PROFESSIONAL BOUNDARY VIOLATIONS IN PSYCHOTHERAPEUTIC WORK

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PROFESSIONAL BOUNDARY VIOLATIONS IN
PSYCHOTHERAPEUTIC WORK

• byGlen O. Gabbard, M.D.Brown Foundation Chair
  of Psychoanalysis
• andProfessor of Psychiatry Baylor College of
  Medicine

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Two Connotations of Boundaries

• The architecture of the analytic frame
• The limits of widening scope technique

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Fundamental Paradox

• Radical departures from the analytic frame are
  rationalized in the treatment of highly disturbed
  and traumatized patients exactly the ones who
  require a containing but clear boundedness to
  avoid the retraumatization and boundarylessness
  of childhood.

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Dimensions of Therapeutic Boundaries

• Professional role
• Place space
• Business transactions
• Language
• Confidentiality
• Excessive self-disclosure

• Time
• Money
• Gifts
• Clothing
• Sexual relations
• Physical contact

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• Therapeutic boundaries are established so they
  can be psychologically crossed through empathy,
  projective identification, and introjective
  identification.

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The Analytic Object

• Analytic boundaries facilitate the emergence of
  the analytic object an amalgam of the
  transference object and the new object, and a
  joint creation of the interpenetrating
  subjectivities of the two participants.

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Boundary Violations

• Egregious enactments that are often repetitive,
  not subject to therapeutic scrutiny, pervasive,
  and harmful to the patient while also destroying
  the viability of the psychotherapy

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Boundary Crossings

• Benign, and even helpful, countertransference
  enactments that are attenuated, occur in
  isolation, are subject to therapeutic scrutiny,
  and extend the therapeutic work, in a positive
  direction

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Our Historical Legacy
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• The way these women manage to charm us with
  every conceivable psychic perfection until they
  have attained their purpose is one of Natures
  greatest spectacles. -- Freud
• 
  - McGuire 1974, p. 231

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• Ethics are remote from meI do not break my head
  very much about good and evil, but I have found
  little that is good about human beings on the
  whole. In my experience most of them are trash,
  no matter whether they publicly subscribe to this
  or that ethical doctrine or to none at all. -
  Freud
• 
  - Roazen 1975, p.
  146

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Profile of Therapists

• No simple formula
• 20 are female therapists
• 20 are same-sex dyads
• Vulnerability is univeral

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A Psychoanalytically Based Classification

• Psychotic disorders
• Predatory psychopathy
• Lovesickness
• Masochistic surrender

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Common Themes

• Omnipotence
• Only I can save the patient.

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Common Themes (cont.)

• Disidentification with the aggressor

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Common Themes (cont.)

• Sadomasochistic object relations masked by love

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• Aggression is loves shadow.
• 
  - Mitchell 1997

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Common Themes (cont.)

• Envy of the patient

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Common Themes (cont.)

• Perception of deficit

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Chrobaks Prescription

• Penis normalis dosim repetatur!
• - Freud (1914)

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Common Themes (cont.)

• A particular fit between the internal object
  relations of the patient and those of the
  therapist

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Common Themes (cont.)

• Failure of mentalization/collapse of analytic
  space

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• The Case of Dr. F

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• The Search
• for a
• Bad Enough Object

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• Autonomy
• and
• Consultation

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• The
• Need
• for
• Compartmentalization

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Prevention

• Inherent limitations
• Address group and institutional
  resistances/family secrets
• Regular consultation
• Lifeguard analogy