In the Therapeutic Setting Elizabeth M. Wallace, MD, FRCPC

 1. Describe components and functions of the therapeutic frame  2. Differentiate boundary crossings from boundary violations.  3. Describe common characteristics of physicians who commit sexual boundary violations.  4. Appreciate the inherent power imbalance in the therapeutic relationship.  5. List elements in the prevention of sexual boundary violations.

◦ Define the relationship with the patient ◦ Establish a framework for treatment ◦ Set expectations ◦ Major factor in establishing trust ◦ Make possible evaluation of deviations from the frame

◦ Setting, duration, frequency, procedures, policies e.g. cancellation policy ◦ Clinician is paid to deliver a service ◦ Absence of unnecessary physical contact ◦ Limited self-disclosure ◦ Absence of dual relationships outside the treatment ◦ Confidentiality and limits of confidentiality ◦ Clothing and language (mostly implicit)

CROSSINGS VIOLATIONS ◦ Benign and even helpful breaks in the frame ◦ Usually occur in isolation ◦ Minor and attenuated ◦ Discussable ◦ Ultimately cause no harm to patient, clinician, or treatment ◦ Exploitive breaks in the frame ◦ Usually repetitive ◦ Egregious and often extreme e.g. sexual ◦ Clinician discourages discussion ◦ Typically cause harm to patient, clinician or treatment

◦ DEFINITION:  Any kind of physical contact occurring in the context of a therapeutic relationship for the purpose of erotic pleasure  (Many affectionate gestures made by clinicians are misconstrued at the time they occur or at some later point e.g. hug)

◦ 7-12% of practitioners in the U.S. (anonymous self- report, all disciplines) ◦ Gender: Male practitioners account for 80+% of incidences  7-9% of male practitioners (most with female patients)  2-3% of female practitioners (most with female patients)  Least frequent: Male practitioner – male pt., Female practitioner – male pt.

◦ Middle-aged male ◦ In solo practice ◦ Sexual dual relationship with one female patient ◦ Female transgressors  70% same sex  Practitioner views herself as heterosexual  Love and tenderness in relationship drifts to sexual relationship  Male patient: may feel triumphant rather than victimized

◦ Gabbard (1994) proposed 4 underlying psychological profiles:  1. Psychotic disorders  2. Predatory psychopathy and paraphilias  3. Lovesickness – on a continuum with 4.  4. Masochistic Surrender

◦ These cases have attracted media attention, but not the most prevalent ◦ Typically refuse to be evaluated ◦ Persistently lie about their conduct despite multiple complaints ◦ Blame the patient(s) ◦ Dynamics involve sadism, need for power or control

◦ Most prevalent category – usually one-time offenders ◦ Seek help, display genuine remorse ◦ Can be effectively rehabilitated ◦ Typical scenario:  Heterosexual male, isolated in practice, treating a difficult patient, in a highly stressful time in his life  Relationship usually intense, may last several years and fell like “true love”  Ethical complaint most likely filed by pt. when MD ends the relationship

◦ Longstanding narcissistic vulnerability ◦ Grandiose (covert) rescue fantasies ◦ Intolerance of negative feelings of pt. ◦ Childhood: emotional deprivation and sexualization ◦ Family history of covert and sanctioned boundary violations ◦ Unresolved anger towards authority figures ◦ Limited awareness of inner world

◦ Therapeutic context is an imbalanced structure with respect to ◦ POWER ◦ NONRECIPROCAL MODES OF RELATING ◦ IMBALANCES ARE CONTEXTUALIZED AND IRREDUCIBLE

◦ EDUCATION – about boundaries, power differential, transference/countertransference, ethics ◦ CONSULTATION – with colleagues on all intense feelings towards patients (love and hate) ◦ SELF-CARE – work/life balance, satisfying relationships, support network, personal therapy if needed

◦ Awareness of clinician risk factors – personal history, current stressors ◦ Awareness of patient risk factors  Challenging patients – personality disorder  Suicidality  History of sexual abuse ◦ Awareness of vulnerability at “edges” of treatment i.e. moments of transition – end of appointment, between chair and door, outside the office

◦ Why am I thinking of doing/saying this? ◦ Would I do this with all my patients? ◦ Why with this particular patient? ◦ Why at this particular time?

◦ How much do I know about how this will be received by the patient? ◦ Is there a safer way of achieving the same goal? ◦ Why do I think I can do this without harm? ◦ Would I hesitate to tell a colleague what I have done? ◦ Would I worry if my patient told someone?