Preventing Boundary Violations in Clinical Practice

Reviewing a book that has enthusiastic endorsements from luminaries such as Glen Gabbard and Ken Pope on the back cover is like commenting on work that God has blessed, which is an extra burden on the hapless reviewer. The job is not made any easier by the fact that the book was published five years ago and reprinted in 2011, raising the inevitable questions in the reader's mind: why another review and why now? What else can be said on this topic?

The book is divided into three sections, Foundations, Explorations, and Implications, and they do exactly what the titles suggest. The Foundation section sets the scene by describing the ethics-related principles and purposes of boundaries in clinical practice. In Explorations the authors use clinical scenarios to distinguish between boundary violations and what they describe as boundary crossings. The last section describes the implications for clinicians and trainers in relation to both prevention of violations and education.

The authors claim that boundary crossings are relatively benign transgressions that ostensibly do not cause any harm. I have never been a big fan of the concept of boundary crossings, as I think the distinction made by the authors between crossings and violations creates a false dichotomy. Based on what I have seen in clinical practice, I have come to believe that boundary crossings are boundary violations waiting to happen and that maintaining the distinction is problematic.

One problem with this distinction is that boundary crossings may be repeated and may develop into boundary-violating behaviors over time. Further, it is not clear who will decide whether a behavior may cause or has caused harm. For example, is taking a tip on how a stock will perform from a stockbroker patient a crossing or a violation? And who decides? Robert Simon, a dean of American forensic psychiatry, has called such apparent mini transgressions the road much traveled and warns that repeated so-called boundary crossings may lead to what Gutheil would call a boundary violation. After all, the therapist's neutrality is eroded, even in the most apparently harmless of boundary crossings. Isn't that the real danger?

There may be some mileage in considering the harm caused as the basis of a contrast between the behaviors. After all, this is a distinction that may have a significant impact in the forensic arena, whether in terms of a financial award or revocation of a doctor's license. The assessment of harm is complex, however, depending as it does on a multitude of host factors such as resilience and psychological makeup. To what extent can the harm be assessed according to a formula, however faithfully recreated every time? What if the patient sees no harm, but other professionals do? I leave these questions for the reader to contemplate.

Gutheil and Brodsky tell a good tale, and they know how to hold the audience's attention. In this regard, the book has achieved something rarely found in academic books: it can be read in one sitting. However, the book cries out for a second or revised edition, as it does not deal with the modern scourges of the Internet and social media. At the time the book was written, presumably social media was not as popular. Facebook was still a fetish for teenagers, and Twitter had just been invented. In the age of the Internet and social media, the goalposts have widened. Educators are forced to include social media and its dangers in their courses on boundaries in medical schools everywhere. What if your patient asks you to friend her on Facebook? Or wants to follow you on Twitter? How do you deal with the request? Do you say yes or no? Or do you say, in Woody Allen fashion, “wonder what that means to you?”

The authors cleverly describe their book as a “supervisor on a book shelf” (p 11). The book is replete with exceptionally crafted case vignettes and analysis, which is the main strength of the book, along with the authors' beautifully flowing prose. This book is a very welcome addition to the existing literature on professional boundary violation, and reading it may well (as the cover suggests) prevent such violations in clinical practice. The book really is a supervisor, but it is more. Like a good supervisor, it stays in your professional conscience and imprints on your mind the harm that is caused by boundary transgressions. It is also a reminder that to label a behavior as either a crossing or a violation may not really matter all that much, as long as you are prepared to take time to reflect on your professional behavior and seek advice from your peers. Perhaps what is most important is to realize that everyone is vulnerable in certain situations and that boundary setting and maintenance is a life-long professional commitment.

• © 2013 American Academy of Psychiatry and the Law