While the most widely discussed boundary violation is sexual relations between the analyst and the patient, nonsexual boundary violations are common as well. These may include such phenomena as soliciting donations from one's patient, entering into a business transaction with one's patient, excessive self-disclosure of the analyst's personal problems, and breaking the patient's confidentiality.
Maintaining professional boundaries should not be construed as a call for rigidity. Indeed, a flexible analytic frame is necessary to respond to patients with varying needs, conflicts, and deficits. The elasticity of the frame reflects not only the patient's specific needs, of course, but also the analyst's subjectivity. Moreover, there are situations in which a break of the frame may be a helpful departure from the usual boundaries. Gutheil and Gabbard have referred to these instances as boundary crossings rather than violations.
In addition, counter-transference enactments are inevitable to some extent, and the differentiation between a useful enactment and a boundary violation is sometimes ambiguous. A useful enactment generally involves an analyst who has caught himself or herself in the midst of the enactment before it escalates to the point of becoming a serious violation. Also, the capacity of both patient and analyst to analyze the incident may determine whether a particular behavior is destructive or productive. Finally, enactments that are repetitive and unresponsive to the analyst's own self-analytic efforts are more likely to be harmful than those that are subjected to self-analytic scrutiny and prevented from recurring.
The concept of boundary violations is a relatively recent addition to the psychoanalytic literature, although the early history of psychoanalysis was replete with such violations. While Sándor Ferenczi was analyzing Elma Palos, he professed his love for her and ultimately referred her to Freud for analysis. Ernest Jones's common-law wife, Loë Kann, was a former patient of his. Margaret Mahler acknowledged in her memoirs that she had been sexually involved with her analyst, August Aichhorn. Many of these instances were ignored; if they did come to light within psychoanalytic institutes, the solution was often to send the analyst back for more analysis rather than to take any form of disciplinary action.
With the rise of the women's movement, female patients became more assertive in expressing their sense of having been exploited by male analysts (cases of sexual boundary violations most commonly involve a male analyst and a female patient), and some form of reparation was often demanded.
Gutheil and Gabbard first attempted to delineate the concept of boundary violation and boundary crossings in a 1993 article. Subsequently, Gabbard and Lester argued that preservation of professional boundaries not only protects the patient from harm, but also serves to create "the analytic object," which is an amalgam of the transference object and the new object jointly created by the subjectivities of analyst and patient.
Critics of the new emphasis on boundary violations have expressed concern that such limits may constrict the spontaneity of the analyst. Rigidity might prevent the analyst from engaging the patient. Attention to boundaries, however, does not promote coldness or rigidity in the analytic relationship. The intent is exactly the opposite. Professional boundaries define the parameters of the analytic relationship so that the patient can interact in an atmosphere of safety that includes an analyst who can be warm and spontaneous.
Another concern expressed about the concept of professional boundaries is that sexual boundary violations are committed by predatory analysts with severe psychopathy or antisocial personality disorders. Other analysts, the argument goes, need not concern themselves with boundaries because they are essentially ethical. Systematic studies of analysts who have had sexual and nonsexual boundary violations with patients, however, suggest that many who have otherwise been ethical and honest may be susceptible to falling in love with the patient and transgressing boundaries at a time in their lives when they are under great personal stress. Hence there is a strong argument for teaching constructs like professional boundaries and boundary violations to all analysts.
- Abstinence/rule of abstinence
- Collected Papers on Schizophrenia and Related Subjects
- Psychoanalytic treatment
- Transference love