Clinical Commentary

The doctor-patient relationship has an important role in medical practice and in medical ethics.¹ In modern times, the word “boundary” is used to frame the relationship. In the context of therapy, Gutheil and Simon have described it as “the edge of appropriate or professional behaviour, transgression of which involves the therapist stepping out of the clinical role”.² Boundaries establish for medical professionals the distinctions between professional and personal identity.³ In a therapeutic setting, boundaries distinguish acceptable and appropriate interactions and the parameters of professional conduct.⁴ Implicit in the concept of boundaries are the basic ethical principles of beneficence (doing good, acting in another person’s best interests), non-maleficence (doing no harm) and justice with respect for the individual’s needs and autonomy.

The doctor-patient relationship is particularly important in psychological therapies where trust, integrity, confidentiality, a safe environment and empathy are fundamental to the therapeutic process. A person with BPD manifests emotional dysregulation with instability in interpersonal relationships, self-image, affect and impulsivity.⁵ This, together with identity disturbances, makes them a particularly vulnerable group with heightened reliance on their therapist.⁶

Psychotherapy has been described as an interaction which serves to alleviate distress, change behaviour and alter the patient’s perspective of issues. This description however does not reflect the magnitude and significant power differentials in the relationship. Trust and a close bond are needed to allow issues to be addressed.⁷ In the process, patients’ fantasies and unmet emotional needs might lead them to knowingly or unknowingly view their therapist differently and to seek a relationship. Similarly, multiple factors in the therapist (situational factors, intrapsychic and interpersonal factors) can undermine the therapeutic process.⁸

Boundary Transgressions

There is really no universal definition for a “therapeutic boundary” possibly because, as Simon explains, it is “a function of the nature of the patient, the treatment and the status of the therapeutic alliance”.⁹ Minor violations are referred to as boundary crossings which may arise because the therapist exhibits poor judgement.¹⁰ Such actions are non-exploitative and pose little risk to patients.¹¹ Duckworth et al. describe how boundary crossings begin as “exaggerations of desirable attitudes”. Special arrangements and sessions for the patient and extending therapy sessions may be construed as desirable and arguably as effective for the therapeutic alliance.¹² Yet, if not examined objectively, they become “subtle breaks in the therapeutic frame”.¹³

Psychotherapists trained in analytic therapy hold very rigid views of doctor-patient interactions in psychological therapy. Some would argue that providing a personal telephone number for a patient in crisis situations is a permissible boundary crossing.¹⁴ Similarly, self-disclosure for modelling and on-site behaviour therapy interventions may be viewed as necessary for the therapeutic encounter.¹⁵

The most commonly recognised boundary crossing, however, is self-disclosure.¹⁶ It occurs when the therapist relates a personal experience or information to the patient which is how the incident began in this case.¹⁷ It gradually progressed to an informal, friendly style of interaction, accepting a hug, thanking her for being a good friend, all of which are dissonant with the psychotherapeutic process.¹⁸

In the first place, should the therapist have even offered to drive her home, notwithstanding the heavy downpour? While that offer could be viewed as helpful, the disclosure of marital problems was inappropriate and created confusion. We can only speculate upon the therapist’s behaviour. Was he trying to establish for his patient that they were both experiencing problems to gain her trust? Was he exhibiting some form of identification or did he have some unmet need for affirmation and for care and nurturance? It is difficult to rationalise the apparently thoughtless and impulsive behaviour.¹⁹

The therapist was, at that point, vulnerable with marital problems and facing separation.²⁰ Procci has highlighted that therapists who breach boundaries, “usually have serious personal problems and may have a psychiatric diagnoses”.²¹ Even though the relationship was non-sexual, it moved beyond a boundary crossing and should be viewed as a boundary violation. While the most serious form of boundary violation is the sexual encounter...