Boundaries Crossing


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Boundaries Crossing

  1. 1. BOUNDARIES CROSSING 2 April 2010 RANZCP Congress Aukland, NZ <ul><li>Gary R. Schoener </li></ul><ul><li>Clinical Psychologist & Executive Director </li></ul><ul><li>Walk-In Counseling Center </li></ul><ul><li>Minneapolis, Minnesota </li></ul>
  2. 2. WHAT ARE BOUNDARIES? <ul><li>“ Professional boundaries in medical practice are not well defined. In general, they are the parameters that describe the limits of a fiduciary relationship in which one person (a patient) [or client] entrusts his or her welfare to another (a physician) [or professional], to whom a fee is [usually] paid for the provision of a service.”* </li></ul><ul><li>*(Taken from Gabbard & Nadelson, “Professional Boundaries in the Physician-Patient Relationship” JAMA, May 10, 1995-Vol. 273, No. 18). </li></ul>
  3. 3. BOUNDARIES ALWAYS DEPENDENT ON CONTEXT <ul><li>Type of Therapy/Therapeutic Frame </li></ul><ul><li>Treatment Contract </li></ul><ul><li>Organizational Rules </li></ul><ul><li>Setting – small town, rural vs. urban </li></ul><ul><li>Cultural differences/expectations   </li></ul>
  4. 4. CONTEXT: Other Situational Factors <ul><ul><li>Faith Group or Faith – Based </li></ul></ul><ul><ul><li>Gay/Lesbian/Transgender </li></ul></ul><ul><ul><li>Military </li></ul></ul><ul><ul><li>Ethnic Group </li></ul></ul><ul><ul><li>Small College </li></ul></ul><ul><ul><li>Institute (Therapist treating Therapist) </li></ul></ul><ul><ul><li>Age/Health Status (e.g. homebound) </li></ul></ul>
  5. 5. <ul><li>Changed Perception of Relationship </li></ul><ul><ul><li>Can lead to a positive or negative interpretation by patient; </li></ul></ul><ul><ul><li>Impact on perception of patients, relatives, others in community </li></ul></ul><ul><li>Self-Disclosure by Practitioner </li></ul><ul><ul><li>Role Reversal </li></ul></ul><ul><ul><li>Changed perception by patient </li></ul></ul>Social Contact w/ Patients
  6. 6. Commonwealth of Massachusetts Board of Registration in Medicine Policy 94-001, January 12, 1994 <ul><li>General Guidelines related to the maint. of boundaries in the practice of psycho-therapy by physicians (adult pts.)* </li></ul><ul><ul><ul><li>Appointment place and time </li></ul></ul></ul><ul><ul><ul><li>Billing practices </li></ul></ul></ul><ul><ul><ul><li>Other economic relationships </li></ul></ul></ul><ul><ul><ul><li>Physical contact </li></ul></ul></ul><ul><ul><ul><li>Self disclosure </li></ul></ul></ul>
  7. 7. <ul><li>General Guidelines continued… </li></ul><ul><ul><ul><li>Gifts </li></ul></ul></ul><ul><ul><ul><li>Non-sexual social relations </li></ul></ul></ul><ul><ul><ul><li>Patients’ families </li></ul></ul></ul><ul><ul><ul><li>Changes in behavior regarding boundaries </li></ul></ul></ul><ul><ul><ul><li>Circumstances in which termination should be considered because boundaries cannot be maintained </li></ul></ul></ul><ul><li>* Developed in conjunction with the Mass. Psychiatric Society, the Boston Psychoanalytic Institute and the Mass. Medical Society) </li></ul>
  8. 8. <ul><li>“ Self-disclosure, in general, should be kept to a minimum in psycho-therapy. There are, however, a few circumstances in which self-disclosure may be appropriate … </li></ul>Example: Self Disclosure
  9. 9. <ul><li>... First, patients have a right to know the physician’s training and qualifications when deciding whether to establish a physician-patient relationship. Second, in the treatment of addictions, disclosure of the psychotherapist’s own history of substance abuse treatment has become common… </li></ul>
  10. 10. <ul><li>... Finally, there are infrequent occasions when self-disclosure can have an important therapeutic impact. These situations need to be well thought out, and it must be clear that these disclosures serve the patient, not the therapist… </li></ul>
  11. 11. <ul><li>... It is never appropriate for physicians practicing psychotherapy to discuss their own current emotional problems or to disclose details of their sexual lives.” </li></ul><ul><ul><li>Commonwealth of Mass. Board </li></ul></ul><ul><ul><li>of Registration in Medicine, General Guidelines related to the maint. </li></ul></ul><ul><ul><li>of boundaries in the practice of psychotherapy by physicians (adult patients), January 12, 1994. </li></ul></ul>
  12. 12. BOUNDARY CROSSINGS <ul><li>Myth of the Slippery Slope : There is not good evidence that one boundary crossing leads to another – however, if boundaries are being broken down there may be a succession of crossings. </li></ul><ul><li>Myth of the Small Violation : Some times a seemingly minor crossing is ignored – it could be the beginning of a major breakdown or simply the one visible sign of it. </li></ul>