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Boundaries preserve psychotherapeutic process. (Atmosphere of Safety).

NEW YORK -- Clear boundaries create structure and preserve the integrity of the therapeutic relationship, a panel of psychiatrists said at a psychiatric meeting sponsored by the New York Academy of Medicine.

"Boundaries define who we are--without them, there would be chaos," said Dr. Herbert Peyser of Mount Sinai School of Medicine, New York.

Boundaries are confining and can appear restrictive, but ultimately they lead to greater freedom of expression for the therapist. "Boundaries do not connote rigidity, remoteness, coldness, or aloofness," said Dr. Richard Milone, medical director of St. Vincent's Westchester in Harrison, N.Y. Rather, they are designed "to create an atmosphere of safety and predictability that facilitates treatment." Within that climate of safety, the therapist can interact with "warmth, empathy, sincerity, and spontaneity."

Boundaries also enable therapists to be attuned to their own inner experiences--particularly countertransference. The nature of the therapeutic relationship makes the therapist privy to the patient's intimate revelations, which often are of a sexual nature. This can invite countertransference reactions and can potentially create an exploitative" atmosphere, said Dr. Elizabeth Tillinghast, director of the Columbia/Cornell Residency in Psychiatry and the Law.

Even well-intentioned, nonpredatory therapists can exploit a patient's "need, vulnerability, and dependence" as a result of their own unresolved emotional conflicts, she noted.

Observing clear boundaries can protect therapists from the "slippery slope" that might end in severe sexual exploitation and can keep therapists aware of their own actions and motives. "Without boundary definitions, we don't know what's going on inside ourselves," said Dr. Zev Labins of Columbia University, New York.

Boundaries apply to all aspects of the patient-therapist relationship, not only to the sexual arena. The agreed-upon length of each session is a time-related boundary. Extending a particular patient's session beyond the contracted time might be a clue to a countertransferential process at work within the therapist. "If my usual session time is 45 minutes and I have allowed my patient to overstay, this gives me the opportunity to question what's going on inside me," Dr. Labins said.

Dr. Milone listed other boundaries:

* Abstaining from physical contact.

* Declining to accept lavish gifts from the patient.

* Avoiding dual relationships (social or financial) with the patient.

* Asymmetry of self-disclosure.

* Designating a specific location for appointments.

He noted that the boundaries can vary, depending on the nature of treatment. For example, a behavioral therapist might meet with an agoraphobic patient at a shopping mall or restaurant. A psychopharmacologist might need to touch a patient during a physical examination, and a community mental health worker might visit a patient's apartment. Such clinicians should "make sure that whatever they are doing is part of a carefully organized and documented treatment plan," Dr. Milone cautioned.

Panelists agreed that boundaries can and must be established, but there are no hard and fast rules to their application in all circumstances. Although boundaries "have to be defined ... they can't always be maintained," Dr. Labins said.

Dr. Milone concurred, further distinguishing between "boundary violations" and "boundary crossings." Boundary violations are "harmful or potentially harmful or exploitative of the patients." Boundary crossings, on the other hand, can be "positive ... in that they advance the therapy constructively" and are "inevitable in the course of psychotherapy."

For example, it may be appropriate to grasp the hand of a patient who has lost a loved one, or to accept a cookie from a guarded, hypervigilant patient. These "boundary crossings" enhance the message of empathy or encouragement that the clinician wishes to convey.

Dr. Stephen Billick of New York Medical College, Valhalla, cited the case of a patient whose bar mitzvah he considered attending. The patient, who had begun therapy several years earlier during a near-suicidal depression, expressed to Dr. Billick how much his attendance at the bar mitzvah would mean to him. Dr. Billick considered accepting the invitation as a way of demonstrating support and sharing his patient's pride in this important milestone. "I received advice from colleagues that my attendance was 'therapeutically essential,'" said Dr. Billick, who is a member of the Ethics Committee of the New York County District Branch of the American Psychiatric Association.

Family and culture must be taken into account, said Dr. Billick, who noted that in small towns, or among certain ethnic groups, the usual boundary guidelines might need to be re-examined.

In the words of Dr. Karl Menninger, Dr. Milone advised: "When in doubt, act human." But, acting human should be accompanied by definitive action to resolve questions of boundary violation. "Don't act alone. Consult, consult, consult," he advised. "Get good supervision, and document your decisions."

RELATED ARTICLE: Wise Boundaries

Protect yourself from misunderstandings, even if you are not engaging in outright boundary violations, Dr. Milone advised at the meeting. These misunderstandings can cause disruptions in the therapeutic relationship and may have legal repercussions.

Speaking in his capacity as a clinician rather than as chairman of the American Psychiatric Association Ethics Committee, Dr. Milone gave the following advice:

* Schedule appointments with intense erotic-transference patients during high traffic times of day.

* Use only dedicated office space for appointments. Don't hold sessions in restaurants or cars--unless you are a behavioral therapist working with a phobia related to these environments.

* Dress in clothing considered "professional" in your community Avoid dressing provocatively.

* Do not use four-letter words. Some patients regard these words as "verbal rape" and feel assaulted.

* Be wary of calling the patient by his or her first name too soon.

* Avoid barter arrangements. These may be illegal and are ill-advised.

* Do not see patients free of charge.

* Make clear financial arrangements with patients, and follow through on them.

* Avoid accepting large gifts from patients.

* Small gifts, especially handmade ones, are acceptable and may, for the patient, represent a step toward health and strength.

* Do not display your patients' gifts.

* Begin and end sessions on time.
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Author:Yasgur, Batya Swift
Publication:Clinical Psychiatry News
Geographic Code:1USA
Date:Jun 1, 2002
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