Boundary violations in therapy: the patient's experience of harm

Abstract

SUMMARYHarm in talking therapies, and in healthcare professionals’ relationships with patients generally, has received little attention in comparison with harm by medication and other treatments. There has been little research into causes, types and effects. Professionals behave as if it does not happen and tend to react defensively to complaints. We believe that it is essential for professionals to understand the potential for harm and evaluate their actions in order to make them safer. This article defines harm in the therapeutic context, discusses its prevalence and then focuses on adverse idealising transference: the adverse effects that may arise when a patient transfers idealising feelings onto the professional.LEARNING OBJECTIVES•Develop a greater understanding of the problem of harm in psychotherapy•Be aware of adverse idealising transference and its possible harmful implications•Be aware of therapist actions that may encourage the development of an adverse idealising transferenceDECLARATION OF INTERESTNone.

Sexual boundary violations: victims, perpetrators and risk reduction

“…In addition to the negative effects that sexual exploitation has on a person in any sphere of life, sexual boundary violations involving patients result in additional harm due to difficulties in trusting other professionals and accessing treatment. Sexual boundary violations are not always viewed (by the patient and others) as exploitation, because the effects of the power differential and factors such as adverse idealising transference (Hook 2018) are insufficiently recognised. Patients frequently feel a degree of complicity and lose trust in their own judgement.…”

“…This is the second of two articles in BJPsych Advances considering harm arising from boundary violations in psychotherapy in particular and healthcare in general. The first (Hook 2018) discussed the general problem of harm in the therapeutic context and explored the adverse idealising transference. In this article we consider sexual boundary violation, its categories, the harm that ensues, the typologies of perpetrators, sanction and remediation, and finally suggestions for improving knowledge in the professions and safeguarding patients.…”

Explanatory paradigms for professional boundary violations

“…In their second article Hook & Devereux (2018b) cite the study by MacDonald et al (2015) which found high levels of insecurity of attachment in doctors referred to a therapy programme for professional boundary violations. Insecure attachment might explain the adverse idealising transference described by Hook & Devereux (2018a), because idealisation is a key aspect of dismissing/avoidant attachment strategies. The dismissing stance deactivates distressing emotions and keeps them out of consciousness, and this results in both conscious dismissal of need (‘I'm fine, I don't need help’) and unconscious idealisation processes which keep painful or disturbing affects and thoughts out of consciousness.…”

“…I am grateful to both the Editor of BJPsych Advances and to the authors of these two stimulating articles (Hook 2018a,b) for an opportunity to reflect on this most important of topics. Reading these articles reminded me of a conversation about sexual boundary violations by therapists that I had in 1990 with a senior and highly respected professor of psychiatry who was a leader in mental health ethics.…”

The Harmful Effects of Psychotherapy: When the Therapeutic Alliance Fails

“…In examining these issues, in this paper I will not include the impact of extreme events, catastrophic ruptures to the therapeutic frame and relationship (death, suicide or boundary violations) which a number of researchers have described (Crawford et al ., ; Deutsch, ; Hook & Devereux, , ; Sarkar, ) and which constitute experiences of betrayal or abandonment. Instead I shall be considering issues arising in normal psychotherapy practice, regardless of the therapist's theoretical orientation.…”