|
A well written article in the current Psychiatric Services by Donna M. Norris, M.D., Thomas G. Gutheil, M.D. and Larry H. Strasburger, M.D. discusses the issues of boundary problems (sexual and non-sexual) between patients and psychotherapists. The authors point out that television and movie dramas have portrayed boundary dilemmas in serious and humourous ways.Recent examples include the television program The Sopranos and the film Analyze This. "Despite broad agreement in psychiatry that sexual misconduct and other boundary violations can cause notable harm to patients, some of our most senior and accomplished practitioners and teachers continue to find themselves embroiled in these difficulties."
The authors describe a vignette where a board-certified psychotherapist saw a woman in individual psychotherapy for ten years. During the course of the therapeutic relationship, he negotiated with her to sell her two of his boats, sight unseen. Additional transactions involved sales of other personal property to him. The patient had financial problems and within a year, the bank repossessed the boat and the patient declared bankruptcy.
After suicide, boundary problems and sexual misconduct rank highest as causes of malpractice actions against mental health providers. The authors believe that, psychiatric training about boundary issues has continued to be ineffective despite today's wider awareness of the dangers to patients, threats to psychiatrists' licensure and professional ostracism. They speculate that these deficits of modern psychiatric training and practice may reflect the additional pressures of managed care that encouraged "a paradigm shift in psychiatry away from psychotherapy and toward pharmacology and excessively brief psychotherapies.. We continue to see a steady stream of boundary violations, both sexual and nonsexual,in all psychiatric contexts." They point out that despite wide publicity, denial "This couldn't happen to me" must also play a significant role in the persistence of the problem.
They point out that therapists must learn to recognize trouble spots as risk factors for developing boundary difficulties:
Life crises - midlife and late-life crises in therapists' development
Transitions - retirement,job loss,job change,promotion or job transfer
Illness of the therapist - increases therapist's vulnerability to turning inappropriately to a patient for solace and support
Loneliness and the impulse to confide - a therapist encountering some life difficulty and seeking a "sympathetic" ear may struggle with the need to confide in a patient about financial reversals, marital or sexual problems, professional setbacks, problems with his or her children, etc
Idealization and the "special patient"
Pride, shame, and envy
Problems with limit setting -
"Small town" issues -Closed communities pose another sort of boundary problem
Denial
Drs Norris, Gutheil, Strasburger also outline factors exacerbating patient vulnerability that therapists should be aware of and finally, they suggest that the solution should include education, supervision and consultation.
Psychiatr Serv 54:517-522, April 2003
12:14:44 AM 
|
|
