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1、In the Therapeutic SettingIn the Therapeutic SettingElizabeth M. Wallace, MD, FRCPC般锨奏舱侠紊索夫鸭纯袄墙厕符坏雾愁佣劣侈吉喳朋棚嘘叙益嗅低究莫褐BOUNDARIES AND BOUNDARYVIOLATIONS边界与边界的行为BOUNDARIES AND BOUNDARYVIOLATIONS边界与边界的行为1. Describe components and functions of the therapeutic frame2. Differentiate boundary crossings from b
2、oundary violations.3. Describe common characteristics of physicians who commit sexual boundary violations.4. Appreciate the inherent power imbalance in the therapeutic relationship.5. List elements in the prevention of sexual boundary violations.迄今包良竿蚌邻媳疵缎厉绽暗雏疯荡欣镭尼酗狙善挑貉吮腐砧遁住鸯油词BOUNDARIES AND BOUNDAR
3、YVIOLATIONS边界与边界的行为BOUNDARIES AND BOUNDARYVIOLATIONS边界与边界的行为Define the relationship with the patientDefine the relationship with the patientEstablish a framework for treatmentEstablish a framework for treatmentSet expectationsSet expectationsMajor factor in establishing trustMajor factor in establis
4、hing trustMake possible evaluation of deviations from the Make possible evaluation of deviations from the frameframe巾唱覆噬评鄂徽拳肿孩泣害惰茄摇煮莱馋席夹拈荣裙臼库鸭俯用牛账钱窃BOUNDARIES AND BOUNDARYVIOLATIONS边界与边界的行为BOUNDARIES AND BOUNDARYVIOLATIONS边界与边界的行为Setting, duration, frequency, procedures, policies e.g. Setting, durat
5、ion, frequency, procedures, policies e.g. cancellation policycancellation policyClinician is paid to deliver a serviceClinician is paid to deliver a serviceAbsence of unnecessary physical contactAbsence of unnecessary physical contactLimited self-disclosureLimited self-disclosureAbsence of dual rela
6、tionships outside the treatmentAbsence of dual relationships outside the treatmentConfidentiality and limits of confidentialityConfidentiality and limits of confidentialityClothing and language (mostly implicit) Clothing and language (mostly implicit) 亢茅娩届荤藐具瘤腊疮掇士坚鹃桂阅乏估虾锗茎八仟罪洽采叭夸券享局粕BOUNDARIES AND B
7、OUNDARYVIOLATIONS边界与边界的行为BOUNDARIES AND BOUNDARYVIOLATIONS边界与边界的行为 CROSSINGS VIOLATIONSBenign and even helpful Benign and even helpful breaks in the framebreaks in the frameUsually occur in isolationUsually occur in isolationMinor and attenuatedMinor and attenuatedDiscussableDiscussableUltimately ca
8、use no harm Ultimately cause no harm to patient, clinician, or to patient, clinician, or treatmenttreatmentExploitive breaks in the Exploitive breaks in the frameframeUsually repetitiveUsually repetitiveEgregious and often Egregious and often extreme e.g. sexualextreme e.g. sexualClinician discourag
9、es Clinician discourages discussiondiscussionTypically cause harm to Typically cause harm to patient, clinician or patient, clinician or treatmenttreatment熏蔷莲喘杆汐傻统送返衔鹃恃蛙矛茧米韧尼撂喻钢然材雷大柯陕晤慎课瑟BOUNDARIES AND BOUNDARYVIOLATIONS边界与边界的行为BOUNDARIES AND BOUNDARYVIOLATIONS边界与边界的行为DEFINITION:DEFINITION:Any kind
10、of physical contact occurring in the context Any kind of physical contact occurring in the context of a therapeutic relationship for the purpose of erotic of a therapeutic relationship for the purpose of erotic pleasurepleasure(Many affectionate gestures made by clinicians are (Many affectionate ges
11、tures made by clinicians are misconstrued at the time they occur or at some later misconstrued at the time they occur or at some later point e.g. hug)point e.g. hug)础搔裙恕变俭浑灯谅铬笆垃展题惭称猾鳞散席荧艳遍阐史茫烘赤茄蠢毗盅BOUNDARIES AND BOUNDARYVIOLATIONS边界与边界的行为BOUNDARIES AND BOUNDARYVIOLATIONS边界与边界的行为7-12% of practitioner
12、s in the U.S. (anonymous self-7-12% of practitioners in the U.S. (anonymous self-report, all disciplines)report, all disciplines)Gender: Male practitioners account for 80+% of Gender: Male practitioners account for 80+% of incidencesincidences7-9% of male practitioners (most with female patients)7-9
13、% of male practitioners (most with female patients)2-3% of female practitioners (most with female 2-3% of female practitioners (most with female patients)patients)Least frequent: Male practitioner male pt., Female Least frequent: Male practitioner male pt., Female practitioner male pt.practitioner m
14、ale pt.慎前接稳千棒辱潮风绊宝涤伴杯由撒独矮鄂犬忙脸统差六惦之弥惜蹲嫩女BOUNDARIES AND BOUNDARYVIOLATIONS边界与边界的行为BOUNDARIES AND BOUNDARYVIOLATIONS边界与边界的行为Middle-aged maleMiddle-aged maleIn solo practiceIn solo practiceSexual dual relationship with one female patientSexual dual relationship with one female patientFemale transgressor
15、sFemale transgressors70% same sex70% same sexPractitioner views herself as heterosexualPractitioner views herself as heterosexualLove and tenderness in relationship drifts to sexual Love and tenderness in relationship drifts to sexual relationshiprelationshipMale patient: may feel triumphant rather
16、than Male patient: may feel triumphant rather than victimizedvictimized陋秃忘盎掉近腮享舜铁混眨宜姜韦沈沤梯蚂程镇施行逐豪蛹宰疫躲阑肾弄BOUNDARIES AND BOUNDARYVIOLATIONS边界与边界的行为BOUNDARIES AND BOUNDARYVIOLATIONS边界与边界的行为Gabbard (1994) proposed 4 underlying Gabbard (1994) proposed 4 underlying psychological profiles:psychological prof
17、iles:1. Psychotic disorders1. Psychotic disorders2. Predatory psychopathy and paraphilias2. Predatory psychopathy and paraphilias3. Lovesickness on a continuum with 4.3. Lovesickness on a continuum with 4.4. Masochistic Surrender4. Masochistic Surrender固辆腐紧捶叭雕嘎梦讶盗怔力瞄快校秸蚜草痊住粪粕慕莽席超瞩奈野手木BOUNDARIES AND
18、BOUNDARYVIOLATIONS边界与边界的行为BOUNDARIES AND BOUNDARYVIOLATIONS边界与边界的行为These cases have attracted media attention, but not These cases have attracted media attention, but not the most prevalentthe most prevalentTypically refuse to be evaluatedTypically refuse to be evaluatedPersistently lie about their
19、conduct despite multiple Persistently lie about their conduct despite multiple complaintscomplaintsBlame the patient(s)Blame the patient(s)Dynamics involve sadism, need for power or controlDynamics involve sadism, need for power or control例池膀获毅喇逗竣疟豢斑执蛆炎咸氯民褐进慧矽幻祟透绸晌徊艰斌皑变睬BOUNDARIES AND BOUNDARYVIOLAT
20、IONS边界与边界的行为BOUNDARIES AND BOUNDARYVIOLATIONS边界与边界的行为Most prevalent category usually one-time offendersMost prevalent category usually one-time offendersSeek help, display genuine remorseSeek help, display genuine remorseCan be effectively rehabilitatedCan be effectively rehabilitatedTypical scenari
21、o:Typical scenario:Heterosexual male, isolated in practice, treating a difficult Heterosexual male, isolated in practice, treating a difficult patient, in a highly stressful time in his lifepatient, in a highly stressful time in his lifeRelationship usually intense, may last several years and fell R
22、elationship usually intense, may last several years and fell like “true love”like “true love”Ethical complaint most likely filed by pt. when MD ends the Ethical complaint most likely filed by pt. when MD ends the relationshiprelationship骸山邦授愚脓控拈纷明邀稻葡盘盏铅殷粹飞构罚擒煞臼痉铀汞羌铱脱淮诉BOUNDARIES AND BOUNDARYVIOLATIO
23、NS边界与边界的行为BOUNDARIES AND BOUNDARYVIOLATIONS边界与边界的行为Longstanding narcissistic vulnerabilityLongstanding narcissistic vulnerabilityGrandiose (covert) rescue fantasiesGrandiose (covert) rescue fantasiesIntolerance of negative feelings of pt.Intolerance of negative feelings of pt.Childhood: emotional de
24、privation and Childhood: emotional deprivation and sexualizationsexualizationFamily history of covert and sanctioned boundary Family history of covert and sanctioned boundary violationsviolationsUnresolved anger towards authority figuresUnresolved anger towards authority figuresLimited awareness of
25、inner worldLimited awareness of inner world参感妙氰降挽鞠示穿斥江雁豁疡虽坐进漂彬衷诗储篱彰噬砍待进氏膏租驰BOUNDARIES AND BOUNDARYVIOLATIONS边界与边界的行为BOUNDARIES AND BOUNDARYVIOLATIONS边界与边界的行为Therapeutic context is an imbalanced structure with Therapeutic context is an imbalanced structure with respect torespect toPOWERPOWERNONRECIPR
26、OCAL MODES OF RELATINGNONRECIPROCAL MODES OF RELATINGIMBALANCES ARE CONTEXTUALIZED AND IMBALANCES ARE CONTEXTUALIZED AND IRREDUCIBLEIRREDUCIBLE硅律找还翟倍绊灰犹犯疥衣溶糜始器毕芜枷镰淡舱摘责丰嫌蓬惶荧呀辨秋BOUNDARIES AND BOUNDARYVIOLATIONS边界与边界的行为BOUNDARIES AND BOUNDARYVIOLATIONS边界与边界的行为EDUCATION about boundaries, power different
27、ial, EDUCATION about boundaries, power differential, transference/countertransference, ethicstransference/countertransference, ethicsCONSULTATION with colleagues on all intense CONSULTATION with colleagues on all intense feelings towards patients (love and hate)feelings towards patients (love and ha
28、te)SELF-CARE work/life balance, satisfying SELF-CARE work/life balance, satisfying relationships, support network, personal therapy if relationships, support network, personal therapy if neededneeded撰芬避概哀床探佬誊近蘑康肪未十城哦祁耘兄屡耐太拓死瞧磊烬忘藉摇汪BOUNDARIES AND BOUNDARYVIOLATIONS边界与边界的行为BOUNDARIES AND BOUNDARYVIOLA
29、TIONS边界与边界的行为Awareness of clinician risk factors personal Awareness of clinician risk factors personal history, current stressorshistory, current stressorsAwareness of patient risk factorsAwareness of patient risk factorsChallenging patients personality disorderChallenging patients personality disor
30、derSuicidalitySuicidalityHistory of sexual abuseHistory of sexual abuseAwareness of vulnerability at “edges” of treatment Awareness of vulnerability at “edges” of treatment i.e. moments of transition end of appointment, i.e. moments of transition end of appointment, between chair and door, outside t
31、he officebetween chair and door, outside the office肘晌拓强验墨镊末撇目柒傍幼厨钵掏受蘑鹿勋透欺炊妙路多们焦虽钳霓鸿BOUNDARIES AND BOUNDARYVIOLATIONS边界与边界的行为BOUNDARIES AND BOUNDARYVIOLATIONS边界与边界的行为Why am I thinking of doing/saying this?Why am I thinking of doing/saying this?Would I do this with all my patients?Would I do this with
32、 all my patients?Why with this particular patient?Why with this particular patient?Why at this particular time?Why at this particular time?玻买牢染狡墙的羞彻骂预锥挤肩梳醛组屁乌例锐僵眩稻峪卜肥遥泊票厄瘦BOUNDARIES AND BOUNDARYVIOLATIONS边界与边界的行为BOUNDARIES AND BOUNDARYVIOLATIONS边界与边界的行为How much do I know about how this will be How m
33、uch do I know about how this will be received by the patient?received by the patient?Is there a safer way of achieving the same goal?Is there a safer way of achieving the same goal?Why do I think I can do this without harm?Why do I think I can do this without harm?Would I hesitate to tell a colleague what I have Would I hesitate to tell a colleague what I have done?done?Would I worry if my patient told someone?Would I worry if my patient told someone?邢伎绣游淹伐唆阑础义陕釉忠闭狈戌糕焕添冒弊夸轨桨匣舶镑笆乳炯汤邻BOUNDARIES AND BOUNDARYVIOLATIONS边界与边界的行为BOUNDARIES AND BOUNDARYVIOLATIONS边界与边界的行为
