages in their crossings and violations. This multifaceted analysis of the boundary issue proves its value and alerts the need to reinforce their maintenance.
CHAPTER III: METHODOLOGY
Introduction
This chapter touches upon all crucial methodological aspects of the research design selected in alignment with the pursued research purpose. To set up the contextual background to the chosen research design, the chapter restates the current research problem and research questions formulated to direct the inquiry process. Next, it discusses research method selected in accordance with research goals. In this vein, the section outlines the difference between positivist and non-positivist paradigms and their applicability to the current research project. Then, the chapter discusses all aspects concerning selection of study participants. Further on, the chapter focuses on discussing the research instrument utilized in this study to fulfill the research purpose. Finally, the chapter outlines procedures for data collection and analysis.
Research Design
In the pursuit of discovering challenges and difficulties faced by therapists in maintaining boundaries and the perceived value of boundaries in therapy, the research utilizes qualitative research methodology and to conduct personal interviews with therapists. The approach allows obtaining first-hand perception and experiences with adhering to boundaries in therapy. The selected research design enables fulfillment of the established research goal and answering formulated questions.
Restatement of the Research Purpose and Research Questions
Psychotherapy is a relationship-based process evoked from a combination of two disciplines – health care and social service. Delivered by various actors, including therapists, clinical psychologists, social counselors, and the like, psychotherapy pursues the core purpose of assisting people to lead happier, healthier, and more productive lives by coping with their mental, emotional, and social problems (APA, 2016). Because of its direct influence on an individual’s well-being and life, psychotherapy is subject to professional ethical guidelines designed to regulate the relationship between a therapist and a client (Welfel, 2015). The APA’s Code of Ethics is the key source of therapeutic boundaries outlining behavior patterns appropriate and acceptable in the practice.
Though the industry’s ethics sets up rules and regulations for the therapeutic process, the reality produces its impact on the relationship between a therapist and a client. Thus, long-standing regular interactions between two parties of the therapeutic process may lead to emergence of other kinds of relationships between a therapist and a client (Barnett & Hynes, 2015). Psychotherapy distinguishes two types of withdrawals from therapeutic boundaries, such as boundary violations and boundary crossing. While the former is a rule violation that causes harm or exploitation of a client, the latter is s minor departure from boundaries with no negative consequences to client’s health or wellbeing (Dewane, 2010). Dual or multiple relationships are a subset of boundary crossing being an additional non-sexual kind of relationship evolved during the therapeutic process.
The perception of dual or multiple relationships between a clinician and a patient among industry professions is subject to the kind of ethics underpinning their reasoning. Hence, advocates of deontological or absolutists ethics urge the importance of maintaining therapeutic boundaries with no exception. Contrary to them, proponents of utilitarian or relativist ethics admit the possibility of non-sexual boundary crossings and even indicate benefits imposed on client’s health and happiness by the emerged dual relationships (Barnett & Hynes, 2015). The issue of non-sexual dual relationships is the major cornerstone in the enduring debate between deontologists and utilitarians. Unclear and vague provisions of the APA’s Code of Ethics in regard for boundary crossing and dual relationships maintain the inconsistency in professionals’ perception of such minor departures from boundaries. As a result, while one groups urges for the obligatory adherence to boundaries, another one claims the need to recognize the value of non-exploitative non-offensive boundary crossing on the therapeutic process and progress (Dewane, 2010).
This research project seeks to conduct an in-depth examination of industry boundaries to provide theoretical and factual evidence to the importance of maintaining boundaries. On the ground of prior empirical research findings and primary data collection, the research intends to outline the value of boundaries in the therapeutic practice, while indicating gaps in ethical provisions and shortages in the practice that challenge boundary maintenance by therapists. In accordance with the pursued aim, a list of research questions was formulated to govern the research process. The scope was as follows:
What procedures should therapists follow to maintain boundaries?
What are benefits in boundary maintenance?
What are challenges in maintaining boundaries as a therapist?
How is the role of APA’s Code of Ethics in maintaining therapy boundaries?
What therapeutic situations imply boundary violations?
Research Method
In line with the posed research question, this research is a qualitative field research with interview as a method of data collection. This qualitative research method is widely used in the field of social research, where a social researcher or an authorized assistant arranges meetings with particular individuals for communication about various things (Merriam & Tisdell, 2015). However, interview does not pursue the aim of obtaining superficial detail or a large-scale volume of information about the interviewee, but seeks to get to the interviewee’s inner life. In this pursuit, interview requires establishing a rapport between a researcher and an interviewee in terms of physical proximity as well as elimination of any social and cultural barriers. These conditions are crucial for ensuring a free productive exchange of ideas, perceptions, and experiences (Sharma, 1997). Laid down formalities in interview lead to openness, which allows the researcher to ponder in the depth of the interviewee’s perspective on the matter. Interviews enables the researcher to learn interviewee’s feeling, intentions, and thoughts about a given phenomenon as well as to discover associated behaviors (Merriam & Tisdell, 2015).
Though some skeptics claim that there is no difference between interview and writing down responses to open-ended questions, the difference exists. An informal interview allows the researcher to obtain both verbal and non-verbal information reported by the interview during the communication process (Seidman, 2015). The scientist is also able to interpret interviewee’s responses in regard for particular situational and emotional contexts. Furthermore, in interview, the researcher is able to adjust the interview process by changing the order of questions, asking additional questions, explaining their meanings, or requesting explanations (King & Horrocks, 2010). Relying on this scholarly basis, this research uses interview as the most suitable method of data collection for this research project. Personal communication with therapists is expected to enable the author to learn individual experiences of each interviewee in applying and maintaining boundaries in therapy.
Participants
Despite the origins of the executed boundary crossing, therapists carry out responsibility for preventing and avoiding any departure from boundaries. In light of unstable or damaged mental or emotional state of a client, the therapist is the one to provide assistance, while keeping track on the therapeutic process to maintain it within professional relationship boundaries. In other words, therapists are responsible not only for improving client’s well-being and state of happiness, but also for mitigating any risk of harm or exploitation evoked with development of additional relationships of another form of boundary violation. Hence, the research addresses practicing therapists to learn their perceptions of the role of boundaries and factors reducing their maintenance. Therapists constitute the target population in this study aimed at discovering whether cases of boundary violations occur because of inadequate professional preparation, commitment to client welfare, or underestimated value of their maintenance.
In the pursuit of conducting personal interviews with therapists, study participants will be selected in accordance with the only criterion – therapist licensure in the state of Georgia. Georgia has two major specific licenses that indicate one eligibility to provide therapeutic services and counseling in the state of Georgia. Both the psychologist license and mental health counselor license provide accreditation to Master and Doctor’s degree professionals. Hence, this study will recruit both Master and Doctoral level therapists licensed as psychologists or mental health counselors in the state of Georgia. Thus, the research will target and recruit therapists licensed and employed in therapeutic settings in the state of Georgia.
The desired sample will include therapists of all ages above 25 , years of practice and gender, who provide therapeutic services within Georgia. In keeping with this selection strategy and in the pursuit of obtaining a state-representative sample for Georgia, recruitment letters will be sent to the mental health specialists listed on the Psychology Today website under the therapists’ section on the cities of Atlanta and Savannah. The list of therapists on the PsychologyToday.com website is publicly available and has open access. The letters will briefly describe the study and indicate researcher’s contact information while requesting psychology staff for the participation in this study.
Instrumentation
The selected interview as a method of qualitative data collection requires further determination of its structure as a current research instrument. By structure, interviewing may be standardized, semi-structured, or unstructured. This research uses a semi-structured interview with flexible order and wording of questions, since this interview structure is an asset for obtaining specific data required from a particular population (Merriam & Tisdell, 2015). The semi-structured interview questionnaire for this study will contain 15 open-ended questions aligned with previously formulated research questions. In particular, each research question will be addressed by three interview questions. In the domain of therapist’s performance in maintaining boundaries, the questionnaire will ask the following questions: “Do you inform a client about particular boundaries in your further relationship at the first meeting? Have you ever shared personal problems with clients, touched them, arranged extra meetings that were not necessary, or something of that kind? What is your vision on the client-therapist relationship?”
In terms of simplicity about maintaining boundaries, the questionnaire will ask the interviewee to tell about most therapy-supportive boundaries, unplanned and unexpected meetings outside the therapeutic office, and arrangement of the therapeutic process. In reference to challenges faced by therapists in maintaining boundaries, the questionnaire will focus on issues concerning client gifts, emotional attachment to their counselors, and business offers. The next portion of questions will address provisions of the APA’s Code of Conduct in terms of maintaining therapeutic boundaries. Finally, the interview will ask interviewees to tell about cases from their practice, when boundary violations appeared unavoidable and their response to those situations. During the communication process, it is possible to modify questions or ask additional one in response to a particular situational context. The only fixed question will be the last one, questioning whether a therapist wants or recognizes the value in undergoing continuing professional development to ensure proper interpretation of professional boundaries to any given clinical case.
Prior to asking interview questions, the research will investigate demographics of the recruited sample to ensure compliance with the defined selection criteria. Precisely, the following questions will be asked:
What is your age?
What is your educational status?
How long have you been working as a therapist?
Methodological Assumptions
The choice of selecting interview as a method of data collection for this inquiry dedicated to investigating therapists’ experiences in applying and maintaining professional boundaries has evoked from multiple advantages offered by this research method. First, in personal communication, an interviewee is likely to reveal details and sensitive information relevant for the investigated matter because of a sense of confidence, trust, and intimacy with the researcher (Sharma, 1997). Second, in informal interview, the researcher is able to capture both verbal and non-verbal information to perceive and produce a comprehensive perspective on the issue (Merriam & Tisdell, 2015). Third, interview enables the researcher to capture interviewee emotions and behaviors in response to particular issues of the examined matter. Fourth, interview allows the researcher to keep the interviewee focused on the research process and purpose (Klenke, 2015).
Along with its apparent strengths, interview has a number of weaknesses considered by the author in advance. As a method of qualitative methodology, interview is subject to criticism for high subjectivity and descriptiveness of its findings. The researcher’s direct involvement in data collection and processing requires skills and personal withdrawal from the research context (Schacter et al., 2015). The appropriate sample size for qualitative data collection is 12 to 15 participants. Besides, personal interview requires the use of additional devices, such as audio and video recording to preserve the interview content for further transcription, translation, and interpretation (Holloway & Wheeler, 2013). To facilitate data collection, interviews will be conducted via phone with all therapists licensed to work in the state of Georgia who will have agreed to participate in the study.
Ethical Considerations
This primary data research requires following ethical guidelines for academic endeavors engaging human participants. In this vein, it is essential to develop an informed consent form for the selected participants to indicate the research purpose, aims, procedures, and expected significance. It is necessary to ensure participant’s confidentiality and protection of all information provided. By granting confidentiality and protection of all data obtained, the research will encourage participants to share their experiences, feelings, emotions, and observations concerning boundary maintenance. In the pursuit of securing participant data from public disclosure, all data will be stored on personal computer in a password-requiring folder. Furthermore, participant are assured in protection from any physical, emotional, psychological, or another harm. Klenke (2015) claimed that it is not “just talking” in interview that seeks to get to individual’s perspective by investigating one’s attitudes, beliefs, or perceptions about a given matter. Hence, qualitative researchers must develop interview questionnaire to illustrate deep respect for professional life and personal emotions of participants. They are also expected to conduct interview in an objective manner to facilitate interviewee’s sharing of personal views and opinions instead of governing one to a particular position. In this vein, an in-depth literature review and a holistic approach to the research process planning enables the author to formulate clear non-subjective interview questions to encourage therapists to report their experiences in maintaining industry boundaries.
Procedures
As any scholarly endeavor, this project follows a set of procedures to meet all academic criteria. First, permission from the institutional board will be gained to conduct a study engaging human participants. In this vein, a research proposal will be developed to indicate background to the problem, outline the research problem, indicate the research purpose and questions, and explain the chosen research design. The commission reviewed the submitted prospectus and approved the planned study. Second, the author has to contact and recruit a sample of selected target population.
Through the above-discussed procedures, a sample of 12-15 therapists licensed in the state of Georgia and working in therapeutic services’ settings is expected to recruitment. The project requires potential participants to spend their highly demanding time and thus, which implies getting into contact with therapists via phone to introduce the research purpose and goals first. In support of the declared necessity to investigate the field, several prior empirical findings will be cited to emphasize dramatic outcomes inherent to any minor boundary violation. In addition, responsibilities and rights of future participants in this endeavor will be outlined as well as the voluntary and non-paid nature of their participation will be indicated.
All interview sessions will be conducted via phone in order to obtain a more robust sample of participants who are located throughout the state of Georgia. As for the interviewee, the therapists will not have to spend additional time to get to the interview place and back. During the participant interviews, a smartphone with dictophone (app I Talk) will be used to record the conversation, while Hyper Research software will be used to transcribe those records later. The only material used during interview will be a list with a semi-structured interview questionnaire to govern and keep communication with therapists focused on the issue of boundary maintenance.
Data Processing and Analysis
Processing of the scope of data obtained will follow accurate data collection. In theory, qualitative analysis is a comprehensive process comprised of data review, organization, categorization into manageable informational units, synthesis, identification of patterns, determination of important issues for learning, and decision on what and how to share new piece of knowledge (Klenke, 2015). Processing of qualitative data aims at condensing, interpreting, categorizing, narrative structuring, and generating a meaning by using various analytical techniques to qualify and summarize collected data (Merriam & Tisdell, 2015).
Content analysis also called as ethnographic content analysis is the most widely used technique to process qualitative data. This unobtrusive technique “allows researcher to analyze relatively unstructured data in view of the meanings, symbolic qualities, and expressive contents they have and of the communicative roles they play in the lives of the data’s sources” (Merriam & Tisdell, 2015, p. 179). Keeping the researcher continuingly central, content analysis processes qualitative data in reflection to the investigator’s personality, concepts, and ideas. To ensure accuracy and to avoid researcher bias, qualitative content analysis requires application of specific coding strategies and careful processing procedures. In addition, this study will utilize Hyper Research software a tool designed for coding and retrieving qualitative data by moving through cases, determining new codes, and organizing the overall data set.
References
Abeles, N. (1998). What practitioners should know about working with older adults. Professional Psychology: Research and Practice, 29(5), 413-427.
Anzul, M., Ely, M., Freidman, T., Garner, D., & McCormack-Steinmetz, A. (2003). Doing qualitative research: Circles within circles. New York, NY: Routledge.
APA (2010). Ethical principles of psychologists and Code of Conduct. Including 2010 amendments. American Psychological Association. Retrieved from http://www.apa.org/ethics/code/
APA (2016). Understanding psychotherapy and how it works. American Psychological Association. Retrieved from http://www.apa.org/helpcenter/understanding-psychotherapy.aspx
Aravind, V. K., Krishnaram, V. D., & Thasneem, Z. (2012). Boundary crossing and violations in clinical settings. Indian Journal of Psychological Medicine, 34(1), 21-24.
Atiq, R. (2006). Common themes and issues in geriatric psychotherapy. Psychiatry, 3(6), 53-56.
Barnett, J. E., & Hynes, K. C. (2015). Boundaries and multiple relationships in psychotherapy: Recommendations for ethical practice. The Society for the Advancement of Psychotherapy. Retrieved from http://societyforpsychotherapy.org/boundaries-and-multiple-relationships-in-psychotherapy-recommendations-for-ethical-practice/
Bartels, D. M., Bauman, C. W., Cushman, F. A., Pizarro, D. A., & McGraw, A. P. (2016). Moral judgement and decision-making. In G. Keren & G. Wu (Eds.), Blackwell reader of judgment and decision-making (pp. 478-515). Malden, MA: Blackwell.
Bateman, A., Brown, D., & Peddler, J. (2010). Introduction to psychotherapy: An outline of psychodynamic principles and practice. 4th ed. New York, NY: Routledge.
Benjamin, D. (2010). The role of psychotherapy in the treatment of cancer. Journal of Alternative Medicine Research, 2(4), 429-438.
Bloch, S., & Green, S. A. (2005). An ethical framework for psychiatry. The British Journal of Psychiatry, 188(1), 7-12.
Blunt, D. R. (2006). Confindentiality, informed consent, and ethical considerations in reviewing the client’s psychotherapy records. ERIC Document Reproduction Service, No. ED490794, 1-22.
Bouhoutsos, J., Holroyd, J., Lerman, H., Forer, B. R., & Greenberg, M. (1983). Sexual intimacy between psychotherapists and patients. Professional Psychology: Research and Practice, 14(2), 185-196.
Bridges, N. A. (1999). Psychodynamic perspective on therapeutic boundaries. The Journal of Psychotherapy: Practice and Research, 8(4), 292-300.
Burgard, E. L. (2013). Ethical concerns about dual relationships in small and rural communities: A review. Journal of European Psychology Students, 4, 69-77.
Cahill, J., Barkham, M., Hardy, G., Gilbody, S., Richards, D., Bower, P., Audin, K., & Connell, J. (2008). A review and critical appraisal of measures of therapist-patient interactions in mental health settings. Health Technology Assessment, 12(24), 1-428.
Cameron, P. M., Ennis, J., & Deadman, J. (1998). Standards and guidelines for the psychotherapies. Toronto, Canada: University of Toronto Press.
Carlberg, G., Eresund, P., & Boethius, S. b. (2008). Child and adolescent psychotherapy research. Workshop for clinicians and researchers at the Erica Foundation October 2008. Stockholm, Sweden: Erica Foundation.
Cohn, T. J., & Hastings, S. L. (2013). Building a practice in rural settings: Special considerations. Journal of Mental Health Counseling, 35(3), n. p.
College of Psychotherapists of Ontario (2013). Guide to therapeutic relationships and professional boundaries. Ontario, Canada: College of Psychotherapists of Ontario.
Conway, P. (2013). The process dissociation of moral judgements: Clarifying the psychology of deontology and utilitarianism. Electronic Thesis and Dissertation Repository, 1630, 1-129.
Corey, G. (2009). Theory and practice of counseling and psychotherapy. London, UK: Cengage Learning EMEA.
CPSO (2004, September/October). Maintaining boundaries with patients. Member’s Dialogue, 7-15.
Craighead, W. E., & Craighead, L. W. (2001). The role of psychotherapy in treating psychiatric disorders. The Medical Clinics of North America, 85(3), 617-629.
Dewane, C. J. (2010). Respecting boundaries – The don’ts of dual relationships. Social Work Today, 10(1), p. 18.
Doverspike, W. F. (2008). Risk management: Clinical, ethical, and legal guidelines for successful practice. Sarasota, FL: Professional Resource Press.
Drukteinis, A. M. (2015). Strict liability for psychotherapists-patient sex. New England Psychodiagnostics. Retrieved from http://www.psychlaw.com/LibraryFiles/Liability.html
Eagle, R., & Barnes, D. (2013). Independent practice for the mental health professionals. New York, NY: Routledge.
Eddington, N., & Shuman, R. (2008). Ethics and boundary issues. Continuing Psychology Education Inc. Retrieved from http://www.texcpe.com/html/pdf/fl/FLETH.pdf
Elzer, M., & Gerlach, A. (2014). Psychoanalytic psychotherapy: A handbook. London, UK: Karnac Books.
Frank, J. D., & Frank, J. B. (1991). Persuasion and healing: A comparative study of psychotherapy. Baltimore, MD: Johns Hopkins University Press.
Freud, S., & Krug, S. (2002). Beyond the code of ethics, part II: Dual relationships revisited. Families in Society, 83(5), 483-492.
Galletly, C. A. (2004). Crossing professional boundaries on medicine: The slippery slope to patient sexual exploitation. The Medical Journal of Australia, 181(7), 380-383.
Garfinkel, P. E., Dorian, B., Sadavoy, J., Bagby, R. M. (1997). Boundary violations and departments of psychiatry. Canadian Journal of Psychiatry, 42, 764-770.
Goldstein, W. N., & Goldberg, S. T. (2006). Using the transference in psychotherapy. Lanham, MD: Jason Aronson Incorporated.
Gordon, N. S. (2000). Researching psychotherapy, the importance of the client’s view: A methodological challenge. The Qualitative Report, 4(3&4). Retrieved from http://www.nova.edu/ssss/QR/QR4-3/gordon.html
Greaves, A. L. (2006). The active client: A qualitative analysis of thirteen clients’ contributions to the psychotherapeutic process. Ann Arbor, MI: ProQuest.
Greenhalgh, T., & Health, I. (2010). Measuring quality in the therapeutic relationship. The King’s Fund. Retrieved from http://www.kingsfund.org.uk/sites/files/kf/field/field_document/quality-therapeutic-relationship-gp-inquiry-discussion-paper-mar11.pdf
Herman, S. M. (1998). The relationship between therapist-client modality similarity and psychotherapy outcome. The Journal of Psychotherapy: Practice and Research, 7(1), 56-64.
Holloway, I., & Wheeler, S. (2013). Qualitative research in nursing and healthcare. Chester, UK: John Wiley & Sons.
Jackson, L. C., & Greene, B. (2000). Psychotherapy with African American women: Innovations in psychodynamic perspectives and practice. New York, NY: Guilford Press.
Jarvis, M. (2004). Psychodynamic psychology: Classical theory and contemporary research. London, UK: Cengage Learning EMEA.
Johnson, S. H., & Farber, B. (1996). The maintenance of boundaries in psychotherapeutic practice. Psychotherapy Theory, Research, and Practice, 33(3), 391-402.
King, N., & Horrocks, C. (2010). Interviews in qualitative research. Thousand Oaks, CA: Sage Publications.
Klenke, K. (2008). Qualitative research in the study of leadership. Bingley, UK: Emerald Group Publishing.
Launder, S. D., Berk, M., Castle, D. J., Dodd, S., & Berk, L. (2010). The role of psychotherapy in bipolar disorder. The Medical Journal of Australia, 193(4), S31-S35.
Loue, S. (2015). Ethical issues in sandplay therapy practice and research. Cleveland, OH: Springer.
Loue, S. (2015). Ethical issues in sandplay therapy practice and research. Cleveland, OH: Springer.
Mander, G. 92007). Diversity, discipline, and devotion in psychoanalytic psychotherapy: Clinical and training perspectives. London, UK: Karnac Books.
Merriam, S. B., & Tisdell, E. J. (2015). Qualitative research: A guide to design and implementation. San Francisco, CA: John Wiley & Sons.
Miller, P. (2007). Ethical decision-making in social work and counseling: A problem/inquiry-based approach. Toronto, Canada: Nelson.
Moodley, R., Gielen, U. P., & Wu, R. (2013). Handbook of counseling and psychotherapy in an international context. New York, NY: Routledge.
Morgan, A. (2008). Being human: Reflections on mental distress in society. Ross-on-Wye, UK: PCCS Books.
Munhall, P. L., & Chenail, R. J. (2008). Qualitative research proposals and reports: A guide. Sudbury, MA: Jones & Bartlett Learning.
Norton, C. L. (2010). Innovative interventions in child and adolescent mental health. New York, NY: Routledge.
Novalis, P. N., Rojcewicz, S. J., & Peele, R. (1993). Clinical manual of supportive psychotherapy. Washington, DC: American Psychiatric Pub.
Owen, J., & Hilsenroth, M. J. (2014). Treatment adherence: The importance of therapist flexibility in relation to therapy outcomes. Journal of Counseling Psychology, 61(2), 280-288.
Perry, C., & Kuruc, J. W. (1993). Psychotherapists’ sexual relationships with their patients. Annals of Health Law, 2(1), 35-54.
Piper, W. E., & Ogrodniczuk, J. S. (2004). Quality of object relations as a moderator of the relationship between pattern of alliance and outcome in short-term individual psychotherapy. Journal of Personality Assessment, 83(3), 345-356.
Playford, R. C., Roberts, T., & Playford, E. D. (2014). Deontological and utilitarian ethics: A brief introduction in the context of disorders and consciousness. Disability and Rehabilitation, 37(21), 2006-2011.
Pope, K. S. (1990). Therapist-patient sex as sex abuse: Six scientific, professional, and practical dilemmas in addressing victimization and rehabilitation. Professional psychology: Research and Practice, 21(4), 227-239.
Pope, K. S., & Keith-Spiegel, P. (2008). A practical approach to boundaries in psychotherapy: Making decisions, bypassing blunders, and mending fences. Journal of Clinical Psychology, 64(5), 638-652.
Pope, K. S., & Vasquez, M. J. (2007). Ethics in Psychotherapy and counseling: A practical guide. San Francisco, CA: John Wiley & Sons.
Pope, K. S., & Vetter, V. A. (1992). Ethical dilemmas encountered by members of the American Psychological Association: A national survey. American Psychologist, 47(3), 397-411.
Pope, K. S., Tabachnick, B. G., & Keith-Spiegel, P. (2006). Sexual attraction to clients: The human therapists and the (sometimes) inhuman training system. American Psychologist, 41(2), 147-158.
Pope, K.S., & Vasquez, M. J. T. (2011). Ethics in psychotherapy and counseling: A practical guide. New York, NY: John Wiley & Sons.
Ramsdell, P. S., & Ramsdell, E. R. (1993). Dual relationships: Client perceptions of the effect of client-counselor relationship on the therapeutic process. Clinical Social Work Journal, 21(2), 195-212.
Riskin, L. L. (1979). Sexual relations between psychotherapists and their patients: Toward research or restraint. Cal L Review, 67, 1000-1027.
Rowson, R. (2001). Ethical principles. In F. Palmer Barnes & L. Murdin (Eds.), Values and ethics in the practice of psychotherapy and counselling (pp. 6-22). Buckingham, UK: Open University Press.
Ryan, R. M., Lynch, M. F., Vansteenkiste, M., & Deci, E. L. (2011). Motivation and autonomy in counseling, psychotherapy, and behavior change: A look at theory and practice. The Counseling Psychologist, 39(2), 193-260.
Sanderson, C. (2009). Introduction to counseling survivors of interpersonal trauma. London, UK: Jessica Kingsley Publishers.
Schacter, D., Gilbert, D., Wegner, D., & Hood, B. (2015). Psychology: Second European edition. London, UK: Palgrave Macmillan.
Schumann, J. H., & Alfandre, D. (2008). Clinical ethical decision-making: The four topics approach. Seminars in medical Practice, 11, 36-42.
Schuster, D. P., & Powers, W. J. (2005). Translational and experimental clinical research. Baltimore, MD: Lippincott Williams & Wilkins.
Seidman, I. (2015). Interviewing as qualitative research: A guide for researchers in education and the social sciences. 4th ed. New York, NY: Teachers College Press.
Sharma, R. K. (1997). Sociological methods and techniques. New Delhi: Atlantic Publishers & Distributors.
Shavit, N., & Bucky, S. (2004). Sexual contact between psychologists and their former therapy patients: Psychoanalytic perspectives and professional implications. The American Journal of Psychoanalysis, 64(3), 229-248.
Simon, R. I. (1989). Sexual exploitation of patients: How it begins before it happens. Psychiatry Annals, 19, 104-122.
Simon, R. I. (1992). Treatment boundary violations: Clinical, ethical, and legal considerations. Bull Am Acad Psychiatry Law, 20(3), 269-288.
Smith, D., & Fitzpatrick, M. (1995). Patient-therapy boundary issues: An integrative review of theory and research. Professional Psychology: Research and Practice, 26(5), 499-506.
Smith, H. (2008). Client factors predicting outcome in group treatment for driving anger. Ann Arbor, MI: ProQuest.
Sommers-Flanagan, J., & Sommers-Flanagan, R. (2011). DVD counseling and psychotherapy theories in context and practice: Skills, strategies, and techniques. Hoboken, NJ: John Wiley & Sons.
Strauss, B., Barber, J. P., & Castonguay, L. (2015). Visions in psychotherapy research and practice: Reflections from the presidents of the Society for Psychotherapy Research. New York, NY: Routledge.
Svartberg, M. (1992). Sexual contacts between psychotherapists and patients. A review of recent American literature. Tidsskr Nor Laegeforen, 112(26), 3298-3301.
Totton, N. (2010). Boundaries and boundlessness. Therapy Today, 21(8). Retrieved from http://www.therapytoday.net/article/show/2101/boundaries-and-boundlessness/
Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work. New York, NY: Routledge.
Wedding, D., & Corsini, R. J. (2013). Case studies in psychotherapy. Stamford, CT: Cengage Learning.
Weiner, I. B., & Craighead, W. E. (2010). The Corsini encyclopedia of psychology, 2nd volume. Hoboken, NJ: John Wiley & Sons.
Weisz, J. R. (2004). Psychotherapy for children and adolescents. Evidence-based treatments and case examples. Cambridge, UK: Cambridge University Press.
Welfel, E. R. (2015). Ethics in counseling and psychotherapy. Boston, MA: Cengage Learning.
Whitaker, C. A., & Malone, T. P. (2014). Roots of psychotherapy. New York, NY: Routledge.
Wright, J. H., & Davis, D. (1994). The therapeutic relationship in cognitive-behavioral therapy: Patient perceptions and therapist responses. Cognitive and Behavioral Practice, 1, 25-45.
Wright, R. H., & Cummings, N. A. (2013). Destructive trends in mental health: The well intentioned path to harm. New York, NY: Routledge.
Yonan, J., Bardick, A. D., & Willment, J. A. H. (2011). Ethical decision-making, therapeutic boundaries, and communicating using online technology and cellular phones. Canadian Journal of Counseling and Psychotherapy, 45(4), 307-326.
Younggren, J. N. (2002). Ethical decision-making and dual relationships. Retrieved from
Zur (2015). Dual relationships, multiple relationships, boundaries, boundary crossing and boundary violations in psychotherapy, counseling, and mental health. Zur Institute. Retrieved from http://www.zurinstitute.com/dualrelationships.html
Zur, O. (2004). To cross or not to cross: Do boundaries in therapy protect or harm? Psychotherapy Bulletin, 39(3), 27-32.
Our Service Charter
-
Excellent Quality / 100% Plagiarism-Free
We employ a number of measures to ensure top quality essays. The papers go through a system of quality control prior to delivery. We run plagiarism checks on each paper to ensure that they will be 100% plagiarism-free. So, only clean copies hit customers’ emails. We also never resell the papers completed by our writers. So, once it is checked using a plagiarism checker, the paper will be unique. Speaking of the academic writing standards, we will stick to the assignment brief given by the customer and assign the perfect writer. By saying “the perfect writer” we mean the one having an academic degree in the customer’s study field and positive feedback from other customers. -
Free Revisions
We keep the quality bar of all papers high. But in case you need some extra brilliance to the paper, here’s what to do. First of all, you can choose a top writer. It means that we will assign an expert with a degree in your subject. And secondly, you can rely on our editing services. Our editors will revise your papers, checking whether or not they comply with high standards of academic writing. In addition, editing entails adjusting content if it’s off the topic, adding more sources, refining the language style, and making sure the referencing style is followed. -
Confidentiality / 100% No Disclosure
We make sure that clients’ personal data remains confidential and is not exploited for any purposes beyond those related to our services. We only ask you to provide us with the information that is required to produce the paper according to your writing needs. Please note that the payment info is protected as well. Feel free to refer to the support team for more information about our payment methods. The fact that you used our service is kept secret due to the advanced security standards. So, you can be sure that no one will find out that you got a paper from our writing service. -
Money Back Guarantee
If the writer doesn’t address all the questions on your assignment brief or the delivered paper appears to be off the topic, you can ask for a refund. Or, if it is applicable, you can opt in for free revision within 14-30 days, depending on your paper’s length. The revision or refund request should be sent within 14 days after delivery. The customer gets 100% money-back in case they haven't downloaded the paper. All approved refunds will be returned to the customer’s credit card or Bonus Balance in a form of store credit. Take a note that we will send an extra compensation if the customers goes with a store credit. -
24/7 Customer Support
We have a support team working 24/7 ready to give your issue concerning the order their immediate attention. If you have any questions about the ordering process, communication with the writer, payment options, feel free to join live chat. Be sure to get a fast response. They can also give you the exact price quote, taking into account the timing, desired academic level of the paper, and the number of pages.