An Essential Article on Boundaries:
How The Field Began To Focus on Distinguishing Boundary Crossings (Helpful or Neutral) from Boundary Violations (Harmful) in the Early 1990s
A vast array of authors have made valuable contributions to our understanding of boundaries in psychotherapy. A literature search shows that the topic (boundaries, dual relationships, etc.) has served as the title of over 1,500 books, articles, or dissertations.
It seems worth highlighting a frequently-cited key article that has helped transform our understanding and formed the framework for what seems to be the predominant view of boundaries today.
The 15 years running from the 1980s through the mid 1990s saw a virtual explosion of healthy controversy over dual relationships, bartering, nonsexual touch, meeting therapy clients outside the office for social visits, and other nonsexual boundary issues. Professionals wrote thoughtful articles arguing over virtually every aspect of nonsexual boundaries -- Should all prohibitions be abolished? Was it possible to tell which boundary crossing were therapeutically indicated as helpful, which were therapeutically contra-indicated as harmful, which might be necessary or unavoidable in certain communities or cultures?
Research during this period showed ways in which theoretical orientation, size of the local community, therapist gender, client gender, profession (psychologist, psychiatrist, social worker, etc.), and other factors affected both the degree to which therapists engaged in crossing various boundaries and therapists' beliefs about the nature and appropriateness of boundary crossings.
A landmark 1993 article seemed to draw these evolving viewpoints and research findings into a useful framework that helps shape our current understandings and practices: "The Concept of Boundaries in Clinical Practice" by Thomas G. Gutheil and Glen 0. Gabbard (American Journal of Psychiatry, vol 150, #2, pp. 188-196),
Gutheil and Gabbard cast a new light on the historical context of boundaries. Pointing out that many who endorse inflexible boundaries rely on Freud as an authority, they describe how Freud himself sometimes sent postcards to his patients, lent them his books, gave them gifts, talked with them about his own family members, shared meals with an analytic client while on vacation, conducted an analysis while walking through the countryside, and analyzed his own daughter. (It is worth noting for those who love animals that he routinely brought his beloved dog Jofi into the consulting room with him while he conducted analyses.)
The article emphasizes that "crossing certain boundaries may at times be salutary, at times neutral, and at times harmful."
In their initial "explorations" of this notion they suggest a framework of "boundary crossings" and "boundary violations" in which judgments must be made on a case-by-case basis in light of the context and specifics:
If this exploration is to be useful, we should adopt the convention that "boundary crossing" in this article is a descriptive term, neither laudatory nor pejorative. An assessor could then determine the impact of a boundary crossing on a case-by-case basis that takes into account the context and situation-specific facts, such as the possible harmfulness of this crossing to this patient. A violation, then, represents a harmful crossing, a transgression, of a boundary.
They discuss examples and implications of this basic framework in such diverse areas of boundaries as "role; time; place and space; money; gifts, services, and related matters; clothing; language; self-disclosure and related matters; and physical contact. While broad guidelines are helpful, the specific impact of a particular boundary crossing can only be assessed by careful attention to the clinical context."
The article also introduces a discussion of how some regulatory bodies have had difficulty addressing boundary issues in disciplinary actions in a way that took account of theoretical orientation and other contexts, was consistent with the research, and was fair to the therapist. They addressed their concerns about this aspect in much more detail in their subsequent widely-cited and influential 1998 article: "Misuses and misunderstandings of boundary theory in clinical and regulatory settings" (American Journal of Psychiatry, vol. 155, #3, pp. 409-414).
"The Concept of Boundaries in Clinical Practice" was a turning point for the field. It is a wonderful resource for thinking through and challenging beliefs, for providing thoughtful explorations, for learning from and arguing against, for an understanding of the history and development of this area, and for helping to think through difficult decisions in our day-to-day clinical work.
I believe that this article (along with its follow-up on misuses and misunderstandings of boundary theory in clinical and regulatory settings) is one of those essential works that every clinician, supervisor, expert witness, and member of a licensing board or ethics committee should read and be familiar with. Students in any course on boundaries, ethics, clinical standards of care, clinical judgment and decision-making, or related topics should encounter it on the reading lists.
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G. Gutheil, Professor of
Psychiatry, Harvard Medical School, 6 Wellman St., Brookline MA 02446;
For those interested in these issues, I've made a variety of free resources available on this site. These resources include:
1) standards for dual relationships & other boundary issues quoted from the codes of over 25 professional associations (with links to the complete codes);
2) quotes & research findings about boundaries in therapy from articles, books, & studies;
3) complete articles (those for which I was able to obtain copyright permission from the publisher to post on the web) addressing boundaries from American Psychologist, Professional Psychology: Research & Practice, etc.;
4) widely-used decision-making guides for boundary issues (by Jeff Younggren; by Mike Gottlieb; & by Janet Sonne); and