Setting Boundaries Benefits Both Clinician and Patient

In this Q&A, Ashley H. VanDercar, MD, JD, assistant professor, Case Western Reserve University, Cleveland, Ohio, discusses her session "Boundaries: How Close is Too Close?" presented today at Psych Congress Elevate 2022 in Las Vegas, Nevada. Dr VanDercar explains the benefit of setting clinical boundaries, what constitutes a "crossing" versus a "violation," and how practitioners can incorporate effective boundaries with their patients.  

Question: What are some key takeaways from your Elevate session “Boundaries: How Close is Too Close?”

Answer: Boundaries define the contours of a therapeutic relationship. They include things such as the time and place of a session, the role of the clinician, and methods of communicating between appointments. Some boundaries are universal and apply equally to all mental health clinicians; for example, the prohibition on having sexual contact with, or financially exploiting, a patient. However, most boundaries are context dependent.

When determining your clinical boundaries, it is crucial to consider the clinical milieu within which you work. A psychoanalyst will have a different set of boundaries than a homeless, mentally ill outreach worker. Ultimately, the exact location of a given boundary—and when it is permissible to “cross” that boundary—tends to depend on the specific situation and associated therapeutic concerns.

Q: What is the difference between a “boundary crossing” and a “boundary violation?”

A: When a clinician deviates from clinical boundaries in a way that is exploitive, or foreseeably harmful, it is a boundary violation. This is not to say that all boundary deviations are necessarily bad. In fact, a boundary crossing is when a clinician deviates from a boundary in a way that is not harmful; in certain situations, a boundary crossing can even be therapeutically beneficial.

For example, an office-based therapist typically has a location boundary; they only perform therapy in the office. If, however, their patient is sitting (alone) on the floor outside of the waiting room sobbing after receiving bad news, it would be permissible for the therapist to cross the location boundary and provide brief supportive therapy (at least until the patient could compose themselves and move into the office). That would be a boundary crossing. It was performed for the patient’s benefit. The clinician should document it and could (at a later date) discuss it with the patient. In contrast, deviating from the location boundary by asking a patient out for alcoholic drinks after a therapy session would be unethical and a boundary violation.

Q: What are the major legal concerns regarding boundary violations that clinicians should be aware of?

A: Boundary violations can lead to professional sanctions, civil suits, and—in certain cases—even criminal charges.

Q: How does setting boundaries in clinical practice benefit the patient?

A: Boundaries help delineate the therapeutic contract. They provide clarity on the role (and motivation) of the clinician and the nature—as well as the purpose—of each clinical interaction. This clarity helps facilitate a safe space where patients can share their private thoughts and feelings.

Q: Any final thoughts?

Consider where your boundaries are. With certain issues, such as time, place, and monetary renumeration, this question can be fairly straightforward. When it comes to role issues and self-disclosures, this can become more challenging.

Boundaries should be objectively reasonable; in other words, if someone in the same role as you views your clinical practice, your boundaries should appear justified.

Once you know where your clinical boundaries are, be purposeful and thoughtful before you cross one. Consider why you are crossing the boundary. Weigh out the risks and benefits. Ensure that the likely benefits outweigh the risks, and that the boundary crossing is being done for a therapeutic reason. Document these things; if in doubt, consult a colleague.

References:

Gutheil, T G, Brodsky A. Preventing boundary violations in clinical practice. Guilford Press: 2011.

American Psychiatric Association. APA commentary on ethics in practice. APA: 2015. 

Ashley H. VanDercar, MD, JD, is an Assistant Professor of Psychiatry at Case Western Reserve University and a staff psychiatrist at Northcoast Behavioral Healthcare, where she co-leads a competency restoration unit. Dr VanDercar began her career as an attorney, working in healthcare. She later obtained a medical degree from the University of Miami Miller School of Medicine. She completed her adulty psychiatry residency and forensic psychiatry fellowship at University Hospitals’ Cleveland Medical Center, Case Western Reserve University. She is board certified in adult psychiatry and forensic psychiatry. Dr VanDercar has published on topics ranging from organizational psychiatry to terrorism. She has presented at local and national conferences on topics such as civil commitment, psychiatric malpractice, and expert witness testimony. She teaches medical students, residents, forensic psychiatry fellows, law students, and police officers.