This is a book that would primarily
be read by mental health professionals.  It has been used as a text in
classes and it is a clearly written, excellent resource.  The authors are
well known in their field and have extensive experience in dealing with
these issues.

Gabbard
and Lester are talking about boundary violations in therapy from a dynamic and
treatment oriented perspective.  Thus, the focus is on internal representations,
transference and countertransference rather than
specifics of ethical codes or laws. They
look at both nonsexual and sexual boundary violations. 

The authors begin with an
explanation of how mental representations of self and others are
developed and how people experience psychological boundaries.  When a
patient begins psychoanalytic therapy, a set of parameters of treatment are
instituted:  the analytic frame.  The authors say, "The analytic
frame is an envelope within which the treatment itself takes place." (p.
39) and "the analytic frame creates an atmosphere if safety."
(p. 41).   Within this frame patients are then safe to explore thoughts
and feelings from the past. They establish a
transference to the therapist.  The authors talk about the responsibility the
analyst has in the professional role:  that it is not to gratify libidinal
needs but to help the patient make sense of the past and to preserve the
analytic space so that the treatment can continue.  

This book contains an extensive
chapter on the history or the analytic movement and how an understanding of
transference and countertransference developed over
time. It also contains some unfortunate examples of boundary violations on
the part of some early and well known analysts. The authors appear to feel
the need to provide historical context as "blind spots in one analytic
generation may well become blind spots in the next." (p.
86). 

In the chapter on sexual boundary
violations Gabbard and Lester say "although
discussions of sexual boundary transgressions generally imply that
interpersonal boundaries are being crossed, earlier in the progression down the
‘slippery slope,’ inner boundaries between self and object representation are
eroded." (p. 88).  They look at how this progression can
develop.  In looking at extensive case studies they suggest there are four
categories of therapists who have sex with patients.  The first, psychotic
disorders, is rare and more likely to be a therapist in a manic phase of
bipolar disorder.  A group they call "predatory psychopathy
and paraphilias" (p. 92) they see as possibly
incapable of rehabilitation.  The majority of the therapists who have sex with
patients they categorize as lovesick. These therapists mistake the
transference love of the patient for real love and believe they feel real love
for the patient while being unable to see the harmful effects of their
actions on the patient.  The last group of therapist they categorize
as engaging in a masochistic surrender to the patient.  They list
some commonalities of the therapists in boundary violation
cases: narcissistic issues, grandiosity, sadomasochistic core issues,
tendency toward action over reflection, thick inner boundaries, superego
disturbance, and perception of the patient as having a deficit which requires
enactment.  They also discuss the idea that these therapists overvalue
love and concretely expect it to heal the patient rather than insight or
analytic work. 

In the chapter on nonsexual
boundary violations the authors discuss things like receiving or giving
inappropriate gifts.  They talk about role of projective identification
in confusing boundaries and about countertransference
enactments.  There is an extensive case analysis. They also discuss
instances where the therapist acts inappropriately and concretely in a
mothering role.

It is rare to see discussions of post-termination
issues and this book has a chapter on boundaries and post-termination. Looking
at follow-up studies, the authors suggest that the transference continues as a
latent structure after the termination of therapy  and
that a significant number of patients may ask for consultation of their former analysts
after termination.   They suggest there may be value in former therapists
maintaining sufficient distance to allow the patient to resume therapy if
needed.  This is more difficult where the patient is a mental health
professional and may well subsequently work or supervise at the same workplace
as their former analyst. Gabbard and Lester
suggest that allowing hope of gratifying the patient’s wish for a relationship
after the analysis is done may make a full working through of grief and loss
issues impossible.

There are chapters on boundaries in
supervision and a look at the history of institutions responses to the boundary
questions.

While this book is written about
psychoanalysis, it is applicable to psychodynamically-oriented
psychotherapy and may be useful to therapists of other orientations as
well.   All in all, this book is highly recommended for all
clinicians practicing psychotherapy.  

© 2003 Marilyn Graves

Marilyn Graves, Ph. D. is a clinical psychologist and topic editor of
Psychology and Fiction at suite101.com.

Categories: Ethics, Psychotherapy, Psychoanalysis