|Publications: Book Reviews
Review of Preventing Boundary Violations in Clinical Practice
Title: Preventing Boundary Violations in Clinical Practice
Author: Gutheil, Thomas G. and Brodsky, Archie
Publisher: Guilford Press, 2008
Reviewed By: Richard Ruth, Vol. XXIX, No.1, Winter 2009, pp. 21-24
Far too many therapists and analysts tend to think about ethics from a paranoid–schizoid position. Necessary, but somehow cast with an unsavory and unwelcome tinge of Other, our ethics codes are apt to feel more like intruder than companion, certainly not something easy to fold comfortably into our charged and busy days. When I teach ethics workshops to colleagues, some come with a stoic attitude—in local jurisdictions, six hours a year are required for license renewal—and the braver enter with a note of defiance, as if it were offensive to the analytic enterprise that the rules of our professions should apply to us.
Would it have been easier to live in an earlier, simpler time, when we dissociated the frequency with which some of our colleagues hurt their patients? Not if we work toward integrating the highly disturbing reality that ours is an inherently dangerous enterprise, in which we are well served by guidelines, warning signs, checks and balances. The excellent volumes under review will serve well those in our community who appreciate how difficult, and how necessary, it is to work ethically in our complex contemporary circumstances.
I would caution the reader at the outset that it is far too easy, and perilous, to read on as if the topic under consideration did not apply to oneself. To think about our work as if it were impossible for us to violate a boundary—a even a sexual boundary—with a patient places us at risk not just for being blind to early warning signs that we may be losing our footing, but at the even greater risk of not attuning to the wrenching needs and desires our patients bring to us routinely: the living fire out of which significant therapeutic change, of necessity, emerges. What attunes us to possibility, paradoxically, holds potential to position us at the abyss.
Andrea Celenza, a psychologist and psychoanalyst, has worked for many years treating therapists, analysts, and members of the clergy who have violated sexual boundaries, or who have been referred (or self-referred) to her because they were at risk of such offenses. Her work spans training, consultation, supervisory, therapeutic, rehabilitation, and research contexts, and thus she is able to write from a position of highly specialized experience and expertise; for example, her book includes both a Rorschach investigation (conducted with Mark Hilsenroth) of some of the characteristics of known transgressors and samples of letters that could be written to a licensing board about the treatment/rehabilitation status of a clinician who has transgressed.
Celenza’s thinking combines a frank acknowledgement that it is impossible to know the full scope and dimensions of the problem of sexual boundary violations by helping professionals and a tone that speaks with confidence and conviction about what we do know. Much as some within our professions have worked to make it safe for abuse to be disclosed, reported, discussed, and sanctioned rather than sheltered, there is still no way we can know systematically how many therapists violate sexual boundaries, much less gain detailed knowledge of the operative dynamics in the full variety of kinds of offenses that present. Celenza ably summarizes the available empirical and dynamic literatures, and extends these, from her own clinical experience, by developing categories, outlines, and profiles of what is likely to present in transgressing therapists presenting for assessment and treatment. She also usefully highlights precursor conditions that can make therapists prone to transgress, such as isolation, overwork, limited personal supports, economic strain, and failure to seek necessary consultation and supervision when a treatment reaches impasse. She lends significant evidence to the growing body of data suggesting that therapists who abuse their patients are, in their overwhelming majority, not “bad apples” who cleverly have escaped detection by those charged with selecting and monitoring the progress of candidates for clinical training, but intelligent, competent, empathic clinicians with personality vulnerabilities that come up against the intense demands of clinical work with patients with their own intense needs and weaknesses. She also marshals substantial support for the corollary proposition, that many (not all) helping professionals who transgress can, through adequate treatment, become able to practice safely again.
Several of Celenza’s chapters are re-workings of previously published papers. While this introduces a certain amount of overlap and repetition into the volume, in the end I found it more welcome than intrusive. In the challenging effort to internalize the complexity and charge of the material under discussion, it facilitated my working through Celenza’s lesson to us. The lesson is that we have no choice but to engage in a sustained, reflective manner with issues we would like to avoid. Our responsibility for avoiding therapeutic transgressions is both highly personal and roundly collective, and not at all tangential to, but intricately interwoven with, the essential nature of our work.
I would have liked to see Celenza engage a bit more with two issues that seem to arise from her work. One has to do with how recent history affects the work of contemporary clinicians, particularly those of us whose work has been enlivened by intersubjective and relational thinking. (I am not referring to the fact that managed care and insurance companies hate and exploit us; part of the problem, but too cheap a shot.) By happenstance I wrote part of this review while listening to music on You Tube, and allowed the associative stream of my selections to find its own course. A man of my generation, I wandered for a time into music of the 1960s, where I heard quaintly dated but contextually stunning phrases, such as “We are all outlaws in the eyes of America. . . . . We are forces of chaos and anarchy and we are very proud of ourselves. . . . Tear down the walls; we can be together” (Jefferson Airplane, We Can Be Together). To what extent do the historically recent democratization of hierarchy, welcoming of diversity of sexual exploration and expression, and challenging of conventional certainty open contemporary therapists to unique challenges in our attempts to hold to necessary boundaries? Celenza makes passing mention of some of these factors; I hope she will help us explore them more deeply and thoroughly in future work.
Celenza, as I do, seems to practice in a setting that does not question her right to exist and work. When she, rightly, speaks of the inescapable importance of working clinicians seeking ongoing supervision and frequent consultation, her unstated assumption is that this is possible, echoing the classic Freudian assumption that fees for therapy should easily enough provide the therapist a comfortable living and avoid presenting such a burden to the patient that the transference becomes structurally skewed. Yet many of our colleagues train and work in settings and climates where access to necessary resources and supports is a luxury, attained at best with sacrifice. We should have no doubt that space for the psychodynamic therapies, and reflective living more broadly, is under assault. Celenza helps us frame a very worthy intellectual counter-assault; an equally compelling, and complex, concomitant task is to work out its practical implications.
The Gutheil and Brodsky volume takes a useful step in this direction by framing its primary task as the prevention of boundary violations, which it defines as inclusive of, but not limited to, sexual boundary violations. In adopting such a wide scope, and additionally stating its intention to speak to counselors and psychotherapists of varying theoretical orientations and working in a wide diversity of settings, its goal is ambitious. Admirably, it meets its self-defined task, not by writing at a lowest common denominator level, but in challenging readers to think into the inherently complex and slippery nature of clinical work, and to meld that with a grounding in the principles that the patient’s well-being must always remain central; that the therapist has disproportionate responsibility for maintaining professional boundaries; and that when lapses occur they need to be understood and addressed.
Therapists reading this volume, it is safe to say, will have the uncomfortable experience, mirroring the experience of good therapy, of being simultaneously deeply understood and soundly disrupted. Unlike many treatments of ethical issues, this book does not hold out a distorted oversimplification of the therapeutic encounter as somehow less ambiguous and subtle than we know it to be. Gutheil and Brodsky acknowledge, and help us think very seriously about, the changes in social values, practice contexts, and therapeutic approaches that are part of the modern landscape. But they are insistent that this cannot be grounds for throwing out—does the notion sound as old-fashioned as the Jefferson Airplane?—professionalism.
Several things consistently and systematically reflected in both the tone and the content of this book are unusual and striking. At no point will the reader have any doubt that the writers are working, and very seasoned, clinicians, who both deeply enjoy and deeply think about their clinical work. While their erudition is impressive—the variety of literatures they summarize and evaluate with critical authority is magisterial—we are never far away from the texture of everyday clinical life. The rich case illustrations have the ring of the familiar; if we have not experienced the exact dilemmas the authors discuss, we have experienced something very similar, or heard of someone who has. Thus, they do not leave to the reader the task of working from geometric abstractions to the messier realm of the mundane. They meet us where we live.
I also very much liked that chapters draw out essential axioms and principles, stated plainly as such, simple but far from simplistic. The middle section of the book explores themes such as therapeutic roles; parameters of the therapeutic setting; money and gifts; intentional, unavoidable, and unintentional self-disclosure; extra-therapeutic contacts; physical contact between patients and therapists; and sexual boundaries. Each chapter is followed by a brief series of “Key Reminders.” These are impressively mindful of context and devoid of rigidities, and in this sense more classical than conservative in orientation. Repeatedly echoed themes include the centrality of therapists taking responsibility for their actions and orienting them toward therapeutic intent, consultation early on when we have questions about something that has happened, documenting boundary crossings, and examining and processing their meanings with patients in a forthright manner, as soon as possible after they occur—as they will. The authors draw distinctions between boundary crossings (such as meeting a patient in the community, or offering an extra session during crisis) and counter–therapeutic violations of boundary, but stress that even the latter often lend themselves to repair, if the therapist does the work of exploring and taking responsibility for what has happened, including understanding how it came to occur, and what must change.
I find it especially commendable that Celenza and Gutheil and Brodsky write from an identification with psychodynamic and psychoanalytic therapy, while seeking to address a broader mental health audience—something that does not happen often enough. In doing so, they make a kind of gift of the riches of our tradition, one that I hope will be widely appreciated both for its practicality and its fine crafting. I would think that any student looking for an initial grounding in professional issues in therapy, and any study group of experienced clinicians working on refining and deepening their mastery of ethical issues, would be well served by reading these volumes—as our editor commended to me—together.
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